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)
20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail 90 days); 20% coinsurance/prescription (home delivery 90 days) No charge/preventive drugs 20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail 90 days); 20% coinsurance/prescription (home delivery 90 days) Preferred Brand Preventive: No charge 20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail 90 days); 20% coinsurance/prescription (home delivery 90 days)
50% coinsurance/prescription (retail); Not covered (home delivery)
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.myCigna.com
50% coinsurance/prescription (retail); Not covered (home delivery)
Preferred brand drugs (Tier 2)
50% coinsurance/prescription (retail); Not covered (home delivery)
Non-preferred brand drugs (Tier 3)
Facility fee (e.g., ambulatory surgery center) 20% coinsurance
50% coinsurance 50% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 50% coinsurance 50% coinsurance
50% penalty for no precertification. 50% penalty for no precertification.
If you have outpatient surgery
Physician/surgeon fees Emergency room care Emergency medical transportation Facility fee (e.g., hospital room) Physician/surgeon fees Urgent care
20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance
None None None
If you need immediate medical attention
50% penalty for no precertification. 50% penalty for no precertification.
If you have a hospital stay
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