What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Imaging (CT/PET scans, MRIs)
20% coinsurance
50% coinsurance
None
20% coinsurance but not less than $10 or more than $20/prescription (retail 30 days), 20% coinsurance but not less than $25 or more than $50/prescription (retail 90 days); 20% coinsurance but not less than $25 or more than $50/prescription (home delivery 90 days) Deductible does not apply 30% coinsurance but not less than $25 or more than $50/prescription (retail 30 days), 30% coinsurance but not less than $50 or more than $100/prescription (retail 90 days); 30% coinsurance but not less than $50 or more than $100/prescription (home delivery 90 days) Deductible does not apply
50% coinsurance/prescription (retail); Not covered (home delivery) Deductible does not apply
Generic drugs (Tier 1)
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.
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); Not covered (home delivery) Deductible does not apply
Preferred brand drugs (Tier 2)
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