UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_TAHS_LRG Med: K-11 Rx: $0/$15/$50/$100/$150 Page 6 of 8 Member Cost Sharing Participating Provider Diabetic Equipment, Supplies, and Education Diabetic equipment and supplies (NOTE: If you have prescription drug coverage through a program other than Express Scripts, Inc., that plan will pay for diabetic supplies and equipment first.) Glucometer, test strips, and lancets, insulin and syringes Must be obtained at a Participating Pharmacy. See applicable Prescription Schedule of Benefits for coverage information. Diabetic education Covered at 100%; you pay $0. Prescription Medication Coverage For additional information on your pharmacy benefits, refer to your Prescription Medication Schedule of Benefits. Tier names describe the most common type(s) of medication (such as brands and generics) within that tier. The Your Choice pharmacy program will apply (mandatory generic). Not subject to Plan Deductible Retail prescription medication • Prescriptions must be dispensed by a participating pharmacy. • 30-day supply. Select Generic Medications Tier You pay $0 Copayment for select generic medications. Preferred Generic Medications Tier You pay $15 Copayment for preferred generic medications. Preferred Brand Medications and Generic Medications (Brand and Generic) Tier You pay $50 Copayment for preferred brand medications and generic medications (brand and generic). Nonpreferred Medications (Brand and Generic) Tier You pay $100 Copayment for nonpreferred medications (brand and generic). 90-day maximum retail supply available for three copayments Specialty prescription medication • Specialty medications are limited to a 30-day supply. See Prescription Medication Schedule of Benefits for additional information. • Most specialty medications must be filled at our contracted specialty pharmacy provider (list available upon request). • Your prescription medication benefit includes coverage of certain specialty medications in the SaveOnSP program. See Prescription Medication Schedule of Benefits for additional information. Specialty Medications (Brand and Generic) Tier You pay $150 Copayment for specialty medications (brand and generic). Oral Chemotherapy Medications (Brand and Generic) You pay $0 Copayment for oral chemotherapy medications (brand and generic). 30-day maximum supply Mail-order prescription medication • A three-month supply (up to 90 days) of medication may be dispensed through the contracted mail-service pharmacy. Select Generic Medications Tier You pay $0 Copayment for select generic medications.