What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information 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. 50% penalty for no out-of-network precertification. 50% penalty for no out-of-network precertification.
Services You May Need
In-Network Provider (You will pay the least)
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) 50% coinsurance/prescription (retail); Not covered (home delivery)
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) 20% coinsurance/prescription (retail 30 days), 20% coinsurance/prescription (retail & home delivery 90 days)
Generic drugs (Tier 1)
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.cigna.com
Preferred brand drugs (Tier 2)
Non-preferred brand drugs (Tier 3)
Facility fee (e.g., ambulatory surgery center) 20% coinsurance
50% coinsurance
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
50% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 50% coinsurance
None None None
If you need immediate medical attention
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.). 50% penalty for no out-of-network precertification.
If you have a hospital stay
20% coinsurance
50% coinsurance
20% coinsurance/office 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
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