Page 3 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) www.cigna.com Non-preferred brand drugs (Tier 3) 30% coinsurance/prescription (retail and home delivery) 30% coinsurance/prescription (retail); Not covered (home delivery) including, for example: prior authorization, step therapy, quantity limits. For drugs in the Clinical Day Supply program, you may pay less than the noted cost share for certain specialty drugs. For drugs in the Cigna Patient Assurance Program you may pay less than the noted retail or home delivery cost share amounts. In-network Federally required preventive drugs will be provided at no charge. Facility fee (e.g., ambulatory surgery center) 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification. If you have outpatient surgery Physician/surgeon fees 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification. Emergency room care 30% coinsurance 30% coinsurance Out-of-network services are paid at the in-network cost share and deductible. Emergency medical transportation 30% coinsurance 30% coinsurance Out-of-network air ambulance services are paid at the in-network cost share and deductible. If you need immediate medical attention Urgent care 30% coinsurance 50% coinsurance None Facility fee (e.g., hospital room) 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification. If you have a hospital stay Physician/surgeon fees 30% coinsurance 50% coinsurance $750 penalty for no out-of-network precertification. If you need mental health, behavioral health, or substance abuse services Outpatient services 30% coinsurance/office visit 30% coinsurance/all other services 50% coinsurance/office visit 50% coinsurance/all other services $750 penalty if no precert of out-of- network non-routine services. Includes medical services for MH/SA diagnoses.