GM6000 855125 G Hcr Prevcoverage Zerodollar Ppaca Preventive V4
User Manual: GM6000
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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.
2016 NO COST-SHARE
PREVENTIVE MEDICATIONS
by drug category
Health care reform requires coverage of
specific preventive medications with no
patient cost-sharing
The Patient Protection and Aordable 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.
Preventive medication coverage
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.
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 oer 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.
Your healthcare professional
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
* adults 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
Children’s Ferrous Sulfate
Children’s Iron
Fer-In-Sol
Fer-Iron
Ferrous Sulfate
Flura Drops
Icar
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 cost-
sharing 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.
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.
