CIGNA Price Comparison Report
Available Through
You Pay/Plan Pays
Astelin SPR 137MCG
RITE AID PHARMACY 06413 you pay: $30.00/month
you pay: $30.00/month
you pay: $30.00/month
you pay: $20.00/month *
save $120.00/year
*You must purchase a 90-day supply (your cost $60.00) to get this price.
Please note that prices are not guaranteed, nor is the display of a price at the time you fill your prescription at the pharmacy and pricing at individual pharmacies may vary. Coverage and pricing terms are subject to change. Your pharmacy may offer a special sale price on a specific medication whichmay be less than the price displayed here. Please consult your pharmacy.
Your doctor's instructions on how to take a medication, state and federal dispensing guidelines, or how a medication is packaged may impact the quantityand/or days supply that you can receive from a pharmacy, and therefore, may impact pricing. Data provided is based upon current benefit informationsupplied by your health plan. Please consult your health plan for complete information. This information is for the exclusive use of CIGNA Pharmacymembers and is intended to be used for drug price comparisons under the member's plan. This information is not intended to be used for making medicaldecisions. Please consult with your doctor on medication choices that are specific to your condition or treatment. 12/18/2009 7:43:36 AM (Pacific Time) Physician Visit Checklist

When you visit your doctor, it is important to provide information about medicines
you are already taking. It is equally important to ask questions about new
medications and any changes in your condition, so that you get all of the
information needed to use your medications appropriately.
Use this form as you prepare for your next doctor visit. It will help ensure that
you get your questions answered. You may also want to keep a copy of the form with
you in case of emergency.
Prescription medications you are taking

Over-the-counter medications you are taking

Home remedies and supplements you are taking

Potential questions for your doctor:

1. What can these medications do for me? 2. Can something in my family history impact the medications prescribed? 3. What are possible side-effects or risks from taking these medications? 4. Are there any special restrictions on use that I need to be aware of? 5. Are any medications, over-the-counter drugs, or herbal remedies restricted while taking these medications? Food or drink restrictions? 6. Will this medication interact with anything I am currently taking? 7. Are there any alternatives to the medications you have prescribed for me today (drug or non-drug i.e. diet, exercise)? 8. What should I know about special handling or the shelf-life for these 9. Are any tests or follow-up appointments needed in conjunction with these 10. What do my family members needed to know regarding my use of these Please complete this form for NEW and REFILL prescription
medication. You can also order refills online at myCIGNA.com.
Print all information clearly as shown in the sample belowusing BLUE or BLACK ink.
Fill in the applicable ovals completely ( Step 1: Insurance Cardholder Information Complete if above has changed or appears blank e-mail ________________________________________________ Refrigerated shipments will be expedited at no additional cost. You are responsible for the cost of SPECIAL SHIPPING whichexpedites carrier delivery time only. Order processing is not affected by SPECIAL SHIPPING. These costs may be subject tochange by carrier without prior notification and may vary depending on weight and zone.
Please make check or money order payable to CIGNA Tel-Drug.
Total payment enclosed (excluding credit card payment): I authorize CIGNA Tel-Drug to bill my credit card. I understand that my credit card will be billed the following amounts in effect at the time my order is filled: any applicable copayment(s),coinsurance and/or deductible(s), payments due for any medications not covered under mybenefit plan, plus any special shipping costs. Step 4: Allergies & Health Conditions Complete this section every time Allergies
Health Conditions
If no allergies are selected, for new customers this indicates noknown allergies and for existing customers this indicates no changefrom information provided to CIGNA Tel-Drug previously.
M M / D D / Y Y
M M / D D / Y Y
M M / D D / Y Y
M M / D D / Y Y
Please write the person’s name and list their other allergies and/or other conditions referenced above: Affix Label Here
Affix Label Here
Print Prescription Number Here
Print Prescription Number Here
Drug Name _________________________
Drug Name _________________________
Affix Label Here
Affix Label Here
Print Prescription Number Here
Print Prescription Number Here
Drug Name _________________________
Drug Name _________________________
Remember to enclose the original prescription(s) from your prescriber(s).
You can call us at 1.800.Tel.Drug (835.3784) or visit us at myCIGNA.com. You can also write to us or mail this order form to CIGNA Tel-Drug, PO Box 1019, Horsham PA 19044.
“CIGNA” and “CIGNA HealthCare” refer to various 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. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. In Arizona, HMO plans are offered by CIGNA HealthCare of Arizona, Inc. In California, HMO plans are offered by CIGNA HealthCare of California, Inc. In Connecticut, HMO plans are offered by CIGNA HealthCare of Connecticut, Inc. In Virginia, HMO plans are offered by CIGNA HealthCare Mid-Atlantic, Inc. In North Carolina, HMO plans are offered by CIGNA HealthCare of North Carolina, Inc. All other medical plans in these states are insured or administered by Connecticut General Life Insurance Company. “CIGNA Tel-Drug” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C.

Source: ftp://cpe-76-168-180-57.socal.res.rr.com/AiDisk_a1/Scanned%20files/Records%20Scanned%202009/Medical/Cigna%20Astelin%20prescription%20cost%202009-12-18.pdf


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