20% coinsurance* 20% coinsurance

20% coinsurance (after deductible) 20% coinsurance (after deductible)

Maintenance medications are taken regularly for chronic conditions, such as high blood pressure, asthma,

long-term medications at one of our 9,600 CVS PharmacyH locations or CVS Caremark Mail Service Pharmacy for

Plan Year (Combined with

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MyChoice HSP 3 - Value Formulary

Welcome to your CVS Caremark High-Value Prescription Benefit for MyChoice HSP 3 - Value Formulary. This prescription benefit is designed to bring you quality pharmacy care that will help you save money and stay healthy using the high-value prescription benefit, Value Formulary. The Value Formulary list contains medication options that treat health conditions safely and effectively, including all generic and certain brand-name medications. Coverage is only for the generic and brand-name medications on the list. Ask your doctor to write a prescription for a generic or brand-name medication on the Value Formulary list if you are taking a medication that is not listed.

Your benefit includes an HSP Preventive Drug List. There is no cost to you to fill generic and brand-name insulin included on this list even before you meet your deductible. You pay 20% for preventive brand-name medications on the HSP Preventive Therapy Drug List; no deductible applies. You will pay the full, discounted cost of non-preventive prescription medications until you meet your deductible. Please note: Per U.S. Internal Revenue Service (IRS) rules, the deductible is combined for medical and prescription expenses. You need to meet the full family deductible if you cover any dependents.

(Combined with Medical)$3,375 $6,750 family deductible

(Deductible does not apply)

(Deductible does not apply)

(Generics and brand-name drugs)

diabetes or high cholesterol. After two initial 30-day fills of a long-term medication, you will be required to fill your long-term medication every 90 days, rather than monthly. You have the convenience of getting your

the same 90-day copayment. This will generally cost you less on an annual basis and may also result in better adherence to medications you need to take regularly.

Medical)

$6,750 per individual coverage / $6,750 per each individual within a family

$13,500 for family per plan year

You will pay a $100 copayment for a 30-day supply after your deductible is met. CVS Caremark Mail Service Pharmacy and CVS Pharmacy retail locations can accept prescriptions for specialty medications. If you choose to fill your prescription at a CVS Pharmacy retail location, it will be transferred to CVS Specialty� for evaluation, processing and dispensing. The medications will then be delivered for pick up at your preferred CVS Pharmacy or delivered to your preferred location**. All specialty medications require prior authorization. Personalized clinical support will continue to be provided by our specialty CareTeam. For more information, call 1-888-281-8186 or visit CVSspecialty.com.

Log in to Caremark.com or call Customer Care to find out if your medicine has a quantity limit or requires prior authorization.

Register at Caremark.com to access tools that can help you save money and manage your prescription benefit. To register, have your Benefit ID Card ready.

Call 1-866-284-9226

Individual Coverage Family Coverage (Anyone covering one or more dependents)

Deductible Per Plan Year

Generic Preventive Medications $0 $0

Insulin on the HSP Preventive Therapy Drug List $0 $0

Brand-Name Preventive Medications

Non-Preventive Medications

Maintenance Medications

Out-of-Pocket Maximum Per

Specialty Medications

Quantity Limit and Prior Authorization

Web Services

Customer Care

Your Health Savings Plan Prescription Benefits

This document is intended as a summary of the Prescription Drug Benefit Plan administered by CVS Caremark as of June 1, 2020; it does not fully describe the coverage under the Plan. For details on your prescription drug coverage, please refer to the Summary Plan Description (SPD) for your prescription drug benefits. The SPD is the governing plan document. If there are any discrepancies between the benefits included in this summary document and the SPD, the provisions in the SPD shall govern.

*Copayment, copay or coinsurance means the amount a plan member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.** Where allowed by law. In-store pick up is currently not available in Oklahoma and West Virginia. Some states require first-fill prescriptions to be transmitted directly to the dispensing specialty pharmacy. Products are dispensed by CVS Specialty and certain services are only accessed by calling CVS Specialty directly. Certain specialty medication may not qualify. Services are also available at Long�s Drugs locations.

Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.7434_SUM_MyChoice HSP 3 2020_091219