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