This is a summary of benefits for your Pharmacy Plan. The document will be used to reflect how your Pharmacy plan will be loaded
(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 General Plan Information OAP – TX OAP – NATIONAL RETIREES UNDER 65 Product/Clinical Management Plan Type Prescription Drug List (Formulary) Member Contribution Strategy Retail Copay Retail Days Supply
Mail Order Copay Mail Order Days Supply
Out of Network coverage: Pharmacy Only Deductible/Maximum Deductible A BUSINESS OF CARING Out-of-Pocket Maximum Does copay apply to OOP max? Does deductible apply to OOP max? Annual Benefit Maximum No No No (CIGNA Pharmacy Only) Accumulation Provision (applies to Deductible/Maximums Apply to Mail Additional Options/Inclusions/Exclusions Optional Prescription Coverage Diet Drugs Fertility Oral Drugs Optional Injectable Coverage Lifestyle Drugs Contraception & Devices Smoking Cessation Vitamins Standard Inclusions:
Injectables (Standard package, includes
Diabetic Supplies
Insulin Insulin Needles and Syringes Blood Sugar Diagnostics & Urine Test Strips Lancets
A BUSINESS OF CARING Standard Exclusion
Blood and Blood Plasma & Factors Fluoride Preps Drugs
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):
Your plan provides coverage for medical y necessary Prescription Drugs and Related Supplies. Your plan does not provide coverage for the fol owing, 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 self-
administered 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
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 wil 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
14. [Note: When the prescription smoking cessation products are covered, remove this exclusion.] Prescription smoking cessation
15. Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood
A BUSINESS OF CARING
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. A BUSINESS OF CARING 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
Bupropion HCL / brand form is Wellbutrin - Covered
Doxycycline Hyclate/ brand form is Periostat – Not covered
: Fluconazole / brand form is Diflucan - Covered
Linezolid/ brand form is Zyvox – Covered, with PA
Ammonium Lactate / brand form is Lac-hydrin – Not covered
Finasteride/ brand form is Propecia – Not covered
A BUSINESS OF CARING CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan PRESCRIPTION DIET DRUGS
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.
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 CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan OPTIONAL SELF ADMINISTERED INJECTABLE Available post 7/1/05, Prior Authorization Required
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 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.
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 CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan BASIC INJECTABLE PACKAGE The following drugs are a standard inclusion in all pharmacy plans
Anticoagulant/Treat & Prevent Blood Clots
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 CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan PRESCRIPTON LIFESTYLE DRUGS (Prior Authorization Required)
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 CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan PRESCRIPTION CONTRACEPTIVE DRUGS/DEVICES
(Dispensed only in a 90 day supply, subject to 3 retail co-payments)
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
: This optional prescription coverage has been elected This optional prescription coverage has NOT been elected
A BUSINESS OF CARING CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan PRESCRIPTION SMOKING CESSATON DRUGS
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 CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan PRESCRIPTION VITAMINS DRUGS
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 CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan PRESCRIPTION VITAMINS DRUGS All drugs covered under this BASIC package are standard inclusions
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 CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan ADDITIONAL COVERAGE – PENS AND CARTRIDGES
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 CIGNA Healthcare Pharmacy Customer Worksheet Tektronix, Inc. CIGNA Pharmacy Plan ADDITIONAL COVERAGE – PRESCRIPTION INFERTILITY INJECTABLE DRUGS
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
PAI MU TAN, ORGANIC “Valkoinen pioni” Baimudan on kiinalainen Fujianin maakunnan valkoinen teelaatu. Siihen käytetään dabai- ja shuixian-pensaiden silmuja ja jo avautuneita lehtiä. Hautuessaan lehdet säilyttävät alkuperäisen muotonsa. Juoma on vaaleankellertävä, pehmeä, erityisen hieno ja aromaattinen. Alhainen kofeiinipitoisuus. Haudutus 70-80° 7 min. STRAWBERRY PAI MU TAN. Valko
Evidence Reports of Kampo Treatment 2010 Task Force for Evidence Reports / Clinical Practice Guideline Special Committee for EBM, the Japan Society for Oriental Medicine Reference Ohnishi M, Hitoshi K, Katoh M, et al. Effect of a Kampo preparation, Byakkokaninjinto, on the pharmacokinetics of ciprofloxacin and tetracycline. Biological & Pharmaceutical Bulletin 2009; 32: 1080–4. CE
This is a summary of benefits for your Pharmacy Plan. The document will be used to reflect how your Pharmacy plan will be loaded
(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 
Out-of-Pocket Maximum 
Standard Exclusion 
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.
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet 
CIGNA Healthcare Pharmacy Customer Worksheet