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CIGNA Pharmacy Management

The Clinical Difference SM

Delivering Return On Health Through Clinical Integration

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Health insurance expenses are the fastest growing cost component for employers. Unless something changes dramatically, health insurance costs could overtake profits by 2008.

Source: McKinsey and Company

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PUT CIGNA TO WORK FOR YOU Are you ready to start getting a Return On Health ?

To learn more about lowering your health trend, contact your CIGNA Account Representative today, or visit www.CIGNA.com.

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CIGNA Pharmacy Management: Delivering ROH Through Clinical Integration

The statistics are staggering…

A convincing formula

. . . Employer health insurance premiums increased by approximately twice the rate of inflation last year and show no signs of letting up.2

CIGNA Pharmacy Management can reduce overall health trend by as much as 50 percent when integrated with CIGNA HealthCare.3

However, companies are finding relief from this problem by focusing on one component of their overall health benefit spend — their pharmacy benefit plan.

CIGNA is leading the way by improving health trend.

By focusing on the total health of your employees, and how they use their prescription drugs, CIGNA can reduce your total health costs. It’s a solution that’s far more effective than simply managing drug trend. It’s an integrated approach that we call managing health trend — the annual cost of providing all health-related benefits.

What makes CIGNA unique is our depth and breadth of clinical expertise and focus. With more clinicians on staff than any other health insurer, our clinical approach improves patient outcomes to avoid high-cost medical treatments such as emergency room visits and hospital stays.

Undoubtedly, the integration of medical and pharmacy benefits achieves an ROI. But CIGNA’s holistic clinical approach elevates it to what we call giving our clients a Return On HealthSM (ROH).

What does this mean to you?

By integrating clinical programs and case management across medical and pharmacy and implementing effective cost-management programs, CIGNA improves clinical outcomes that lower your overall healthcare costs and generate a greater Return On Health.

The key word is “integrated.” By itself, CIGNA can reduce your drug trend by 5-10 percent versus other pharmacy benefit plans.4 Through integrated case management, clinical programs and access to medical, behavioral and dental programs, CIGNA can increase the likelihood that employees: • Receive the right medications at the right time; • Avoid unfavorable drug interactions and side effects; and • Adhere to their therapy as prescribed.

Moreover, we can identify employees at risk for more serious conditions, help them obtain the care they need and improve their compliance with that care over time.

The Clinical Difference Best-in-class clinical offering that achieves results CIGNA engages and motivates members to take active steps in the treatment of acute, chronic and complex conditions — steps that can lead to healthier outcomes and lower costs for them and their employers. At the same time, we empower physicians to make decisions based on a more holistic view of their patients’ conditions than would otherwise be available to them.

The key to our ability is our on-staff clinical expertise.

CIGNA has more clinicians than any other health insurer.5 More clinicians mean a stronger emphasis on holistic healthcare. Doctors, nurses, pharmacists — these professionals formulate and implement policy at our most senior levels. And they all work together to develop integrated programs that: • Educate members about potentially beneficial and cost-efficient choices (for example, web tools); • Provide incentives to make those choices (for example, coupon programs); and • Encourage behaviors that lead to successful outcomes from both therapeutic and financial perspectives (for example, Step Therapy).

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Outcome Improvement Programs: More than data — changing behavior to improve outcomes and avoid unnecessary medical costs Americans are aging and taking more medications than ever before. Furthermore, they have more medications to choose from, with brand-name drugs, generics and therapeutic alternatives proliferating in the marketplace and drug companies marketing them directly to consumers.

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CIGNA’s clinical programs can help employees avoid unfavorable drug interactions and side effects that can lead to increased medical expense and even hospitalization.

By identifying gaps in care, our clinical programs help employees adhere to their prescription regimens to improve their overall results, stay healthy and avoid additional medical and pharmacy costs. As their name implies, these Outcome Improvement programs are designed to help members treat conditions with greater safety, efficacy and cost-efficiency.

Well Informed Program Eliminates gaps in care across all member touchpoints A recent study quantified what many plan sponsors have known all along. Prescription nonadherence costs employers approximately $177 billion annually in preventable services and lost productivity.6 And only about 8 percent of United States consumers are aware that their own nonadherence is an issue.7

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CIGNA Pharmacy Management: Delivering ROH Through Clinical Integration

CIGNA’s Well Informed program focuses on the adherence issue and other gaps in care that can negatively affect desired outcomes and even exacerbate medical conditions. Well Informed focuses on the chronic conditions most likely to benefit from disciplined prescription therapy. These include asthma, diabetes, back pain and high cholesterol. Through clinical programs and case management, we determine whether members are adhering to prescriptions, filling prescriptions from multiple sources and receiving immunizations and screenings. We also compare their history to evidence-based medical standards of care.

When a gap in care occurs, we communicate with both the members and their physicians to: • Guide members to appropriate action; and • Alert the physician with information he or she needs to make decisions and communicate with patients.

Well Informed examines member’s integrated pharmacy, medical and other healthcare data on a monthly basis.

The information it creates is timely and actionable.

And depending on the nature and severity of the gap, information is transmitted to CIGNA Case Managers, pharmacists, chronic disease clinicians and health advisors as a part of CIGNA’s Health Advocacy programs.

CIGNA knows that healthy employees are the backbone of a healthy business. Through our clinical programs that address medication adherence, we help your employees achieve healthier outcomes so they can remain the valuable resources your business relies on.

What does this mean to you?

CIGNA’s clinical management can improve member outcomes by identifying gaps in care and addressing adherence issues. By leveraging medical and pharmacy data through proactive case management, CIGNA equips physicians, pharmacists and members with the information and on-going personal support they need to take positive actions toward improving members’ health and reducing overall healthcare costs.

Complex Psychiatric Case Management Program Reduces expensive medical costs and increases productivity For too many employers, the problem is becoming all too familiar — increased absenteeism and decreased productivity because of employees with depression, anxiety and other behavioral disorders. In addition, these employees often account for the top 10 percent of employer medical expenditure8, with frequent emergency room visits and multiple psychotropic drug prescriptions prescribed too often by multiple physicians.

CIGNA’s Complex Psychiatric Case Managment program is offered as an option with CIGNA Behavioral Health.

It identifies employees who fill psychotropic drug prescriptions beyond specific thresholds and alerts their primary-care physicians or psychiatrists with personalized patient profiles. Physicians then have the information they need to consult with their patients and coordinate care with other healthcare providers, if necessary. In addition, our Peer-to-Peer Counseling Service offers primary-care physicians the opportunity to consult with experienced psychiatrists for psychiatric referrals to help accelerate the healing process.

Narcotics Therapy Management Program Identifies potential misuse and fraud Healthcare costs for narcotics abuse are three times those for non-abusers. And with prescription drugs accounting for 25-30 percent9 of all drug abuse in the United States, CIGNA developed its Narcotics Therapy Management program to identify potential abusers and empower their physicians to pursue the most effective courses of therapeutic action.

The program focuses on narcotic analgesics, a leading prescription expense for many of our members. It integrates CIGNA medical and pharmacy data to identify possible abusers and fraud perpetrators. Then CIGNA reaches out to prescribing physicians with information that provides them with evidence and resources to engage members in productive dialogues.

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Cost Management Programs: Key driver to lowest net cost CIGNA’s Cost Management programs generate a generic dispensing rate that ranks among the highest in the industry, at approximately 60 percent. They provide total PMPM savings that range from $2.25 to $2.30.10 However, when it comes to the interplay between member choice and employer cost, different plan sponsors have different points of view. No sponsor, however, wants to compromise quality of care in the interest of savings.

That’s why CIGNA’s Cost Management programs are developed with the same clinical expertise that distinguishes our Outcome Improvement programs.

Save with Generics Lets you capture savings from a $46 billion opportunity occasioned by brand-name drugs coming off patent by 201011 Never has there been a greater opportunity than now to lower prescription drug costs than by encouraging the use of generic drugs among your employees. CIGNA educates, engages and incents members and physicians to try generics and preferred brands. With one of the highest generics utilization rates in the industry, CIGNA has proven its ability to lower your costs while maintaining high member satisfaction. Outreach programs include: • Physician: CIGNA targets physicians to show them how much their patients would save by using generic therapeutic alternatives and encourages them to write prescriptions for alternatives, when appropriate.

• Member: Within one month after he has filled a brand-name prescription, CIGNA corresponds with the member to educate him about generics and urge him to discuss these lower-cost alternatives with his physician.

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CIGNA Tel-Drug: Delivers cost OTC Programs Incents members to try lower-cost, over-the-counter alternatives Over-the-counter (OTC) programs identify members who stand to benefit from OTC alternatives to prescription drugs and offer them money-saving coupons for trying alternatives. Currently, programs are available for Prilosec OTC® and Alavert®.

Step Therapy Program Gradually encourages use of generics and lower-cost alternatives CIGNA’s Step Therapy program gradually encourages the use of generics in a way that reduces member disruption.

The program begins when a member requests a prescription for a brand-name drug that has generic therapeutic alternatives. Unlike many other pharmacy benefit plans, CIGNA fills the first prescription with a brand name if prescribed. Correspondence is sent to members and physicians about refilling with generics.

Physicians are given the opportunity to authorize a brand drug if necessary.

By offering members an initial grace period and the ability to fill a prescription for a brand-name drug and then educating them on the merits of generics, members are given ample time to transition to clinically-appropriate, lower-cost alternatives.

savings for members and clients

1) Employers save

Members save

Increased GDR

larger days’ supply

2) Increased adherence

through refill reminders and pharmacist consultations

3) Improved accuracy is 99.995% through automation

For healthier outcomes at an even lower cost…

Currently, CIGNA offers Step Therapy for anti-ulcer, hypertension, high cholesterol and allergic rhinitis medications.

. . . call CIGNA Tel-Drug, our state-of-the-art home delivery prescription drug program. With two locations (Pennsylvania and South Dakota), Tel-Drug provides fast, efficient service.

What does this mean to you?

Tel-Drug typically saves members the equivalent of a co-pay by ordering a 90-day supply of medication versus three refills at a local pharmacy.

Refills are processed the same day they’re ordered.

And accuracy is an astounding 99.995 percent, far higher than that of any retail pharmacy.

Cost Management programs don’t have to limit member choices. Our education-based programs provide members and their doctors with the information they need to determine whether they should fill brand-name prescriptions with generic therapeutic alternatives. We’re proud of the fact that we’ve helped members adhere to their therapy through equally effective, lower-cost options. And we’re equally proud that we’re helping plan sponsors reduce health trend while maintaining member choice.

Almost 30 percent of all CIGNA prescriptions are filled through Tel-Drug; and, increasingly, many of them are for generic alternatives, thanks to Tel-Drug’s education outreach programs that alert members about less costly but equally effective options to their brand-name medications.

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CIGNA Specialty Pharmacy: Balancing medication access to to deliver a Return On Health Specialty pharmacy is the fastest growth area of pharmacy healthcare. The Compound Annual Growth Rate for the 2003-2008 period is estimated to be 20 percent, with the 2008 CAGR forecasted to be $78 billion.12 The high cost of specialty drugs is becoming an issue for employers who are faced with per-patient costs potentially reaching $1 million annually.13 With a major increase expected in the number of biotech medications available and an aging population, total specialty drug costs could rise considerably higher.

CIGNA’s Specialty Pharmacy solutions balance your needs with those of your employees and their dependents so that costs are managed, access to specialty medications is made affordable and positive therapy outcomes are maximized.

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CIGNA’s integrated approach to managing specialty medications can help control your specialty pharmacy costs while improving member outcomes. Through integrated case management, CIGNA consolidates members’ medical, pharmacy, lab and behavioral healthcare to help members at risk of incurring high claims costs better manage their conditions. This ability to integrate case management with the delivery and coordination of specialty medications in real time allows clinical experts and trained support professionals to help improve medication adherence and promote healthier member outcomes.

Our industry-leading clinical capabilities allow us to go far beyond the adjudication and fulfillment of specialty medications to encompass how these medications are administered and the role they play in members’ overall therapy regimens. Better therapy management means less confusion and disruption of care, better health outcomes and lower plan costs. In the end, that means a better Return On Health.

CIGNA Pharmacy’s Financial Management and Service Model: Starts with a complete analysis of opportunities, behaviors and goals CIGNA offers numerous programs and cost structures from which you can design your pharmacy management plan.

The question is which combination of benefits and pricing offers the optimal solution for your business.

CIGNA provides the right balance of quality care while lowering health trend.

Just as CIGNA provides members with the educational tools they need to make informed decisions, we offer plan sponsors the ability to understand current employee behaviors and structure their plans to accommodate those behaviors and perhaps change them over time. For example, what’s your current employee generic utilization rate? Your formulary compliance rate? How much is your plan spending on the chronic conditions that typically constitute more than 50 percent of drug spend — asthma, depression and high cholesterol, to name but a few?

By understanding your employee claim patterns and demographics, you can design a plan that offers the maximum opportunity for improved employee health at the lowest net cost. And you can weigh this information against the cost and employee choice variables that run the flexibility spectrum from self-insured plans and step therapy to the variety of integrated health outcome programs discussed earlier.

What does this mean to you?

One design does not fit all plans. We analyze your employee demographics and claims history before recommending a design specifically structured to address the conditions most likely to influence your overall health trend. As one of America’s oldest and most respected insurance companies, CIGNA understands risk. What’s more, we help you minimize your risk by maximizing your Return On Health potential.

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CIGNA Pharmacy Management: Delivering ROH Through Clinical Integration

Whatever choices you make, however, you can be certain that CIGNA provides you with:

Total Transparency From a partner you can trust CIGNA welcomes the move toward transparency. Our approach has always been to maximize savings for clients and members while providing the most clinically appropriate drugs for members. Through aggressive contracting strategies, member and physician education and incentive programs, and clinical management, CIGNA provides a fully transparent approach to managing pharmacy benefits that you can count on.

CIGNA’s Pharmacy and Therapeutics Committee is charged with analyzing new drugs to determine their safety and efficacy versus other alternatives. The Committee is comprised primarily of leading physicians and pharmacists and focuses solely on clinical concerns when issuing its recommendations.

Our formulary practices are representative of our commitment to transparency in everything we do. That means an approach to client and member savings that does not rely on rebates. We are proud of the certification of transparency we have received from the Human Resources Policy Association, an organization comprised of senior human resource executives representing nearly every major industry group in the United States economy.

Comprehensive Service Empowers you to measure your ROH Your CIGNA Pharmacy Clinical Account Manager is dedicated to helping you define objectives for your plan, design it accordingly and track your progress over time.

In fact, the vast majority of our Account Managers are licensed pharmacists with an extensive background in benefits management and a keen understanding of how pharmacy benefits can be used to improve member health outcomes and decrease client cost.

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You can depend on your Account Manager to help you evaluate CIGNA’s quarterly and annual performance reports that provide in-depth views of plan activities.

You’ll gain important insights on: • What’s really driving your plan’s cost; • Which therapeutic conditions demand special focus; and

We think you should consider a plan that does.

• Where the opportunities to optimize utilization and adherence may be found.

Return On Health = CIGNA Pharmacy Management

The technology behind our reporting function is designed to capture and analyze the rich data available from our integrated approach to improving health trend. We combine pharmacy data with lab results, diagnoses, emergency room visits and other medical information to provide you with a total portrait of where you stand and what you have to do to achieve your members’ health and cost objectives.

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Is your current pharmacy benefit plan generating a Return On Health?

It’s a powerful formula that can be quantified. And as you would expect, it’s a formula that we can substantiate.

With roots that go back to 1792, CIGNA is one of America’s oldest and most respected employee benefit plan providers. Our heritage is insurance and our ability to manage risk prudently serves our clients well.

Member Communications that Educate, Engage and Empower

Because CIGNA assumes much of the risk inherent in pharmacy management and other healthcare plans, we are acutely aware of the need to minimize your risk as much as possible.

CIGNA’s clinical programs all feature extensive member outreach components that engage members at specific trigger points and motivate them to take positive action.

Central to our member communications efforts is myCIGNA.com, our secure member website that offers a wide variety of online tools to facilitate member decisions.

In an industry that sometimes produces commoditized programs, CIGNA stands out with its clinical focus and unique approach to controlling health trend. For more information, contact your CIGNA representative and find out how you can achieve a higher Return On HealthSM for your employees and your business.

myCIGNA.com provides members with access to their personal claims history, as well as an overview of the benefits to which their plan entitles them. Our Prescription Drug Price Comparison Tool enables members to: • Search for specific drugs and price them out at Tel-Drug or any of the more than 57,000 retail pharmacies in CIGNA’s nationwide network; • Order prescriptions and refills directly from CIGNA Tel-Drug; and • Determine whether a generic equivalent or other therapeutic alternative to the specified drug is available and, if so, compare pricing. myCIGNA.com also, offers money-saving coupons, with incentives for members to consider generics.

And educational alliances with well-known medical information providers enable quick reference to medication characteristics and comparisons.

F. Lichtenberg, “Are the Benefits of Newer Drugs Worth Their Cost?

Evidence from the 1996 MEPS.” Health Affairs. Sept/Oct 2001: 5:241-251.

2 The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2006 Annual Survey.

3 CIGNA Actuarial Sourcing and Underwriting.

4 CIGNA Best Total Results collateral piece, page 2.

5 “How Consumerism is Changing the Health Insurance Industry—Q&A with David Cordani.” Strategy + Business. March 27, 2007. www.strategy-business.com/li/leadingideas/li00019?tid=230&pg=all 6 National Council on Patient Information and Education. Newsvine Report: “Skipping Doses Could be Deadly. “ www.newsvine.com/_news/2007/07/30/867467 7 EW Boehm et al. Rx Adherence Hits the Ignorance Wall. Forrester.

April 2006.

8 “Patient Compliance: A Problem that Plagues the Healthcare Industry.”

Pharmacy Times. April 7, 2006.

9 DA Reiger, WE Narrow, DS Rae, et al. “The defacto US mental and addictive disorders service system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services.” Archives of General Psychiatry. 1993; 50:85-94.

10 CIGNA Commercial Book of Business as of 1/1/07.

11 Pharmacy Benefit Management Market Overview — 2007. (A BusIntel Report). KnowledgeSource. April 2007.

12 Citigroup Industry In-Depth Report on PBMs. May 10, 2007 13 “Specialty drugs to drive future health costs.” Benefit News.com. www.benefitnew.com/pfv.cfm?id=8064.

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Alavert is a registered trademark of Wyeth Consumer Healthcare and Prilosec OTC is a registered trademark of Proctor & Gamble.

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CIGNA Pharmacy Management CIGNA 900 Cottage Grove Road Hartford, CT 06152 www.CIGNA.com “CIGNA Pharmacy Management” is a registered service mark, and "Return on Health" is a service mark, of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries.

“CIGNA Pharmacy Management” refers to operating subsidiaries of CIGNA Corporation.

Products and services are provided by these operating subsidiaries and not by CIGNA Corporation.

These operating subsidiaries include Connecticut General Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation. © 2007 CIGNA Pharmacy Management. All rights reserved.

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