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* Network and non-network annual deductibles and coinsurance out-of-pocket maximums are applied separately.
** General provisions: Reimbursement is limited to the generic drug benefit when a non-generic is utilized; and participants will pay the lesser of the prescription co-pay or the actual cost of the drug. Mail order prescriptions are available in a 90-day supply except Specialty Drugs, which are only available in a 30-day supply.
*** Health Savings Account (HSA) compatible plan must meet an annual combined medical and prescription drug deductible before prescription coinsurance applies. The Department of the Treasury provides FAQs about HSAs.
Note: Bariatric surgery (including gastric bypass and obesity surgery) is limited to one per lifetime as a network benefit only. An additional $2,000 co-pay and appropriate coinsurance applies. This surgery is not covered non-network.
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