Page 42 - 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 50% coinsurance/prescription

copay/prescription (retail 90 (retail); Not covered (home
Generic drugs (Tier 1)
days); $25 copay/prescription delivery)
(home 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
your illness or condition $35 copay/prescription (retail supply (retail and home delivery); up
30 days), $105 50% coinsurance/prescription to a 30-day supply (retail and home
Preferred brand drugs (Tier copay/prescription (retail 90 (retail); Not covered (home delivery) for Specialty drugs.
More information about 2) days); $88 copay/prescription delivery) Certain limitations may apply,

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

(Tier 3) days); $175 copay/prescription delivery)
(home delivery 90 days) Deductible does not apply

Deductible does not apply
Facility fee (e.g.,
If you have outpatient ambulatory surgery center) No charge 30% coinsurance $250 penalty for no precertification.

surgery
Physician/surgeon fees No charge 30% coinsurance $250 penalty for no precertification.

$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 No charge No charge None
medical attention transportation

$100 copay/visit
Urgent care 30% coinsurance None
Deductible does not apply
$600 deductible/admission,
Facility fee (e.g., hospital $300 deductible/admission plus 30% coinsurance $250 penalty for no precertification.
If you have a hospital stay room) Deductible does not apply
Deductible does not apply

Physician/surgeon fees No charge 30% coinsurance $250 penalty for no precertification.

3 of 8