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) Primary care visit to $25 / visit, deductible does not treat an injury or Not Covered None apply. illness $25 / visit, deductible does not If you visit a health Specialist visit Not Covered None apply. 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- $10 / encounter, deductible does Not Covered None ray, blood work) not apply. If you have a test 20% coinsurance up to $150 / Imaging (CT/PET procedure, deductible does not Not Covered None scans, MRI's) apply. Up to a 30-day supply retail or 100-day supply Retail: $10 / prescription; Mail Generic drugs (Tier mail order. Subject to formulary guidelines. No order: $20 / prescription, Not Covered 1) Charge for Contraceptives, deductible does not deductible does not apply. apply. If you need drugs to Up to a 30-day supply retail or 100-day supply Retail: $30 / prescription; Mail treat your illness or Preferred brand mail order. Subject to formulary guidelines. No order: $60 / prescription, Not Covered condition drugs (Tier 2) Charge for Contraceptives, deductible does not deductible does not apply. More information apply. about prescription The cost sharing for non-preferred brand drugs drug coverage is Retail: $30 / prescription; Mail Non-preferred brand under this plan aligns with the cost sharing for available at order: $60 / prescription, Not Covered drugs (Tier 2) preferred brand drugs (Tier 2), when approved www.kp.org/formulary deductible does not apply. through the formulary exception process. 20% coinsurance up to $250 / Specialty drugs (Tier Up to a 30-day supply retail. Subject to prescription, deductible does not Not Covered 4) formulary guidelines. apply. 2 of 8