Your Pharmacy Benefits Eff ective Date January 1, 2020 Benefi t Type Plan A Days’ Supply Dispensed Retail Pharmacy Up to 90 Days Mail Order Up to 90 Days Specialty Pharmacy 30 days only Benefi t Structure - Plan A Retail Pharmacy Applies to Tier Retail pharmacy Mail Order Up to 34-Days Out-of-Pocket Level 35-90 days* 90-Day Supply Supply Maximum Greater of Tier 1 10% 10% Yes $10 or 15% Greater of Greater of Greater of Tier 2 Yes $40 or 40% $40 or 40% $40 or 40% Greater of Greater of Greater of Tier 3 Yes $60 or 60% $60 or 60% $60 or 60% *Fills for Days’ Supply greater than 34 are limited to Kroger pharmacies Specialty - Plan A Lumicera Pharmacy 10% Annual Out-of-Pocket Maximum - Plan A - copays will no longer apply once the out-of- pocket maximum is satisfi ed Combined Individual Maximum $3,000 Medical and Rx Combined Family Maximum $6,000 Medical and Rx Tier 1: Usually includes generic medications Tier 2: Usually includes preferred brand-name medications Tier 3: Usually includes non-preferred brand-name medications 1410-1119MB