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Cigna Open Access Plus Cigna Open Access Plus Cigna Open Access Plus
Base—$2,000 PPO Choice—$1,000 PPO HDHP 1—$3,000 HDHP
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Prescription Drugs
Please note: for the HDHP qualiied plan, all non-preventive, non-generic prescription Drugs on Cigna's Preventive Generic
drug expenses are subject to the medical deductible. Once you meet your deductible, drug list are covered at 100%, no
copays, or coinsurance will apply. deductible.
Retail (per 30-day supply)
Generic* $10 copay $10 copay Deductible, then
$10 copay
Preferred Brand $35 copay $35 copay Deductible, then
Formulary $35 copay
Non-Preferred $60 copay $60 copay Deductible, then
Brand Formulary $60 copay
Specialty 25% up to 25% up to Deductible,
a maximum a maximum then 25% up
of $250 of $250 to a maximum
of $250
Mail Order — Retail and Home Delivery (per 90-day supply)
Generic* $20 copay $20 copay Deductible, then
$20 copay
Preferred Brand $70 copay $70 copay Deductible, then
Formulary $70 copay
Non-Preferred $120 copay $120 copay Deductible, then
Brand Formulary $120 copay

* If you select a brand name drug when a generic equivalent is available, the plan will only pay the cost of the generic drug unless your physician
indicates “Dispense as Written” on the prescription.

This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.

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