Page 5 of 9 Covered Prescription Drug Benefits Cost if you use an In- Network Pharmacy Cost if you use an Out-of-Network Pharmacy 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. Preventive Drugs No deductible, copayment or coinsurance applies to prescription drugs on the PreventiveRX Plus drug list when you use an In-Network Pharmacy. Tier 1a - Typically Lower Cost Generic $5 copay per prescription after deductible is met (retail) and $10 copay per prescription after deductible is met (home delivery) 30% coinsurance up to $250 per prescription after deductible is met (retail) and Not covered (home delivery) Tier 1b - Typically Generic $15 copay per prescription after deductible is met (retail) and $30 copay per prescription after deductible is met (home delivery) 30% coinsurance up to $250 per prescription after deductible is met (retail) and Not covered (home delivery) Tier 2 - Typically Preferred Brand $40 copay per prescription after deductible is met (retail) and $100 copay per prescription after deductible is met (home delivery) 30% coinsurance up to $250 per prescription after deductible is met (retail) and Not covered (home delivery) Tier 3 - Typically Non-Preferred Brand $60 copay per prescription after deductible is met (retail) and $150 copay per prescription after deductible is met (home delivery) 30% coinsurance up to $250 per prescription after deductible is met (retail) and Not covered (home delivery) Tier 4 - Typically Specialty (brand and generic) 30% coinsurance up to $250 per prescription after deductible is met (retail and home delivery) 30% coinsurance up to $250 per prescription after deductible is met (retail) and Not covered (home delivery)