What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information $250 penalty for no out-of-network precertification. Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail and home delivery) for Specialty drugs. Certain limitations may apply, including, for example: prior authorization, step therapy, quantity limits. For drugs in the Cigna Patient Assurance Program you may pay less than the noted retail or home delivery cost share amounts. In-network Federally required preventive drugs will be provided at no charge. $250 penalty for no out-of-network precertification. $250 penalty for no out-of-network precertification. Per visit copay is waived if admitted. Out-of-network services are paid at the in-network cost share. Out-of-network air ambulance services are paid at the in-network cost share and deductible. Per visit copay is waived if admitted.
Services You May Need
In-Network Provider (You will pay the least) 20% coinsurance at an outpatient facility 20% coinsurance in the office $10 copay/prescription (retail 30 days), $30 copay/prescription (retail & home delivery 90 days) Deductible does not apply $50 copay/prescription (retail 30 days), $150 copay/prescription (retail & home delivery 90 days) Deductible does not apply $100 copay/prescription (retail 30 days), $300 copay/prescription (retail & home delivery 90 days) Deductible does not apply $250 copay/prescription (retail & home delivery 30 days) Deductible does not apply
Out-of-Network Provider (You will pay the most) 40% coinsurance at an outpatient facility 40% coinsurance in the office 50% coinsurance/prescription (retail and home delivery) Deductible does not apply
Imaging (CT/PET scans, MRIs)
Generic drugs (Tier 1)
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.cigna.com
50% coinsurance/prescription (retail and home delivery) Deductible does not apply
Preferred brand drugs (Tier 2)
50% coinsurance/prescription (retail and home delivery) Deductible does not apply 50% coinsurance/prescription (retail and home delivery) Deductible does not apply
Non-preferred brand drugs (Tier 3)
Specialty drugs (Tier 4)
Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees
20% coinsurance
40% coinsurance
If you have outpatient surgery
20% coinsurance
40% coinsurance
$500 copay/visit, plus 20% coinsurance Deductible does not apply
$500 copay/visit, plus 20% coinsurance Deductible does not apply
Emergency room care
If you need immediate medical attention
Emergency medical transportation
20% coinsurance
20% coinsurance
$75 copay/visit Deductible does not apply
$75 copay/visit Deductible does not apply
Urgent care
Page 3 of 8
Made with FlippingBook - Online Brochure Maker