All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Services You May In-Network Provider Out-of-Network Provider Limitations, Exceptions, & Other Important Event Need (You will pay the least) (You will pay the most) Information $5 copay, deductible does not apply / first 3 upfront visits / year; Primary care visit to $30 copay / office visit after 40% coinsurance treat an injury or illness 3 upfront visits, deductible First 3 upfront visits combined for primary care and does not apply; behavioral health services. If you visit a health Copayment applies to each in-network provider office care provider's office 20% coinsurance for all visit only. All other services are covered at the or clinic other services coinsurance specified, after deductible. $60 copay / office visit, deductible does not apply; Specialist visit 40% coinsurance 20% coinsurance for all other services Preventive No charge, deductible does You may have to pay for services that aren't care/screening/ not apply 40% coinsurance preventive. Ask your provider if the services needed immunization are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, 20% coinsurance 40% coinsurance If you have a test blood work) None Imaging (CT/PET scans, 20% coinsurance 40% coinsurance MRIs) $10 copay, deductible does $10 copay, deductible does Prescription drugs not on the Drug List are not If you need drugs to not apply / retail not apply / retail covered, unless an exception is approved. treat your illness or prescription; prescription; 90-day supply / retail prescription (your cost share is condition per 30-day supply) More information about Tier 1 (Typically, generic $20 copay, deductible does $20 copay, deductible does 90-day supply / home delivery prescription prescription drug drugs with highest not apply / home delivery not apply / home delivery 30-day supply / specialty drug prescription coverage is available at overall value) prescription; prescription; Specialty drugs are not available through home https://regence.com/go/ delivery. 2024/OR/4tier $10 copay, deductible does $10 copay, deductible does Coverage includes compound medications at 50% not apply / self- not apply / self- coinsurance, deductible does not apply. administrable cancer administrable cancer Page 2 of 7