COVERED SERVICE BENEFIT Inpatient professional Services 100% subject to 15% Coinsurance after Deductible 26. Out-of-Area Coverage for Dependents Limited office visits, laboratory, diagnostic X-rays, and prescription drug fills as described in the EOC under “Out-of-Area Coverage for Dependents” in the “Benefit Details” section. (Coinsurance is 100% subject to 20% Coinsurance based on the actual fee the provider, facility or vendor charged for the Service). 27. Outpatient Surgery Visit 100% subject to 15% Coinsurance after Deductible 28. Prescription Drugs, Insulin, and Diabetic Supplies Certain preventive medications (including, but not limited to, aspirin, fluoride, liquid iron for infants, and tobacco use cessation 100% drugs) Certain self-administered IV drugs, fluids, additives, and nutrients including the supplies and equipment required for their 100% administration Blood glucose test strips Subject to the generic drug tier Copayment or Coinsurance FDA approved prescription and over-the-counter contraceptive 100% drugs or devices 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. Male condoms 100% Self-administered chemotherapy medications used for the treatment 100% subject to 15% Coinsurance or of cancer subject to the applicable prescription drug tier Cost Share, whichever is less Retail—up to a 30-day supply Generic Drugs 100% subject to $15 Copayment per prescription or refill Preferred Brand-Name Drugs or supplies 100% subject to $40 Copayment per prescription or refill Non-Preferred Brand-Name Drugs or supplies 100% subject to $75 Copayment per prescription or refill Specialty Drugs or supplies 100% subject to 50% Coinsurance up to $150 per prescription or refill Mail-Order—up to a 90-day supply Generic Drugs 100% subject to $30 Copayment per prescription or refill Preferred Brand-Name Drugs or supplies 100% subject to $80 Copayment per prescription or refill Non-Preferred Brand-Name Drugs or supplies 100% subject to $150 Copayment per prescription or refill Specialty Drugs or supplies (Most specialty drugs are not available for Mail-Order) 29. Preventive Care Services 100% EWCLGDED1983ACT0124 4 WAPEBB-CL-ACT