What You Will Pay Common Medical Event Services You May Need In-Network Out-of-Network Limitations, Exceptions, & Other (You will pay the (You will pay the Important Information least) most) $15 / retail supply or $30 / retail supply Generic drugs $30 / mail service and all charges for supply mail service Deductible applies first; up to 30-day 50% coinsurance / retail (90-day mail service) supply; Preferred brand drugs 50% coinsurance retail supply and all cost share may be waived or reduced If you need drugs to treat charges for mail for certain covered drugs and your illness or condition service supplies; pre-authorization required More information about 50% coinsurance / for certain drugs prescription drug coverage Non-preferred brand drugs 50% coinsurance retail supply and all is available at charges for mail bluecrossma.org/medicatio service n Deductible applies first; when Applicable cost share obtained from a designated specialty Specialty drugs (generic, preferred, Not covered pharmacy; cost share may be waived non-preferred) or reduced for certain covered drugs and supplies; pre-authorization required for certain drugs Deductible applies first; pre- Facility fee (e.g., ambulatory surgery center) $1,000 / admission 20% coinsurance authorization required for certain If you have outpatient services surgery Deductible applies first; pre- Physician/surgeon fees No charge 20% coinsurance authorization required for certain services Deductible applies first; copayment Emergency room care $750 / visit $750 / visit waived if admitted or for observation If you need immediate stay medical attention Emergency medical transportation No charge No charge Deductible applies first Urgent care $60 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable Page 3 of 8