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* For more information about limitations and exceptions, see the plan or policy document atwww.HorizonBlue.com/members.3 of 9Common Medical EventServices You May NeedWhat You Will PayLimitations, Exceptions, & OMNIA Tier 1 Other Important InformationProvider(You will pay the least)Tier 2 Network ProviderOut-of-Network Provider (You will pay the most) If you need drugs to treat your illness orconditionMore information about prescription drug coverage is available at Prime Therapeutics LLC (Prime) Service Center www.MyPrime.comor 1-800-370-5088Generic drugs 40% Coinsurance/Retail and Mail Order. 40% Coinsurance/ Retail and Mail Order. 40% Coinsurance/ Retail and Mail Order.Prior authorization may be required. Covers up to a 90 day supply (retail) and a 90 day supply (mail order). Preferred brand drugs 40% Coinsurance/Retail and Mail Order. 40% Coinsurance/ Retail and Mail Order. 40% Coinsurance/ Retail and Mail Order.Non-preferred brand drugs 40% Coinsurance/Retail and Mail Order. 40% Coinsurance/ Retail and Mail Order. 40% Coinsurance/ Retail and Mail Order.Specialty drugs Covered at retail benefit in above applicable categories. Covered at retail benefit in above applicable categories. Covered at retail benefit in above applicable categories. If you haveoutpatient surgeryFacility fee (e.g., ambulatory surgery center) 20% Coinsurance for Outpatient Hospital, Ambulatory Surgical Center. 50% Coinsurance for Outpatient Hospital, Ambulatory Surgical Center. Not Covered. Procedures related to spine surgery are subject to pre-service and postservice utilization management review. 20% Coinsurance for anesthesia (OMNIA Tier 1). 50% Coinsurance for anesthesia (Tier 2). Physician/surgeon fees 20% Coinsurance for Outpatient Hospital. 50% Coinsurance for Outpatient Hospital. Not Covered.If you needimmediate medicalattentionEmergency room care $100.00 Copayment per visit for Outpatient Hospital. 20% Coinsurance for Outpatient Hospital. $100.00 Copayment per visit for Outpatient Hospital. 20% Coinsurance for Outpatient Hospital. $100.00 Copayment per visit for Outpatient Hospital. 20% Coinsurance for Outpatient Hospital. Copayment waived if admitted within 24 hours. Out-of-network payment at the in-network OMNIA Tier 1 level of benefits applies only to true medical emergencies and accidental injuries. Emergency medical transportation Deductible applies. Deductible applies. Not Covered. __________none__________Urgent care $40.00 Copayment per visit for Specialist. $50.00 Copayment per visit for Specialist. Not Covered. __________none__________11