Eff ective Date January 1, 2020 Benefit Type Select 3 Tier Days’ Supply Dispensed Participating Pharmacy Up to 34 Days Mail Order Up to 90 Days Specialty Pharmacy Up to 34 Days Benefit Structure - Plan B Retail Pharmacy Kroger Retail Applies to Tier Up to 34-Days Pharmacy Mail Order Out-of-Pocket Level Supply 35-90 Days 90-Day Supply Maximum Supply* Tier 1 $10 10% 10% Yes Tier 2 Greater of Greater of Greater of Yes $40 or 40% $40 or 40% $40 or 40% Tier 3 Greater of Greater of Greater of Yes $60 or 60% $60 or 60% $60 or 60% *Fills for Days’ Supply greater than 34 are limited to Kroger pharmacies Specialty - Plan B Lumicera Pharmacy 20% Annual Out-of-Pocket Maximum - Plan B - copays will no longer apply once the out-of- pocket maximum is satisfied Individual Maximum $6,000 Combined Medical and Rx Family Maximum $12,000 Combined 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