Benefit |
You
Pay |
| Hospitalization (no precertification
required) |
Inpatient Medical/Surgical
and Mental Health |
Nothing |
| Outpatient |
Nothing |
| Physician
Care |
| Inpatient
and Outpatient Medical and Surgical Care |
Nothing |
| Mental
Health and Substance Abuse |
Nothing - no limitations |
Prescription
Drugs
*This is a mandatory generic program with a 30-day limit at local retail. |
| Retail: |
Network Retail
Non-network Retail
|
15% of cost
50% of allowance |
| Mail
Order: |
60-day supply |
$7 generic
$20 brand
name |
| 90-day supply |
$10 generic
$30 brand name
|
| Catastrophic Limits |
Nothing |
When you have Medicare Part D
We waive the following at retail when Medicare Part D is the primary payer:
- Refill limitations
- Day supply
- Calendar year drug deductible
|