All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay What You Will Pay Common Services You May Limitations, Exceptions & Other Important Plan Provider Non-Plan Provider Medical Event Need Information (You will pay the least) (You will pay the most) Deductible waived for first three visits combined Primary care visit to for non-preventive primary care, urgent care, treat an injury or $50 / visit Not Covered mental/behavioral health and substance use illness disorder outpatient services. If you visit a health Specialist visit $50 / visit Not Covered None care provider's office or clinic You may have to pay for services that aren't Preventive care/ No Charge, deductible does not preventive. Ask your provider if the services screening/ Not Covered apply. needed are preventive. Then check what your immunization plan will pay for. Diagnostic test (x- 40% coinsurance Not Covered None ray, blood work) If you have a test Imaging (CT/PET 40% coinsurance Not Covered None scans, MRI's) Up to a 30-day supply retail or 100-day supply Generic drugs (Tier Retail: $15 / prescription; Mail mail order. Subject to formulary guidelines. No Not Covered 1) order: $30 / prescription Charge for Contraceptives, deductible does not apply. If you need drugs to treat your illness or Up to a 100-day supply retail and mail order. Preferred brand 40% coinsurance up to $100 / condition Not Covered Subject to formulary guidelines. No Charge for drugs (Tier 2) prescription More information Contraceptives, deductible does not apply. about prescription The cost sharing for non-preferred brand drugs drug coverage is Non-preferred brand 40% coinsurance up to $100 / under this plan aligns with the cost sharing for available at Not Covered drugs (Tier 2) prescription preferred brand drugs (Tier 2), when approved www.kp.org/formulary through the formulary exception process. Specialty drugs (Tier 40% coinsurance up to $250 / Up to a 30-day supply retail. Subject to Not Covered 4) prescription formulary guidelines. 2 of 8