NETWORK PHARMACY
NON-NETWORK PHARMACY
BENEFIT HIGHLIGHTS
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 Tier 4 Specialty Prescription Drug Products . Prescription Drug Products at Retail Designated Pharmacies
20%, subject to a minimum of $15 and a maximum of $30, then the Plan pays 100%
50%
30%, subject to a minimum of $30 and a maximum of $60, then the Plan pays 100%
50%
40%, subject to a minimum of $60 and a maximum of $120, then the Plan pays 100%
50%
50%, subject to a minimum of $80 and a maximum of $160, then the Plan pays 100% The amount you pay for up to a consecutive 90-day supply at a Designated Pharmacy
50%
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%, subject to a minimum of $30 and a maximum of $60, then the Plan pays 100% 50%
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
30%, subject to a minimum of $60 and a maximum of $120, then the Plan pays 100%
50%
40%, subject to a minimum of $120 and a maximum of $240, then the Plan pays 100%
50%
myCigna.com
51
Made with FlippingBook - Online magazine maker