Page 38 - New Hire Kit (Non-Union)

HDHP Single / Family

Welcome to your new prescription benefit plan administered by CVS Caremark. Your prescription benefit plan is
designed to bring you quality pharmacy care that will help you save money.
Following is a brief summary of your prescription benefits. CVS Caremark and Palomar Health are confident you will
find value with your new prescription benefit program.
CVS Caremark Retail CVS Caremark Mail Service
Pharmacy Network (Up to a Pharmacy or any retail
30-day supply) pharmacy in our network (Up to
a 90-day supply)

Generic Medicines $15 at Palomar Pharmacy $40 at CVS Caremark Mail Service
Always ask your doctor if there s a Escondido Pharmacy
generic option available. It could save
$20 at any retail pharmacy in our
you money. $60 at any retail pharmacy in our
network
network
Preferred Brand-Name Medicines $30 at Palomar Pharmacy $80 at CVS Caremark Mail Service
If a generic is not available or Escondido Pharmacy
appropriate, ask your doctor to
prescribe from your plan s preferred $40 at any retail pharmacy in our $120 at any retail pharmacy in our
drug list. network network
Non-Preferred $70 at Palomar Pharmacy $160 at CVS Caremark Mail Service
Brand-Name Medicines Escondido Pharmacy
Drugs that aren t on your plan s
preferred list will cost more. $80 at any retail pharmacy in our $240 at any retail pharmacy in our
00001 network network
With the change to CVS Caremark, you will have a new preferred drug list
which means you may see a change to the amount you pay for your
prescription(s). Some medications may be considered non-preferred after
1/1/2020, which means your cost may increase and likewise some
Changes affecting your current medications will now be considered preferred under the plan and your cost
medications will go down.
We encourage you to talk to your doctor today about these changes to your
plan. To see where your medication falls on the preferred drug list for your
plan, visit info.Caremark.com/stodruglist.

Maximum Out-of-Pocket $3,000 per individual / $6,000 per family (combined with medical)
Your plan comes with a Preventive Drug List. Medications on this list are not
subject to your deductible. You will only pay the applicable
Preventive Drug List
copay/coinsurance for medications on this list. You can access your
Preventive Drug List on Caremark.com.
Please Note: When a generic is available, but the pharmacy dispenses the brand-name medication for any reason, you will pay the difference between the
brand-name medication and the generic plus the brand copayment.

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