Medical benefits Office/home visits 100 per cent 100 per cent 100 per cent 80 per cent after 80 per cent after after $15/$20 after $15/$20 deductible deductible primary care primary care physician/ physician/ specialist specialist co-pay Routine physical 100 per cent 100 per cent 100 per cent 80 per cent after 80 per cent after once every after after deductible once deductible once 12 months $15 co-pay once $15 co-pay once every 12 months every 12 months every 12 months every 12 months Surgery 100 per cent 100 per cent 100 per cent 80 per cent after 80 per cent after deductible deductible Prescription drugs Pharmacy $5.00 for 20 per cent 20 per cent United States: United States: generic/brand copay up to $20 copay up to $20 60 per cent after 60 per cent after per 30-day per 30-day per 30-day deductible deductible supply supply for supply for International: International: generic generic 80 per cent after 80 per cent after 25 per cent 25 per cent deductible deductible copay up to copay up to $30 $30 per 30-day per 30-day supply for brand supply for brand name name Mail order $2.50 for 100 per cent 100 per cent Not applicable Not applicable generic/brand after $15 co-pay after $15 co-pay per 30-day per 90-day per 90-day supply supply supply Behavioural health-care benefits (must be pre-certified; benefit maximum for in-network and network combined) Inpatient mental 100 per cent 100 per cent 100 per cent 100 per cent 80 per cent after health care after deductible deductible Outpatient 100 per cent 100 per cent 100 per cent 80 per cent after 80 per cent after mental health deductible deductible care Inpatient alcohol 100 per cent 100 per cent 100 per cent 100 per cent 80 per cent after and substance after deductible deductible abuse care
Medical benefits Office/home visits 100 per cent 100 per cent after $15/$20 primary care physician/ specialist 100 per cent after $15/$20 primary care physician/ specialist co-pay 80 per cent after deductible 80 per cent after deductible Routine physical 100 per cent once every 12 months 100 per cent after $15 co-pay once every 12 months 100 per cent after $15 co-pay once every 12 months 80 per cent after deductible once every 12 months 80 per cent after deductible once every 12 months Surgery 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Prescription drugs Pharmacy $5.00 for generic/brand per 30-day supply 20 per cent copay up to $20 per 30-day supply for generic 25 per cent copay up to $30 per 30-day supply for brand name 20 per cent copay up to $20 per 30-day supply for generic 25 per cent copay up to $30 per 30-day supply for brand name United States: 60 per cent after deductible International: 80 per cent after deductible United States: 60 per cent after deductible International: 80 per cent after deductible Mail order $2.50 for generic/brand per 30-day supply 100 per cent after $15 co-pay per 90-day supply 100 per cent after $15 co-pay per 90-day supply Not applicable Not applicable Behavioural health-care benefits (must be pre-certified; benefit maximum for in-network and combined) Inpatient mental health care 100 per cent 100 per cent 100 per cent 100 per cent after deductible 80 per cent after deductible Outpatient mental health care 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Inpatient alcohol and substance abuse care 100 per cent 100 per cent 100 per cent 100 per cent after deductible 80 per cent after deductible network