EPO PRESCRIPTION PLAN COST IN-HOUSE NETWORK RETAIL PHARMACY (30-DAY SUPPLY) GENERIC DRUG $10 copay $15 copay GENERIC DIABETIC PRESCRIPTION MEDICATIONS AND SUPPLIES $0 copay $0 copay PREFERRED DRUG $35 copay $70 copay NON-PREFERRED DRUG $70 copay $110 copay SPECIALTY DRUG Filled by RxONE – $100 copay Filled by Express Scripts – $150 copay MAIL ORDER PHARMACY (90-DAY SUPPLY — RXONE OR EXPRESS SCRIPTS) GENERIC DRUG PREFERRED DRUG 2x in-house copay* 3x network copay* 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. PPO PRESCRIPTION PLAN COST IN-HOUSE NETWORK RETAIL PHARMACY (30-DAY SUPPLY) GENERIC DRUG $10 copay $15 copay GENERIC DIABETIC PRESCRIPTION MEDICATIONS AND SUPPLIES $0 copay $0 copay PREFERRED DRUG $45 copay $70 copay NON-PREFERRED DRUG $70 copay $110 copay SPECIALTY DRUG Filled by RxONE – $100 copay Filled by Express Scripts – $150 copay MAIL ORDER PHARMACY (90-DAY SUPPLY – RXONE OR EXPRESS SCRIPTS) GENERIC DRUG PREFERRED DRUG 2x In-house copay* 3x Network copay* 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. 26