Rx Plan Option #3 Deductible Stage $100.00 Initial Coverage Stage After you pay your yearly deductible: You will pay the following until your total yearly drug costs (what you and the plan pay) reach $2,000 : Tier Retail One- Month (31-day) Supply Retail 3-Month (90-day) Supply (Standard) Home Delivery Three-Month (90- day) Supply Tier 1: Generic Drugs 15% 15% 10% Tier 2: Preferred Brand Drugs 30% 30% 25% Tier 3: Non- Preferred Brand 40% 40% 35% Tier 4: Specialty 25% 25% 25% If your doctor prescribes less than a full month’s supply of certain drugs, you will pay a daily cost-sharing rate based on the actual number of days of the drug that you receive. You may receive up to a 90-day supply of certain maintenance drugs (medications taken on a long-term basis) by mail through the Express Scripts PharmacySM. There is no charge for standard shipping. Not all drugs are available at a 90-day supply, and not all retail pharmacies offer a 90-day supply. Non-part D Drugs Covered; Excluding lifestyle Compound Compound Management Solution applies. Compound Management Solution is in place to mitigate compound drug abuse by means of inclusion and exclusion lists Catastrophic Coverage Stage After your yearly out-of-pocket drug costs reach $2,100, you will pay $0