Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) chemotherapy prescription chemotherapy prescription Cost shares for insulin will not exceed $85 / 30-day $50 copay, deductible does $50 copay, deductible does supply retail prescription or $255 / 90-day supply home not apply / retail not apply / retail delivery prescription. prescription; prescription; No charge, deductible does not apply for certain preventive drugs, contraceptives and immunizations at Tier 2 (Typically, brand $100 copay, deductible $100 copay, deductible a participating pharmacy. drugs with moderate does not apply / home does not apply / home If you fill a brand drug or specialty drug when there is overall value) delivery prescription; delivery prescription; an equivalent generic drug or specialty biosimilar drug available, you pay the difference in cost in addition to $50 copay, deductible does $50 copay, deductible does the copayment and/or coinsurance. not apply / self- not apply / self- The first fill of specialty drugs may be provided by a administrable cancer administrable cancer retail pharmacy; additional refills must be provided by a chemotherapy prescription chemotherapy prescription specialty pharmacy. $75 copay, deductible does $75 copay, deductible does not apply / retail not apply / retail prescription; prescription; Tier 3 (Typically, brand $150 copay, deductible $150 copay, deductible drugs with lower overall does not apply / home does not apply / home value) delivery prescription; delivery prescription; $100 copay, deductible $100 copay, deductible does not apply / self- does not apply / self- administrable cancer administrable cancer chemotherapy prescription chemotherapy prescription 50% coinsurance, 50% coinsurance, deductible does not apply / deductible does not apply / specialty drug; specialty drug; Tier 4 (Specialty drugs) $100 copay, deductible $100 copay, deductible does not apply / self- does not apply / self- administrable cancer administrable cancer chemotherapy prescription chemotherapy prescription Page 3 of 7