An extensive network of pharmacies. Choose from over 60,000 retail pharmacies in our national network you are sure to find your favorite one.

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1 For Retirees of Features that Add Value Prescription drugs delivered to your door. CIGNA Home Delivery is designed especially for individuals who take prescription medications on an ongoing basis. Savings and delivery right to your home that s an offer that s hard to pass up. An expansive drug list, referred to as a formulary, includes over 6,000 medications and the most commonly used drugs for Medicare-eligible individuals. An extensive network of pharmacies. Choose from over 60,000 retail pharmacies in our national network you are sure to find your favorite one. Quality Service Is Part of Quality Care Service is at the heart of everything we do. Our goal is to give you: fast, accurate answers; responsive, courteous and professional assistance; and ease and convenience in finding the information you need to manage your health. To talk with a Medicare Part D Specialist, call We are available 8 am to 8 pm, local time, Monday through Friday. Between October 15 and February 14 we are also open Saturday and Sunday (TTY/TDD users call ) Once you enroll, register for mycigna.com, our convenient, secure members-only website that combines web tools with personalized benefits information to help you make the most of your plan, 24 hours a day. We Speak Many Languages SM. We offer Language Line Services so that you can talk with us in 150 different languages. Just call Customer Service and ask for an interpreter. Thank you for your interest in Plans. Our plans are offered by CONNECTICUT GENERAL LIFE INSURANCE COMPANY/CIGNA Medicare Rx, a Medicare Prescription Drug Plan that contracts with the Federal government. This Summary of Benefits tells you some features of our plan. It doesn t list the drugs we cover, every limitation, or exclusion. To get a complete list of our benefits, please call and ask for the Certificate of Coverage. Page 1 CIGNA Medicare Services 2012 S5617

2 CIGNA HealthCare Benefit Summary Benefit Highlights You pay General: This plan uses a formulary (List of Covered Drugs). The Plan will send you the formulary. You can also see the formulary at on the web. Please refer to the formulary document for more details. In-Network Deductible* Individual Deductible $0 yearly deductible Initial Coverage Level After you pay your yearly deductible, you pay the following until total yearly drug costs reach $ day supply Retail or 31-day supply From a Long Term Care 30-day supply for Mail Order Retail Mail Order 1 $10 Copay $10 Copay $30 Copay $20 Copay 2 $25 Copay $25 Copay $75 Copay $50 Copay 3 $40 Copay $40 Copay $120 Copay $80 Copay 4 $40 Copay $40 Copay $120 Copay $80 Copay Benefit Highlights You pay Coverage Gap Coverage Gap "Donut Hole" Begins after Initial Coverage reaches $2,930 and up to $4,700 in out-of-pocket costs that you pay During this payment stage, you receive limited coverage by the plan and may receive a discount on brand name drugs. You (or others on your behalf) pay the lesser of the plan benefits or the costs of generic drugs. * Beginning in 2012, individuals who reach the Coverage Gap may receive a discount of approximately 50% on the cost share portion (copay/coinsurance) of their Part D brand-name drugs in the gap as agreed to by pharmaceutical manufacturers. The discount will be applied at the point of sale. Note: Supplemental drugs, known as non-part D drugs are excluded from the discount. For example, if you have a $50 copay for brand-name drugs in the coverage gap, you would pay $25 after the manufacturer discount. Page 2 CIGNA Medicare Services 2012 S5617

3 30-day supply Retail or 31-day supply 30-day supply for Mail From a Order Long Term Care Generic $40 Copay Generic $40 Copay 4 Brand $80 Copay Brand $80 Copay Retail Mail Order $10 Copay $10 Copay $30 Copay $20 Copay $50 Copay $50 Copay $150 Copay $100 Copay $80 Copay $80 Copay $240 Copay $160 Copay Catastrophic Coverage Catastrophic Coverage Begins after you have paid $4,700 in True Outof-pocket (TrOOP) costs Generic Drugs and Brands treated as Generics All other Brand Drugs Out-of-Network Coverage Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy s full charge for the drug and submit documentation to receive reimbursement from. Drug List Enhancements through your CIGNA Medicare Rx plan Drug List Enhancements through your CIGNA Medicare Rx plan Generic $120 Copay Brand $240 Copay You pay the greater of: 5% of the cost of the drug or $2.60 copay 5% of the cost of the drug or $6.50 copay 40% coinsurance for a 10 day supply Generic $80 Copay Brand $160 Copay Your plan waives the following clinical management edits (see formulary document or Certificate of Coverage for definitions): Step Therapy Your plan pays for the following drugs at the same copays as other covered drugs on your plan: Barbiturates & Benzodiazepines Cough & Cold Preps Page 3 CIGNA Medicare Services 2012 S5617

4 Erectile Dysfunction Drugs Prescription Vitamins Term Coinsurance Copay Coverage Gap (a.k.a., Donut Hole) ( Benefit) Deductible Initial Coverage Limit ( Benefit) True Out-of- Pocket (TrOOP) ( Benefits) Out-of-Network Coverage The copays you pay on these drugs do not count toward your annual TrOOP. Definition After you have met your deductible for the year (if applicable), you and your benefit plan will share the cost of covered expenses. The part you are responsible to pay is called coinsurance. A fixed charge for specific services like doctor visits. You may be responsible to pay all or a portion of this charge. Medicare drug plans may have a coverage gap, which is sometimes called the donut hole. The coverage gap begins after you and your plan have spent $2,930. The amount you must pay before the plan begins to reimburse for covered expenses. The initial coverage limit for 2012 is $2,930. The amount that you and your plan pay for your prescription drugs count toward this limit. Once you and your plan have spent $2,930, you will enter into the coverage gap benefit level. True out-of-pocket (TrOOP) costs help you qualify for catastrophic coverage so long as the drug is normally covered by a Medicare Prescription Drug Plan, and included on your plan formulary. TrOOP includes: Your annual deductible Your coinsurance or copays made on covered drugs (excluding drugs purchased outside the U.S. and it's territories, drugs not covered by the plan or drugs covered by your plan under the additional drug benefit category. When you have spent a total of $4,700 out-of-pocket for these items, you will reach the catastrophic level. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy s full charge for the drug and submit documentation to receive reimbursement from your CIGNA Medicare Rx Plan (PDP). Drug exclusions A Medicare Prescription Drug Plan can t cover a drug that would be covered under Medicare Part A or Part B. Also, while a Medicare Prescription Drug Plan can cover off label uses (meaning for uses other than those indicated on a drug s label as approved by the Food and Drug Administration) of a prescription drug; we cover the off-label use only in cases where the use is supported by certain reference book citations. Congress specifically listed the reference books that list whether the off-label use would be permitted (these reference books are: (1) American Hospital Formulary Service Drug Information, (2) the DRUGDEX Information System, and (3) USPDI (or its successor)). If the use is not supported by one of Page 4 CIGNA Medicare Services 2012 S5617

5 these reference books (known as compendia), then the drug would be considered a non-part D drug and could not be covered by our Plan. By law, certain types of drugs, or categories of drugs, are not covered by Medicare Prescription Drug Plans. These drugs are not considered Part D drugs and may be referred to as exclusions or non-part D drugs. These drugs include: Non-prescription drugs (or over-the counter drugs). Drugs when used for anorexia, weight loss, or weight gain. Drugs when used to promote fertility. Drugs when used for cosmetic purposes or hair growth. Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale. "CIGNA Medicare Services," "CIGNA Medicare Rx" (PDP) and the "Tree of Life" logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. plans are offered by operating subsidiary Connecticut General Life Insurance Company, and not by CIGNA Corporation. Connecticut General Life Insurance Company is a Medicare approved Part D sponsor. Page 5 CIGNA Medicare Services 2012 S5617