74 Prescription Drug Coverage—CVS Caremark / Virta The Plan will pay for certain drugs that are prescribed by your physician, after you pay the applicable copayment. If you, your Spouse, or Eligible Dependent Child get a covered prescription filled or refilled at a participating pharmacy that has an agreement with the pharmacy benefit manager (CVS Caremark), the Plan pays the total cost of the prescription minus your copayment. You will be supplied with a CVS Caremark Prescription Drug Card, which you must present at the participating pharmacy when you get a prescription filled. CVS Caremark Specialty Pharmacy Services include a program called ACSF, which means Advanced Control Specialty Formulary. With ACSF, in addition to the required Medical Necessity review, Specialty Medications will also be reviewed to determine whether a preferred alternative exists that should be tried first. If an alternative is available, it will be discussed with your physician and the script changed. This is part of the prior authorization process which will be transparent to you. The prescription copayment shown in the Schedule of Benefits is your out-of-pocket expense for each covered prescription that is filled. Under the terms of the Plan, different copayment levels apply for generic drugs, preferred brand name drugs, and non-preferred brand name drugs. If you use generic drugs whenever possible you will incur the lowest out-of-pocket expense to you and to the Plan. To determine the applicable copayment for any particular drug, go to the CVS Caremark website at www.caremark.com , and register to obtain specific benefit information. In addition, you may call the CVS Caremark Customer Care line at 866-282-8503. Note: Prescription drug copayments are not reimbursable under this benefit or any other provision of the Plan. The Plan limits the amount of a drug you can get at any one time under the prescription drug benefit. You have the following options to obtain your prescription: • Mail Order will provide up to a 90-day supply of covered maintenance medication. • CVS Retail Pharmacies will provide up to a 90-day supply of covered maintenance medication. • Other Retail Pharmacies will provide up to a 34-day supply of any covered medication. • CVS Specialty will provide up to a 34-day supply of specialty medication, or as appropriate based on dosing, therapy, and handling limitations. Out-of-Pocket Limit The Plan includes an out-of-pocket limit on the prescription drug program administered by CVS Caremark. The out-of-pocket limit is shown in the Schedule of Benefits. When a participant’s cumulative out-of-pocket expenses in a calendar year reach the applicable out-of-pocket limit shown in the Schedule of Benefits, prescription drug copayments will be waived for that participant for the rest of the applicable calendar year. When covered participants in your family have accumulated individual out-of-pocket amounts in the applicable calendar year that, when combined, equals or exceeds the family out-of-pocket limit shown in the Schedule of Benefits, copayments for prescription drugs will be waived for all covered participants in your family for the remaining months of the applicable calendar year.