Exclusions and limitations for coverage 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 be medically necessary. If your plan provides coverage for certain preventive prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, the prescription may not be covered. Certain drugs may require prior authorization, or be subject to step therapy, quantity limits or other utilization management requirements. Plans generally do not provide coverage for the following under the pharmacy benefit, except as required by state or federal law, or by the terms of your specific plan: 9 • over-the-counter (OTC) medicines (those that do not require a prescription) except insulin unless state or federal law requires coverage of such medicines; • prescription medications or supplies for which there is a prescription or OTC therapeutic equivalent or therapeutic alternative;
fractions and medications used for travel prophylaxis; • replacement of prescription medications and related supplies due to loss or theft; • medications which are to be taken by or administered to a covered person while they are a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals; • prescriptions more than one year from the date of issue; or • coverage for prescription medication products for the amount dispensed (days’ supply) which is more than the applicable supply limit, or is less than any applicable supply minimum set forth in The Schedule, or which is more than the quantity limit(s) or dosage limit(s) set by the P&T Committee. • more than one prescription order or refill for a given prescription supply period for the same prescription medication product prescribed by one or more doctors and dispensed by one or more pharmacies. • prescription medication products dispensed outside the jurisdiction of the United States, except as required for emergency or urgent care treatment. In addition to the plan’s standard pharmacy exclusions, certain new FDA-approved medication products (including, but not limited to, medications, medical supplies or devices that are covered under standard pharmacy benefit plans) may not be covered for the first six months of market availability unless approved by Cigna Healthcare as medically necessary.
• doctor-administered injectable medications covered under the Plan’s medical benefit, unless otherwise covered under the Plan’s prescription drug list or approved by Cigna Healthcare; • implantable contraceptive devices covered under the Plan’s medical benefit; • medications that are not medically necessary; • experimental or investigational medications, including FDA-approved medications used for purposes other than those approved by the FDA unless the medication is recognized for the treatment of the particular indication; • medications that are not approved by the Food & Drug Administration (FDA); • prescription and non-prescription devices, supplies, and appliances other than those supplies specifically listed as covered; • medications used for fertility, 10 sexual dysfunction, cosmetic purposes, weight loss, smoking cessation, 10 or athletic enhancement; • prescription vitamins (other than prenatal vitamins) or dietary supplements unless state or federal law requires coverage of such products; • immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or
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