1. Subject to the terms of your plan’s pharmacy coverage, certain drugs and products may be covered at 100%. Your doctor is required to give you a prescription, including for those that are available over the counter (unless your state does not require a prescription for OTC products), for them to be covered under your Pharmacy benefit. Cost sharing may be applied for brand- name products where generic alternatives are available. Please refer to Cigna’s“No Cost Preventive Medications by Drug Category”Guide for information on drugs and products with no out-of-pocket cost. 2. Subject to the terms of your plan’s medical coverage, home blood pressure monitoring supplies, breast-feeding equipment rental and supplies may be covered at the preventive level. Your doctor is required to provide a prescription for home blood pressure monitoring equipment and some breast pump equipment. 3.Examples include oral contraceptives; diaphragms; hormonal injections and contraceptive supplies (spermicide, condoms); emergency contraception. 4. Subject to the terms of your plan’s medical coverage, contraceptive products and services such as some types of IUD’s, implants and sterilization procedures may be covered at the preventive level. Check your plan materials for details about your specific medical plan. These preventive health services are based on recommendations from the U.S. Preventive Services Task Force (A and B recommendations), the Advisory Committee on Immunization Practices (ACIP) for immunizations, the American Academy of Pediatrics’Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care, the Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children and, with respect to women, evidence-informed preventive care and screening guidelines supported by the Health Resources and Services Administration. For additional information on immunizations, visit the immunization schedule section of www.cdc.gov . This document is a general guide. Always discuss your particular preventive care needs with your doctor. Some plans choose to supplement the preventive care services listed above with a few additional services, such as other common laboratory panel tests. When delivered during a preventive care visit, these services also may be covered at the preventive level. Exclusions This document provides highlights of preventive care coverage generally. Some preventive services may not be covered under your plan. For example, immunizations for travel are generally not covered. Other non-covered services/supplies may include any service or device that is not medically necessary or services/supplies that are unproven (experimental or investigational). For the specific coverage terms of your plan, refer to the Evidence of Coverage, Summary Plan Description or Insurance Certificate. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna Healthcare representative. All Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., 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. (CHC-TN), and Cigna HealthCare of Texas, Inc. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, OR - HP-POL3812-13 TN - HP-POL43/HC- CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN). The Cigna Healthcare name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 855050 s 05/24 © 2024 Cigna Healthcare. Some content provided under license.
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