Covered Medical Benefits Cost if you use an In-Network Provider Prosthetic Devices No charge Cost if you use an In- Cost if you use a Covered Prescription Drug Benefits Network Pharmacy Non-Network Pharmacy Pharmacy Deductible $250 person / Not covered $750 family (does not apply to Tier 1a, Tier 1b drugs) Pharmacy Out-of-Pocket Limit Combined with In- Not covered Network medical out- 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 Not covered (retail and prescription, Pharmacy home delivery) deductible does not apply (retail) and $10 copay per prescription, Pharmacy deductible does not apply (home delivery) Tier 1b - Typically Generic $20 copay per Not covered (retail and prescription, Pharmacy home delivery) deductible does not apply (retail) and $40 copay per prescription, Pharmacy deductible does not apply (home delivery) Tier 2 – Typically Preferred Brand $50 copay per Not covered (retail and prescription after home delivery) Pharmacy deductible is met (retail) and $125 Page 5 of 10