Page 3 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In - Network (You will pay the least) Out - of - Network (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at bluecrossma.org/medicatio n Generic drugs $15 / retail supply or $30 / mail service supply $30 / retail supply and all charges for mail service This plan uses the Blue Cross Blue Shield of Massachusetts Formulary — Focused; deductible applies first; up to 30 - day retail (90 - day mail service ) supply; cost share may be waived, reduced, or increased for certain covered drugs and supplies ; pre - authorization required for certain drugs Preferred brand drugs 50% coinsurance 50% coinsurance / retail supply and all charges for mail service Non - preferred brand drugs 50% coinsurance 50% coinsurance / retail supply and all charges for mail service Specialty drugs Applicable cost share (generic, preferred, non - preferred) Not covered This plan uses the Blue Cross Blue Shield of Massachusetts Formulary — Focused; deductible applies first; when obtained from a designated specialty pharmacy; cost share may be waived, reduced, or increased for certain covered drugs and supplies; pre - authorization required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $1,000 / admission 20% coinsurance Deductible applies first ; pre - authorization required for certain services Physician/surgeon fees No charge 20% coinsurance Deductible applies first ; pre - authorization required for certain services