Step 1 of 2: Medical profile   Gender Date of birth Height Weight Smoker? Applicant* M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Spouse -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children 0  1 2 3 4 5 6         Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Currently Insured?* Yes No Have conditions?* yes   no Please specify  Take medications?* yes   no Please specify  Step 2 of 2: Tell us about yourself First Name* Last Name* Address* City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Day Phone* Evening Phone* Contact Time* Morning Afternoon Evening Email* By submitting this form, you agree to be legally bound to, and abide by, the Privacy Policy.

Pharmacy Plans

Aetna's Three-Tier/Open Formulary Plan provides the option of brand-name drugs and their less expensive generic equivalents. Your employees will pay a lower copay for generic drugs, which meet the same FDA standards for safety and effectiveness as brand-name drugs.

TIER 3- HIGHEST COPAY	Covered brand-name drugs NOT on the formulary
TIER 2- MIDDLE COPAY	Covered brand-name drugs on the formulary
TIER 1- LOWEST COPAY	Covered generic drugs on the formulary

Your employees will pay a higher copay for brand-name drugs on the formulary. The highest copay applies to brand-name drugs that are not included on the formulary.

CIGNA

Cigna's Indemnity Pharmacy program gives your employees the advantage of cost-savings and the freedom of traditional indemnity coverage. Members can visit any pharmacy and pay the retail cost of their prescriptions, or benefit from the reduced rates when using their prescription drug card to at any of the program's 53,000 participating pharmacies nationwide.

Cigna's Managed Pharmacy programs are offered with the HMO and POS plans, and provides local access to more than 48,500 participating national and independent pharmacies. Typically, the employer offers either a Two- or Three-Tier Prescription Drug Program and sets the copayment amounts.

• Two-Tier Prescription Drug Program- Two-Tier Formulary is a list of FDA-approved, brand-name and generic prescription drugs. Most of the prescriptions filled will be for drugs already on the list. The benefit plan covers the cost of formulary medications, minus any applicable copayments.
• Three-Tier Prescription Drug Program- The lowest copayment level is the generic drugs (first tier). Preferred brand drugs (second tier) do not have a generic equivalent and a slightly higher copay applies. Non-Preferred brand drugs (third tier) have less costly generic equivalents and the highest copayment applies, which is still cheaper than the retail cost.

UNITEDHEALTHCARE

Through myuhc.com, your employees are able to:

• Visit the online pharmacy
• Access pharmacacutical information
• Ask questions and get information about the safe use of prescription drugs
• Find information about their particular benefit plan, their prescription history and even place and refill orders online and set up refill reminders

Order Prescriptions Online:

Your employees have the option to order prescriptions online but can also fill their prescriptions at any of the pharmacies in the national network. There is also an online pharmacy directory to help you to find a pharmacy close by.

Payment Program:

The three-tier payment program offers distinct copayment levels for brand-name and generic drugs. The lowest copayment level is for generic drugs, a higher copayment for brand-name drugs on the Preferred Drug List, and the highest copayment for brand-name drugs not on the formulary list.

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