Prescription Drug Benefits The Schedule
For You and Your Dependents
This plan provides Prescription Drug benefits for Prescription Drug Products provided by Pharmacies as shown in this Schedule. To receive Prescription Drug Benefits, you and your Dependents may be required to pay a Deductible, Copayment or Coinsurance requirement for Covered Expenses for Prescription Drug Products. Coinsurance The term Coinsurance means the percentage of the Prescription Drug Charge for a covered Prescription Drug Product that you or your Dependent are required to pay under this plan in addition to the Deductible, if any.
NETWORK PHARMACY
NON-NETWORK PHARMACY
BENEFIT HIGHLIGHTS
Refer to the Medical Benefits Schedule
Refer to the Medical Benefits Schedule
Lifetime Maximum
Out-of-Pocket Maximum
Individual
Refer to the Medical Benefits Schedule Refer to the Medical Benefits Schedule
Refer to the Medical Benefits Schedule Refer to the Medical Benefits Schedule
Family
Maintenance Drug Products Maintenance Drug Products may be filled in an amount up to a consecutive 90 day supply per Prescription Order or Refill at a retail Pharmacy or home delivery Pharmacy. Certain Preventive Care Medications covered under this plan and required as part of preventive care services (detailed information is available at www.healthcare.gov) are payable at 100% with no Copayment or Deductible, when purchased from a Network Pharmacy. A written prescription is required. . Prescription Drug Products at Retail Pharmacies The amount you pay for up to a consecutive 30-day supply at a non- Network Pharmacy The amount you pay for up to a consecutive 30-day supply at a Network Pharmacy
Tier 1
Generic Drugs on the Prescription Drug List
20%, subject to a minimum of $10 and a maximum of $20, then the Plan pays 100%
50%
40
myCigna.com
Made with FlippingBook Publishing Software