COVERED SERVICE BENEFIT Subject to the applicable drug tier Copayment or Coinsurance, not subject Insulin to the Deductible, up to $35 for each 30- day supply. Any Cost Share paid will apply toward the Deductible. 100% after meeting $1,600 of the self- Male condoms only or $3,200 of the individual Family Member Deductible or the Family Deductible (whichever applies) Self-administered chemotherapy medications used for the 100% after Deductible or subject to the treatment of cancer applicable prescription drug tier Cost Share, whichever is less Retail—up to a 30-day supply Generic Drugs 100% subject to $15 Copayment after Deductible per prescription or refill Preferred Brand-Name Drugs or supplies 100% subject to $40 Copayment after Deductible per prescription or refill Non-Preferred Brand-Name Drugs or supplies 100% subject to $75 after Deductible Copayment per prescription or refill 100% subject to 50% Coinsurance after Specialty Drugs or supplies Deductible up to $150 per prescription or refill Preventive drugs or supplies 100% Mail-Order—up to a 90-day supply Generic Drugs 100% subject to $30 Copayment after Deductible per prescription or refill Preferred Brand-Name Drugs or supplies 100% subject to $80 Copayment after Deductible per prescription or refill Non-Preferred Brand-Name Drugs or supplies 100% subject to $150 Copayment after Deductible per prescription or refill Specialty Drugs or supplies (Most specialty drugs are not available for Mail-Order) Preventive drugs or supplies 100% 29. Preventive Care Services 100% 30. Radiation and Chemotherapy Services 100% after Deductible 31. Reconstructive Surgery Services Payment levels are determined by the setting in which the Service is provided 32. Rehabilitative Physical, Occupational, Speech, and Massage Therapies (Visit maximums do not apply for treatment of mental health conditions.) Inpatient 100% subject to 15% Coinsurance after Deductible Outpatient (up to 60 visits per Year for all therapies combined) 100% subject to $30 Copayment after Deductible per visit 33. Skilled Nursing Facility Services (up to 150 days per Year) 100% subject to 15% Coinsurance after Deductible 34. Spinal and Extremity Manipulation Therapy Services Self-referred Spinal and Extremity Manipulation therapy (up to 12 100% subject to $30 Copayment after visits per Year) Deductible per visit EWCLGHDHP1983ACT0124 5 WAPEBB-CD-ACT