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 copay up to 60 per cent after 60 per cent after per 30-day $20 per 30-day $20 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 per 30-day $30 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 90day per 90day 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 Outpatient 100 per cent 100 per cent 100 per cent 80 per cent after 80 per cent after alcohol and deductible deductible substance abuse care Vision care Eye exam 100 per cent 100 per cent 100 per cent 80 per cent $40 allowance after $20 co-pay after $15 co-pay 1 exam every 1 exam every 1 exam every 12 months 1 exam every 1 exam every 12 months 12 months 12 months 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 90day supply 100 per cent after $15 co-pay per 90day 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 Outpatient alcohol and substance abuse care 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Vision care Eye exam 100 per cent 1 exam every 12 months 100 per cent after $20 co-pay 1 exam every 12 months 100 per cent after $15 co-pay 1 exam every 12 months 80 per cent 1 exam every 12 months $40 allowance 1 exam every 12 months network
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