| 10 | Health Insurance, continued Compare Health Insurance Plans, continued HEALTH SAVINGS PLAN (HSA) NETWORK PLAN Prescription Drug Coverage Retail Clinic (Up to 30-day supply) Any Retail Pharmacy (excluding CVS pharmacies) Tier 1 Pharmacies Tier 2 Pharmacies (excluding CVS pharmacies) Formulary Generic 20% after deductible is met $10 copay $20 copay Formulary Brand 20% after deductible is met $40 copay $50 copay Specialty Drugs Designated Network Specialty Pharmacy only Designated Network Specialty Pharmacy only Formulary Specialty 20% after deductible is met $60 copay Up to 90-Day Supply HealthPartners Mail Order Pharmacy and UPH Affiliate HealthPartners Mail Order Pharmacy UPH Affiliate Pharmacies Formulary Generic 20% after deductible is met $30 copay $25 copay Formulary Brand 20% after deductible is met $120 copay $100 copay