HDHSA PRESCRIPTION PLAN COST IN-HOUSE NETWORK RETAIL PHARMACY (30-DAY SUPPLY) GENERIC DRUG 20% after deductible 20% after deductible GENERIC DIABETIC PRESCRIPTION MEDICATIONS AND SUPPLIES 20% after deductible 20% after deductible PREFERRED DRUG 20% after deductible 20% after deductible NON-PREFERRED DRUG 20% after deductible 20% after deductible SPECIALTY DRUG (RXONE OR EXPRESS SCRIPTS) 20% after deductible 20% after deductible MAIL ORDER PHARMACY (90-DAY SUPPLY — RXONE OR EXPRESS SCRIPTS) GENERIC DRUG PREFERRED DRUG 20% after deductible NON-PREFERRED DRUG BRAND-NAME DRUGS WHEN GENERIC IS AVAILABLE The brand copayment, plus the difference between the retail cost of the brand-name drug and of the generic drug. Note: The difference will not be applied to the out-of-pocket maximum. IMMUNIZATIONS According to CDC Immunization Schedules; Subject to age limitations *Mail order copays do not apply to mail order Specialty Prescriptions. IN-HOUSE PHARMACY OVERVIEW SERVICES SERVICE PHARMACY LOCATION EMPLOYEE AREA FLAVOR- MAIL IMMUNI- RETAIL SPECIALTY DELIVERY HEALTHPLAN ING ORDER ZATIONS DISCOUNT * 1014 West St. Claire Blvd Ste. 1010      RxONE | Ascension LA 225-271-6098 7777 Hennessy Blvd Ste 114, BR      RxONE | Med Plaza LA 225-765-8951 5000 Hennessy, Chapel Hallway Rm 101, BR      RxONE| Lake LA 225-374-0260 2600 Tower Dr., Monroe     RxONE | Tower Drive LA 318-966-6290 309 Jackson St, Monroe    RxONE | St Francis LA & MS MS only 318-966-7242 4809 Ambassador Caffery Pkwy, Laf     RxONE | Lourdes 337-470-4342 LA & MS MS only 5131 O’Donovan Dr, BR       O'Donovan Pharmacy 225-374-0270 LA 1401 N. Foster Dr, BR     Mid City Pharmacy LA 225-987-9184 8300 Constantin Blvd, BR      Lake Children's Pharmacy LA 225-374-1350 433 Plaza St., Bogalusa, LA  Our Lady of the Angel OP LA 985-730-7219 27