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56 health and substance abuse combined health and substance abuse combined Annual Out-of-Pocket Maximums (excludes mental health/sub abuse) $1,300 per individual; $2,600 family $3,900 per individual; $7,800 family None None Annual Pharmacy Copay Maximum $1,350 per individual** None None

MAC – Maximum Allowable Charge. Use of out-of-network providers will result in increased cost to members as you will be required to pay the difference between the MAC and the amount billed by the provider. * Separate $150 deductible for mental health/substance abuse care required under the PPO; Benefits must be preauthorized by Magellan Health Services to be reimbursable at the highest level for the PPO. If preauthorization is not obtained, benefits will be reduced for the PPO and denied for the POS and HMO. ** Does not apply to annual medical deductible or the annual medical out-of-pocket, if applicable. If cost of prescription is less than the copay, the lesser amount will apply. Extended prescriptions written for 90-102 days (as authorized by the claims administrator) available for one copay when using home delivery or certain participating retail pharmacies. *** A PCP designation is not required for the POS. The $20 copay will apply when using any in-network pediatric, family practice, internal medicine or OB-GYN physician.