Gold Buy-Up PPO Buy-Up PPO Core HDHP Basic HDHP IN NETWORK OUT-OF-NETWORK IN NETWORK OUT-OF-NETWORK IN NETWORK OUT-OF-NETWORK IN NETWORK OUT-OF-NETWORK Retail Prescriptions: 50% 50% 10% 40% 0% 30% Generic $10 copay after deductible, $10 copay after deductible, after deductible after deductible after deductible after deductible Minimum $30 Minimum $30 Retail Prescriptions: 50% 50% 10% 40% 0% 30% Preferred $30 copay after deductible, $30 copay after deductible, after deductible after deductible after deductible after deductible Minimum $30 Minimum $30 Retail Prescriptions: 50% 50% 10% 40% 0% 30% Non-Preferred $75 copay after deductible, $75 copay after deductible, after deductible after deductible after deductible after deductible Minimum $30 Minimum $30 Retail Prescriptions: 50% 50% 10% 40% 0% 0% $300 copay after deductible, $300 copay after deductible, after deductible after deductible after deductible after deductible Specialty Minimum $30 Minimum $30 Mail Order: $10 copay Not covered $10 copay Not covered 10% Not covered 0% Not covered Generic after deductible after deductible Mail Order: $30 copay Not covered $30 copay Not covered 10% Not covered 0% Not covered Preferred after deductible after deductible Mail Order: $75 copay Not covered $75 copay Not covered 10% Not covered 0% Not covered Non-Preferred after deductible after deductible Mail Order: Not covered $300 Copay Not covered 10% Not covered 0% Not covered Specialty $300 Copay after deductible after deductible