Tier 2 31 - 90 $187.50 Tier 3 1 - 30 $150 Tier 3 31 - 90 $375 Specialty Tier 1 1 - 30 $400 Specialty Tier 2 1 - 30 20% to $550 maximum Specialty Tier 3 1 - 30 20% to $2000 maximum Specialty Tier 4 1 - 30 20% Specialty Tier 5 1 - 30 50% Deductible N/A Max Out of Pocket RX & Medical Combined / Individual $7,000.00 / Family $14,000.00 • Family Max OOP is Embedded. If the Plan is intended to be a high deductible health Plan (HDHP), benefits will be processed to maintain HSA eligibility. Plan Name Drug Type Day Supply CoPay Structure PPO Option 2 Tier 1 1 - 30 $10 Tier 1 31 - 90 $25 Tier 2 1 - 30 $75 Tier 2 31 - 90 $187.50 Tier 3 1 - 30 $150 Tier 3 31 - 90 $375 Specialty Tier 1 1 - 30 $400 Specialty Tier 2 1 - 30 20% to $550 maximum Specialty Tier 3 1 - 30 20% to $2000 maximum Specialty Tier 4 1 - 30 20% Specialty Tier 5 1 - 30 50% Deductible N/A Max Out of Pocket RX & Medical Combined / Individual $7,350.00 / Family $14,700.00 • Family Max OOP is Embedded. If the Plan is intended to be a high deductible health Plan (HDHP), benefits will be processed to maintain HSA eligibility. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 5 of 15