This article is intended for members enrolled in an individual health insurance plan.

Do you know that you may save money by using an in-network pharmacy?

When you go to an in-network pharmacy, you generally have lower copay or coinsurance amounts. These costs will apply to your in-network deductible (if your plan has one) and in-network, out-of-pocket spending amounts.

When you go to an out-of-network pharmacy, you generally have higher copay or coinsurance amounts. These costs will apply only to your out-of-network deductible (if your plan has one) and your out-of-network, out-of-pocket spending amounts.

In addition, some plans have separate in-network and out-of-network deductibles and out-of-pocket spending amounts. As you may already know, you pay most of the costs of your health care until you reach your plan’s deductibles (if applicable to your plan). If you are using both in-network and out-of-network options, it may take longer and cost you more to meet the plan’s deductibles and out-of-pocket spending amounts.

And there may be additional charges under your plan when you use an out-of-network pharmacy. These additional charges will not apply to any of the out-of-pocket spending amounts under your plan (if your plan includes this. See your Summary of Benefits and Coverage for specific plan details).

Let’s look at an example. If a prescription drug costs $500 per month, the in-network vs. out-of-network costs could be as follows:

If the plan copay amount is $100:

In network

Out of network

You pay any applicable in-network deductible and then $100, which counts toward the in-network, out-of-pocket (OOP) spending limit.

You pay $100, plus a 50 percent out-of-network charge ($250 in this example) for using an out-of-network pharmacy. The pharmacy claims apply to the out-of-network deductible (if the plan has a deductible) and the out-of-network, out-of-pocket spending limit. The $250 additional charge for using an out-of-network pharmacy will not apply to the out-of-pocket amount.

If the plan coinsurance amount is 30 percent:

In network:

Out of network:

You pay any applicable in-network deductible and then 30 percent of drug cost, in this case $150. This counts toward the in-network deductible (if the plan has a deductible) and the in-network, out-of-pocket spending limit.

You pay $150 plus a 50 percent out-of-network charge ($250) for using an out-of-network pharmacy. The pharmacy claims apply to the out-of-network deductible (if the plan has a deductible) and the out-of-network, out-of-pocket spending limit. But the $250 additional charge for using an out-of-network pharmacy will not apply to the out-of-pocket amount.

Please note that your plan may have different copay and/or coinsurance amounts. Please see your Benefit Book for details.