UPMC Health Options, Inc. Schedule of Benefits 2025_EPO_MCA_TAHS_LRG Med: K-7 Rx: $0/$15/$75/$125/$250 Page 8 of 9 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 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.