Prescription Drug Benefits The Schedule
For You and Your Dependents This plan provides Prescription Drug benefits for Prescription Drug Products provided by Pharmacies as shown in this Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a Deductible, Copayment or Coinsurance requirement for Covered Expenses for Prescription Drug Products. You and your Dependents will pay 100% of the cost of any Prescription Drug Product excluded from coverage under this plan. The amount you and your Dependent pays for any excluded Prescription Drug Product to the dispensing Pharmacy, will not count towards your Deductible, if any, or Out-of-Pocket Maximum. Coinsurance The term Coinsurance means the percentage of the Prescription Drug Charge for a covered Prescription Drug Product dispensed by a Network Pharmacy, and it means the percentage of the benchmark price used by Cigna for a covered Prescription Drug Product dispensed by a non-Network Pharmacy, that you or your Dependent are required to pay under this plan in addition to the Deductible, if any.
NETWORK PHARMACY
NON-NETWORK PHARMACY
BENEFIT HIGHLIGHTS
Lifetime Maximum
Refer to the Medical Benefits Schedule
Refer to the Medical Benefits Schedule
Out-of-Pocket Maximum Individual
Refer to the Medical Benefits Schedule Refer to the Medical Benefits Schedule
Refer to the Medical Benefits Schedule Refer to the Medical Benefits Schedule
Family
Maintenance Drug Products Maintenance Drug Products may be filled in an amount up to a consecutive 90 day supply per Prescription Order or Refill at a retail Pharmacy or home delivery Pharmacy. Certain PPACA Preventive Medications covered under this plan and required as part of preventive care services (detailed information is available at www.healthcare.gov) and certain other preventive care medications as recommended by Cigna are payable at 100% with no Copayment or Deductible, when purchased from a Network Pharmacy. A written prescription is required. . 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.
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