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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 A BUSINESS OF CARING Page 1 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 A BUSINESS OF CARING Page 2 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 A BUSINESS OF CARING Page 3 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 4 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 A BUSINESS OF CARING Page 5 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 6 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 7 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 8 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 9 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 10 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 11 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 12 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 13 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 14 of 16 Cigna Pharmacy Benefit.doc Version 05/2005 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 Page 15 of 16 Cigna Pharmacy Benefit.doc 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 Page 16 of 16 Cigna Pharmacy Benefit.doc Version 05/2005
