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Let%u2019s see what Lily may pay to control and manage her multiple sclerosis using in-network providers, services and facilities under each TRS-ActiveCare plan.This example includes:%u2022 PCP visit %u2013 1 visit to diagnose her MS%u2022 $0 annual well woman%u2019s visit%u2022 specialist visits %u2013 4 per year %u2022 12 months of specialty prescription medication at $8,700 per month before insurance%u2022 MRI %u2022 physical therapy visits %u2013 8 per year%u2022 lab work %u2013 2 per yearNote: When Lily uses third-party copay assistance for any specialty medication, she won%u2019t get credit toward her MOOP or deductible for any copay or coinsurance amounts applied by a manufacturer coupon or rebate. Only the amount she pays out of pocket will apply toward her deductible and MOOP. *Some specialty medications may qualify for third-party copay assistance programs, which can lower your out-of-pocket costs. COST OF CARE $106,450TRS-ACTIVECARE PRIMARYTRS-ACTIVECARE PRIMARY+ TRS-ACTIVECARE HDDeductible $2,500 $1,200 $3,300Coinsurance 30% after deductible 20% after deductible 30% after deductibleCopay/coinsurance for PCP $30 $15 30% after deductibleCopay/coinsurance for specialist $70 $70 30% after deductibleCopay/coinsurance for physical therapy $30 $15 30% after deductibleCoinsurance for high-tech radiology 30% after deductible 20% after deductible 30% after deductibleLab work $0 $0 30% after deductibleSpecialty medication copay/coinsuranceBased on a yearly cost of $104,400$0 through SaveOnSP Specialty Medication Copay Assistance Program$0 through SaveOnSP Specialty Medication Copay Assistance Program20% after deductible*WHAT LILY MAY PAY BASED ON $106,450 TOTAL COST OF CAREDeductible $750 for MRI $750 for MRI $3,300Copays $550 $415 No copaysCoinsurance $0 $0 $5,000Health plan paid $105,150 $105,285 $98,150Total paid by Lily $1,300 $1,165 $8,300SaveOnSP is an independent company that has contracted with Blue Cross and Blue Shield of Texas to provide pharmacy benefit management for members with coverage through BCBSTX.www.bcbstx.com/trsactivecare 33