Covered expenses and limitations

Covered expenses and limitations for the ExxonMobil Retiree Medical HMO - Cigna OAPIN Plan

Covered expenses

The term Covered Expenses means the expenses incurred by or on behalf of a covered person for the charges listed below. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician and are essential for the necessary care and treatment of an Injury or Sickness. For expenses incurred for such charges to be considered Covered Expenses, the services or supplies provided must be Medically Necessary.

No Cigna OAPIN Option benefits are payable unless the services or supplies are Covered Expenses recommended by and received from, or approved by, Participating Providers and are authorized by the person's Primary Care Physician and the Provider Organization, except in the case of Emergency Services. For Emergency Services from non-participating providers, participants must submit a claim no later than 60 days after the first Emergency Service is provided or as soon as reasonably possible. The claim should contain an itemized statement of treatment, expenses, and diagnosis. In the case of mental illness or substance abuse treatment, other than Hospital Confinement solely for detoxification, authorization by the Primary Care Physician will be waived.

  • Charges made by a Hospital, on its own behalf, for Bed and Board and other Necessary Services and Supplies; except that for any day of Hospital Confinement, Covered Expenses will not include that portion of charges for Bed and Board which is more than the Bed and Board Daily Limit shown in the In-Network Co-Pay Schedule.
  • Charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided.
  • Charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient.
  • Charges made by a Free-standing Surgical Facility, on its own behalf, for medical care and treatment.
  • Charges made for infertility Treatment for testing, counseling and surgical treatment, but limited to procedures for correction of infertility. [In-vitro Fertilization, Artificial Insemination, GIFT (Gamete Intrafallopian Transfer), ZIFT (Zygote Intrafallopian Transfer), etc. are excluded.]
  • Charges made by a Skilled Nursing Facility, on its own behalf, for medical care and treatment; except that for any day of Skilled Nursing Facility confinement, Covered Expenses will not include that portion which is more than the Skilled Nursing Facility Limit shown in the In-Network Co-Pay Schedule; nor will benefits be payable for more than the maximum number of days shown in the In-Network Co-Pay Schedule. Benefits for Rehabilitative Hospitals and Sub-Acute Facilities are also included.
  • Charges made by a facility licensed to furnish mental health services, on its own behalf, for care and treatment of mental illness provided on an inpatient or outpatient basis.
  • Charges made by a facility licensed to furnish treatment of alcohol and drug abuse, on its own behalf, for care and treatment provided on an inpatient or outpatient basis.
  • Charges made by a Physician or a Psychologist for professional services.
  • Charges made by a Nurse, other than a member of your family or your Eligible Family Member's family, for professional services.
  • Charges made for Emergency Services and Urgent Care.
  • Charges made for anesthetics and their administration; diagnostic x-ray and laboratory examinations; x-ray, radium, and radioactive isotope treatment; chemotherapy; blood transfusions; oxygen and other gases and their administration; formulas for PKU, Maple Disease, Histidinemia or Homocystinuria; and therapy provided by a licensed physical, occupational or speech therapist.
  • Charges made for the purchase or rental of Durable Medical Equipment that is ordered or prescribed by a Physician and provided by a vendor approved by Cigna for use outside a Hospital or Other Health Care facility. Coverage for repair, replacement or duplicate equipment is provided only when required due to anatomical change and/or reasonable wear and tear. All maintenance and repairs that result from misuse are your responsibility. Durable Medical Equipment is defined as items which are designed for and able to withstand repeated use by more than one person; customarily serve a medical purpose; generally are not useful in the absence of Injury or Sickness; are appropriate for use in the home; and are not disposable. Such equipment includes, but is not limited to, crutches, hospital beds, wheel chairs, and dialysis machines.
  • Durable Medical Equipment items not covered, include but are not limited to those listed below.
  • Bed related items: bed trays, over the bed tables, bed wedges, custom bedroom equipment, non-power mattresses, pillows, posturepedic mattresses, low air mattresses (powered), alternating pressure mattresses.
  • Bath related items: bath lifts, non-portable whirlpool, bathtub rails, toilet rails, raised toilet seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, spas.
  • Chairs, Lifts and Standing Devices: computerized or gyroscopic mobility systems, roll about chairs, geri chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts (mechanical or motorized - manual hydraulic lifts are covered if the patient is two-person transfer), vitrectomy chairs, auto tilt chairs and fixtures to real property (ceiling lifts, wheelchair ramps, automobile lifts customizations).
  • Air quality items: room humidifiers, vaporizers, air purifiers, electrostatic machines.
  • Blood/injection related items: blood pressure cuffs, centrifuges, nova pens, needle-less injectors.
  • Pumps: back packs for portable pumps.
  • Other equipment: heat lamps, heating pads, cryo-units, ultraviolet cabinets, sheepskin pads and boots, postural drainage board, AC/DC adapters, Enuresis alarms, magnetic equipment, scales (baby and adult), stair gliders, elevators, saunas, exercise equipment, diathermy machines.
  • Charges made for or in connection with approved organ transplant services, including immunosuppressive medication; organ procurement costs; and donor's medical costs. The amount payable for donor's medical costs will be reduced by the amount payable for those costs from any other plan. Certain transplants will not be covered based on General Limitations. Contact Cigna before you incur any such costs.
  • Charges for the purchase, maintenance or repair of internal prosthetic medical appliances consisting of permanent or temporary internal aids and supports for defective body parts; specifically intraocular lenses, artificial heart valves, cardiac pacemakers, artificial joints, intrauterine devices and other surgical materials such as screw nails sutures, and wire mesh; excluding all other prostheses.
  • Charges for external breast prostheses incidental to a mastectomy (the Co-payments and Maximums for external prostheses do not apply to breast prostheses).
  • Charges made for the initial purchase and fitting of external prosthetic devices ordered or prescribed by a Physician which are to be used as replacements or substitutes for missing body parts and are necessary for the alleviation or correction of Sickness, Injury or congenital defect. External prosthetic devices shall include:
  • Basic limb prosthetics; terminal devices such as hands or hooks; braces and splints; non-foot orthoses. Only the following nonfoot orthoses are covered: (a) rigid and semirigid custom fabricated orthoses, (b) semirigid prefabricated and flexible orthoses; and (c) rigid prefabricated orthoses including preparation, fitting and basic additions, such as bars and joints.
  • Custom foot orthotic. Custom foot orthotics are only covered as follows:
  • For covered persons with impaired peripheral sensation and/or altered peripheral circulation (e.g. diabetic neuropathy and peripheral vascular disease).
  • When the foot orthotic is an integral part of a leg brace and it is necessary for the proper functioning of the brace.
  • When the foot orthotic is for use as a replacement or substitute for a missing part of the foot (e.g. amputation) and is necessary for the alleviation or correction of illness, injury, or congenital defect.
  • For covered persons with neurologic or neuromuscular condition (e.g. cerebral palsy, hemiplegia, spina bifida) producing spasticity, malalignment, or pathological positioning of the foot and there is reasonable expectation of improvement.
  • The following are specifically excluded:
  • External power enhancements or power controls for prosthetic limbs and terminal devices;
  • Orthotic shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers; and
  • Orthoses primarily used for cosmetic rather than functional reasons.
  • Replacement and repair of external prosthetic appliances is covered only when required due to reasonable wear and tear and/or anatomical change. All maintenance and repairs that result from the covered person's misuse are the covered person's responsibility.
  • Charges made for Home Health Care Services when you;  (a) require skilled care;  (b) are unable to obtain the required care as an ambulatory outpatient; and (c) do not require confinement in a Hospital or Other Health Care Facility. Home Health Care Services are provided only if Cigna has determined that the home is a medically appropriate setting. If you are a minor or an adult who is dependent upon others for non-skilled care (e.g., bathing, eating, toileting), Home Health Services will only be provided for you during times when there is a family member or care giver present in the home to meet your non-skilled care needs. Home Health Services are those skilled health care services that can be provided during visits by Other Health Care Professionals. The services of a home health aide are covered when rendered in direct support of skilled health care services provided by Other Health Professionals. A visit is defined as a period of 2 hours or less. Home Health Services are subject to a maximum of 16 hours in total per day. Necessary consumable medical supplies and home infusion therapy administered or used by Other Health Professionals in providing Home Health Services are covered. Home Health Services do not include services by a person who is a member of your family or your Eligible Family Member's family or who normally resides in your house or your Eligible Family Member's house even if that person is an Other Health Professional. Physical, occupational, and other Short-Term Rehabilitative Therapy services provided in the home are not subject to the Home Health Services benefit limitations in the Schedule, but are subject to the benefit limitations described under Short-Term Rehabilitative Therapy Maximum shown in the In-Network Co-Pay Schedule.
  • Covered Expenses do not include charges made by a Home Health Care Agency for: (a) care or treatment which is not stated in the Home Health Care Plan; (b) the services of a person who is a member of your family or your Eligible Family Member's family or who normally lives in your home or your Eligible Family Member's home; or (c) a period when a person is not under the continuing care of a Physician.
  • Charges made for varicose veins surgery when medically necessary.
  • Charges made for you or a covered family member who has been diagnosed as having six months or fewer to live, due to Terminal Illness, for the following Hospice Care Services provided under a Hospice Care Program: (a) by a Hospice Facility for Bed and Board and Services and Supplies, except that, for any day of confinement in a private room, Covered Expenses will not include that portion of charges which is more than the Hospice Bed and Board Limit shown in the In-Network Co-Pay Schedule; (b) by a Hospice Facility for services provided on an outpatient basis; (c) by a Physician for professional services; (d) by a Psychologist, social worker, family counselor or ordained minister for individual and family counseling, including bereavement counseling within one year after the person's death; (e) for pain relief treatment, including drugs, medicines and medical supplies; (f) by a Home Health Care Agency for: part-time or intermittent nursing care by or under the supervision of a Nurse; or part-time or intermittent services of a Home Health Aide; (g) physical, occupational and speech therapy; and (h) medical supplies; drugs and medicines lawfully dispensed only on the written prescription of a Physician; and laboratory services; but only to the extent such charges would have been payable under the Cigna OAPIN Option if the person had remained or been Confined in a Hospital or Hospice Facility.
  • The following charges for Hospice Care Services are not included as Covered Expenses:
  • For the services of a person who is a member of your family or your Eligible Family Member's family or who normally resides in your house or your Eligible Family Member's house;
  • For any period when you or your Eligible Family Member is not under the care of a Physician;
  • For services or supplies not listed in the Hospice Care Program;
  • For any curative or life-prolonging procedures;
  • To the extent that any other benefits are payable for those expenses under the Cigna OAPIN Option;
  • For services or supplies that are primarily to aid you or your Eligible Family Member in daily living;
  • For more than three bereavement counseling sessions;
  • For services for respite care; or
  • For nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals.

Charges made for Mental Health and Substance Abuse Services:

  • Mental Health Services are services that are required to treat a disorder that impairs the behavior, emotional reaction or thought processes. In determining benefits payable, charges made for the treatment of any physiological conditions related to Mental Health will not be considered to be charges made for treatment of Mental Health.
  • Substance Abuse is defined as the psychological or physical dependence on alcohol or other mind-altering drugs requiring diagnosis, care, and treatment. To determine benefits payable, charges made for the treatment of any physiological conditions related to rehabilitation services for alcohol or drug abuse or addiction will not be considered to be charges made for treatment of Substance Abuse.
  • Inpatient Mental Health Services are services provided by a facility designated for the treatment and evaluation of Mental Illness.  In lieu of hospitalization and upon authorization by Cigna, coverage can be provided in a participating Psychiatric Day Treatment Center, Crisis Stabilization Unit, or Residential Treatment Center for Children and Adolescents.
  • Outpatient Mental Health Services are services of participating providers qualified to treat Mental Illness on an outpatient basis for treatment of conditions such as: anxiety or depression interfering with daily functioning; emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; emotional reactions associated with marital problems or divorce; child/adolescent problems of conduct or poor impulse control; affective disorders; suicidal or homicidal threats or acts; eating disorders; acute exacerbation of chronic mental illness (crisis intervention and relapse prevention). Coverage will also be provided for outpatient testing and assessment as authorized.
  • Adjunctive Group Therapy can be utilized for treatment of depression, stress, phobia or other emotional disorders as authorized.    
  • Inpatient Substance Abuse Rehabilitation Services are services provided In-Network for rehabilitation, while you or your eligible Family Member are Confined in a Hospital, requiring diagnosis and treatment of abuse or addiction to alcohol and/or drugs. Inpatient Substance Abuse Services include Partial Hospitalization sessions.
  • Outpatient Substance Abuse Rehabilitation Services are services provided for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs, while you or your eligible Family Member is not confined in a Hospital, including outpatient rehabilitation in an individual, group, structured group or in a Substance Abuse Intensive Outpatient Structured Therapy Program.  A Substance Abuse Outpatient Structured Therapy Program consists of distinct levels or phases of treatment that are provided by a certified/licensed substance abuse program. Intensive Outpatient Structured Therapy programs provide a combination of individual, family and/or group therapy.
  • Substance Abuse Detoxification Services are detoxification and related medical ancillary services provided when required for the diagnosis and treatment of addiction to alcohol and/or drugs. Cigna will decide, based on the Medical Necessity of each situation, whether such services will be provided in an inpatient or outpatient setting.
  • Mental Health and Substance Abuse Services Exclusions - The following are specifically excluded from Mental Health and Substance Abuse Services:
  • Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Necessary and otherwise covered under this plan.
  • Treatment of medical disorders which have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain.
  • Developmental disorders, including but not limited to, developmental reading disorders, developmental arithmetic disorders, developmental language disorders or developmental articulation disorders.
  • Counseling for activities of an educational nature.
  • Counseling for borderline intellectual functioning.
  • Counseling for occupational problems.
  • Counseling related to consciousness raising.
  • Vocational or religious counseling.
  • I.Q. testing.
  • Residential treatment.
  • Custodial care, including but not limited to geriatric day care.
  • Psychological testing on children requested by or for a school system.
  • Occupational/recreational therapy programs even if combined with supportive therapy for age-related cognitive decline.
  • Other limitations are shown in the "General Limitations" section.
  • Charges made for Infertility Services, including services related to the diagnosis of infertility and treatment of infertility once a condition of infertility has been diagnosed.
  • Infertility Services include approved surgical and medical treatment programs that have been established to have a reasonable likelihood of resulting in pregnancy.
  • The following are specifically excluded infertility services:
  • infertility drugs;
  • artificial insemination, gamete intrafallopian transfer (GIFT), in vitro fertilization (IVF), zygote   intrafallopian transfer (ZIFT), and variations of these procedures;
  • any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees);
  • a reversal of voluntary sterilization;
  • infertility services when the infertility is caused by or related to voluntary sterilization;
  • cryopreservation of donor sperm and eggs; and
  • any experimental of investigational infertility procedures or therapies.
  • Charges made for Short-Term Rehabilitative Therapy that is part of a rehabilitation program which is medically necessary, including physical, speech, occupational, cognitive, cardiac rehabilitation and pulmonary rehabilitation therapy, when provided in the most medically appropriate setting. Services are provided on an outpatient basis are limited to sixty (60) days per Plan Year for any combination of these therapies, but only if significant improvement can be expected. Also included are services that are provided by a Participating chiropractic Physician when provided in an outpatient setting. Services of a chiropractic Physician include the management of neuromusculoskeletal conditions through manipulation and ancillary physiological treatment that is rendered to restore motion, reduce pain and improve function. Such coverage is available only for rehabilitation following injuries, surgery or medical conditions.
  • The following benefit limitations apply to Short-Term Rehabilitative Therapy and Chiropractic Care services:
  • Services which are considered custodial or educational in nature are not covered.
  • Occupational therapy provided only for purposes of enabling performance of the activities of daily living is not covered.
  • Speech therapy is not covered when (a) used to improve speech skills that have not fully developed except when speech is not fully developed in children due to underlying disease or malformation that prevented speech development; (b) intended to maintain speech communication; or (c) not restorative in nature.
  • If multiple outpatient services are provided on the same day they constitute one visit, but a separate Co-payment will apply to the services provided by each provider.
  • Charges made for human organ and tissue transplant services at designated facilities through the United States. All Organ Transplant Services listed below, other than cornea, kidney and autologous bone marrow/stem cell transplants are available when received at a qualified or provisional Cigna Lifesource Organ Transplant Network facility. The transplants that are covered at Participating Provider facilities, other than a Cigna Lifesource Organ Transplant Network facility are cornea, kidney and autologous bone marrow/stem cell transplants.
  • Coverage is subject to the following conditions and limitations:
  • Organ Transplant Services include the recipient's medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Organ Transplant Services are only covered when they are required to perform any of the following human to human organ or tissue transplants: allogeneic bone marrow/stem cell, autologous bone marrow/stem cell, cornea, heart, heart/lung, kidney, kidney/pancreas, liver, lung, pancreas or small bowel/liver.
  • Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.
  • Charges made for travel expenses incurred by you or your covered Family Member for charges for transportation, lodging and food associated with a pre-approved organ/tissue transplant. All expenses must be pre-approved by your Transplant Case Manager. Organ Transplant Travel Benefits are not available for cornea, kidney and autologous bone marrow/stem cell transplants. Benefits for transportation, lodging and food are available to you only if you or your covered Family Member is the recipient of a pre-approved organ/tissue transplant from a Cigna Lifesource Organ Transplant Network Facility; such benefits are not subject to any individual or family deductible shown in the In-Network Co-Pay Schedule. The term recipient is defined to include you or your covered Family Member receiving preapproved transplant-related services during any of the following: (a) evaluation, (b) candidacy, (c) transplant event, or (d) post-transplant care. Additionally, this benefit is not subject to the Lifetime Maximum Benefit shown in the In-Network Co-Pay Schedule.
  • Travel expenses for the person receiving the transplant will include charges for:
  • Transportation to and from the transplant site (including charges for a rental car used during a period of care at the transplant facility);
  • Lodging while at, or traveling to and from the transplant site; and
  • Food while at, or traveling to and from the transplant site.
  • By way of example, but not of limitation, travel expenses will not include any charges for:
  • Transplant travel benefit costs incurred due to travel within 60 miles of your home;
  • Laundry bills;
  • Telephone bills;
  • Alcohol or tobacco products; and
  • Transportation charges which exceed coach class rates.
  • These benefits are only available if you or your Family Member are the recipient of an organ transplant. No benefits are available if you or your Family Member is a donor.
  • The charges associated with the items (1), (2) and (3) above will also be considered covered travel expenses for one companion to accompany you. The term companion includes a spouse, family member, legal guardian of you or your Family Member, or any person not related to you, but actively involved as your caregiver.
  • Charges made for non-taxable travel expenses incurred by you in connection with a preapproved organ/tissue transplant are covered subject to the following conditions and limitations. Transplant travel benefits are not available for cornea transplants. Benefits for transportation and lodging are available to you only if you are the recipient of a preapproved organ/tissue transplant from a designated Cigna LIFESOURCE Transplant Network® facility. The term recipient is defined to include a person receiving authorized transplant related services during any of the following: evaluation, candidacy, transplant event, or post-transplant care. Travel expenses for the person receiving the transplant will include charges for: transportation to and from the transplant site (including charges for a rental car used during a period of care at the transplant facility); and lodging while at, or traveling to and from the transplant site.
  • In addition to your coverage for the charges associated with the items above, such charges will also be considered covered travel expenses for one companion to accompany you. The term companion includes your spouse, a member of your family, your legal guardian, or any person not related to you, but actively involved as your caregiver who is at least 21 years of age. The following are specifically excluded travel expenses: any expenses that if reimbursed would be taxable income; travel costs incurred due to travel within 60 miles of your home; food, and meals, laundry bills; telephone bills; alcohol or tobacco products; and charges for transportation that exceed coach class rates.
  • These benefits are only available when the covered person is the recipient of an organ/tissue transplant. Travel expenses for the designated live donor for a covered recipient are covered subject to the same conditions and limitations noted above.  Charges for the expenses of a donor companion are not covered.  No benefits are available when the covered person is a donor.
  • Charges made for reconstructive surgery following a mastectomy; benefits include:  (a) surgical services for reconstruction of the breast on which surgery was performed; (b) surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance; (c) postoperative breast prostheses; and (d) mastectomy bras and external prosthetics, limited to the lowest cost alternative available that meets external prosthetic placement needs. During all stages of mastectomy, treatment of physical complications, including lymphedema therapy are covered.
  • Charges made for reconstructive surgery or therapy to repair or correct a severe facial disfigurement or severe physical deformity (other than abnormalities of the jaw related to TMJ disorder) provided that (a) the surgery or therapy restores or improves function; or (b) reconstruction is required as a result of medically necessary non-cosmetic surgery; or (c) the surgery or therapy is performed prior to age 19 and is required as a result of the congenital absence or agenesis (lack of formation or development) of a body part including, but not limited to:  microtia, amastia, and Poland Syndrome. Repeat or subsequent surgeries for the same condition are covered only when there is the probability of significant additional improvement as determined by Cigna.
  • Nutritional Evaluation and counseling from a Participating Provider is offered when diet is part of the medical management of a documented disease, including morbid obesity.  

Treatment of last resort

Under Cigna's clinical review guidelines, experimental and investigational services are not covered, unless such services are authorized as a treatment of last resort by the Administrator-Benefits. However, medically necessary treatment of complications stemming from experimental and investigational services is covered.

In life-threatening situations, experimental or investigational treatment may be considered a covered expense as a treatment of last resort. A person's condition is considered life-threatening if there is a reasonable likelihood that death will result in a matter of months without treatment or that premature death will occur without early treatment. In this case, proposed experimental or investigational treatments will be reviewed by a panel of specialty-matched experts. The review will include factors such as the efficacy of the proposed treatment, the patient's condition, availability and efficacy of other treatments that are approved for the patient's diagnosis, and the prior use of appropriate treatments for the condition.

Treatment of last resort must be authorized by the Administrator-Benefits, and will be based on the fact that the covered person's condition is life-threatening and the treatment is recommended by a panel of specialty-matched physicians chosen to review the treatment.

Expenses not covered

Covered Expenses will not include, and no payment will be made for, expenses incurred:

  • For Cosmetic Surgery or Therapy. Cosmetic Surgery or Therapy is defined as surgery or therapy performed to improve appearance or self-esteem.
  • Any services, except Emergencies, not provided upon the prior written approval of the Cigna Medical Director or rendered by Participating Providers after preauthorization by the Primary Care Physician.
  • Care for health conditions, which are required by state or local law to be treated in a public facility.
  • Assistance in the activities of daily living, including, but not limited to eating, bathing, dressing, or other custodial or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.
  • For hearing aids or examinations for prescription or fitting thereof, except as otherwise specified in this section.
  • For or in connection with treatment of the teeth or periodontium unless such expenses are incurred for: (a) charges made for a continuous course of Dental treatment started within six months of an Injury to sound natural teeth; or (b) charges made by a Hospital for Bed and Board or Necessary Services and Supplies; or (c) charges made by a Free-Standing Surgical Facility or the outpatient department of a Hospital in connection with surgery.
  • For routine physical examinations not required for health reasons including, but not limited to, employment, insurance, government license, court-ordered, forensic or custodial evaluations.
  • For which benefits are not payable according to the General Limitations section; except that the following will not apply to this section: (a) limitations with respect to a maximum for multiple surgical procedures, an allowable charge for an assistant surgeon or co-surgeon and covered providers being family members; (b) the limitation, if any, with respect to a child under 15 days old; and (c) any certification or second opinion requirements shown in the In-Network Co-Pay Schedule.
  • For rehabilitative therapy by a licensed physical, occupational or speech therapist, or chiropractor, on an outpatient basis, which is provided for all conditions more than 60 visits per calendar year.
  • For therapy to improve general physical condition if not Medically Necessary, including, but not limited to, routine, long-term chiropractic care, and rehabilitative services which are provided to reduce potential risk factors in patients in which significant therapeutic improvement is not expected.
  • For replacement of external prostheses due to wear and tear, loss, theft or destruction; or for any biomechanical external prosthetic devices.
  • For penile prostheses, unless Medically Necessary.
  • For the following vision care service, by way of example, but not of limitation: services or items related to orthopetics or vision training; magnification vision aids; charges for tinting, antireflective coatings, prescription sunglasses or light sensitive lenses; an eye examination required by an employer as a condition of employment or which an employer is required to provide under a collective-bargaining agreement; any eye exam required by law; safety glasses or lenses required for employment; any non-prescription eyeglasses, lenses or contact lenses.
  • For craniosacral therapy, panniculectomy and abdominoplasty, or prolotherapy.
  • The limitation with respect to routine eye refraction's in the "General Limitations" section will not apply to coverage for complete eye examinations.
  • For temporomandibular joint dysfunction services.
  • For bariatric surgery.
  • For varicose vein treatment except when medically necessary.
  • For in connection with procedures to reverse sterilization.
  • Unless otherwise covered as a basic benefit, reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court ordered, forensic or custodial evaluations.
  • For treatment by acupuncture.
  • For artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, hearing aids, dentures and wigs.
  • For court ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed under the "Covered Expenses" section of this booklet.
  • For non-medical ancillary services, including but not limited to vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, work hardening, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning disabilities, developmental delays, intellectual or developmental disability.
  • For consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the "Home Health Services" or "Breast Reconstruction and Breast Prostheses" sections of "Covered Expenses".
  • For private Hospital rooms and/or private duty nursing unless determined by Cigna to be Medically Necessary
  • For membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs.
  • For amniocentesis, ultrasound, or any other procedures requested solely for gender determination of a fetus, unless Medically Necessary to determine the existence of a gender -linked genetic disorder.
  • For genetic testing and therapy including germ line and somatic unless determined Medically Necessary by Cigna for the purpose of making treatment decisions.
  • For fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in Cigna’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
  • For blood administration for the purpose of general improvement in physical condition.
  • For the cost of biologicals that are immunizations or medications for the purpose of the travel, or to protect against occupational hazards and risks.
  • For cosmetics, dietary supplements, health and beauty aids and nutritional formulae. However, nutritional formulae are covered when required for:  (a) the treatment of inborn errors of metabolism or inherited metabolic disease (including disorders of amino acid and organic acid metabolism); or (b) enteral feeding for which the nutritional formulae under state or federal law can be dispensed only through a Physician's prescription, and are Medically Necessary as the primary source of nutrition.
  • For personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness.
  • For Treatment/surgery of mandibular or maxillary prognathism, microprognathism or malocclusion, surgical augmentation for orthodontics, or maxillary constriction.
  • For all noninjectable prescription drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the "Covered Expenses" section of this booklet.
  • For Infertility services including infertility drugs, surgical or medical treatment programs for infertility, including in vitro fertilization, artificial insemination, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs is also excluded from coverage.
  • For which benefits are not payable according to the "General Limitations" section.
  • For rhinoplasty

Prescription drug benefits

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 Co-payment shown in the In-Network Co-Pay 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.

Limitations

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 co-insurance 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.

Exclusions

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, including injectable infertility drugs other than injectables included on the Formulary, 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 Co-payment;
  • 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), dietary supplements and fluoride products, except for formulas prescribed by a Participating Physician as necessary for the treatment of phenylketonuria or similar inheritable diseases that may cause or result in mental or physical retardation.
  • 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.
  • 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 P&T Committee (such as antihistamines).
  • All newly FDA approved drugs, prior to review by the Pharmacy and Therapeutics committee.
  • Norplant and other implantable contraceptive products.

General limitations

Medical benefits

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 or in connection with in vitro fertilization, artificial insemination, GIFT (Gamete Intrafallopian Transfer), ZIFT (Zygote Intrafallopian Transfer), or similar procedures.
  • For charges made by an assistant surgeon exceeding 20 percent of the surgeon's allowable charge.  (For purposes of this limitation, allowable charge means the amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts.)
  • For total charges made by co-surgeons exceeding 62.5% of the surgeon's allowable charge.  (For purposes of this limitation, allowable charge means the amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts.)
  • 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 or in connection with speech therapy, if such therapy is (a) used to improve speech skills that have not fully developed; (b) can be considered custodial or educational; or (c) is intended to maintain speech communication; speech therapy which is not restorative in nature will not be covered.
  • 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, substance abuse 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 or educational therapy for learning disabilities, developmental delays, autism or mental retardation.
  • 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 OAPIN Option.