Page 18 - Benefits Summary 2018-2019

What You Will Pay
Common Services You May Need Limitations, Exceptions, & Other
Medical Event In-Network Provider Out-of-Network Provider Important Information
(You will pay the least) (You will pay the most)

$10 copay/prescription (retail 30
days), $30 copay/prescription 50%

(retail 90 days); $25 coinsurance/prescription
Generic drugs (Tier 1) (retail); Not covered (home
copay/prescription (home delivery delivery)
90 days) Deductible does not apply

Deductible does not apply Coverage is limited up to a 90-day
If you need drugs to treat $35 copay/prescription (retail 30 supply (retail and home delivery); up

your illness or condition 50%
days), $105 copay/prescription to a 30-day supply (retail and home
Preferred brand drugs (Tier (retail 90 days); $88 coinsurance/prescription delivery) for Specialty drugs.
More information about 2) copay/prescription (home delivery (retail); Not covered (home Certain limitations may apply,

prescription drug coverage 90 days) delivery) including, for example: prior
is available at Deductible does not apply
www.myCigna.com Deductible does not apply authorization, step therapy, quantity
$70 copay/prescription (retail 30 limits.
days), $210 copay/prescription 50%
Non-preferred brand drugs (retail 90 days); $175 coinsurance/prescription

(Tier 3) copay/prescription (home delivery (retail); Not covered (home
90 days) delivery)

Deductible does not apply Deductible does not apply
Facility fee (e.g.,
If you have outpatient ambulatory surgery center) 30% coinsurance Not covered None
surgery
Physician/surgeon fees 30% coinsurance Not covered None

$200 copay/visit $200 copay/visit
Emergency room care Per visit copay is waived if admitted
Deductible does not apply Deductible does not apply

If you need immediate Emergency medical
medical attention transportation 30% coinsurance 30% coinsurance None

$100 copay/visit
Urgent care Not covered None
Deductible does not apply

$350 deductible/admission, plus
Facility fee (e.g., hospital
If you have a hospital stay room) 30% coinsurance Not covered None
Deductible does not apply

Physician/surgeon fees 30% coinsurance Not covered None

3 of 8