GM6000 855125 G Hcr Prevcoverage Zerodollar Ppaca Preventive V4
User Manual: GM6000
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2016 NO COST-SHARE PREVENTIVE MEDICATIONS by drug category At Cigna, your health and well-being is most important, and we want you to be at your 100% best. It’s good to take care of yourself. Getting the right preventive care services at the right time can help you stay healthy. Health care reform requires coverage of specific preventive medications with no patient cost-sharing The Patient Protection and Affordable Care Act (PPACA) requires that certain categories of drugs and other products be included in preventive care services coverage based on recommendations from the U.S. Preventive Services Task Force as well as the Institute of Medicine. These recommendations are meant to help prevent disease and meet women’s unique health care needs, and are updated periodically to reflect new advances in science and medicine. Religious exemptions to covering contraceptives PPACA allows certain employers to exclude coverage for contraceptive services due to religious beliefs. If you’re a woman with medical coverage though one of these employers, Cigna will let you know that your plan does not cover these medications. Where required by law, Cigna will offer to pay for your contraceptive services and specific medications at no additional cost to you if you choose. This coverage isn’t administered, funded by or connected in any way to your employer’s health coverage, and is private and confidential. Preventive medication coverage Your healthcare professional The following prescription medications (as well as certain over-the-counter medications) and products may be available to you with no cost-sharing (copay, coinsurance and/or deductible) depending on your plan. Check your plan materials or visit myCigna.com for more information. You can also use the Prescription Drug Price Quote tool on myCigna.com to compare prices at local retail pharmacies and Cigna Home Delivery PharmacySM. If you have questions, you can call customer service using the number on the back of your ID card, 24 hours a day, 365 days a year, and we’ll be happy to help. Talk with your doctor about choosing the medication or product that’s right for you. If your doctor feels a certain contraceptive product (on this list) or smoking cessation product (on this list) isn’t medically appropriate for you, have your doctor contact us to determine what other products (not on this list) may be available with no cost-sharing. For preventive medications (including over-the-counter medications) or products to be covered, you’ll need to get a prescription from your doctor. Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. 855125 g 08/15 This list represents the medications that Cigna administered plans will cover with no cost-sharing due to PPACA requirements. Please note: this list is subject to change. Aspirin Products Available to: Males: 45-79 years Females*: 55-79 years *Available for females of childbearing age at risk of preeclampsia during pregnancy Adult Low Dose Aspirin Adult Low Dose Aspirin EC Aspir EC 81 Aspirin 81 mg Aspir-Low Bayer Chewable Aspirin Children’s Aspirin Children’s Chewable Aspirin Ecotrin 81 mg Halfprin Low Dose Aspirin Low Dose Aspirin EC St. Joseph Aspirin Breast Cancer Prevention (Females) raloxifene tamoxifen Barrier Contraception Available to Females Conceptrol FC2 Female Condom Femcap Gynol II Options Conceptrol Vaginal Contraceptive Options Gynol II Vaginal Contraceptive Today Contraceptive Sponge VCF Vaginal Contraceptive Film VCF Vaginal Contraceptive Foam Wide Seal Diaphragm 60 Wide Seal Diaphragm 70 Wide Seal Diaphragm 75 Wide Seal Diaphragm 80 Wide Seal Diaphragm 85 Wide Seal Diaphragm 90 Wide Seal Diaphragm 95 Wide Seal Diaphragm 65 Emergency Contraception Available to Females Ella My Way Next Choice One Dose Take Action Hormonal Contraception^* Available to Females Altavera Alyacen 1/35 Alyacen 7/7/7 Amethia Amethia Lo Apri Aranelle Aubra Aviane Azurette Balziva Briellyn Camila Camrese Camrese Lo Caziant Chateal Cryselle-28 Cyclafem 1/35 Cyclafem 7/7/7 Dasetta 1/35 Dasetta 7/7/7 Daysee desogestrel/ethinyl estradiol drospirenone/ethinyl estradiol Elinest Emoquette Enpresse-28 Enskyce Errin Estarylla Falmina Generess Fe Gianvi Gildagia Gildess 1.5/30 Gildess 1/20 Gildess FE 1.5/30 Gildess FE 1/20 Heather Introvale Jencycla Jolessa Jolivette Junel 1.5/30 Junel 1/20 Junel FE 1.5/30 Junel FE 1/20 Kariva Kurvelo Larin 1/20 Larin FE 1.5/30 Larin FE 1/20 Leena Lessina Levonest levonorgestrel levonorgestrel and ethinyl estradiol levonorgestrel/ehtinyl estradiolL Levora 0.15/30-28 Loryna Low-Ogestrel Lutera Lyza Marlissa medroxyprogesterone acetate 150 MG/ML Microgestin 1.5/30 Microgestin 1/20 Microgestin FE Microgestin FE 1.5/30 Mono-Linyah Mononessa Myzilra Necon 0.5/35-28 Necon 1/35 Necon 7/7/7 Nora-Be norethindrone norgestimate/ethinyl estradiol norgestrel/ethinyl estradiol Nortrel 0.5/35 (28) Nortrel 1/35 Nortrel 7/7/7 Nuvaring Ocella Orsythia Philith Pimtrea Pirmella 1/35 Pirmella 7/7/7 Portia-28 Previfem Quasense Reclipsen Sprintec 28 Sronyx Syeda Tilia FE Tri-Estarylla Tri-Legest FE Tri-Linyah Trinessa Tri-Previfem Tri-Sprintec Trivora-28 Velivet Vestura Viorele Vyfemla Wera Wymzya FE Xulane Zarah Zenchent Zenchent FE Zeosa Zovia 1/35E ^ If your doctor feels these medications are medically inappropriate, have them call us. Brands may be available with no cost-sharing to you. * Generic hormonal contraceptives are available at no cost-sharing to you, even though they may not be listed here. Fall Prevention / Vitamin D Supplementation * a dults 65 years of age and older to prevent falls Children’s Replesta Children’s Vitamin D D3 Dots D3-2000 D3-50 Decara Delta D3 Dialyte Vitamin D3 Max Dialyvite Vitamin D D-Vi-Sol D-Vita Just D Kids Vitamin D3 Maximum D3 Optimal D3 Replesta Replesta NX Thera-D Vitamin D Vitamin D3 Vitamin D-400 Folic Acid Supplementation Available to Females (Only products containing 0.4 mg-0.8 mg of folic acid are included) Classic Prenatal Daily Prenatal Folic Acid KPN Maxinate One Daily Prenatal P-D Natal Plus With Folic Acid Prenatal Prenatal Formula Prenatal Multi + DHA Prenatal OTC Prenatal Vitamins Preque 10 Right Step Prenatal Vitamins Urosex Pediatric Multivitamins (containing fluoride and fluoride supplements) Available to Males and Females: six months six years Escavite Escavite D Floriva Fluorabon Fluor-a-day Fluoride Fluoritab Flura-drops Ludent Fluoride Multivitamin and Fluoride Multivitamins with Fluoride Multivitamins with Fluoride-Iron MVC-Fluoride MyKidz Iron FL Poly-VI-Flor Poly-VI-Flor with Iron Polyvitamins with Fluoride Quflora Sodium Fluoride Texavite LQ Triple Vitamin w/Fluoride Tri-VI-Flor Tri-vitamin with Fluoride Tri-vite w/Fluoride Tri-vite w/Fluoride Iron Vitamins A,C,D & Fluoride Pediatric Iron-Containing Products/Fluoride Supplementation Available to Males and Females: six months - 12 months IronUp Multivitamins with Fluoride-Iron MyKidz Iron 10 Novaferrum Wee Care Smoking Cessation^* Quantity Limitations apply. bupropion (generic for Zyban®) May also be known as: Bupropion HCl SR 12HR Buproban nicotine replacement therapy* patches, gum and lozenges May also be known as: Commit Nicoderm Nicorelief Nicorette Nicotine Polacrilex Gum Nicotine Polacrilex Lozenge Nicotine TD Patch 24HR Nicotine Transdermal System ^ If your doctor feels these medications are medically inappropriate, have them call us. Brands may be available with no costsharing to you. * Generic nicotine replacement therapy (so called “store-brands”) are available at no cost-sharing to you, even though they may not be listed here. Children’s Ferrous Sulfate Children’s Iron Fer-In-Sol Fer-Iron Ferrous Sulfate Flura Drops Icar All health benefit plans and insurance policies contain exclusions and limitations. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill or purchase the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company (CGLIC), Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc., and Cigna HealthCare of Texas, Inc. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. OK policy forms: HP-APP-1 et al (CHLIC), GM6000 C1 et al (CGLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 855125 g 08/15 © 2016 Cigna. Some content provided under license.
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