NETWORK PHARMACY
NON-NETWORK PHARMACY
BENEFIT HIGHLIGHTS
Tier 2 Preventive Brand Drugs designated as preferred on the Prescription Drug List
No charge
50% after plan Deductible
Non Preventive Brand Drugs designated as preferred on the Prescription Drug List
20% after plan Deductible
50% after plan Deductible
Tier 3 Brand Drugs designated as non- preferred on the Prescription Drug List . Prescription Drug Products at Retail Designated Pharmacies
20% after plan Deductible
50% after plan Deductible
The amount you pay for up to a consecutive 90-day supply at a Designated Pharmacy
The amount you pay for up to a consecutive 90-day supply at a non- Designated Pharmacy
Specialty medications must be filled through home delivery; otherwise you pay the entire cost of the prescription upon your first fill. Some exceptions may apply.
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
Preventive Generic Drugs on the Prescription Drug List
No charge
50% after plan Deductible
Non Preventive Generic Drugs on the Prescription Drug List
20% after plan Deductible
50% after plan Deductible
Tier 2
Preventive Brand Drugs designated as preferred on the Prescription Drug List Non Preventive Brand Drugs designated as preferred on the Prescription Drug List
No charge
50% after plan Deductible
20% after plan Deductible
50% after plan Deductible
Tier 3
Brand Drugs designated as non- preferred on the Prescription Drug List
20% after plan Deductible
50% after plan Deductible
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