Common use of Five-Tier Copayment Structure Clause in Contracts

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 Not Covered Tier 3: $50 Not Covered Tier 4: $75 Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 Not Covered Tier 3: $125 Not Covered Tier 4: $225 Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 25 Not Covered Tier 3: $50 35 Not Covered Tier 4: $75 60 Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 62.50 Not Covered Tier 3: $125 87.50 Not Covered Tier 4: $225 180 Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 - After deductible Not Covered Tier 2: $30 45 - After deductible Not Covered Tier 3: $50 70 - After deductible Not Covered Tier 4: $75 90 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 - After deductible Not Covered Tier 2: $75 112.50 - After deductible Not Covered Tier 3: $125 175 - After deductible Not Covered Tier 4: $225 270 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription DrugsIn accordance with RIGL § 27-18.94, other than Specialty Prescription Drugsthis plan covers one two-pack epinephrine auto- injector kit, and Diabetic Equipment and Supplies (which includes Glucometerswith no copayment after deductible, Test Stripsper plan year, Lancet and Lancet Devicesas indicated on our formulary. Please contact our Customer Service Department for details. This plan allows for certain preventive prescriptions drugs to be covered, Needles and Syringeswith a copayment, and Miscellaneous Supplies, calibration fluid): When purchased at before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a Retail Pharmacy: For maintenance and non-maintenance list of these preventive prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, please visit our website. Tier 1: $10 Not Covered Tier 2: $30 Not Covered Tier 3: $50 Not Covered Tier 4: $75 Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 Not Covered Tier 3: $125 Not Covered Tier 4: $225 Not Covered Tier 5: See specialty prescription drug section below. Not Coveredwebsite or call our Customer Service Department.

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 40 Not Covered Tier 3: $50 70 Not Covered Tier 4: $75 90 Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 100 Not Covered Tier 3: $125 175 Not Covered Tier 4: $225 270 Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail or Specialty Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 35 Not Covered Tier 3: $50 70 Not Covered Tier 4: $75 Not Covered 4 and Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 87.50 Not Covered Tier 3: $125 210 Not Covered Tier 4: $225 Not Covered 4 and Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The First Tier: generally includes formulary low cost preferred generic prescription drugs, which require the lowest copayment. Second Tier: generally includes other certain formulary low cost preferred generic prescription drugs, which require a higher copayment for than the First Tier. Third Tier: generally includes formulary high cost non-preferred generic prescription drugs and preferred brand name prescription drugs, which require a higher copayment. Fourth Tier: generally includes other formulary generic and non-preferred brand name drugs which require a higher Fifth Tier: generally includes formulary specialty prescription drug will vary by tierdrugs, which require a copayment. The tier placement of a prescription drug on our Our formulary is subject to change. For more information about our formularylists generic, preferred brand name, and to see non-preferred brand name prescription drugs and specialty prescription drugs covered under this agreement. To obtain a copy of the tier placement of a particular prescription drugmost current formulary listing, visit our website Web site at ▇▇▇▇▇▇.▇▇▇. or you may call our Customer Service Department at (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇. See the Summary of Pharmacy Benefits for benefit limits and level of coverage. Maintenance and non-maintenance generic, preferred brand name, or non-preferred brand name prescription drugs and diabetic equipment and supplies may be bought from a network mail order pharmacy. The prescription is limited to the benefit limit and the amount that you pay shown in the Summary of Pharmacy Benefits. For mail order instructions, please call our Customer Service Department. Below indicates The following diabetic equipment and supplies can be bought at a network pharmacy: • Glucometers; • Test Strips; • Lancet and Lancet Devices; and • Miscellaneous Supplies (including calibration fluid). See the tier structure Summary of Pharmacy Benefits for this plan benefit limits and the amount that you are pay. When you buy covered prescription drugs and diabetic equipment and supplies from a network pharmacy, you will be responsible for the copayment and prescription drug deductible (if any) shown in the Summary of Pharmacy Benefits at the time you buy the prescription drugs and diabetic equipment and supplies. Coverage is based on our pharmacy allowance. This agreement does NOT cover generic, preferred brand name, and non-preferred brand name prescription drugs or diabetic equipment and supplies when bought at non-network pharmacies. If you buy generic, preferred brand name, and non-preferred brand name prescription drugs or diabetic equipment and supplies from non-network pharmacies, you will be responsible to paypay the charge for the prescription drug or diabetic equipment and supplies at the time the prescription is filled. If you buy specialty prescription drugs from a retail network pharmacy or a non-network pharmacy, you will be responsible to pay the charge for the specialty prescription drug at the time the prescription is filled. You may submit a claim to us and we will reimburse you directly. You will be responsible for paying the lowest cost copayment shown in the Summary of either your copayment, Pharmacy Benefits and the retail cost of difference between the drug, or charge and the pharmacy allowance. We reserve the right not See Section 7.1 - How to accept manufacturer coupons, discount plan payments or other cost share assistance program payments File a Claim. Prescription drug preauthorization is required for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin certain brand name prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 Not Covered Tier 3: $50 Not Covered Tier 4: $75 Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 Not Covered Tier 3: $125 Not Covered Tier 4: $225 Not Covered Tier 5: See specialty To obtain prescription drug section belowpreauthorization, the prescribing provider must submit a completed prescription drug preauthorization request form. Not CoveredThe prescribing provider may obtain a prescription drug preauthorization form by visiting our Web site at ▇▇▇▇▇▇.▇▇▇ or calling the Physician and Provider Service Center. Preauthorization requests may be submitted in one of the following ways: • By fax, submit the form to Catamaran at ▇-▇▇▇-▇▇▇-▇▇▇▇; • By phone, contact Catamaran at ▇-▇▇▇-▇▇▇-▇▇▇▇; • By mail, send the completed form to: Catamaran Prior Authorization P. O. ▇▇▇ ▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇] Prescription drugs that require prescription drug preauthorization will only be approved when our clinical guidelines are met. The guidelines are based upon clinically appropriate criteria that ensure that the prescription drug is appropriate and cost-effective for the illness, injury or condition for which it has been prescribed. We will send to you written notification of the prescription drug preauthorization determination within two (2) business days of receipt of all medical documentation required to conduct the review, but not to exceed fourteen (14) calendar days from the receipt of the request.

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs and devices is available at all network retail pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 Not Covered Tier 3: $125 - After deductible Not Covered Tier 4: $225 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered five -tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. (+) Preauthorization is required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing prescribed dosing period. Prorated copayments for a shorter supply periodmay period may apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 0 - After deductible Not Covered Tier 2: $30 0 - After deductible Not Covered Tier 3: $50 0 - After deductible Not Covered Tier 4: $75 0 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 0 - After deductible Not Covered Tier 2: $75 0 - After deductible Not Covered Tier 3: $125 0 - After deductible Not Covered Tier 4: $225 0 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered HSA Preventive Prescription Drugs - Coverage for certain preventive prescription drugs before meeting your plan year deductible. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. When purchased at a Retail or Specialty Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribed dosing period. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain retail pharmacies. For a 90-day supply; three retail copayments apply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 $0 - After deductible Not Covered Tier 2: $50 $0 - After deductible Not Covered Tier 3: $75 $0 - After deductible Not Covered Tier 4: $95 $0 - After deductible Not Covered Tier 5: Not applicable before deductible. See specialty prescription drug section below for after deductible. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs and devices is available at all network retail pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 7 Not Covered Tier 2: $30 35 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 17.50 Not Covered Tier 2: $75 87.50 Not Covered Tier 3: $125 - After deductible Not Covered Tier 4: $225 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail or Specialty Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 - After deductible Not Covered Tier 2: $30 35 - After deductible Not Covered Tier 3: $50 70 - After deductible Not Covered Tier 4: $75 Not Covered 4 and Tier 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 non- maintenance prescription drugs. Tier 1: $25 - After deductible Not Covered Tier 2: $75 87.50 - After deductible Not Covered Tier 3: $125 210 - After deductible Not Covered Tier 4: $225 Not Covered 4 and Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 15 Not Covered Tier 2: $30 50 Not Covered Tier 3: $50 100 Not Covered Tier 4: $75 200 Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 37.50 Not Covered Tier 2: $75 125 Not Covered Tier 3: $125 250 Not Covered Tier 4: $225 600 Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 40 Not Covered Tier 3: $50 80 Not Covered Tier 4: $75 150 Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 100 Not Covered Tier 3: $125 200 Not Covered Tier 4: $225 450 Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs and devices is available at all network retail pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 - After deductible Not Covered Tier 2: $30 25 - After deductible Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 - After deductible Not Covered Tier 2: $75 62.50 - After deductible Not Covered Tier 3: $125 - After deductible Not Covered Tier 4: $225 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs and devices is available at all network retail pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 25 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 62.50 Not Covered Tier 3: $125 - After deductible Not Covered Tier 4: $225 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs and devices is available at all network retail pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 25 Not Covered Tier 3: $50 Not Covered Tier 4: $75 Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 62.50 Not Covered Tier 3: $125 Not Covered Tier 4: $225 Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments LG-COC/SOB-4-2019-BX 7 BlueSolutions for prescription drug copayments and/or deductiblesHSA Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for this service. In accordance with RIGL § 27-20.8-3, copayments Please see Preauthorization in Section 3 for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductiblemore information. You Pay You Pay Prescription Drugs, other than otherthan Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, Suppl calibration fluid): When purchased at a Retail or Specialty Pharmacy: For Copaymentapplies per each 3-0day supply or portion thereof for maintenance and nonn-maintenance omnaintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day -9d0ay supply of maintenance and maintenanceand non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day For -ad9ay0 supply; three retail copayments apply. For more information about pharmacies offering this option, visit our website. Proratedcopaymentsfor a shorter supplyepriod may apply fornetwork pharmacoynly. See Prescription Drug section for details. Tier 1: $10 0%- Afterdeductible Not Covered Tier 2: $30 0%- Afterdeductible Not Covered Tier 3: $50 0%- Afterdeductible Not Covered Tier 4: $75 Not Covered 4 and Tier 5: See specialty Sesepecialty prescription drug section drusgection below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- n-on maintenance prescription drugs. Tier 1: $25 0%- Afterdeductible Not Covered Tier 2: $75 0%- Afterdeductible Not Covered Tier 3: $125 0%- Afterdeductible Not Covered Tier 4 and Tier 5: Sesepecialty prescription drusgection below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. Tier 4: $225 0%- Afterdeductible Not Covered Tier 5: 0%- 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 reimburesment is based on the pharmacy allowance. Tier 4: 0%- Afterdeductible Not Covered Tier 5: 0%- 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: 0%- Afterdeductible Not Covered Tier 2: 0%- Afterdeductible Not Covered Tier 3: 0%- Afterdeductible Not Covered When purchased at a Specialty Pharmacy(+) Tier 4: 0%- Afterdeductible Not Covered Tier 5: 0%- 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 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. Tier 4: 0%- Afterdeductible Not Covered Tier 5: 0%- Afterdeductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods - Coverage includes barrier method(diaphragm or cervical cap), hormonal method (bi control pill), and emergency 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: 0%- Afterdeductible Not Covered Tier 3: 0%- Afterdeductible Not Covered Tier 4 and Tier 5: Contraceptive are only placed in Tier 1, Tier 2 or Tier 3. See specialty above. Not Covered When purchased at aMail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drug section belowdrugs. Tier 1: 0% Not Covered Tier 2: 0%- Afterdeductible Not Covered Tier 3: 0%- Afterdeductible Not Covered Tier 4 and Tier 5: Contraceptive are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 0 - After deductible Not Covered Tier 2: $30 0 - After deductible Not Covered Tier 3: $50 0 - After deductible Not Covered Tier 4: $75 0 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 0 - After deductible Not Covered Tier 2: $75 0 - After deductible Not Covered Tier 3: $125 0 - After deductible Not Covered Tier 4: $225 0 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered HSA Preventive Prescription Drugs - Coverage for certain preventive prescription drugs before meeting your plan year deductible. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. When purchased at a Retail or Specialty Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain retail pharmacies. For a 90-day supply; three retail copayments apply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 $0 - After deductible Not Covered Tier 2: $50 $0 - After deductible Not Covered Tier 3: $75 $0 - After deductible Not Covered Tier 4: $95 $0 - After deductible Not Covered Tier 5: Not applicable before deductible. See specialty prescription drug section below for after deductible. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- maintenance prescription drugs. Tier 1: $25 $0 - After deductible Not Covered Tier 2: $125 $0 - After deductible Not Covered Tier 3: $187.50 $0 - After deductible Not Covered Tier 4: $285 $0 - After deductible Not Covered Tier 5: Not Applicable Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. In accordance with RIGL § 27-18.94, this plan covers one two-pack epinephrine auto- injector kit, with no copayment after deductible, per plan year, as indicated on our formulary. Please contact our Customer Service Department for details. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. (+) Preauthorization is required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing prescribed dosing period. Prorated copayments for a shorter supply periodmay period may apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 0 - After deductible Not Covered Tier 2: $30 0 - After deductible Not Covered Tier 3: $50 0 - After deductible Not Covered Tier 4: $75 0 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 0 - After deductible Not Covered Tier 2: $75 0 - After deductible Not Covered Tier 3: $125 0 - After deductible Not Covered Tier 4: $225 0 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered HSA Preventive Prescription Drugs - Coverage for certain preventive prescription drugs before meeting your plan year deductible. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. When purchased at a Retail or Specialty Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribed dosing period. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain retail pharmacies. For a 90-day supply; three retail copayments apply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 $0 - After deductible Not Covered Tier 2: $45 $0 - After deductible Not Covered Tier 3: $70 $0 - After deductible Not Covered Tier 4: $90 $0 - After deductible Not Covered Tier 5: Not applicable before deductible. See specialty prescription drug section below for after deductible. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. Summary of Pharmacy Benefits‌ Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 0 - After deductible Not Covered Tier 2: $30 0 - After deductible Not Covered Tier 3: $50 0 - After deductible Not Covered Tier 4: $75 0 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 0 - After deductible Not Covered Tier 2: $75 0 - After deductible Not Covered Tier 3: $125 0 - After deductible Not Covered Tier 4: $225 0 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered HSA Preventive Prescription Drugs - Coverage for certain preventive prescription drugs before meeting your plan year deductible. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. When purchased at a Retail or Specialty Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain retail pharmacies. For a 90-day supply; three retail copayments apply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 $0 - After deductible Not Covered Tier 2: $50 $0 - After deductible Not Covered Tier 3: $75 $0 - After deductible Not Covered Tier 4: $95 $0 - After deductible Not Covered Tier 5: Not applicable before deductible. See specialty prescription drug section below for after deductible. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- maintenance prescription drugs. Tier 1: $25 $0 - After deductible Not Covered Tier 2: $125 $0 - After deductible Not Covered Tier 3: $187.50 $0 - After deductible Not Covered Tier 4: $285 $0 - After deductible Not Covered Tier 5: Not Applicable Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates Our formulary lists generic, preferred brand name, and non-preferred brand name prescription drugs and specialty prescription drugs covered under this agreement. To obtain a copy of the tier structure most current formulary listing, visit our website at or you may call our Customer Service Department. See the Summary of Pharmacy Benefits for this plan benefit limits and the amount you pay. Maintenance and non-maintenance generic, preferred brand name, or non-preferred brand name prescription drugs and diabetic equipment and supplies may be bought from a network mail order pharmacy. The prescription is limited to the benefit limit and the amount that you are responsible to pay shown in the Summary of Pharmacy Benefits. For mail order instructions, please call our Customer Service Department. The following diabetic equipment and supplies can be bought at a network pharmacy: • Glucometers; • Test Strips; • Lancet and Lancet Devices; and • Miscellaneous Supplies (including calibration fluid). See the Summary of Pharmacy Benefits for benefit limits and the amount that you pay. You When you buy covered prescription drugs and diabetic equipment and supplies from a network pharmacy, you will be responsible for paying the lowest cost copayment and prescription drug deductible (if any) shown in the Summary of either your copayment, Pharmacy Benefits at the retail cost of time you buy the drug, or the prescription drugs and diabetic equipment and supplies. Coverage is based on our pharmacy allowance. We reserve the right not to accept manufacturer couponsThis agreement does NOT cover generic, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. In accordance with RIGL § 27-20.8-3preferred brand name, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance preferred brand name prescription drugsdrugs or diabetic equipment and supplies when bought at non-network pharmacies. If you buy generic, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1preferred brand name, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance preferred brand name prescription drugs or diabetic equipment and supplies from non-network pharmacies, you will be responsible to pay the charge for the prescription drug or diabetic equipment and supplies at the time the prescription is available at certain network retail pharmacies and a 365-day supply for contraceptive filled. If you buy specialty prescription drugs is available at all from a retail network pharmacies. A copayment pharmacy or a non-network pharmacy, you will apply be responsible to pay the pharmacy allowance for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 Not Covered Tier 3: $50 Not Covered Tier 4: $75 Not Covered Tier 5: See the specialty prescription drug section belowat the time the prescription is filled. Not You may submit a claim to us and we will reimburse you directly. If you buy specialty prescription drugs from a non-network pharmacy, the specialty prescription drugs are not covered. See How Your Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance Health Care Services Are Paid for further information. Prescription drug preauthorization is required for certain brand name prescription drugs and non- maintenance specialty prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 Not Covered Tier 3: $125 Not Covered Tier 4: $225 Not Covered Tier 5: See specialty To obtain prescription drug preauthorization, the prescribing provider must submit a completed prescription drug preauthorization request form. The prescribing provider may obtain a prescription drug preauthorization form by visiting our website or calling the Physician and Provider Service Center. Preauthorization requests can be submitted by fax, by phone, or by mail to our pharmacy benefit manager. See Contact Information at the beginning of this section belowfor contact details. Not CoveredPrescription drugs that require prescription drug preauthorization will only be approved when our clinical guidelines are met. The guidelines are based upon clinically appropriate criteria that ensure that the prescription drug is appropriate and cost-effective for the illness, injury or condition for which it has been prescribed. We will send to you written notification of the prescription drug preauthorization determination within two (2) business days of receipt of all medical documentation required to conduct the review, but not to exceed fourteen (14) calendar days from the receipt of the request. Expedited Preauthorization Review Process You may request an expedited review if the circumstances are an emergency. Due to the urgent nature of an expedited review, your prescribing provider must either call or fax the completed form and indicate the urgent nature of the request. If an expedited preauthorization review is received by us, we will respond to you with a determination within seventy-two (72) hours or in less than seventy-two (72) hours (taking into consideration medical exigencies) following receipt of the request.

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments SG-COC-3-2019-BX & ▇▇-▇▇▇-▇▇▇-▇▇▇▇-▇▇ ▇ ▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇ Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for prescription drug copayments and/or deductiblesthis service. In accordance with RIGL § 27-20.8-3, copayments Please see Preauthorization in Section 3 for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductiblemore information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which Suppliesw( hich includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and SyringesSyrgines, and Miscellaneous Supplies, Supplie calibration fluid): When purchased at a Retail Pharmacy: For Copaymentapplies per each 3-0day supply or portion thereof for maintenance and nonn-maintenance omnaintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for Proratedcopaymentsfor a shorter supply periodmay period may apply for network pharmacy onlyfornetwork pharmacoynly. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 Not Covered Tier 2: $30 Not Covered Tier 3: $50 Not Covered Tier 4: $75 Not Covered Tier 5: See specialty Seespecialty prescription drug section drusgection below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- n-on maintenance prescription drugs. Tier 1: $25 Not Covered Tier 2: $75 NotCovered Tier 3: $125 Not Covered Tier 4: $225 Not Covered Tier 5: Seespecialty prescription drusgection below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See 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. When purchased at a RetaPilharmacy(+): 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. When purchased at a Mail Order Pharmacy: NotCovered 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% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy(+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugpsurchased at a retail pharmacy wil require a significantly higher out of pocket expense than if purchased from 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 Contraceptive Methods - Coverage includes barrier method (diaphragm or cervical cap), hormomneatlhod (birth control pill), and emergency contraception. When purchased at a Retail Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof of maintenance and n-omnaintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $30 Not Covered Tier 3: $50 Not Covered Tier 4: $75 Not Covered Tier 5: Contraceptives are only placed in Tier 1, Tier 2, Tier 3, or Tier 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: $75 Not Covered Tier 3: $125 Not Covered Tier 4: $225 Not Covered Tier 5: Contraceptives are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See specialty prescription drug section belowabove. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 - After deductible Not Covered Tier 2: $30 50 - After deductible Not Covered Tier 3: $50 75 - After deductible Not Covered Tier 4: $75 95 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 - After deductible Not Covered Tier 2: $75 125 - After deductible Not Covered Tier 3: $125 187.50 - After deductible Not Covered Tier 4: $225 285 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered

Five-Tier Copayment Structure. This prescription drug plan formulary has a five-tiered copayment structure. The copayment for a prescription drug will vary by tier. The tier placement of a prescription drug on our formulary is subject to change. For more information about our formulary, and to see the tier placement of a particular prescription drug, visit our website or call our Customer Service Department. Below indicates the tier structure for this plan and the amount that you are responsible to pay. You will be responsible for paying the lowest cost of either your copayment, the retail cost of the drug, or the pharmacy allowance. We reserve the right not to accept manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments and/or deductibles. If prescription drug manufacturer coupons, discount plan payments or other cost share assistance program payments for prescription drug copayments are accepted they may not be counted towards your deductible (if applicable) or your maximum out-of-pocket expense limit. In accordance with RIGL § 27-20.8-3, copayments for insulin prescription drugs will not exceed $40 for each thirty-day supply and are not subject to a deductible. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. (+) Preauthorization is required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing prescribed dosing period. Prorated copayments for a shorter supply periodmay period may apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 0 - After deductible Not Covered Tier 2: $30 0 - After deductible Not Covered Tier 3: $50 0 - After deductible Not Covered Tier 4: $75 0 - After deductible Not Covered Tier 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 non- maintenance prescription drugs. Tier 1: $25 0 - After deductible Not Covered Tier 2: $75 0 - After deductible Not Covered Tier 3: $125 0 - After deductible Not Covered Tier 4: $225 0 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered HSA Preventive Prescription Drugs - Coverage for certain preventive prescription drugs before meeting your plan year deductible. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. When purchased at a Retail or Specialty Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribed dosing period. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain retail pharmacies. For a 90-day supply; three retail copayments apply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 $0 - After deductible Not Covered Tier 2: $45 $0 - After deductible Not Covered Tier 3: $70 $0 - After deductible Not Covered Tier 4: $90 $0 - After deductible Not Covered Tier 5: Not applicable before deductible. See specialty prescription drug section below for after deductible. Not Covered