Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Prosthetic Devices 20% coinsurance after 40% coinsurance after 50% coinsurance after Coverage for wigs is limited to 1 item after deductible is met deductible is met deductible is met cancer treatment per benefit period. Cost if you use a Cost if you use an In- Cost if you use an Covered Prescription Drug Benefits Preferred Network Network Pharmacy Out-of-Network Pharmacy Pharmacy Pharmacy Deductible Combined with In-Network medical deductible Combined with Out-of- Network medical deductible Pharmacy Out-of-Pocket Limit Combined with In-Network medical out-of-pocket Combined with Out-of- limit Network medical out-of- pocket limit Prescription Drug Coverage Network: TRUESCRIPTS TEAM – ASSIST WITH INSERTING LANGUAGE HERE Drug List: TRUESCRIPTS TEAM – ASSIST WITH INSERTING LANGUAGE HERE Day Supply Limits: TRUESCRIPTS TEAM – ASSIST WITH INSERTING LANGUAGE HERE Tier 1 – Generic $10 / $25 copay Not Applicable (Retail/Mail Order) Tier 2 - Preferred Brand $75 / $187.50 copay Not Applicable (Retail/Mail Order) Tier 3 - Non-Preferred Brand $150 / $375 copay Not Applicable (Retail/Mail Order) Tier 4 - Specialty $400 copay Not Applicable (Retail/Mail Order) Notes: • Dependent Age Limit: to the end of the month in which the child attains age 26. • Members are encouraged to always obtain prior approval when using Out-of-Network Providers. Precertification will help the member know if the services are considered not medically necessary. • No charge means no deductible / copayment / coinsurance up to the maximum allowable amount. 0% means no coinsurance up to the maximum allowable amount. However, when choosing an Out-of-Network Provider, the member is responsible for any balance due after the plan payment. • If you have an office visit with your Primary Care Physician or Specialist at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under “Outpatient Facility Services”. Page 6 of 10