What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Services You May Need
In-Network Provider (You will pay the least) 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 No charge/preventive drugs 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
Out-of-Network Provider (You will pay the most)
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.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.myCigna.com
50% coinsurance/prescription (retail); Not covered (home delivery) Deductible does not apply
Preferred brand drugs (Tier 2)
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