What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information including, for example: prior authorization, step therapy, quantity limits. In-network Federally required preventive drugs will be provided at no charge. 50% penalty for no out-of-network precertification. 50% penalty for no out-of-network precertification. Out-of-network services are paid at the in-network cost share and deductible. Out-of-network air ambulance services are paid at the in-network cost share and deductible. 50% penalty for no out-of-network precertification. 50% penalty for no out-of-network precertification. 50% penalty if no precert of out-of- network non-routine services (i.e., partial hospitalization, etc.). Includes medical services for MH/SA diagnoses. 50% penalty for no out-of-network precertification. Includes medical services for MH/SA diagnoses. Primary Care or Specialist benefit levels apply for initial visit to confirm None
Services You May Need
In-Network Provider (You will pay the least) 20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail & home delivery 90 days) 20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail & home delivery 90 days)
Out-of-Network Provider (You will pay the most) 50% coinsurance/prescription (retail); Not covered (home delivery) 50% coinsurance/prescription (retail); Not covered (home delivery)
is available at www.cigna.com
Preferred brand drugs (Tier 2)
Non-preferred brand drugs (Tier 3) Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees
20% coinsurance
50% coinsurance
If you have outpatient surgery
20% coinsurance
50% coinsurance
Emergency room care
20% coinsurance
20% coinsurance
If you need immediate medical attention
Emergency medical transportation
20% coinsurance
20% coinsurance
Urgent care
20% coinsurance 20% coinsurance
20% coinsurance 50% coinsurance
Facility fee (e.g., hospital room) Physician/surgeon fees
If you have a hospital stay
20% coinsurance
50% coinsurance
20% coinsurance/office visit 20% coinsurance/MDLIVE visit 20% coinsurance/all other services
50% coinsurance/office visit 50% coinsurance/all other services
Outpatient services
If you need mental health, behavioral health, or substance abuse services
Inpatient services
20% coinsurance
50% coinsurance
Office visits
20% coinsurance
50% coinsurance
If you are pregnant
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