Allegiance



Cigna

P.O. Box 3050

Easton, PA 18043-3050

Dear ,

We’re writing to let you know about changes to your prescription drug coverage starting January 1, 2016*. Please read this letter carefully.

Every year the cost of prescription medication rises. To help lower your costs, Cigna is updating our drug list to feature more affordable drugs. Because of the updates, your drug list will be changing. The information in this letter will help you plan for these changes.

We understand you’re taking – or have taken – the medications listed below.

[Section only included if customer has drugs moving to non-preferred]

Medications where you may pay more

Starting January 1, 2016*, these medications will now be considered non-preferred brand. This means that if you continue to use any of these medications past January 1, 2016, your costs may be higher at the pharmacy.

You may also need approval from Cigna to continue receiving coverage for some of these medications. You should check your drug list on – if your medication has a symbol listed next to it (PA, ST, AGE, QL), you’ll need to get approval from Cigna to have it covered under your plan.

|Non-preferred brand medication |Generic and/or preferred brand alternatives |

| | |

| | |

[Section only included if customer has drugs excluded from the drug list]

Medications no longer covered on your drug list^

Starting January 1, 2016*, your Cigna plan won’t cover the medications listed below. This means that if you continue to use any of these medications past January 1, 2016, you’ll have to pay the full cost of the medication.

|Medication no longer covered |Generic and/or preferred brand alternatives |

| | |

| | |

What you should do.

Talk with your doctor (or bring him or her this letter) to see if one of the generic or preferred brand alternatives might be right for you.

If you received approval from Cigna to have the drug(s) listed above covered under your plan, you can continue to take that drug until your approval period runs out. Before the approval runs out, you should talk to your doctor about switching to a generic or preferred brand alternative listed above.

If you have questions or concerns.

Please call Customer Service using the number on the back of your Cigna ID card. Customer Service is available 24/7/365. We’re here to help.

Sincerely,

Jon Maesner, PharmD

Chief Pharmacy Officer

Cigna Pharmacy Management

* In accordance with Texas and Louisiana state law, customers with affected benefit plans who receive coverage for medications that are removed from the prescription drug list during the plan year will continue to have those medications covered at the same benefit level until their plan renewal date. To find out if these state mandates apply to your plan, please call Customer Service.

^ Where state regulation requires a medical necessity review for coverage of drugs not on your prescription drug list, we will work with your healthcare provider to review.

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