NETWORK PHARMACY
NON-NETWORK PHARMACY
BENEFIT HIGHLIGHTS
Prescription Drug Products at Retail Pharmacies
The amount you pay for up to a consecutive 30-day supply at a Network Pharmacy
The amount you pay for up to a consecutive 30-day supply at a non- Network Pharmacy
Certain Specialty Prescription Drug Products are only covered when dispensed by a home delivery Pharmacy.
Tier 1 Generic Drugs on the Prescription Drug List Tier 2 Brand Drugs designated as preferred on the Prescription Drug List Tier 3 Brand Drugs designated as non- preferred on the Prescription Drug List Prescription Drug Products at Retail Designated Pharmacies
20% after plan Deductible
50% after plan Deductible
20% after plan Deductible
50% after plan Deductible
20% after plan Deductible
50% after plan Deductible
The amount you pay for up to a consecutive 90-day supply at a Designated Pharmacy
The amount you pay for up to a consecutive 90-day supply at a non- Designated Pharmacy
Certain Specialty Prescription Drug Products are only covered when dispensed by a home delivery Pharmacy. Specialty Prescription Drug Products are limited to up to a consecutive 30-day supply per Prescription Order or Refill. Note: In this context, a retail Designated Pharmacy is a retail Network Pharmacy that has contracted with Cigna for dispensing of covered Prescription Drug Products, including Maintenance Drug Products, in 90-day supplies per Prescription Order or Refill. Tier 1 Generic Drugs on the Prescription Drug List 20% after plan Deductible 50% after plan Deductible Tier 2 Brand Drugs designated as preferred on the Prescription Drug List 20% after plan Deductible 50% after plan Deductible Tier 3
Brand Drugs designated as non- preferred on the Prescription Drug List
20% after plan Deductible
50% after plan Deductible
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