If you or any one of your Family Members, while covered for these benefits, incurs expenses for charges made by a Participating Pharmacy for Prescription Drugs for an Injury or a Sickness, Cigna will pay that portion of the expense remaining after you or your Family Member has paid the required Copayment shown in the In-Network Benefits Schedule.
Covered expenses will include only Medically Necessary Prescription Drugs and Related Supplies.
Covered charges will include those Prescription Drugs lawfully dispensed upon the written prescription of a Participating Physician or licensed Dentist, at a Participating Pharmacy. Coverage for Prescription Drugs is subject to a Co-payment. The Co-payment amount will never exceed the cost of the drug.
Benefits include coverage of insulin, insulin needles and syringes, glucose test strips and lancets.
If you or any one of your Family Members, while covered for these benefits, is issued a Prescription for a Prescription Drug as part of the rendering of Emergency Services and the prescription cannot reasonably be filled by a Participating Pharmacy, such prescription will be covered as if filled by a Participating Pharmacy.
Each prescription drug order or refill will be limited as follows:
- Up to a consecutive thirty (30)-day supply at a Participating Retail Pharmacy, unless limited by the drug manufacturer's packaging;
- Up to a consecutive ninety (90)-day supply at a Participating Mail-Order Pharmacy, unless limited by the drug manufacturer's packaging;
- If two or more prescriptions or refills are dispensed at the same time a Co-payment must be paid for each prescription order or refill;
- When a treatment regimen contains more than one type of drug and the drugs are packaged together for the convenience of the covered person, a coinsurance will apply to each type of drug; or
- To a dosage limit as determined by the Cigna HealthCare Pharmacy and Therapeutics Committee.
- For maintenance medications, as determined by OAPIN, and generally drugs taken on a regular basis to treat ongoing conditions, OAPIN will provide coverage for two fills at a retail pharmacy. For additional refills, these maintenance medications will only be covered when members use Cigna Home Delivery Pharmacy.
- OAPIN will also apply, step therapy (prior authorization program) rules for certain medications as identified by OAPIN. Individuals affected by these rules will be contacted directly by Cigna.
- When both a generic and a name brand drug are available, and the participant receives the name brand drug, the member is responsible for the applicable copay and the difference in cost between the name brand drug and the generic drug.
No payment will be made for the following expenses:
- Drugs or medications available over-the-counter for which state or federal laws do not require a prescription or medication that is equivalent (in strength, regardless of form) to an over the counter drug or medication.
- Injectable drugs or medicines used to treat diabetes, acute migraine headaches, anaphylactic reactions, vitamin deficiencies and injectables used for anticoagulation. However, upon prior authorization by Cigna, injectable drugs may be covered subject to the required Copayment;
- Any drugs that are labeled as experimental or investigational.
- Food and Drug Administration (FDA) approved prescription 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 Pharmacopeia 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.
- Prescription and nonprescription supplies (such as ostomy supplies), devices, and appliances other than syringes used in conjunction with injectable medications and glucose test strips.
- Prescription drugs or medications used for treatment of sexual dysfunction, including, but not limited to erectile dysfunction, delayed ejaculation, anorgasmy and decreased libido.
- Prescription vitamins (other than prenatal vitamins and/or as required by applicable law), dietary supplements and fluoride products, except for formulas prescribed for infants (less than one year of age) by a Participating Physician as necessary for the treatment of phenylketonuria or similar inheritable diseases that may cause or result in mental or physical disability.
- Prescription drugs used for cosmetic purposes such as: drugs used to reduce wrinkles, drugs to promote hair growth, drugs used to control perspiration and fade cream products.
- Diet pills or appetite suppressants (anorectics).
- Prescription smoking cessation products above the dosage limit as determined by Cigna HealthCare Pharmacy and Therapeutics Committee.
- Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis, with the exception of malaria prophylactic drugs. Malaria prophylactic drugs are covered.
- Replacement of Prescription Drugs due to loss or theft except as part of disaster relief efforts.
- Medications used to enhance athletic performance.
- Medications which are to be taken by or administered to a participant while the participant is a patient in a licensed Hospital, skilled nursing facility, rest home or similar institution with a facility dispensing pharmaceuticals on it premises.
- Prescriptions more than one year from the original date of issue.
- A 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 Pharmacy and Therapeutics Committee (such as antihistamines).
- All newly FDA approved drugs, prior to review by the Pharmacy and Therapeutics committee.
- Norplant and other implantable contraceptive products.
- Any procedure, treatment or other type of coverage prohibited under federal, state, local or other applicable law.
No payment will be made for expenses incurred for you or any one of your Family Members:
- For or in connection with an Injury arising out of, or in the course of, any employment for wage or profit.
- For or in connection with a Sickness which is covered under any workers' compensation or similar law.
- For charges made by a Hospital owned or operated by or which provides care or performs services for the United States Government, if such charges are directly related to a military-service-connected Sickness or Injury.
- To the extent that payment is unlawful where the person resides when the expenses are incurred;
- For charges which the person is not legally required to pay.
- For charges for unnecessary care, treatment or surgery.
- For or in connection with Custodial Services, education or training.
- To the extent that you or any one of your Family Members is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid.
- For experimental drugs or substances not approved by the Food and Drug Administration, or for drugs labeled: "Caution - limited by federal law to investigational use".
- For or in connection with experimental procedures or treatment methods not approved by the American Medical Association or the appropriate medical specialty society.
- For charges made by a Physician for or in connection with surgery which exceed the following maximum when two or more surgical procedures are performed at one time: the maximum amount payable will be the amount otherwise payable for the most expensive procedure, and 1/2 of the amount otherwise payable for all other surgical procedures.
- For charges made by an assistant surgeon / co-surgeons that does not meet: a) the scheduled surgery being in a participating facility and b) participating primary surgeon.
- For charges made for or in connection with the purchase or replacement of contact lenses except as specifically provided under "Exclusive Provider Medical Benefits"; however, the purchase of the first pair of contact lenses that follows cataract surgery will be covered.
- For charges made for or in connection with routine refractions, eye exercises and for surgical treatment for the correction of a refractive error, including radial keratotomy, when eyeglasses or contact lenses may be worn.
- For charges for supplies, care, treatment or surgery which are not considered essential for the necessary care and treatment of an Injury or Sickness, as determined by Cigna.
- For charges made for or in connection with tired, weak or strained feet for which treatment consists of routine footcare, including but not limited to, the removal of calluses and corns or the trimming of nails unless medically necessary.
- For charges made by any covered provider who is a member of your family or your Eligible Family Member's family.
- No payment will be made for expenses incurred for you or any one of your Family Members to the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with:
- A "no-fault" insurance law; or
- An uninsured motorist insurance law.
- Cigna will take into account any adjustment option chosen under such part by you or any one of your Family Members.
- For charges which would not have been made if the person had no insurance;
- To the extent that you or any one of your Family Members is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid;
- For Experimental, Investigational or Unproven Services which are medical, surgical, psychiatric, related to substance use disorder or other healthcare technologies, supplies, treatments, procedures, drug therapies, or devices that are determined by Cigna , to be:
- ·not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopeia 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 journal; or
- the subject of review or approval by an Institutional Review Board for the proposed use; or
- the subject of an ongoing clinical trial that meets the definition of a phase I, II, or III Clinical Trial as set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight; or
- ·not demonstrated, through existing peer-reviewed literature, to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.
- For expenses incurred outside the United States or Canada, unless you or your Family Member is a U.S. or Canadian resident and the charges are incurred while traveling on business or for pleasure.
- For non-medical ancillary services, including but not limited to, vocational rehabilitation, behavioral training, sleep therapy, employment counseling, driving safety and services, training, custodial care, or educational therapy for learning, intellectual or developmental disabilities.
- For medical treatment when payment is denied by a Primary Group Health Plan because treatment was received from a non-participating provider;
- For charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan.
- For medical and Hospital care and costs for the infant child of an Eligible Family Member, unless that infant child is otherwise eligible under this Cigna Option.
Anything not specifically listed as included in “Covered expenses and limitations” section, is excluded.