Common use of Specialty Prescription Drugs (+ Clause in Contracts

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 100 Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 4: $150 Not Covered Tier 5: $125 300 Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will 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: 50% Not Covered Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 4: 20% Not Covered Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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: 20% Not Covered Tier 5: 20% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 4: $150 Not Covered Tier 5: $125 300 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will 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: 50% Not Covered Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 4: 20% Not Covered Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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: 20% Not Covered Tier 5: 20% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 4: $150 Not Covered Tier 5: $125 300 Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will 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: 50% Not Covered Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 When purchased at a Specialty Pharmacy(+) Tier 4: 20% Not Covered When purchased at 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 will 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: 20% Not Covered Tier 5: 20% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Preventive Methods - Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Copayment applies per each 30-day supply or portion thereof of maintenance and non-maintenance prescription drugs. For tiers 1, 2, and 3: Up to a 36590-day supply of contraceptive maintenance and non-maintenance prescription drugs is available at all network 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: $0 Not Covered Tier 2: $35 Not Covered Tier 3: $70 Not Covered Tier 4 and Tier 5: Contraceptives are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supplysupply of maintenance and non- maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $87.50 Not Covered Tier 3: $210 Not Covered Tier 4 and Tier 5: Contraceptives are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 150 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 4: $150 Not Covered Tier 5: $125 300 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will 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: 50% Not Covered Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 4: 20% Not Covered Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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: 20% Not Covered Tier 5: 20% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 0 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% $0 - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 200% - After deductible Not Covered Tier 2: 200% - After deductible Not Covered Tier 3: 200% - After deductible Not Covered Tier 4: 200% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 200% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 200% - After deductible Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For nonCovered Benefits Network Pharmacy Non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail network Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 4: $150 - After deductible Not Covered Tier 5: $125 300 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will 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: 50% - After deductible Not Covered Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 4: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 300 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 202:20% 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 100 Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 4: $150 - After deductible Not Covered Tier 5: $125 300 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will 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: 50% - After deductible Not Covered Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 4: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 5: $125 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Preventive Methods - when covered as a preventive care service as described in Section 3. Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive all other contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for those copayment details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 5: $125 100 - After deductible Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 100 - After deductible Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+Pharmacy(+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 400 Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 400 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 0 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% $0 - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 200% - After deductible Not Covered Tier 2: 200% - After deductible Not Covered Tier 3: 200% - After deductible Not Covered Tier 4: 200% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 200% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 200% - After deductible Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 100 - After deductible Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 5: $125 100 - After deductible Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+Pharmacy(+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 54: $125 Not Covered 65 Tier 4: 50% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Tier 4: 50% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. Tier 54: 50% Not Covered Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs (+) - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 When purchased at a Specialty Pharmacy(+) Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 54: 20% Not Covered Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 54: 20% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. Tier 4: 20% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 Not Covered Copayment applies per each 30-day supply or applies per recommended treatment interval. When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: 50% Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+Pharmacy(+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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- Preventive Methods - Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365Copayment applies per each 30-day supply or portion thereof of contraceptive maintenance and non-maintenance prescription drugs is available at all network retail pharmacies. For more information about this option, visit our websitedrugs. Tier 1: $0 Not Covered Tier 2: $30 Not Covered Tier 3: $60 Not Covered Tier 4: $80 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 supplysupply of maintenance and non- maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $75 Not Covered Tier 3: $150 Not Covered Tier 4: $240 Not Covered Tier 5: Contraceptives are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 100 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 150 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 54: $125 Not Covered 65 Tier 4: 50% When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 54: 50% Not Covered Tier 4: 50% When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 When purchased at a Specialty Pharmacy(+) Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 54: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 54: 20% Tier 4: 20% When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 Not Covered Copayment applies per each 30-day supply or applies per recommended treatment interval. When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: 50% Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+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 will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Methods - Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Copayment applies per each 30-day supply or portion thereof of maintenance and non-maintenance prescription drugs. For tiers 1, 2, and 3: Up to a 36590-day supply of contraceptive maintenance and non-maintenance prescription drugs is available at all network 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: $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 supplysupply of maintenance and non- 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 above. Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 5: $125 - After deductible Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 - After deductible Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 - After deductible Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 300 Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 202:20% 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 54: $125 Not Covered 65 Tier 4: 50% When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 54: 50% Not Covered Tier 4: 50% When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 When purchased at a Specialty Pharmacy(+) Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 54: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 54: 20% Tier 4: 20% When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 54: 20% not to exceed $125 200 Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 54: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+Pharmacy(+) Tier 54: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 54: 20% Not Covered When purchased at a Mail Order Pharmacy: Not Covered 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- Preventive Methods - Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365Copayment applies per each 30-day supply or portion thereof of contraceptive maintenance and non-maintenance prescription drugs is available at all network retail pharmacies. For more information about this option, visit our websitedrugs. Tier 1: $0 Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered Tier 4: Contraceptives are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supplysupply of maintenance and non- maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered Tier 4: Contraceptives are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 54: $125 100 Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 54: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs (+) - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+Pharmacy(+) Tier 54: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 54: 20% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 4: $150 - After deductible Not Covered Tier 5: $125 300 - After deductible Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will 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: 50% - After deductible Not Covered Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 4: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered When purchased at a Retail Covered Benefits Network Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For nonNon-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail network Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 100 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Methods - when covered as a preventive care service as described in Section 3. Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive all other contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for those copayment details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+Pharmacy(+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 5: $125 300 Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+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 will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a ata Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 54: $125 Not Covered 65 Tier 4: 50% When purchased at a ata Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat a purchased ata retail pharmacy will require a significantly higher out of pocket expense than if purchased from a froma Specialty Pharmacy. Our reimbursement is reimbursementis based on the pharmacy allowance. Tier 54: 50% Not Covered Tier 4: 50% When purchased at a ata Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs When purchased ata Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 ata Specialty Pharmacy(+) Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 54: 20% Not Covered When purchased at a ata Retail Pharmacy (+): Specialty Prescription Drugs purchased at a ata retail pharmacy will require a significantly higher out of pocket expense than if purchased from a froma specialty pharmacy. Our reimbursementis based on the pharmacy allowance. Tier 54: 20% Tier 4: 20% When purchased ata Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes Coverageincludes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a ata Retail Pharmacy: Up to a 365-day supply of contraceptive ofcontraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this aboutthis option, visit our website. Tier 1: $0 Not Covered When purchased at a ata Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 54: $125 Not Covered 65 Tier 4: 50% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Tier 4: 50% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. Tier 54: 50% Not Covered Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs (+) - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 When purchased at a Specialty Pharmacy(+) Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 54: 20% Not Covered Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 54: 20% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. Tier 4: 20% Our reimbursement is based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 250 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 250 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Preventive Methods - when covered as a preventive care service as described in Section 3. Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive all other contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for those copayment details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 54: $125 Not Covered 65 Tier 4: 50% Our reimbursement is based on the pharmacy allowance. 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Tier 4: 50% Our reimbursement is based on the pharmacy allowance. Tier 54: 50% Not Covered Our reimbursement is based on the pharmacy allowance. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 When purchased at a Specialty Pharmacy(+) Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 54: 20% Not Covered Our reimbursement is based on the pharmacy allowance. When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 54: 20% Our reimbursement is based on the pharmacy allowance. Tier 4: 20% Our reimbursement is based on the pharmacy allowance. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered Tier 2: $25 Not Covered Tier 3: $40 Not Covered Tier 4: Contraceptives are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered Tier 2: $62.50 Not Covered Tier 3: $100 Not Covered Tier 4: Contraceptives are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a ata Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 54: $125 Not Covered 65 Tier 4: 50% Our reimbursementis based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a ata Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat a purchased ata retail pharmacy will require a significantly higher out of pocket expense than if purchased from a froma Specialty Pharmacy. Tier 4: 50% Our reimbursement is reimbursementis based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. Tier 54: 50% Not Covered Our reimbursementis based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a ata Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs Drugs(+) - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a ata Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered When purchased ata Specialty Pharmacy(+) Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 54: 20% Not Covered Our reimbursementis based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased at a ata Retail Pharmacy (+): Specialty Prescription Drugs purchased at a ata retail pharmacy will require a significantly higher out of pocket expense than if purchased from a froma specialty pharmacy. Tier 54: 20% Our reimbursementis based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. Tier 4: 20% Our reimbursementis based on the pharmacy allowance. You are responsible to pay up to the retail cost of the drug. When purchased ata Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes Coverageincludes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a ata Retail Pharmacy: Up to a 365-day supply of contraceptive ofcontraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this aboutthis option, visit our website. Tier 1: $0 Not Covered When purchased at a ata Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 54: $125 Not Covered 65 Tier 4: 50% Our reimbursement is based on the pharmacy allowance. 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Tier 4: 50% Our reimbursement is based on the pharmacy allowance. Tier 54: 50% Not Covered Our reimbursement is based on the pharmacy allowance. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 When purchased at a Specialty Pharmacy(+) Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 54: 20% Not Covered Our reimbursement is based on the pharmacy allowance. When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 54: 20% Our reimbursement is based on the pharmacy allowance. Tier 4: 20% Our reimbursement is based on the pharmacy allowance. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered Tier 2: $25 Not Covered Tier 3: $40 Not Covered Tier 4: Contraceptives are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered Tier 2: $62.50 Not Covered Tier 3: $100 Not Covered Tier 4: Contraceptives are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 - After deductible Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 5: $125 - After deductible Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 0 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% $0 - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 200% - After deductible Not Covered Tier 2: 200% - After deductible Not Covered Tier 3: 200% - After deductible Not Covered Tier 4: 200% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 200% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 200% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 0 - After deductible Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% $0 - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Drugs- Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 200% - After deductible Not Covered Tier 2: 200% - After deductible Not Covered Tier 3: 200% - After deductible Not Covered Tier 4: 200% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 200% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 200% - After deductible Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor method(diaphragmor cervical cap), hormonal method (birth method(birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug prescriptiondrug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this aboutthis option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 Not Covered 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. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 400 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 250 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Methods - when covered as a preventive care service as described in Section 3. Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive all other contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for those copayment details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 4: $150 - after deductible Not Covered Tier 5: $125 300 - after deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will 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: 50% - after deductible Not Covered Tier 5: 50% - after deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - after deductible Not Covered Tier 2: 20% - after deductible Not Covered Tier 3: 20% Not Covered Tier 4: 20% - after deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 4: 20% - after deductible Not Covered Tier 5: 20% - after deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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: 20% - after deductible Not Covered Tier 5: 20% - after deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Preventive Methods - when covered as a preventive care service as described in Section 3. Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive all other contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for those copayment details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: $100 - After deductible Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: 50% - After deductible Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For nonCovered Benefits Network Pharmacy Non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail network Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 5: $125 - After deductible Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 300 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 202:20% 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+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. Tier 5: $125 200 - After deductible Not Covered When purchased at a Retail Pharmacy (+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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 - After deductible Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 - After deductible Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 - After deductible Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a ata Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 54: $125 Not Covered 65 Tier 4: 50% Our reimbursementis based on the pharmacy allowance. When purchased at a ata Retail Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat a purchased ata retail pharmacy will require a significantly higher out of pocket expense than if purchased from a froma Specialty Pharmacy. Tier 4: 50% Our reimbursement is reimbursementis based on the pharmacy allowance. Tier 54: 50% Not Covered Our reimbursementis based on the pharmacy allowance. When purchased at a ata Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a ata Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered When purchased ata Specialty Pharmacy(+) Tier 4: 20% Not Tier 4: 20% Our reimbursementis based on the pharmacy allowance. Covered When purchased at a Specialty Benefits Network Pharmacy Non-network Pharmacy (+) Tier 5: 20% Not Covered Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay When purchased at a ata Retail Pharmacy (+): Specialty Prescription Drugs purchased at a ata retail pharmacy will require a significantly higher out of pocket expense than if purchased from a froma specialty pharmacy. Tier 54: 20% Our reimbursementis based on the pharmacy allowance. Tier 4: 20% Our reimbursementis based on the pharmacy allowance. When purchased ata Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes Coverageincludes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a ata Retail Pharmacy: Up to a 365-day supply of contraceptive ofcontraceptive prescription drugs and devices is available at all network retail pharmacies. For more information about this aboutthis option, visit our website. Tier 1: $0 Not Covered When purchased at a ata Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 4: $150 - After deductible Not Covered Tier 5: $125 300 - After deductible Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will 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: 50% - After deductible Not Covered Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+) Tier 4: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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: 20% - After deductible Not Covered Tier 5: 20% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: $250 Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: 50% Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+Pharmacy(+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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- Preventive Methods - Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365Copayment applies per each 30-day supply or portion thereof of contraceptive maintenance and non-maintenance prescription drugs is available at all network retail pharmacies. For more information about this option, visit our websitedrugs. Tier 1: $0 Not Covered Tier 2: $35 Not Covered Tier 3: $80 Not Covered Tier 4: $100 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 supplysupply of maintenance and non- maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $87.50 Not Covered Tier 3: $200 Not Covered Tier 4: $300 Not Covered Tier 5: Contraceptives are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Methods - when covered as a preventive care service as described in Section 3. Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive all other contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for those copayment details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 100 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: $100 Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: 50% Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 (+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 will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Preventive Methods - Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Copayment applies per each 30-day supply or portion thereof of maintenance and non-maintenance prescription drugs. For tiers 1, 2, and 3: Up to a 36590-day supply of contraceptive maintenance and non-maintenance prescription drugs is available at all network 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: $0 Not Covered Tier 2: $25 Not Covered Tier 3: $35 Not Covered Tier 4: $60 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 supplysupply of maintenance and non- maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $62.50 Not Covered Tier 3: $87.50 Not Covered Tier 4: $180 Not Covered Tier 5: Contraceptives are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Tier 5: $125 - After deductible Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Specialty Prescription Drugs purchasedat a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% - After deductible Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% - After deductible Not Covered Tier 2: 20% - After deductible Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, devices the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 - After deductible Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 - After deductible Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 4: $150 Not Covered Tier 5: $125 300 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will 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: 50% Not Covered Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 4: 20% Not Covered Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will 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: 20% Not Covered Tier 5: 20% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Contraceptive Methods- Preventive Methods - when covered as a preventive care service as described in Section 3. Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive all other contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for those copayment details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty 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. Tier 5: $125 250 Not Covered 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. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 5 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. 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 Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods- Methods - Preventive Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered

Specialty Prescription Drugs (+. Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: $100 - After deductible Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+Pharmacy(+): For maintenance and non-maintenance prescription drugs, a copayment Tier 5: 50% - After deductible Not Covered Copayment applies for per each 30-day period (supply or portion thereof) within the prescribeddosing periodapplies per recommended treatment interval. Specialty Prescription Drugs purchasedat purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three(3Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% - After deductible Not Covered Tier 4: 20% - After deductible Not Covered When purchased at a Specialty Pharmacy (+Pharmacy(+) Tier 5: 20% - After deductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% - After deductible Not Covered Contraceptive Methods- Preventive Methods - Coverage includes barrier method (diaphragmor diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365Copayment applies per each 30-day supply or portion thereof of contraceptive maintenance and non-maintenance prescription drugs is available at all network retail pharmacies. For more information about this option, visit our websitedrugs. Tier 1: $0 Not Covered Tier 2: $35 Not Covered Tier 3: $50 - After deductible Not Covered Tier 4: $75 - After deductible 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 supplysupply of maintenance and non- maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $87.50 Not Covered Tier 3: $125 - After deductible Not Covered Tier 4: $225 - After deductible Not Covered Tier 5: Contraceptives are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered