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BENEFIT TRS-ACTIVECAREPRIMARYTRS-ACTIVECAREPRIMARY+TRS-ACTIVECARE HD TRS-ACTIVECARE 2Drug Deductible(per person, per plan year)Integrated with medical $200 per participant (brand drugs only) Integrated with medical $200 per participant (brand drugs only)Maximum Out of Pocket Integrated with medical Integrated with medical Integrated with medical Integrated with medicalShort-term Supply at a Retail Location (up to a 31-day supply)Generic $15 copay $0 for certain generics $15 copay20% coinsurance after deductible $0 for certain generics before deductible$20 copayPreferred Brand 30% coinsurance after deductible25% coinsurance after deductible ($100 max)*25% coinsurance after deductible25% coinsurance after deductible($40 min/$80 max)*Non-Preferred Brand 50% coinsurance after deductible50% coinsurance after deductible* 50% coinsurance after deductible50% coinsurance after deductible ($100 min/$200 max)*Insulin Out-of-Pocket Cost $25 copay $25 copay 25% coinsurance after deductible $25 copayLong-term Supply through Mail Order or a Participating Pharmacy Location (60- to 90-day supply)Generic $45 copay $0 for certain generics $45 copay20% coinsurance after deductible$0 for certain generics before deductible$45 copayPreferred Brand 30% coinsurance after deductible25% coinsurance after deductible ($265 max)*25% coinsurance after deductible25% coinsurance after deductible($105 min/$210 max)*Non-Preferred Brand 50% coinsurance after deductible50% coinsurance after deductible*50% coinsurance after deductible50% coinsurance($215 min/$430 max)*Formulary Insulin Out-of-Pocket Cost $75 copay $75 copay 25% coinsurance after deductible $75 copaySpecialty Medications through Accredo (up to a 31-day supply)Specialty Medications(31-day max supply)30% coinsurance after deductible30% coinsurance after deductible20% coinsurance after deductible30% coinsurance after deductible($200 min/$900 max)Specialty Medications through SaveOnSP copay assistance programSpecialty Medications on the SaveOnSP Drug List $0 copay $0 copay N/A $0 copayPrescription Drug Benefits Summary*The maximum doesn%u2019t apply if the preferred brand is selected when a generic is available.22 www.bcbstx.com/trsactivecare