Cost if you use an In- Cost if you use a Covered Prescription Drug Benefits Network Pharmacy Non-Network Pharmacy Pharmacy Out-of-Pocket Limit Combined with In- Combined with Non- Network medical out- Network medical out- of-pocket limit of-pocket limit Prescription Drug Coverage Network: Base Network Drug List: Essential Drugs not included on the Essential drug list will not be covered. Day Supply Limits: Retail Pharmacy 30 day supply (cost shares noted below) Retail 90 Pharmacy 90 day supply (3 times the 30 day supply cost share(s) charged at In-Network Retail Pharmacies noted below applies). Home Delivery Pharmacy 90 day supply (maximum cost shares noted below). Maintenance medications are available through CarelonRx Pharmacy. You will need to call us on the number on your ID card to sign up when you first use the service. Specialty Pharmacy 30 day supply (cost shares noted below for retail and home delivery apply). We may require certain drugs with special handling, provider coordination or patient education be filled by our designated specialty pharmacy. Tier 1a - Typically Lower Cost Generic $5 copay per 50% coinsurance up to prescription (retail) and $250 per prescription $10 copay per (retail) and Not covered prescription (home (home delivery) delivery) Tier 1b - Typically Generic $15 copay per 50% coinsurance up to prescription (retail) and $250 per prescription $30 copay per (retail) and Not covered prescription (home (home delivery) delivery) Tier 2 – Typically Preferred Brand $30 copay per 50% coinsurance up to prescription (retail) and $250 per prescription $75 copay per (retail) and Not covered prescription (home (home delivery) delivery) Tier 3 - Typically Non-Preferred Brand $50 copay per 50% coinsurance up to prescription (retail) and $250 per prescription $125 copay per (retail) and Not covered prescription (home (home delivery) delivery) Tier 4 - Typically Specialty (brand and generic) 30% coinsurance up to 50% coinsurance up to $250 per prescription $250 per prescription (retail and home (retail) and Not covered delivery) (home delivery) Page 6 of 10