UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_TAHS_LRG Med: K-11 Rx: $0/$15/$50/$100/$150 Page 7 of 8 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 Preferred Generic Medications Tier You pay $30 Copayment for preferred generic medications. Preferred Brand Medications and Generic Medications (Brand and Generic) Tier You pay $100 Copayment for preferred brand medications and generic medications (brand and generic). Nonpreferred Medications (Brand and Generic) Tier You pay $200 Copayment for nonpreferred medications (brand and generic). 90-day maximum mail-order supply If the brand-name medication is dispensed instead of the generic equivalent, you must pay the Copayment associated with the brand-name medication as well as the price difference between the brand-name medication and the generic medication.