Page 6 of 10 Covered Prescription Drug Benefits Cost if you use an In- Network Pharmacy Cost if you use an Out-of-Network Pharmacy Pharmacy Out-of-Pocket Limit Combined with In- Network medical out- of-pocket limit Combined with Out-of- Network medical out- of-pocket limit Prescription Drug Coverage Network: Base Network Drug List: CA Essential DMHC Drugs not included on the CA Essential DMHC 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 our home delivery 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 prescription (retail) and $10 copay per prescription (home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery) Tier 1b - Typically Generic $20 copay per prescription (retail) and $40 copay per prescription (home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery) Tier 2 - Typically Preferred Brand $30 copay per prescription (retail) and $75 copay per prescription (home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery) Tier 3 - Typically Non-Preferred Brand $50 copay per prescription (retail) and $125 copay per prescription (home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery) Tier 4 - Typically Specialty (brand and generic) 30% coinsurance up to $250 per prescription (retail and home delivery) 50% coinsurance up to $250 per prescription (retail) and Not covered (home delivery)