Common use of SUMMARY OF PHARMACY BENEFITS Clause in Contracts

SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Suppl calibration fluid): When purchased at a Retail or Spaelctiy Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof for maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitn, our website. Proratedcopaymentsfor a shorter supply period may apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 and Tier5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 and Tier5: See specialty prescription drug section below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescrpition Drug section for details. When purchased at a Specialty Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier4: $150 Not Covered Tier5: $300 Not Covered When purchased at a Retail Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4: 50% Not Covered Tier5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight (8)-viintro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% NotCovered Tier 2: 20% Not Covered Tier 3:20% Not Covered When purchased at a Specialty Pharmacy(+) Tier4: 20% Not Covered Tier 5:20% Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy w require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4: 20% Not Covered Tier 5:20% Not Coverde When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods - Coverage includes barrier method (diaphragm or cervical cap), hormonal method (b control pill), and emergencoyntraception. When purchased at a Retail Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof of maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitn, v our website. Tier 1: $0 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 and Tier5: Contraceptives are only placed in Tier 1, Tier 2, or Tier3. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 and Tier5: Contraceptives are only placed in Tier 1, Tier 2, or Tier3. See above. Not Covered

SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more informationmoreinformation. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Suppl calibration fluid): When purchased at a Retail or Spaelctiy Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof for maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitnoption, our website. Proratedcopaymentsfor a shorter shotrer supply period may apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 Tier 4 and Tier5Tier 5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 Tier 4 and Tier5Tier 5: See specialty prescription drug section below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescrpition Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier4Tier 4: $150 Not Covered Tier5Tier 5: $300 Not Covered When purchased at a Retail Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement reimburesment is based on the pharmacy allowance. Tier4Tier 4: 50% Not Covered Tier5Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight (8)-viintro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% NotCovered Not Covered Tier 2: 20% Not Covered Tier 3:203: 20% Not Covered When purchased at a Specialty Pharmacy(+) Tier4Tier 4: 20% Not Covered Tier 5:205: 20% Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more informationmoreinformation. You Pay You Pay When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy w require a significantly higher significanthlyigher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4Tier 4: 20% Not Covered Tier 5:205: 20% Not Coverde Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods - Coverage includes barrier method (diaphragm or cervical cap), hormonal method (b control pill), and emergencoyntraception. emergency contracep.tion When purchased at a Retail Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof of maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs prescriptiodnrugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitnoption, v our website. Tier 1: $0 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 NotCovered Tier 4 and Tier5Tier 5: Contraceptives are only placed in Tier 1, Tier 2, or Tier3Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $0 Not Covered NotCovered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 Tier 4 and Tier5Tier 5: Contraceptives are only placed in Tier 1, Tier 2, or Tier3Tier 3. See above. Not Covered

SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than otherthan Specialty Prescription Drugs, and Diabetic Equipment and Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Suppl calibration fluid): When purchased at a Retail or Spaelctiy Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof for maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitnoption, our website. Proratedcopaymentsfor a shorter supply period may apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 Tier 4 and Tier5Tier 5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 Tier 4 and Tier5Tier 5: See specialty prescription drug section below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescrpition Prescription Drug section for details. When purchased purchsaed at a Specialty Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier4Tier 4: $150 Not Covered Tier5Tier 5: $300 Not Covered When purchased at a Retail Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement reimburesment is based on the pharmacy allowance. Tier4Tier 4: 50% Not Covered Tier5Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight (8)-viintro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% NotCovered Not Covered Tier 2: 20% Not Covered Tier 3:203: 20% Not Covered When purchased at a Specialty Pharmacy(+) Tier4Tier 4: 20% Not Covered Tier 5:205: 20% Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy w require a significantly higher significanthlyigher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4Tier 4: 20% Not Covered Tier 5:205: 20% Not Coverde Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods - Coverage includes barrier method (diaphragm or cervical cap), hormonal method (b control pill), and emergencoyntraception. emergency contracep.tion When purchased at a Retail Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof of maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs prescriptiodnrugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitnoption, v our website. Tier 1: $0 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 Coverde Tier 4 and Tier5Tier 5: Contraceptives are only placed in Tier 1, Tier 2, or Tier3Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 Tier 4 and Tier5Tier 5: Contraceptives are only placed in Tier 1, Tier 2, or Tier3Tier 3. See above. Not Covered

SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Suppliesw( hich includes GlucometersincludesGlucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Suppl calibration fluid): When purchased at a Retail or Spaelctiy Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof for maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitn, our website. Proratedcopaymentsfor a shorter supply period may apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 Not Covered NotCovered Tier 2: $35 30 Not Covered Tier 3: $70 50 Not Covered Tier4 and Tier5Tier 4: See specialty $75 Not Covered Tier 5: Seespecialty prescription drug section drusgection below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $87.50 75 Not Covered Tier 3: $210 125 Not Covered Tier4 and Tier5Tier 4: See specialty $225 Not Covered Tier 5: Seespecialty prescription drug section drusgection below. Not Covered NotCovered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescrpition Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Tier 5: $125 Not Covered Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier4: $150 Not Covered Tier5: $300 Not Covered When purchased at a Retail Pharmacy(+): Tier 5: 50% Not Covered Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4: 50% Not Covered Tier5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight (8)-viintro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% NotCovered Not Covered Tier 2: 20% Not Covered Tier 3:203: 20% Not Covered Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy(+) Tier4Tier 5: 20% Not Covered NotCovered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy w require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5:205: 20% Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy w require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4: 20% Not Covered Tier 5:20% Not Coverde When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods - Coverage includes barrier method (diaphragm or cervical cap), hormonal method (b control pill), and emergencoyntraceptionemergency contraception. When purchased at a Retail Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof of maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitn, v our website. Tier 1: $0 Not Covered Tier 2: $35 30 Not Covered Tier 3: $70 50 Not Covered Tier4 and Tier5Tier 4: $75 Not Covered Tier 5: Contraceptives are only placed in placedin Tier 1, Tier 2, Tier 3, or Tier3Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $87.50 75 Not Covered Tier 3: $210 125 NotCovered Tier 4: $225 Not Covered Tier4 and Tier5Tier 5: Contraceptives are only placed in Tier 1, Tier 2, Tier 3, or Tier3Tier 4. See above. Not Covered

SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay YouPay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Suppl calibration fluid): When purchased at a Retail or Spaelctiy Specialty Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof for maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenanceand non-maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitnoption, our website. Proratedcopaymentsfor a shorter supply period supplyepriod may apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 1:20%- Afterdeductible Not Covered Tier 2: $35 2:20%- Afterdeductible Not Covered Tier 3: $70 3:20%- Afterdeductible Not Covered Tier4 and Tier5: See specialty prescription drug section drusgection below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $25 1:20%- Afterdeductible Not Covered Tier 2: $87.50 2:20%- Afterdeductible Not Covered Tier 3: $210 3:20%- Afterdeductible Not Covered Tier4 and Tier5: See specialty prescription drug section drusgection below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescrpition Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier4: $150 20%- Afterdeductible Not Covered Tier5: $300 20%- Afterdeductible Not Covered When purchased at a Retail Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement reimburesment is based on the pharmacy allowance. Tier4: 50% 50%- Afterdeductible Not Covered Tier5: 50% 50%- Afterdeductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight (8)-viintro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% NotCovered 20%- Afterdeductible Not Covered Tier 2: 20% 20%- Afterdeductible Not Covered Tier 3:20% 3:20%- Afterdeductible Not Covered When purchased at a Specialty Pharmacy(+) Tier4: 20% 20%- Afterdeductible Not Covered Tier 5:20% 5:20%- Afterdeductible Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay YouPay When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy w require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4: 20% 20%- Afterdeductible Not Covered Tier 5:20% 5:20%- Afterdeductible Not Coverde Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods - Coverage includes barrier method (diaphragm method(diaphragm or cervical cap), hormonal method (b bi control pill), and emergencoyntraceptionemergency contraception. When purchased at a Retail Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof of maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitn, v our website. Tier 1: $0 1:0% Not Covered Tier 2: $35 2:20%- Afterdeductible Not Covered Tier 3: $70 3:20%- Afterdeductible Not Covered Tier4 and Tier5: Contraceptives are only placed in Tier 1, Tier 2, 2 or Tier3. See above. Not Covered When purchased at a Mail aMail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $0 1:0% Not Covered Tier 2: $87.50 2:20%- Afterdeductible Not Covered Tier 3: $210 3:20%- Afterdeductible Not Covered Tier4 and Tier5: Contraceptives are only placed in Tier 1, Tier 2, 2 or Tier3. See above. Not Covered

SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription SpecialtyPrescription Drugs, and Diabetic Equipment and Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Suppl calibration fluid): When purchased at a Retail or Spaelctiy Specialty Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof for maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenanceand non-maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitnoption, our website. Proratedcopaymentsfor a shorter supply period supplyepriod may apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 Not Covered Tier 2: $35 30 Not Covered Tier 3: $70 50 Not Covered Tier4 and Tier5Tier 4: See specialty $75 Not Covered Tier 5: Seespecialty prescription drug section drusgection below. Not Covered NotCovered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $87.50 75 Not Covered Tier 3: $210 125 Not Covered Tier4 and Tier5Tier 4: See specialty $225 Not Covered Tier 5: Seespecialty prescription drug section drusgection below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescrpition Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Tier 5: $125 Not Covered Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier4: $150 Not Covered Tier5: $300 Not Covered When purchased at a Retail Pharmacy(+): Tier 5: 50% Not Covered Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement reimburesment is based on the pharmacy allowance. Tier4: 50% Not Covered Tier5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight oefight (8)-viintro 8) i-nvitro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% NotCovered Not Covered Tier 2: 20% Not Covered Tier 3:20% Not Covered When purchased at a Specialty Pharmacy(+) Tier43: 20% Not Covered Tier 5:204: 20% Not Covered When purchasedat a Specialty Pharmacy(+) Tier 5: 20% Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy w require a significantly higher out of pocket expense than if purchased from a specialty pharmacyspeciaplthyarmacy. Our reimbursement is based on the pharmacy allowance. Tier4Tier 5: 20% Not Covered Tier 5:20% Not Coverde When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods - Coverage includes barrier method (diaphragm or cervical cap), hormonal method (b control pill), and emergencoyntraceptionemergency contraception. When purchased at a Retail Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof of maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 aFo9r0-day supply; three retail copayments apply. For more information about pharmacies offering this optisoitnoption, v our website. Tier 1: $0 Not Covered Tier 2: $35 30 Not Covered Tier 3: $70 50 Not Covered Tier4 and Tier5Tier 4: Contraceptives are $75 Not Covered Tier 5: Contraceptiveasre only placed in Tier 1, Tier 22 Tier 3, or Tier3Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $87.50 75 Not Covered Tier 3: $210 125 Not Covered Tier4 and Tier5Tier 4: $225 Not Covered Tier 5: Contraceptives are only placed in Tier 1, Tier 22 Tier 3, or Tier3Tier 4. See above. Not Covered

SUMMARY OF PHARMACY BENEFITS. Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Suppl calibration fluid): When purchased at a Retail or Spaelctiy Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof for maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and noandnon-nmaintenance maintenance prescription drugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitnoption, our website. Proratedcopaymentsfor a shorter supply period may perdiomay apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 Tier 4 and Tier5Tier 5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 Tier 4 and Tier5Tier 5: See specialty prescription drug section below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescrpition Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier4Tier 4: $150 Not Covered Tier5Tier 5: $300 Not Covered When purchased at a Retail Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement reimburesment is based on the pharmacy allowance. Tier4Tier 4: 50% Not Covered Tier5Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight (8)-viintro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% NotCovered Not Covered Tier 2: 20% Not Covered Tier 3:203: 20% Not Covered When purchased at a Specialty Pharmacy(+) Tier4Tier 4: 20% Not Covered Tier 5:205: 20% Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy w require a significantly higher significanthlyigher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier4Tier 4: 20% Not Covered Tier 5:205: 20% Not Coverde Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods - Coverage includes barrier method (diaphragm or cervical cap), hormonal method (b control pill), and emergencoyntraception. emergency contracep.tion When purchased at a Retail Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof of maintenance and n-omnaintenance prescription drugs. For tiers 1, 2, and 3: Up to a -9d0ay supply of maintenance and no-nmaintenance prescription drugs prescriptiodnrugs is available at certain retail pharmacies. For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this optisoitnoption, v our website. Tier 1: $0 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier4 Coverde Tier 4 and Tier5Tier 5: Contraceptives are only placed in Tier 1, Tier 2, or Tier3Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier4 Tier 4 and Tier5Tier 5: Contraceptives are only placed in Tier 1, Tier 2, or Tier3Tier 3. See above. Not Covered