Schedule of Benefits (continued) Preferred Blue PPO Deductible II This chart shows your cost share for covered services. You must pay all charges in excess of a benefit limit. Page 7 hppodedIISoB-0125 Covered Services In-Network Benefits Your Cost Is: Out-of-Network Benefits Your Cost Is:  Retail Pharmacy (30-day supply) $15 copayment $30 copayment $50 copayment $30 copayment $60 copayment $100 copayment Tier 1 (generic): Tier 2 (preferred brand): Tier 3 (non-preferred): This cost share is waived for in-network Tier 1 birth control drugs and devices; certain in-network preventive drugs as required by federal law; insulin infusion pumps; and certain orally-administered anticancer drugs.  Mail Order Pharmacy (90-day supply) $30 copayment $60 copayment $150 copayment Not covered; you pay all charges Prescription Drugs and Supplies Drug Formulary (includes syringes and needles) Tier 1 (generic): Tier 2 (preferred brand): Tier 3 (non-preferred): This cost share is waived for Tier 1 birth control drugs and devices; certain preventive drugs as required by federal law; and certain orally-administered anticancer drugs.  Routine pediatric care (ten visits first year of life, three visits second year of life, two visits age 2, and one visit per calendar year age 3 and older) Routine medical exams and immunizations No charge 20% after deductible No charge 20% after deductible Routine tests These covered services include (but are not limited to): routine exams; immunizations; routine lab tests and x-rays; and blood tests to screen for lead poisoning. Annual mental health wellness exams No charge No charge (deductible does not apply) Preventive Health Services  Preventive dental care for members under age 18 for treatment of cleft lip/cleft palate No charge 20% after deductible