Page 2 of 7 Important Questions Answers Why This Matters: Will you pay less if you use a network provider? Yes. See www.cigna.com or call 1-866-494-2111 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Event Services You May Need In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Primary care visit to treat an injury or illness 30% coinsurance/office visit No charge/MDLIVE visit 50% coinsurance None Specialist visit 30% coinsurance/visit 50% coinsurance None If you visit a health care provider's office or clinic Preventive care/ screening/immunization No charge Deductible does not apply 50% coinsurance You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood work) 30% coinsurance 50% coinsurance None If you have a test Imaging (CT/PET scans, MRIs) 30% coinsurance at an outpatient facility 30% coinsurance in the office 50% coinsurance at an outpatient facility 50% coinsurance in the office $750 penalty for no out-of-network precertification. Generic drugs (Tier 1) 30% coinsurance/prescription (retail and home delivery) 30% coinsurance/prescription (retail); Not covered (home delivery) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Preferred brand drugs (Tier 2) 30% coinsurance/prescription (retail and home delivery) 30% coinsurance/prescription (retail); Not covered (home delivery) Coverage is limited up to a 90-day supply (retail and home delivery); up to a 30-day supply (retail) and a 90- day supply (home delivery) for Specialty drugs. Certain limitations may apply,