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) $10 / retail supply or $20 / retail supply Generic drugs $20 / mail service and all charges for Deductible applies first; up to 30-day supply mail service retail (90-day mail service) supply; $25 / retail supply or $50 / retail supply cost share may be waived, reduced, If you need drugs to treat Preferred brand drugs $50 / mail service and all charges for or increased for certain covered drugs your illness or condition supply mail service and supplies; pre-authorization More information about $45 / retail supply or $90 / retail supply required for certain drugs prescription drug coverage Non-preferred brand drugs $135 / mail service and all charges for is available at supply mail service bluecrossma.org/medicatio Deductible applies first; when n obtained from a designated specialty Applicable cost share pharmacy; cost share may be waived, Specialty drugs (generic, preferred, Not covered reduced, or increased for certain non-preferred) covered drugs and supplies; pre- authorization required for certain drugs Deductible applies first; pre- Facility fee (e.g., ambulatory surgery center) No charge 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 $150 / visit $150 / 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 No charge 20% coinsurance Deductible applies first; a telehealth cost share may be applicable Page 3 of 8