Cigna Pharmacy Benefit

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This is a summary of benefits for your Pharmacy Plan. The document will be used to reflect how your Pharmacy plan will be loaded
into our claim processing systems.
(Pharmacy plan deductibles, out-of-pocket maximums, copays and annual maximums do not integrate with the employer medical
program unless elected as part of the CIGNA Choice Fund product)
CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
BENEFIT HIGHLIGHTS
Effective January 1, 2006
General Plan Information
OAP – TX
OAP – NATIONAL
RETIREES UNDER 65
CIGNA Pharmacy
Yes
Yes
Yes
Clinical Management
Basic
Yes
Yes
Yes
Plan Type
Generic Push – 3 tier
Generic Push – 3 tier
Generic Push – 3 tier
Prescription Drug List (Formulary)
Incentive drug list
Yes
Yes
Yes
Open
Yes
Yes
Yes
Closed
No
No
No
Product/Clinical Management
Member Contribution Strategy
Retail Copay
$10 generic
$10 generic
$10 generic
$25 brand
$20 brand
50% brand
$50 non-preferred brand
$40 non-preferred brand
50% non-preferred brand
30 Days
30 Days
30 Days
$25 generic
$20 generic
$30 generic
$70 brand
$40 brand
50% brand
$145 non-preferred brand
$80 non-preferred brand
50% non-preferred brand
Mail Order Days Supply
(Standard is 90 days)
90 Days
90 Days
90 Days
Out of Network coverage:
If yes, indicate
No
No
No
Retail Days Supply
(Standard is 30 days)
Mail Order Copay
Pharmacy Only Deductible/Maximum
Deductible
No
No
No
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Out-of-Pocket Maximum
No
No
Yes
Individual - $2,000
Family - $6,000
Does copay apply to OOP max?
No
No
Yes
Does deductible apply to OOP max?
No
No
No
Annual Benefit Maximum
(CIGNA Pharmacy Only)
Accumulation Provision (applies to
deductible, out-of-pocket and annual
benefit maximum)
No
No
No
In-Network Only
No
No
Yes
Out-of-Network Only
No
No
No
In and Out-of-Network
No
No
No
No
No
Yes
Deductible/Maximums Apply to Mail
Order?
Additional Options/Inclusions/Exclusions
Optional Prescription Coverage
Diet Drugs
Fertility Oral Drugs
Optional Injectable Coverage
Lifestyle Drugs
Contraception & Devices
Smoking Cessation
Vitamins
Standard Inclusions:
Accutane/Isotretinoin
AIDS Related Medication
Anabolic Steroids
Compound Drugs
Desi Drugs
Injectables (Standard package, includes
self-administered injectables after
7/1/05)
Immunosuppressives
Pens & Cartridges (ASO Only)
Prenatal Vitamins Drugs
Retin-A/Tretinoin Drugs
Vitamins Drugs (Standard Package)
No
No
No
No
Yes
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
No
No
Always Covered
Always Covered
Always Covered
Diabetic Supplies
Insulin
Insulin Needles and Syringes
Blood Sugar Diagnostics & Urine Test
Strips
Lancets
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Standard Exclusion
Not Covered
Biological Drugs
Blood and Blood Plasma & Factors
Fluoride Preps Drugs
Growth Hormones Drugs (Pre 7/1/05 or
renewal, whichever is later)
Implants
Nutritional & Dietary Drugs
Research Drugs
Topical Minoxidil Drugs
Alcohol Antiseptic Pads
Other Syringes
Glucometers
Over the Counter (OTC) Drugs
Dental Prescriptions (i.e. Periostat)
Anti-Malaria Drugs
Benefit Exclusions (by way of example but not limited to):
Not Covered
Not Covered
Your plan provides coverage for medically necessary Prescription Drugs and Related Supplies. Your plan does not provide coverage
for the following, except as required by law or by the terms of your specific plan:
1.
Any drugs available over the counter that do not require a prescription by Federal or State Law, and any drug that is a
pharmaceutical alternative to an over the counter drug other than insulin.
2.
Any drug class in which at least one of the drugs is available over the counter and the drugs in the class are deemed to be
therapeutically equivalent as determined by the P&T Committee.
3.
Injectable infertility drugs and injectable drugs that require Physician supervision and are not typically considered selfadministered drugs. The following are examples of Physician supervised injectable drugs: injectables used to treat hemophilia
and RSV (respiratory syncytial virus), chemotherapy injectables and endocrine and metabolic agents.
4.
Any drugs that are experimental or investigational, within the meaning set forth in the Agreement.
5.
Food and Drug Administration (FDA) approved drugs used for purposes other than those approved by the FDA unless the drug
is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States
Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations; or The American Hospital Formulary
Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed
national professional medical journal.
6.
Any prescription and non-prescription supplies (such as, ostomy supplies), devices, and appliances.
7.
[Note: When contraceptives are covered, remove this exclusion.] Any contraceptive drugs and prescription appliances for
contraception,
8.
Implantable contraceptive products, except as covered in the Agreement.
9.
Any fertility drug.
10. [Note: When the lifestyle drugs are covered, remove this exclusion.] Any drugs used for treatment of sexual dysfunction,
including, but not limited to erectile dysfunction, delayed ejaculation, anorgasmia and decreased libido.
11. [Note: When the prescription vitamins are covered, remove “Any prescription vitamins (other than pre-natal vitamins).” The
exclusion will state: “Dietary supplements and fluoride products.”] Any prescription vitamins (other than pre-natal vitamins),
dietary supplements and fluoride products.
12. Drugs used for cosmetic purposes, such as, drugs used to reduce wrinkles, drugs to promote hair growth as well as drugs used
to control perspiration and fade cream products.
13. [Note: When the prescription diet drugs are covered, remove this exclusion.] Any diet pills or appetite suppressants
(anorectics).
14. [Note: When the prescription smoking cessation products are covered, remove this exclusion.] Prescription smoking cessation
products.
15. Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood
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products or fractions and medications used for travel prophylaxis.
16. Replacement of Prescription Drugs and Related Supplies due to loss or theft.
17. Drugs used to enhance athletic performance.
18. Drugs which are to be taken by or administered to a Member while the Member is a patient in a licensed hospital, skilled
nursing facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a
facility for dispensing pharmaceuticals.
19. Prescriptions more than one year from the original date of issue.
This Benefit Summary highlights some of the benefits available under your plan. A complete description regarding
the terms of coverage, exclusions and limitations, including legislated benefits will be provided in your insurance
certificate or plan description.
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
“COMMONLY QUESTIONED” DRUG COVERAGE
Drugs to treat Attention Deficit Disorder
Amphet Asp/Amphet/D-Amphe/brand form is Adderall and Dexidrine - Covered
D-Amphetamine Sulfate/brand form is Dexedrine - Covered
Methylphenidate HCL / brand form is Ritalin – Covered
Drug to treat depression
Bupropion HCL / brand form is Wellbutrin - Covered
Drug to treat infections
Doxycycline Hyclate/ brand form is Periostat – Not covered
:
Fluconazole / brand form is Diflucan - Covered
Linezolid/ brand form is Zyvox – Covered, with PA
Drug to treat skin conditions
Ammonium Lactate / brand form is Lac-hydrin – Not covered
Drug to treat hair loss
Finasteride/ brand form is Propecia – Not covered
Implant to prevent pregnancy
Levonorgestrel/IUD – Not covered
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
PRESCRIPTION DIET DRUGS
Anorexic Agents
Didrex
Diethylpropion hcl
Ionamin
Meridia
Phendimetrazine Tartate
Phentermine hcl
Prelu-2
Fat absorption decreasing agent
Xenical
All drugs listed above are included in this coverage. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
…
This optional prescription coverage has been elected
:
This optional prescription coverage has NOT been elected
CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
FERTILITY (ORAL) DRUGS
If both the oral contraceptive option is selected under pharmacy and the Medical Option #2 (definition) is selected
under medical, then oral fertility is included as part of the pharmacy plan.
Clomid
Clomiphine Citrate
Serophene
All drugs listed above are included in this coverage. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
…
This optional prescription coverage has been elected
:
This optional prescription coverage has NOT been elected
A BUSINESS OF CARING
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
OPTIONAL SELF ADMINISTERED INJECTABLE
Available post 7/1/05, Prior Authorization Required
Hematopoietic Agent
Aranesp
Neupogen
Neumega
Neulasta
Leukine
Procrit
Epogen
Antibiotic
Rocephin
Anzemet
Kytril
Zofran
Anti-inflammatory
Toradol IM
Toradol IV/IM
Hepatitis-C
Intron-A
Arthritis
Solganol
Myochrystine
Infertility
Lupron
Cancer/Endometriosis
Proleukin
Zoladex
Rheumatoid Arthritis
Remicade
Cystic Fibrosis
Garmycin
Tobrex
Endocrine and Metabolic
Sandostatin
Testosterone
All drugs listed above are included in this coverage. Changes to these drugs may occur under normal formulary plan changes.
OTC Drugs are not included.
…
This optional prescription coverage has been elected
:
This optional prescription coverage has NOT been elected
A BUSINESS OF CARING
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
SELF ADMINISTERED INJECTABLE
The following are standard inclusion in the pharmacy plan post 7/1/05, prior authorization required
All drugs covered under this BASIC package are standard inclusions.
AIDS/HIV Infection
Fuzeon
Hepatitis/Hepatitis C
Infergen
Rebetron
Roferon A
Peg Intron
Pegasys
Asthma
Xolair
Bone Diseases/Osteoporosis
Calcimar
Miacalcin
Forteo
Plaque Psoriasis
Raptiva
Multiple Sclerosis
Avonex
Betaserone
Copaxone
Rebif
Chronic Granulomatous
Actimmune
Central Precocious Puberty (CPP)
Supprelin
Parkinson’s Disease
Apokyn
Endocrine and Metabolic
Somavert
Rheumatoid Arthritis
Humira
Kineret
Enbrel
Growth Hormone
Genotropin
Humatrope
Norditropin
Nutropin
Nutropin AQ
Nutropin Depot
Protropin
Saizen
Serostim
Tev-Tropin
All drugs listed above are included as standard. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
A BUSINESS OF CARING
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
BASIC INJECTABLE PACKAGE
The following drugs are a standard inclusion in all pharmacy plans
Anaphylaxis Prevention
Ana-kit
Epipen
Epipen Jr
Acute Migraine Headache
D.H.E.45
Imitrex
Anticoagulant/Treat & Prevent Blood Clots
Arixtra
Fragmin
Heparin
Innohep
Lovenox
Diabetes
Glucagen
Glucagon
Humulin
Novolin
Vitamin Deficiency
Rubesol-100
All drugs listed above are included as standard. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
A BUSINESS OF CARING
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
PRESCRIPTON LIFESTYLE DRUGS (Prior Authorization Required)
Drugs to Treat Impotency
Caverject (6 vials)
Cialis (8 pills)
Edex (6 vials, 1 kit)
Levitra (8 pills)
Muse (6 suppositories)
Viagra (8 pills)
All drugs listed above are included in this coverage. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
This option must be elected if 4th tier Therapeutic class benefit is erectile & sexual dysfunction and the above drug list of drugs is
moved to the 4th tier for the member contribution. Otherwise, these drugs will be covered per the prescription drug list, if elected as
an option.
…
This optional prescription coverage has been elected
:
This optional prescription coverage has NOT been elected
A BUSINESS OF CARING
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
PRESCRIPTION CONTRACEPTIVE DRUGS/DEVICES
Oral Contraception /Oral Meds
Nuvaring / Vaginal contraceptive
Ortho Evra / Contraceptive patch
Diaphragms / Contraceptive devices
Depo Provera / Contraceptive injectable
(Dispensed only in a 90 day supply, subject to 3 retail co-payments)
Lunelle / Contraceptive injectable
(Dispensed 1 kit)
Seasonal/Oral (dispensed only in 91 day supply subject to 3 retail co-payments)
All drugs listed above are included in this coverage. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
This option must be elected if 4th tier Therapeutic class benefit is contraception & devices and the above drug list of drugs are
moved to the 4th tier for the member contribution. Otherwise, these drugs will be covered per the prescription drug list, if elected as
an option.
:
This optional prescription coverage has been elected
…
This optional prescription coverage has NOT been elected
A BUSINESS OF CARING
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
PRESCRIPTION SMOKING CESSATON DRUGS
Smoking Deterrent
Nicotrol Nasal Spray
Nicotrol Cartridge
Zyban tablet
All drugs listed above are included in this coverage. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
…
This optional prescription coverage has been elected
:
This optional prescription coverage has NOT been elected
A BUSINESS OF CARING
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
PRESCRIPTION VITAMINS DRUGS
Flouride Preps
Fluoride
Sodium Fluoride
Fluoritab
Pediaflor
Fluorabon
Luride
Pediatric Vitamin Preparation
PolyViFlor
PolyViFlor with Iron
TriViFlor
Vi-Daylin/F
Vi-Daylin/F ADC
Vi-Daylin/F with Iron
Iron Replacement
Anemagen FA
Chromagen FA
Niferex 150
Hemocyte
Hemocyte Plus
VitaFol
Vitamin A Preparation
Aquasol A
Vitamin B Preparation
Folgard
Nephrovite
Multivitamin Prep
Berocca Plus
Therobec Plus
Pediatric Fluoride Drops
Fluoritab
Luride
Sodium Fluoride
All drugs listed above are included in this coverage. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
…
This optional prescription coverage has been elected
:
This optional prescription coverage has NOT been elected
A BUSINESS OF CARING
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Cigna Pharmacy Benefit.doc
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
PRESCRIPTION VITAMINS DRUGS
All drugs covered under this BASIC package are standard inclusions
Vitamin D Preparation
DHT
Rocaltrol
Vitamin D
Folic Acid Preparations
Folic Acid
Iron Replacement
Foltrin
Chromagen/FA/Forte
Vitamin K Preparation
Mephyton
All drugs listed above are included as standard. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
A BUSINESS OF CARING
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CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
ADDITIONAL COVERAGE – PENS AND CARTRIDGES
Cartridge
Humalog
Humulin 70/30
Humulin N
Humulin R
Novolin R
Novolin N
Novolin 70/30
Novolog Mix 70/30
Novolog
Disposal Syringe
Humulin 70/30
Humulin N
Humulog Mix 75/25
Humalog
Novolin 70/30
Novolin R
Novolog Mix 70/30
Novolog
All drugs listed above are included in this coverage. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
:
This optional prescription coverage has been elected
…
This optional prescription coverage has NOT been elected
A BUSINESS OF CARING
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Version 05/2005
CIGNA Healthcare Pharmacy Customer Worksheet
Tektronix, Inc.
CIGNA Pharmacy Plan
ADDITIONAL COVERAGE – PRESCRIPTION INFERTILITY INJECTABLE DRUGS
Follicle Stimulants
Antagon
Cerotide
Chorex-10
Chorionic Gonadotropin
Fertinex
Follistim
Gonal-F
Metrodin
Novarel
Ovidrel
Pergonal
Pregnyl
Profasi
Repronex
Luteinizing Hormones
Luveris
All drugs listed above are included in this coverage. Changes to these drugs may occur under normal formulary plan changes. OTC
Drugs are not included.
…
This optional prescription coverage has been elected
:
This optional prescription coverage has NOT been elected
A BUSINESS OF CARING
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