0 copay Mail-Order: $75 copay Retail: $30 copay Tier 3 - Your Highest-Cost Option Retail: $50 copay Mail-Order: $125 copy Retail: $50 copay Tier 4 (if applicable) - Additional High-Cost Options Not applicable Not applicable Facility fee (e.g., ambulatory surgery center) No Charge 20% co-i

20199:48 AM NYM Mousey Units Houtdrg Units. General GN Pout/teem - Summary Taxi: Completed. Fire and safety check conducted all appeal secured, Tier 4 is under eonsaucdon. 7/18/20199:46 AM Day TF18978 Fire and Sewnly Cheek 7/1820199S3AM NYM Housing Unos Housing Units. General BA Population