What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information 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. In-network Federally required preventive drugs will be provided at no charge.
Services You May Need
In-Network Provider (You will pay the least) 20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail & home delivery 90 days) 20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail & home delivery 90 days) 20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail & home delivery 90 days)
Out-of-Network Provider (You will pay the most) 50% coinsurance/prescription (retail); Not covered (home delivery) 50% coinsurance/prescription (retail); Not covered (home delivery) 50% coinsurance/prescription (retail); Not covered (home delivery)
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
Preferred brand drugs (Tier 2)
Non-preferred brand drugs (Tier 3) Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees
20% coinsurance 20% coinsurance
50% coinsurance 50% coinsurance
None None
If you have outpatient surgery
Out-of-network services are paid at the in-network cost share and deductible. Out-of-network air ambulance services are paid at the in-network cost share and deductible.
Emergency room care
20% coinsurance
20% coinsurance
If you need immediate medical attention
Emergency medical transportation
20% coinsurance
20% coinsurance
Urgent care
20% coinsurance 20% coinsurance 20% coinsurance
20% coinsurance 50% coinsurance 50% coinsurance
None None None
Facility fee (e.g., hospital room) Physician/surgeon fees
If you have a hospital stay
20% coinsurance/office visit 20% coinsurance/MDLIVE visit 20% coinsurance/all other services
50% coinsurance/office visit 50% coinsurance/all other services
If you need mental health, behavioral health, or substance abuse services
Outpatient services
None
Inpatient services
20% coinsurance 20% coinsurance
50% coinsurance 50% coinsurance
None
Office visits
Primary Care or Specialist benefit levels apply for initial visit to confirm
If you are pregnant
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