Tier 2 cost-limit after you meet your prescription drug deductible, except for covered insulins. See the UMP Preferred Drug List for cost limits • 0–30-day supply: $75 • 31–60-day supply: $150 • 61–90-day supply: $225 If your normal coinsurance is less than the prescription cost-limit, you pay the normal coinsurance. If the normal coinsurance is more than the prescription cost-limit, you pay the prescription cost-limit. See the table below for examples (these examples assume you’ve met your prescription drug deductible when it applies). Tier of drug Allowed Normal You pay Prescription amount coinsurance cost-limit for a 30-day supply Value Tier (Value) $100 5% $5 $10 (5% x $100=$5) Tier 1 (Tier 1/Tier 1 $300 10% $25 $25 Specialty) (10% x $300=$30) Tier 2 (Tier 2/Tier 2 $500 30% $75 $75 Specialty) (30% x $500=$150) Must meet your prescription drug deductible first ALERT! If you get your prescription filled at a non-network pharmacy, the prescription cost- limit does not apply. See “Non-network pharmacies: Retail” on page 100. Prescriptions purchased from an excluded pharmacy are not covered. Your prescription drug out-of-pocket limit Expenses are counted from January 1, 2024, or your first day of enrollment, whichever is later, to December 31, 2024, or your last day of enrollment, whichever is earlier. For each member enrolled in the plan, the prescription drug out-of-pocket limit is $2,000 per member, with a family limit of $4,000. Each member must meet their own prescription drug out-of-pocket limit separately until the family limit is reached. After you reach this limit, the plan pays 100 percent of the allowed amount for covered prescription drugs and products. If you receive prescription drugs from a non-network pharmacy that charges more than the allowed amount, you must still pay the difference. Prescriptions purchased from an excluded pharmacy are not covered (see the definition of “Excluded pharmacy”) 2024 UMP Classic (PEBB) Certificate of Coverage 97