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caremark.com

Prescription Drug Plan

Plymouth Rock’s Prescription Drug Program is administered by CVS Caremark. When you enroll in
medical coverage, your prescription drug coverage is automatically included; there is no separate
enrollment and no additional cost. Each enrolled member will receive a CVS Caremark ID card to
present at participating pharmacies.

Consumer Choice HSA Open Access Plus Open Access Plus In-Network
(HSA) (PPO) (EPO)
Retail: 30-Day Supply
Generic Preventive $5 Co-pay N/A N/A
Generic $30 after deductible $30 Co-pay $30 Co-pay
$10 Co-pay
$10 Co-pay
$10 after deductible
PHYSICAL WELL-BEING Non-Preferred Brand $50 after deductible $50 Co-pay $50 Co-pay
Preferred Brand

Mail Order and Maintenance Choice: 90-Day Supply

$10 Co-pay
N/A
Generic Preventive
N/A
$20 Co-pay
$20 after deductible
$20 Co-pay
Generic
Preferred Brand
$60 Co-pay
$60 after deductible
$60 Co-pay
Non-Preferred Brand $150 after deductible $100 Co-pay $100 Co-pay
Annual
Out-of-pocket $3,400 / $6,800 $2,000/$4,000 $2,500/$5,000
Maximum medical and prescriptions prescriptions only prescriptions only
Individual/Family

Considering the Consumer Choice HSA Plan?

• Learn how the HSA Plan works by visiting caremark.com/hdhp

• Generic preventive prescriptions are not subject to the deductible. You can obtain these medications
at a low co-pay of $5 for a 30-day supply and $10 for a 90-day supply

• Both medical and prescription costs work towards the deductible and out-of-pocket maximum in the
HSA medical plan. To obtain the list of qualified medications, visit RockTalk Insider

• Look up what your medications would cost in the deductible phase by visting RockTalk Insider and
clicking on the “HDHP Drug Cost Finder” link found on the Prescription Drug Plan benefit page

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