Health Insurance, continued Compare Health Insurance Plans, continued HEALTH SAVINGS PLAN NETWORK PLAN (HSA) Prescription Drug Coverage Tier 2 Retail Clinic Any Retail Pharmacy Tier 1 Pharmacies (Up to 30-day supply) (excluding CVS pharmacies) Pharmacies (excluding CVS pharmacies) Formulary Generic 20% after deductible is met $10 copay $20 copay Formulary Brand 20% after deductible is met $40 copay $50 copay Specialty Drugs Designated Network Specialty Designated Network Specialty Pharmacy only Pharmacy only Formulary Specialty 20% after deductible is met $60 copay Up to 90-Day Supply HealthPartners Mail Order HealthPartners UPH Af昀椀liate Pharmacy and UPH Af昀椀liate Mail Order Pharmacies Pharmacy Formulary Generic 20% after deductible is met $30 copay $25 copay Formulary Brand 20% after deductible is met $120 copay $100 copay | 10 |