2025 Pharmacy Benefit Overview Prescription Benefit Highlights: In-Network* PPO Plan HSA Plan Retail Pharmacy (30 Day Supply) Tier 1 Typically Generic $10 20% coinsurance after Deductible Tier 2 Typically Preferred Brand $30 20% coinsurance after Deductible Tier 3 Typically Non-Preferred Brand $75 20% coinsurance after Deductible Tier 4 Typically Specialty 25% to $350 per Rx 20% coinsurance after Deductible Mail Order (90 Day Supply) Carelon Rx Tier 1 Typically Generic $25 20% coinsurance after Deductible Tier 2 Typically Preferred Brand $105 20% coinsurance after Deductible Tier 3 Typically Non-Preferred Brand $225 20% coinsurance after Deductible Tier 4 Typically Specialty 25% to $350 per Rx 20% coinsurance after Deductible Covered Prescription Drug Benefits Pharmacy Deductible Combined with in-network medical deductible Pharmacy Out of Pocket Limit Combined with in-network medical out-of-pocket limit Prescription Drug Coverage Network: Base Network Drug list: National Drugs not included on the drug list will not be covered, then $30 copay Day Supply Limits: Retail Pharmacy – 30-day supply Retail Pharmacy – 90-day supply (3 times the 30-day supply cost share(s) charged at Preferred Network and in- network retails pharmacies noted below applies). Home Delivery Pharmacy – 90-day supply (maximum cost share noted above) Maintenance medications are available through Carelon Rx Mail (Ingenio Rx will became Carelon Rx on January 1, 2023). 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 above 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. Drug cost share assistance programs may be available for certain specialty drugs. Preventive Drugs - Your pharmacy cost share is waived for in-network drugs included on the Preventive Drug Enhanced drug list, a designated list of drugs to treat health conditions, such as: diabetes, asthma, depression, heart health, high blood pressure, high cholesterol, and osteoporosis. 1) If enrolled in the PPO plan, you will be responsible for RX copays until your total expenses (medical and RX) reach the total out-of-pocket maximum. PPO copays do not accumulate toward your deductible. 2) Specialty medications are limited to a 30-day supply, whether purchased at retail or through mail order. 3) The Preventive Drug Plan covers only preventive drugs listed on the Preventive Drug List at 100% when in- network. Drugs not on the list will be subject to the deductible and coinsurance. A complete list of covered preventive drugs is available in the Preventive Drug List. Page 8 | Duncan Supply Company, Inc.| Plan Year 2025 Open Enrollment This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.