Common What You Will Pay Limitations, Exceptions, & Other Important Medical Event Services You May Need In-network Out-of-network Information (You will pay the least) (You will pay the most) If you need drugs to treat Generic drugs (Tier 1) 0% Coinsurance after 40% Coinsurance after your illness or Deductible Deductible condition. More Preferred brand drugs (Tier 2) 40% Coinsurance after 40% Coinsurance after Pharmacy Benefits are administered by information Deductible Deductible CVS/Caremark. about prescription drug coverage Non-preferred brand drugs 50% Coinsurance after 40% Coinsurance after is available at (Tier 3) Deductible Deductible www.caremark. com. Facility fee (e.g., ambulatory 20% Coinsurance 40% Coinsurance None If you have surgery center) outpatient surgery Physician/surgeon fees 20% Coinsurance 40% Coinsurance None Emergency room care 20% Coinsurance 20% Coinsurance In-network deductible applies to Out-of-network benefits If you need immediate Emergency medical 20% Coinsurance 20% Coinsurance In-network deductible applies to medical transportation Out-of-network benefits attention Urgent care 20% Coinsurance 40% Coinsurance None Page 3 of 7