Preventive Prescriptions 100% covered 100% covered 100% covered 100% covered 100% covered 100% covered Retail Prescriptions: Generic 0% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible $15 copay N/A Retail Prescriptions: Preferred 0% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible $40 copay N/A Retail Prescriptions: Non-Preferred 0% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible $60 copay N/A Retail Prescriptions: Specialty 0% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible $60 copay N/A Mail Order Prescriptions: Generic 0% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible $30 copay N/A Mail Order Prescriptions: Preferred 0% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible $100 copay N/A Mail Order Prescriptions: Non-Preferred 0% coinsurance after deductible 30% coinsurance after deductible 20% coinsurance after deductible 40% coinsurance after deductible $150 copay N/A Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited CDHP #1 CDHP #2 Traditional PPO OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK