PPO Plan #1 PPO Plan #2 IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Retail Prescriptions: Generic $10 copay Not Covered $10 copay Not Covered Retail Prescriptions: Preferred $75 copay Not Covered $75 copay Not Covered Retail Prescriptions: Non-Preferred $150 copay Not Covered $150 copay Not Covered Retail Prescriptions: Specialty $400 copay Not Covered $400 copay Not Covered Mail Order Prescriptions: Generic $25 copay Not Covered $25 copay Not Covered Mail Order Prescriptions: Preferred $187.50 copay Not Covered $187.50 copay Not Covered Mail Order Prescriptions: Non-Preferred $375 copay Not Covered $375 copay Not Covered Mail Order Prescriptions: Specialty $400 copay Not Covered $400 copay Not Covered