Benefits Handbook

1 "Family" applies to all coverage levels except Employee-Only.

2 Not "True" Family: Individual and family deductibles do not apply to this plan. When a covered family member meets his or her individual out-of-pocket maximum, the out-of-pocket maximum is met for that covered family member only, but not for the other covered family members. When the family out-of-pocket maximum is met, the out-of-pocket maximum is met for all covered family members, whether or not each has met the individual out-of-pocket maximum. The family out-of-pocket maximum can only be met by a combination of covered family members, as amounts counted toward individual out-of-pocket maximums count toward the larger family out-of-pocket maximum

3 A mandatory program, the PrudentRx prescription drug program, will apply for eligible specialty medications for complex conditions on the PrudentRx Drug List. If you do not speak with PrudentRx, do not enroll in any copay assistance as required by a manufacturer, or do not choose to participate in the PrudentRx program, i.e. opt out, you'll be responsible for paying the 30% coinsurance cost for each specialty prescription medication, and the costs will NOT count towards either out-of-pocket maximum. The PrudentRx Drug List is available at www.caremark.com. For drugs not on the PrudentRx Drug List, standard mail order copays will apply. For more information, refer to "Are there mandatory discount or copay assistance programs applicable for specialty prescription drugs?" and "Prescription Drug Programs."

4 In addition to mail order, you will be able to fill a 90-day supply of your maintenance medications at a CVS Caremark® retail pharmacy, at the same cost as you would through the mail order program. For all maintenance medications, after the first three fills, you must fill a 90-day supply either at a CVS Caremark® retail pharmacy or through the CVS Caremark® Maintenance Choice Mail Order program otherwise, the maintenance medication will not be covered, you will pay 100% of the full cost for all subsequent fills, and the cost does not accumulate towards the out-of-pocket maximum.