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 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, Pharmacy deductible does not apply (retail) and $10 copay per prescription, Pharmacy deductible does not apply (home delivery) Not covered (retail and home delivery) Tier 1b - Typically Generic $20 copay per prescription, Pharmacy deductible does not apply (retail) and $40 copay per prescription, Pharmacy deductible does not apply (home delivery) Not covered (retail and home delivery) Tier 2 - Typically Preferred Brand $50 copay per prescription after Pharmacy deductible is met (retail) and $125 copay per prescription after Pharmacy deductible is met (home delivery) Not covered (retail and home delivery) Tier 3 - Typically Non-Preferred Brand $75 copay per prescription after Pharmacy deductible is met (retail) and $188 copay per prescription after Pharmacy deductible is met (home delivery) Not covered (retail and home delivery) Tier 4 - Typically Specialty (brand and generic) 30% coinsurance up to $250 per prescription after Pharmacy deductible is met (retail and home delivery) Not covered (retail and home delivery)