NETWORK PHARMACY
NON-NETWORK PHARMACY
BENEFIT HIGHLIGHTS
Tier 2 Brand Drugs designated as preferred on the Prescription Drug List Tier 3 Brand Drugs designated as non- preferred on the Prescription Drug List Tier 4 Specialty Prescription Drug Products . Prescription Drug Products at Retail Designated Pharmacies
30%, subject to a minimum of $25 and a maximum of $50, then the Plan pays 100%
50%
40%, subject to a minimum of $50 and a maximum of $100, then the Plan pays 100%
50%
50%, subject to a minimum of $75 and a maximum of $150, then the Plan pays 100% The amount you pay for up to a consecutive 90-day supply at a Designated Pharmacy
50%
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. *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
Generic Drugs on the Prescription Drug List
20%, subject to a minimum of $25 and a maximum of $50, then the Plan pays 100%
50%
Tier 2
Brand Drugs designated as preferred on the Prescription Drug List
30%, subject to a minimum of $50 and a maximum of $100, then the Plan pays 100%
50%
Tier 3
Brand Drugs designated as non- preferred on the Prescription Drug List
40%, subject to a minimum of $100 and a maximum of $200, then the Plan pays 100%
50%
Tier 4
Specialty Prescription Drug Products
Specialty Prescription Drug Products are limited to up to a consecutive 30 day supply per Prescription Order or Refill.
Specialty Prescription Drug Products are limited to up to a consecutive 30 day supply per Prescription Order or Refill.
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