CY20 Prescription Drug Coverage CVS Healthcare Handbook

Your Prescription Benefits Handbook Summary of State of Maryland Prescription Benefits available through CVS Caremark® Health Benefits State of Maryland Putting the pieces together to improve your health.

1 Your prescription benefit plan through CVS Caremark CVS Caremark manages your prescription benefits just like your health insurance company manages your medical benefits. You have choices when it comes to having your prescriptions filled. CVS Caremark ensures you have access to high-quality, cost-effective medications through a system of more than 68,000 local Welcomepharmacies. You can also request to convenient home delivery of medications you take regularly (also known CVSas maintenance Caremark medications) from the CVS Caremark Mail Service Pharmacy. Understanding your benefits CVS Caremark, the Pharmacy Benefit Manager (PBM), Coveredmanages your medications prescription drug benefit under a contract Yourwith thecoverage State underof Maryland. CVS Caremark CVS Caremark is based maintainson a list of acovered medications known as a formulary. Your formularypreferred offersdrug list,a wide manages selection a networkof clinically of sound,retail pharmacies cost-effective generic and brand-name prescription medications.and operates Prescription Mail Service medications and Specialty must Drug be necessary pharmacies. and not experimental in order to be covered under theIn consultation plan. Covered with medications the plan, willCVS be Caremark limited based also onprovides medical necessity, quantity and/or age limits establishedservices to bypromote the plan the or appropriateutilization management use of pharmacy guidelines. benefits, For more information or to check drug coverage, please visit https://info.caremark.com/stateofmaryla nd. such as review for possible excessive use, recognized and recommended dosage regimens, drug interactions and other

Ysafetyour measures.cost for Employeesprescriptions and dependents covered by the StateThe amount of Maryland you pay prescription for your covered drug benefitmedications—also can use either known retail as yourpharmacies copayment*—will or the CVS depend Caremark on two Mail factors: Service Pharmacy. Your• Whether prescription your prescription is filled benefit as a generic, a brand-nameplan through or CVS Caremark Forspecialty additional medication plan information, please refer to the Evidence of CVS Caremark manages your prescription benefits just like your health insurance company manages your Coverage document located on the DBM Health Benefits Prescription medical• Where benefits.your prescription You have is filledchoices (at awhen participating it comes tolocal having your prescriptions filled. CVS Caremark ensures Drug Coverage webpage or visit https://info.caremark.com/stateofmaryland. youpharmacy, have access at an to out-of-network** high-quality, cost-effective local pharmacy medications or through through a system of more than 68,000 local pharmacies.the CVS Caremark You can Mail also Service request Pharmacy) convenient home delivery of medications you take regularly (also known as maintenance medications) from the CVS Caremark Mail Service Pharmacy. Affordable Care Act Understanding your benefits Covered medications Your coverage under CVS Caremark is based on a list of covered medications known as a formulary. Your formulary offers a wide selection of clinically sound, cost-effective generic and brand-name prescription medications. Prescription medications must be necessary and not experimental in order to be covered under the plan. Covered medications will be limited based on medical necessity, quantity and/or age limits established by the plan or utilization management guidelines. For more information or to check drug coverage, please visit https://info.caremark.com/stateofmaryland.

Your cost for prescriptions The amount you pay for your covered medications—also known as your copayment*—will depend on two factors: • Whether your prescription is filled as a generic, a brand-name or specialty medication • Where your prescription is filled (at a participating local pharmacy, at an out-of-network** local pharmacy or through the CVS Caremark Mail Service Pharmacy)

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3 Your prescription benefit plan through CVS Caremark CVS Caremark manages your prescription benefits just like your health insurance company manages your medical benefits. You have choices when it comes to having your prescriptions filled. CVS Caremark ensures you have access to high-quality, cost-effective medications through a system of more than 68,000 local pharmacies. You can also request convenient home delivery of medications you take regularly (also known as maintenance medications) from the CVS Caremark Mail Service Pharmacy. Understanding your benefits

Covered medicationsExamples of Medications in Specialty Drug Management YourAuto coverage-Immune underDiseases CVS CaremarkCosentyx, isE nbbasedrel, Humi on ara, list Kevzara, of covered Otezla, medications Stelara known as a formulary. Your formulary offers(eg. Rhe uam wideatoid Arthritis, selection Psoriasis of clinically sound, cost-effective generic and brand-name prescription medications. For& Inflammatory more information Bowel Disease) or to check drug coverage, please visit https://info.caremark.com/stateofmaryland. Osteoarthritis Gel-One, Gelsyn-3, Supartz FX, Visco-3 Your cost for prescriptions Multiple Sclerosis Glatiramer, Betaseron, Copaxone, Rebif, Acthar HP, Tysabri, Gilenya, Aubagio, Tecfidera The amount you pay for your covered medications—also known as your copayment*—will depend on twoBlood factors: Disorder Arixtra, Fragmin, Innohep, Lovenox, Nplate, Procrit, Leukine, Neulasta, Zarxio, - • Whether your prescriptionNeumega, is filled Prasoleu a generic,kin, anti hemophiliaca brand-nameage ornts specialty medication •C Whereancer your prescriptionA isfini filledtor, Glee (atvec, a participating Iressa, Nexavar, local Revlimid, pharmacy, Spry catel, an Su out-of-network**tent, Tarcva, Tasigna, local T emodapharmacyr, Thalomid, Treanda, Tykerb, Xeloda, Zolinza, Eligard, Plenaxis, Trelstar, Vantas, Viadur, or through the CVS CaremarkZoladex Mail, Thyro Servicegen, Aloxi Pharmacy) IV, Anzemet IV, Kytril IV, Zofran IV, Bosulif, Stivarga, Pomalyst, Cometriq, Iclusig, Afinitor Disperz Hepatitis C Epclusa,Employees Harvoni, Vosevi, and Alfer Non-Medicareon N, Ribavirin Retirees Osteoporosis Forteo, ReclastLocal and Mail Service Pharmacies TypeGrowth of MedicationHormones Humatrope,Up Norditropin to 45-Day Supply (1 copayment) 46- to 90-Day Supply (2 copayments) GenericsHigh Cholesterol Repatha $10 $20 Preferred Brands $25 $50 *This list is not comprehensive and is subject to change without notice to accommodate new prescription medications and to reflect the most Non-Preferredcurrent medical li teraBrandsture $40 $80 Out-of-Pocket Maximum. Active Employees Non-Medicare Retirees Single only coverage $1,000 $1,500 Family coverage $1,500 $2,000

Active employees represented by Bargaining Unit I (SLEOLA) have a different premium schedule and plan design for prescription drug benefits. Please refer to the SLEOLAExcluded Addendum or visit the Employee Benefit Division's website for mWelcomeore information : www.dbm.maryland.gov/ben to efits Notes for Non-SLEOLA and SLEOLA plan designs 1. If you receive a brand-name medication when a generic is available, you will pay the brand copayment plus the difference in cost CVSbetween the generic Caremark and brand-name medication. 2. Some specialty drugs require limited distribution and must be filled through a specialty pharmacy. Select Specialty drugs are limited to up to a 30-day supply. For these drugs, you will pay one third of the 90-day copayment for up to 30 days' worth of medication. 3. If the cost of your medication is less than the minimum copayment, you will pay the lower amount. **Refer to page 6 for instructions when using out-of-network pharmacies.

Out-of-pocket maximums Once your pharmacy out-of-pocket expense reaches the levels specified below, the plan will pay covered charges at 100% for the remainder of the calendar year. • Active Employees: $1,000 Individual | $1,500 Family • Non-Medicare Retirees: $1,500 Individual | $2,000 Family • SLEOLA: $700 all coverage levels

Additional costs for purchasing a brand-name medication when a generic equivalent 3 is available (ancillary charges) do not apply to the out-of-pocket maximum. These out-of-pocket maximums are separate from out-of-pocket maximums for your medical plan. Refer to your medical plan summary description for information on your medical out-of-pocket maximums.

Affordable Care Act Your health plan offers certain preventive service benefits at no cost to you, which means you don’t have to 5 pay a copay. These no-cost benefits are part of the Affordable Care Act (ACA) and include:

• Medicine and supplements to prevent certain health conditions for adults, women and children • Medicine and products for quitting smoking or chewing tobacco (tobacco cessation) • Medicine used prior to screenings for certain health conditions in adults • Contraceptives for women

CVS Caremark® works with your health plan to provide these benefits. For additional details, refer to “ACA Preventive Services List” link on https://info.caremark.com/stateofmaryland.

2 CVS Specialty® CVS Specialty is a full-service pharmacy that provides your choice of home delivery service or delivery to your local CVS Pharmacy for specialty medications. These medications are used to treat a number of complex conditions, such as cancer and multiple sclerosis. CVS Specialty does more than provide your medication, we help you stay on track so you can stay healthy longer. We do this by providing the support you need to ensure you take them safely and effectively.

Convenient online prescription management Register for a secure, online specialty prescription profile and make managing your medication even easier with these online tools. State of Maryland Zero Copayment For Generics Program Copayments reduced• Fast to $0 refill for requeststhe following: Most generic specialty drug medications classes (local and suppliesand mail canservice be filled pharmacies) at the same time with the one-click “Refill All” tool. Drug Class • Up-to-date prescription informationGeneric Drug: View Examples your prescription history, remaining refills, your costs, last fill date and more. HMG CoA Reductase Inhibitors• Medication (Statins) pick-up or deliverysimvastatin, options pravastatin: Request your refills be sent directly to the location of your choice or pick them up at your local CVS Pharmacy. Angiotensin Converting Enzyme Inhibitors (ACEIs) lisinopril, lisinopril/HCTZ, enalapril, enalapril/HCTZ • Secure prescription information storage: Keep all your specialty prescription PPIs information in one, secure omeprazoleplace. Save your favorite CVS Pharmacy location or address for faster ordering and checkout. Inhaled Corticosteroids budesonide Utilization management programs Selective Serotonin Reuptake Inhibitors (SSRIs) fluoxetine, paroxetine, sertraline, citalopram To promote safety along with appropriate and cost-effective use of prescription medications, the plan includes several utilization management programs. GenericsSpecialty preferred Guidelineprogram (automatic Management generic substitution) If you want toYo lowerur plan your has out-of-pocket guidelines in pl costs,ace to askens uyourre the doctor appro whetherpriate us ea ogenericf select medicationclasses of specialty is available and right for myou.edications. With a genericMany s pecimedication,alty medicat youions get a there b sameiotech high-quality, drugs that are effective expensive treatment or have thatlimited you get with its brand-nameaccess, com counterpart—withoutplicated treatment regi mensthe high, comp cost.liance FDA-approved issues, special generic storage equivalent requirements medications and/or contain the samemanufa activecturer ingredients reporting req anduirem aree subjectnts. If yo tour thedoctor same pr escribesrigid standards one of theestablished specialty mbyedications the FDA for quality, strength and purity, as their brand-name counterparts. To help manage the cost of prescription benefits, isted on the next page, it will be automatically reviewed for any additional requirements (such as the plan includesl an automatic generic substitution feature. step therapy, prior authorization, and quantity or dosage limits). The medications listed below are How does theex “genericsamples of thopreferredse that program”will be limited work? to aWhen maximum your 30-doctorday suprescribespply per presa brand-namecription fill. Thismedication list may and a genericch substituteange over istim available,e as new prescriyou willptio automaticallyn medication receives become the ava genericilable. unless: 8and a generic substitute is available, you will automatically receive the generic unless: • Your doctor writes “dispense as written” (DAW) on the prescription; or • Your Fdoctoror those writes medications “dispense limited as written” to a (DAW)30-day on supply, the prescription; you will pay or one-third of the 90-day • You requestcopayment the brand-name up to 30 days’ medication worth of at medication. the time you fill your prescription If you choose generic medications, you get high-quality, effective medication at the lowest cost. Your copayment for the generic medication will be less than the copayment for the brand-name medication.

If a generic is available, but you or your doctor request the brand-name medication, you will pay the brand copayment PLUS the full difference in cost between the brand-name medication and the generic equivalent.

For example: 30-day supply of medication 4 Brand-name medication cost $120

Generic medication cost $50

Difference (ancillary fee) $70 Copayment $40 Copayment $40 Please note: if your doctor requests you take the brand-name medication due to Total cost $110 take the brand-name medication due to medical necessity, please call CVS Customer Care at 1-844-460-8767 and If you chose the generic medication, you would pay $10 Customer Care at 1-844-460-8767 and request the Brand Exception Process.

Step4 therapy Step therapy is a process for finding the best treatment while ensuring you are receiving the most appropriate medication therapy and reducing prescription costs. Medications are grouped into two categories: • First-line medications: These are the medications recommended for you to take first—usually generics, which have been proven safe and effective. You pay the lowest copayment for these. • Second-line medications: These are brand-name medications. They are recommended for you only if a first-line medication does not work. You may pay more for brand-name medications. These steps follow the most current and appropriate medication therapy recommendations. CVS Caremark will review your records for step therapy medications when you go to the pharmacy to fill a prescription. If your prescription is for a step therapy medication, the pharmacy will search your prescription records for use of a first-line alternative.

If prior use of a first-line medication is not found, the second-line medication will not be covered. You will need to obtain a new prescription from your doctor for one of the first-line alternatives, or have your doctor request a prior authorization for coverage of the second-line medication. For more information on step therapy, visit https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767. Prior authorization Prescriptions for certain medications require a Prior Authorization—also known as a coverage review—to ensure the medication is cost-effective and clinically appropriate. This review uses formulary, clinical guidelines and other criteria to determine if the plan will pay for certain medications. At the time you fill a prescription, the pharmacist is informed of the Prior Authorization requirement through the pharmacy’s computer system and your doctor will need to contact CVS Caremark’s Prior Authorization department to provide justification for CVS Caremark’s consideration of why you should be on the prescribed medication.

9 Current Prospective Drug Utilization Review Programs

Quantity Limits/Managed Drug Limitations Prior Authorizations - Erectile Dysfunction - Growth Hormones - Proton Pump Inhibitors (PPIs) - Select ADHD/Narcolepsy, such as Adderall, Desoxyn, ® CVS Specialty - Nasal Inhalers Dexedrine and Dextrostat CVS Specialty is a full-service pharmacy that provides your choice of home delivery service or delivery to your - Sedative/Hypnotics - Tretinoin Products, such as Altinac, Avita, Retin-A, Tretinoin local CVS Pharmacy for specialty medications. These medications are used to treat a number of complex - Praluent, Repatha and future approved PCSK9 drugs conditions, such as cancer and multiple sclerosis. CVS Specialty does more than provide your medication, Step Therapy we help you stay on track so you can stay healthy longer. We do this by providing the support you need to - COX-2 Inhibitors (Celebrex®) ensure you take them safely and effectively.

Getting started To get started, call a CVS Specialty representative at 1-800-237-2767 or register online at CVSspecialty.com You may also request that CVS Specialty contact your doctor for you, then call you to arrange for delivery of State of Maryland Zero Copayment For Generics Program your medication on a day that is convenient for you. You may refill specialty medications one month at a time Copayments reduced to $0 for the following generic drug classes (local and mail service pharmacies) (maximum 30-day supply per copayment). Drug Class Generic Drug Examples 24/7 personalized care CVS Specialty provides 24/7 support from an entire CareTeam of specially-trained pharmacists and nurses. HMG CoA Reductase Inhibitors (Statins) simvastatin, pravastatin Your CareTeam can help you manage your condition by: checking dosing and medication schedules; answering your medication questions; helping you manage side effects; helping you set up new medication regimens; and Angiotensin Converting Enzyme Inhibitors (ACEIs) lisinopril, lisinopril/HCTZ, enalapril, enalapril/HCTZ checking that you are taking your medication as prescribed. PPIs omeprazole Flexible medication pick-up or delivery CVS Specialty lets you stay in control and on track with flexible medication pick-up or delivery service. You Inhaled Corticosteroids budesonide can pick up your medication at any of the 9,900 CVS Pharmacy locations nationwide or have it delivered to your home or work—the choice is yours.+ Selective Serotonin Reuptake Inhibitors (SSRIs) fluoxetine, paroxetine, sertraline, citalopram

Convenient online prescription management Register for a secure, online specialty prescription profile and make managing your medication even easier with these online tools. Specialty Guideline Management Your plan has guidelines in place to ensure the appropriate use of select classes of specialty • Fast refill requests: Most specialty medications and supplies can be filled at the same time with the one-click “Refill All” tool. medications. Many specialty medications are biotech drugs that are expensive or have limited access, complicated treatment regimens, compliance issues, special storage requirements and/or • Up-to-date prescription information: View your prescription history, remaining refills, your costs, last fill date and more. manufacturer reporting requirements. If your doctor prescribes one of the specialty medications isted on the next page, it will be automatically reviewed for any additional requirements (such as • Medication pick-up or delivery options: Request your refills be sent directly to the l step therapy, prior authorization, and quantity or dosage limits). The medications listed below are location of your choice or pick them up at your local CVS Pharmacy. examples of those that will be limited to a maximum 30-day supply per prescription fill. This list may • Secure prescription information storage: Keep all your specialty prescription change over time as new prescription medications become available. information in one, secure place. Save your favorite CVS Pharmacy location or address for faster ordering and checkout. For those medications limited to a 30-day supply, you will pay one-third of the 90-day copayment up to 30 days’ worth of medication. Utilization management programs To promote safety along with appropriate and cost-effective use of prescription medications, the plan includes Examples of Medications in Specialty Drug Management several utilization management programs. Examples of Medications in Specialty Drug Management Auto-Immune Diseases Cosentyx, Enbrel, Humira, Kevzara, Otezla, Stelara (Autoeg. Rh-Immuneeumatoid Arthritis, Diseases Psoriasis Cosentyx, Enbrel, Humira, Kevzara, Otezla, Stelara Generics preferred program (automatic generic substitution) & Inflammatory Bowel Disease) If you want to lower your out-of-pocket costs, ask your doctor whether a generic medication is available (eg. Rheumatoid Arthritis, Psoriasis Osteoarthritis& Inflammatory Bow el Disease) Gel-One, Gelsyn-3, Supartz FX, Visco-3 and right for you. With a generic medication, you get the same high-quality, effective treatment that you get with its brand-name counterpart—without the high cost. FDA-approved generic equivalent medications Osteoarthritis Gel-One, Gelsyn-3, Supartz FX, Visco-3 4Multiple Sclerosis Glatiramer, Betaseron, Copaxone, Rebif, Acthar HP, Tysabri, Gilenya, Aubagio, Tecfidera contain the same active ingredients and are subject to the same rigid standards established by the FDA for Multiple Sclerosis Glatiramer, Betaseron, Copaxone, Rebif, Acthar HP, Tysabri, Gilenya, Aubagio, Tecfidera quality, strength and purity, as their brand-name counterparts. To help manage the cost of prescription benefits, Blood Disorder Arixtra, Fragmin, Innohep, Lovenox, Nplate, Procrit, Leukine, Neulasta, Zarxio, Neumega, Proleukin, anti-hemophiliac agents the plan includes an automatic generic substitution feature. Blood Disorder Arixtra, Fragmin, Innohep, Lovenox, Nplate, Procrit, Leukine, Neulasta, Zarxio, Cancer ANfinieumega,tor, Glee Prvec,oleu Irkessa,in, an tiNexavar,-hemophiliac Revlimid, agen Spts rycel, Sutent, Tarcva, Tasigna, Temodar, Thalomid, Treanda, Tykerb, Xeloda, Zolinza, Eligard, Plenaxis, Trelstar, Vantas, Viadur, How does the “generics preferred program” work? When your doctor prescribes a brand-name medication Cancer ZoAfiniladtor,ex ,Glee Thyrovec,gen, Iressa, Aloxi Nexavar, IV, Anze Revlimid,met IV, Ky Sptrilr yIV,cel, Zo Sufratent,n IV, Tarcv Bosulia,f, T Stasigna,ivarga, Temodar, and a generic substitute is available, you will automatically receive the generic unless: PoThalomimalysd,t, TrCoeanda,metriq, Tyk Iclusig,erb, X Afeloda,initor ZDisperzolinza, Eligard, Plenaxis, Trelstar, Vantas, Viadur, 8 Zoladex, Thyrogen, Aloxi IV, Anzemet IV, Kytril IV, Zofran IV, Bosulif, Stivarga, • Your doctor writes “dispense as written” (DAW) on the prescription; or Hepatitis C PoEpclusa,malyst, Harvoni, Cometri q,Vosevi, Iclusig, Alfer Afinionto N,r Disperz Ribavirin • You request the brand-name medication at the time you fill your prescription OsHepteopoatitisrosis C Epclusa,Forteo, Reclast Harvoni, Vosevi, Alferon N, Ribavirin If you choose generic medications, you get high-quality, effective medication at the lowest cost. Your copayment GrowthOsteopo Hormonesrosis Humatrope,Forteo, Reclast Norditropin for the generic medication will be less than the copayment for the brand-name medication. HighGrowth Cholesterol Hormones RepathaHumatrope, Norditropin

If a generic is available, but you or your doctor request the brand-name medication, you will pay the brand *ThisHigh list Cholesterol is not comprehensive andRepatha is subject to change without notice to accommodate new prescription medications and to reflect the most copayment PLUS the full difference in cost between the brand-name medication and the generic equivalent. current medical literature *This list is not comprehensive. and is subject to change without notice to accommodate new prescription medications and to reflect the most current medical literature . For example: 30-day supply of medication Excluded Brand-name medication cost $120 Excluded Generic medication cost $50 • Anorectics (any drug used for the purpose of • Bulk Compounding Ingredients, kits, high cost bases weight loss) Difference (ancillary fee) $70 • Medications used for cosmetic purposes only such • Pregnancy Termination Drugs (e.g., RU486, as hair growth stimulants Copayment $40 Please note: if your doctor requests you Mifeprex) • Experimental/Investigative Drugs Total cost $110 take the brand-name medication due to • Aerochamber, Aerochamber with Mask and Nebu- • Homeopathic Products medical necessity, please call CVS lizer Masks and all other medical supplies • Worker’s Compensation Claims If you chose the generic medication, you would pay $10 Customer Care at 1-844-460-8767 and • Over-the-counter products with the exception of request the Brand Exception Process. insulin, diabetic monitoring products and those • Unapproved Products covered under the Out-of-pocketAffordable Care Act maximums OnceOut-of-pocket your pharmacy out-of-pocketmaximums expense reaches the levels specified below, the Step therapy 5 Onceplan will your pay pharmacy covered out-of-pocketcharges at 100% expense for the reaches remainder the oflevels the calendarspecified year. below, the Step therapy is a process for finding the best treatment while ensuring you are receiving the most plan will pay covered charges at 100% for the remainder of the calendar year. appropriate medication therapy and reducing prescription costs. Medications are grouped into two • Active Employees: $1,000 Individual | $1,500 Family categories: • Non-MedicareActive Employees Retirees: $1,000: $1,500 Individual Individual | $1,500 | $2,000 Family Family • First-line medications: These are the medications recommended for you to take first—usually generics, • SLEOLANon-Medicare: $700 Retireesall coverage: $1,500 levels Individual | $2,000 Family which have been proven safe and effective. You pay the lowest copayment for these. • SLEOLA: $700 all coverage levels Additional costs for purchasing a brand-name medication when a generic equivalent • Second-line medications: These are brand-name medications. They are recommended for you only if a is available (ancillary charges) do not apply to the out-of-pocket maximum. These first-line medication does not work. You may pay more for brand-name medications. Additional costs for purchasing a brand-name medication when a generic equivalent isout-of-pocket available (ancillary maximums charges) are separatedo not apply from to out-of-pocket the out-of-pocket maximums maximum. for your These These steps follow the most current and appropriate medication therapy recommendations. CVS Caremark out-of-pocketmedical plan. Refermaximums to your are medical separate plan from summary out-of-pocket description maximums for information for your on will review your records for step therapy medications when you go to the pharmacy to fill a prescription. If medicalyour medical plan. out-of-pocketRefer to your medicalmaximums. plan summary description for information on your prescription is for a step therapy medication, the pharmacy will search your prescription records for use of a first-line alternative. your medical out-of-pocket maximums.

If prior use of a first-line medication is not found, the second-line medication will not be covered. You will need to obtain a new prescription from your doctor for one of the first-line alternatives, or have your doctor request 5 a prior authorization for coverage of the second-line medication. For more information on step therapy, visit 5 https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767. Prior authorization Prescriptions for certain medications require a Prior Authorization—also known as a coverage review—to ensure the medication is cost-effective and clinically appropriate. This review uses formulary, clinical guidelines and other criteria to determine if the plan will pay for certain medications. At the time you fill a prescription, the pharmacist is informed of the Prior Authorization requirement through the pharmacy’s computer system and your doctor will need to contact CVS Caremark’s Prior Authorization department to provide justification for CVS Caremark’s consideration of why you should be on the prescribed medication.

9 How to use your plan Filling your prescriptions There are several ways to fill your prescriptions depending on your needs:

For medications taken for a short time For medications you take for a short time, such as antibiotics for strep throat or pain relievers for an injury, filling your prescription at a participating local pharmacy is optimal. Simply present your CVS Caremark member ID card to your pharmacist and pay the copayment as shown in the appropriate charts.

For medications you take regularly For prescription medications you take regularly to treat ongoing conditions (such as medications used to treat high-blood pressure or diabetes), you may fill a 90-day supply for convenience. See below for how to get started with the CVS Caremark Mail Service Pharmacy. You may also fill your 90-day supply at a participating local pharmacy.

For medications taken for complex conditions (specialty medications) For specialty medications used to treat complex conditions, such as medications that treat cancer or multiple sclerosis, CVS Specialty can help. While CVS Specialty isn’t a neighborhood pharmacy you can walk into, we can have your specialty medications available for pickup at any local CVS Pharmacy®, including those inside Target stores. Or you can have your medications delivered to your home, office or location of your choice. Visit CVSspecialty.com to get started. You may also get your specialty medications at any in-network pharmacy that carries it (i.e., you are not limited to only CVS Specialty for specialty medications).

Please note: You must use 75% of your medication before requesting a refill (controlled substance refill threshold is 80%). Using an out-of-network pharmacy Most pharmacy chains such as Walmart, Walgreen's and Giant, as well as independent pharmacies are in network. However, if you use a pharmacy that’s not covered in the network, you must pay the entire cost of the medication and then submit a claim for reimbursement. Claim forms are located online at https://info.caremark.com/stateofmaryland and can also be requested by calling CVS Caremark Customer Care at 1-844-460-8767. Claims must be submitted within 365 days of the prescription purchase date. You will be reimbursed for the amount the plan would have paid if you had obtained your medication at a participating local pharmacy, minus the appropriate copayment.

6 How to use your plan Filling your prescriptions There are several ways to fill your prescriptions depending on your needs:

When you use the CVS Caremark Mail Service Pharmacy, you can count on: • Up to a 90-day supply of your medications for two copayments • No-cost standard shipping in a plain, weather-resistant package • Flexible payment options and, (if you elect), automatic refills • Refill orders placed at your convenience, by telephone or online • Access to a registered pharmacist any time, day or night

Getting started with mail service You can begin using the CVS Caremark Mail Service Pharmacy for home delivery of your medications using one6 of the following options:

Online Register online at https://info.caremark.com/stateofmaryland to begin managing your prescriptions online. You can also download the CVS Caremark app to get started with mail service today.

By mail Ask your doctor to provide you with a written prescription for your medications. Sign in to caremark.com to download and print a mail service form. Mail the prescription(s) along with a completed order form to the address below: CVS Caremark P.O. Box 94467 Palatine, IL 60094 Please note: to avoid delays in filling your prescription, be sure to include payment with your order. Please do not send correspondence to this address.

By fax or electronic submission from your doctor Your doctor's office can fax or electronically send the prescription for a 90- day supply, plus the appropriate number of refills (maximum one-year supply). Your doctor's office will have the appropriate fax number. Important notes: - Faxes must be sent from your doctor’s office. Faxes from other locations, such as your home or workplace, cannot be accepted. - For new prescriptions, please allow approximately one week from the day CVS Caremark Mail Service receives your request. - You must use 75% of your medication before you can request a refill through mail service (80% of your medication for controlled substances).

Vacation overrides If you are going on vacation and need an additional supply of your medication, contact CVS Caremark Customer Care at 1-844-460-8767 for assistance.

7 CVS Specialty® CVS Specialty is a full-service pharmacy that provides your choice of home delivery service or delivery to your local CVS Pharmacy for specialty medications. These medications are used to treat a number of complex conditions, such as cancer and multiple sclerosis. CVS Specialty does more than provide your medication, we help you stay on track so you can stay healthy longer. We do this by providing the support you need to ensure you take them safely and effectively.

Getting started To get started, call a CVS Specialty representative at 1-800-237-2767 or register online at CVSspecialty.com You may also request that CVS Specialty contact your doctor for you, then call you to arrange for delivery of your medication on a day that is convenient for you. You may refill specialty medications one month at a time (maximum 30-day supply per copayment). ® CVS Specialty® CVS Specialty® 24/7 personalized care CVS Specialty Specialty is a full-service® pharmacy that provides your choice of home delivery service or delivery to your CVS Specialty Specialty is a full-service® pharmacy that provides your choice of home delivery service or delivery to your CVS Specialty provides 24/7 support from an entire CareTeam of specially-trained pharmacists and nurses. 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You may refill specialty medications one month at a time Register for a secure, online specialty prescription profile and make managing your medication even easier (maximum 30-day supply per copayment). (maximum24/7 personalized 30-day supply care per copayment). with these online tools. 24/7 personalized care 24/7CVS Specialty personalized provides care 24/7 support from an entire CareTeam of specially-trained pharmacists and nurses. 24/7CVS Specialty personalized provides care 24/7 support from an entire CareTeam of specially-trained pharmacists and nurses. • Fast refill requests: Most specialty medications and supplies can be filled at the CVSYour CareTeamSpecialty provides can help 24/7you managesupport yourfrom condition an entire by:CareTeam checking of dosingspecially-trained and medication pharmacists schedules; and answering nurses. 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Flexiblechecking medicationthat you are takingpick-up your or medication delivery as prescribed. Flexible medication pick-up or delivery • Medication pick-up or delivery options: Request your refills be sent directly to the FlexibleCVS Specialty medication lets you pick-up stay in control or delivery and on track with flexible medication pick-up or delivery service. You FlexibleCVS Specialty medication lets you pick-up stay in control or delivery and on track with flexible medication pick-up or delivery service. You location of your choice or pick them up at your local CVS Pharmacy. CVScan pick Specialty up your lets medication you stay in at control any of andthe 9,on9 00track CVS with Pharmacy flexible medicationlocations nationwide pick-up or or delivery have it service.delivered You to CVS Specialty lets you stay in control and+ on track with flexible medication pick-up or delivery service. You • Secure prescription information storage: Keep all your specialty prescription yourcan pick home up or your work—the medication choice at anyis yours. of the+ 9,900 CVS Pharmacy locations nationwide or have it delivered to yourcan pick home up or your work—the medication choice at anyis yours. of the+ 9,900 CVS Pharmacy locations nationwide or have it delivered to information in one, secure place. Save your favorite CVS Pharmacy location or yourcan pick home up or your work—the medication choice at anyis yours. of the+ 9,900 CVS Pharmacy locations nationwide or have it delivered to your home or work—the choice is yours.+ address for faster ordering and checkout. yourConvenient home or onlinework—the prescription choice is yours. management Convenient online prescription management RegisterConvenient for a onlinesecure, prescription online specialty management prescription profile and make managing your medication even easier RegisterConvenient for a onlinesecure, prescription online specialty management prescription profile and make managing your medication even easier withRegister these for online a secure, tools. online specialty prescription profile and make managing your medication even easier withRegister these for online a secure, tools. online specialty prescription profile and make managing your medication even easier Utilization management programs with these online tools. To promote safety along with appropriate and cost-effective use of prescription medications, the plan includes with these online tools.• Fast refill requests: Most specialty medications and supplies can be filled at the • Fast refill requests: Most specialty medications and supplies can be filled at the several utilization management programs. • Fastsame refill time requestswith the :one-click Most specialty “Refill medications All” tool. and supplies can be filled at the • Fastsame refill time requestswith the :one-click Most specialty “Refill medications All” tool. and supplies can be filled at the • Up-to-date same time with prescription the one-click information “Refill :All” View tool. your prescription history, remaining refills, • yourUp-to-date same costs, time with lastprescription thefill date one-click and information more. “Refill :All” View tool. your prescription history, remaining refills, Generics preferred program (automatic generic substitution) • Up-to-date your costs, lastprescription fill date and information more. : View your prescription history, remaining refills, • Up-to-date your costs, lastprescription fill date and information more. : View your prescription history, remaining refills, If you want to lower your out-of-pocket costs, ask your doctor whether a generic medication is available • Medication your costs, lastpick-up fill date or deliveryand more. options: Request your refills be sent directly to the • Medication your costs, lastpick-up fill date or deliveryand more. options: Request your refills be sent directly to the and right for you. With a generic medication, you get the same high-quality, effective treatment that you • Medicationlocation of your pick-up choice or ordelivery pick them options up at: Request your local your CVS refills Pharmacy. be sent directly to the • Medicationlocation of your pick-up choice or ordelivery pick them options up at: Request your local your CVS refills Pharmacy. be sent directly to the get with its brand-name counterpart—without the high cost. FDA-approved generic equivalent medications • Secure location prescription of your choice information or pick them storage up at: Keep your alllocal your CVS specialty Pharmacy. prescription • Secure location prescription of your choice information or pick them storage up at: Keep your alllocal your CVS specialty Pharmacy. prescription contain the same active ingredients and are subject to the same rigid standards established by the FDA for • Secureinformation prescription in one, secure information place. storageSave your: Keep favorite all your CVS specialty Pharmacy prescription location or • Secureinformation prescription in one, secure information place. storageSave your: Keep favorite all your CVS specialty Pharmacy prescription location or quality, strength and purity, as their brand-name counterparts. To help manage the cost of prescription benefits, addressinformation for infaster one, ordering secure place. and checkout. Save your favorite CVS Pharmacy location or addressinformation for infaster one, ordering secure place. and checkout. Save your favorite CVS Pharmacy location or the plan includes an automatic generic substitution feature. address for faster ordering and checkout. address for faster ordering and checkout. Utilization management programs Utilization+Where allowed by law. Basedmanagement on the availability of CVS Pharmacyprograms locations and subject to applicable laws and regulations. 8 ToUtilization promote safety along management with appropriate and cost-effective programs use of prescription medications, the plan includes severalToUtilizationServices promote areutilization also safety available managementalong management at withLong’s appropriate Drugs programs. locations. and Products cost-effective programs are dispensed use of by prescription CVS Specialty medications, pharmacy and thecertain plan services includes are severalToonly promote accessed utilization safety by calling managementalong CVS with Specialty appropriate programs. pharmacy and directly. cost-effective Certain specialty use medicationof prescription may not medications, qualify. 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(automatic generic substitution) Generics preferred program (automatic generic substitution) IfGenerics you want to preferredlower your out-of-pocket program costs, (automatic ask your doctor generic whether substitution) a generic medication is available IfGenerics you want to preferredlower your out-of-pocket program costs, (automatic ask your doctor generic whether substitution) a generic medication is available andIf you right want for to you. lower With your a genericout-of-pocket medication, costs, you ask get your the doctor same whetherhigh-quality, a generic effective medication treatment is thatavailable you andIf you right want for to you. lower With your a genericout-of-pocket medication, costs, you ask get your the doctor same whetherhigh-quality, a generic effective medication treatment is thatavailable you getand withright its for brand-name you. 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To help manage the cost of prescription benefits, thequality, plan strength includes and an purity,automatic as their generic brand-name substitution counterparts. feature. To help manage the cost of prescription benefits, the plan includes an automatic generic substitution feature. the8 plan includes an automatic generic substitution feature. 8 8 8 8 8 CVS Specialty® CVS Specialty is a full-service pharmacy that provides your choice of home delivery service or delivery to your local CVS Pharmacy for specialty medications. These medications are used to treat a number of complex conditions, such as cancer and multiple sclerosis. CVS Specialty does more than provide your medication, we help you stay on track so you can stay healthy longer. We do this by providing the support you need to ensure you take them safely and effectively.

If prior use of a first-line medication is not found, the second-line medication will not be covered. You will need to obtain a new prescription from your doctor for one of the first-line alternatives, or have your doctor request a prior authorization for coverage of the second-line medication. For more information on step therapy, visit https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767. Prior authorization Prescriptions for certain medications require a Prior Authorization—also known as a coverage review—to 9 ensure the medication is cost-effective and clinically appropriate. This review uses formulary, clinical guidelines and other criteria to determine if the plan will pay for certain medications. At the time you fill a prescription, the pharmacist is informed of the Prior Authorization requirement through the pharmacy’s computer system and your doctor will need to contact CVS Caremark’s Prior Authorization department to provide justification for CVS Caremark’s consideration of why you should be on the prescribed medication.

9 How does the “generics preferred program” work? When your doctor prescribes a brand-name medication and a generic substitute is available, you will automatically receive the generic unless: • Your doctor writes “dispense as written” (DAW) on the prescription; or • You request the brand-name medication at the time you fill your prescription If you choose generic medications, you get high-quality, effective medication at the lowest cost. Your copayment for the generic medication will be less than the copayment for the brand-name medication.

If a generic is available, but you or your doctor request the brand-name medication, you will pay the brand The following are examples that may require prior authorization for your prescription: copayment PLUS the full difference in cost between the brand-name medication and the generic equivalent. • Your doctor prescribes a medication not covered by the formulary • The medication prescribed is subject to age limits • The medication is only covered for certain conditions For example: 30-day supply of medication If the Prior Authorization is denied, written notification is sent to both you and your provider. You have The following are examples that may require prior authorization for your prescription: the right to appeal the denial through the appeals process. The written notification of denial you Brand-name medication cost $120 receive• Yourprovides doctor instructions prescribes for a medicationfiling an appeal. not covered For more by information the formulary on prior authorization, visit Generic medication cost $50 https://info.caremark.com/stateofmaryland• The medication prescribed is subject or to call age CVS limits Caremark Customer Care at 1-844-460-8767. • The medication is only covered for certain conditions Difference (ancillary fee) $70 QuantityIf the Prior Authorization �limits is denied, written notification is sent to both you and your provider. You have the right to appeal the denial through the appeals process. The written notification of denial you Copayment $40 Please note: if your doctor requests you For some medications, such as medications used to treat sleep disorders, your plan covers a limited receive provides instructions for filing an appeal. For more information on prior authorization, visit take the brand-name medication due to quantity within a specific time period. These limits are based on FDA-approved prescribing information, Total cost $110 https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767. medical necessity, please call CVS approved medical guidelines and/or the average utilization quantity for the drugs. Some medications with If you chose the generic medication, you would pay $10 Customer Care at 1-844-460-8767 and quantity limits have a prior authorization available if a greater quantity is medically necessary. For more request the Brand Exception Process. Quantityinformation on �limits quantity limits, visit https://info.caremark.com/stateofmaryland or call CVS Caremark ForCustomer some medications,Care at 1-844-460-8767. such as medications used to treat sleep disorders, your plan covers a limited Step therapy quantity within a specific time period. These limits are based on FDA-approved prescribing information, approved medical guidelines and/or the average utilization quantity for the drugs. Some medications with Step therapy is a process for finding the best treatment while ensuring you are receiving the most quantity limits have a prior authorization available if a greater quantity is medically necessary. For more appropriate medication therapy and reducing prescription costs. Medications are grouped into two information on quantity limits, visit https://info.caremark.com/stateofmaryland or call CVS Caremark categories: Customer Care at 1-844-460-8767. • First-line medications: These are the medications recommended for you to take first—usually generics, which have been proven safe and effective. You pay the lowest copayment for these. • Second-line medications: These are brand-name medications. They are recommended for you only if a first-line medication does not work. You may pay more for brand-name medications. These steps follow the most current and appropriate medication therapy recommendations. CVS Caremark will review your records for step therapy medications when you go to the pharmacy to fill a prescription. If your prescription is for a step therapy medication, the pharmacy will search your prescription records for use of a first-line alternative. If you require an urgent review, please call Customer Care at 1-844-460-8767 for instructions. Please note that not all appeal requests are eligible for the urgent review process. Urgent appeals will be decided within If prior use of a first-line medication is not found, the second-line medication will not be covered. You will need 72 hours. If you choose to fill this prescription without prior authorization approval, you will be responsible for to obtain a new prescription from your doctor for one of the first-line alternatives, or have your doctor request the full cost of the medication. You have a right to receive, upon written request and at no charge, information a prior authorization for coverage of the second-line medication. For more information on step therapy, visit used to review your request. Please note: You must submit an appeal within 180 calendar days after you https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767. Ifreceive you require the notice an urgent of a denial review, of pleasea prior callauthorization. Customer Care at 1-844-460-8767 for instructions. Please note Prior authorization that not all appeal requests are eligible for the urgent review process. Urgent appeals will be decided within Claims72 hours. If you inquiry choose to fill this prescription without prior authorization approval, you will be responsible for Prescriptions for certain medications require a Prior Authorization—also known as a coverage review—to Ifthe you full believe cost of your the medication.claim was incorrectly You have denieda right toor receive,you have upon questions written about request a processed and at no claim,charge, call information ensure the medication is cost-effective and clinically appropriate. This review uses formulary, clinical CVSused Caremarkto review yourCustomer request. Care Please at 1-844-460-8767 note: You must. submit an appeal within 180 calendar days after you guidelines and other criteria to determine if the plan will pay for certain medications. At the time you fill a receive the notice of a denial of a prior authorization. prescription, the pharmacist is informed of the Prior Authorization requirement through the pharmacy’s computer system and your doctor will need to contact CVS Caremark’s Prior Authorization department to Privacy provide justification for CVS Caremark’s consideration of why you should be on the prescribed medication. YourClaims State of Maryland inquiry Benefit Plan meets the provisions of the Health Insurance Portability and Accountability ActIf you of believe1996 (HIPAA) your claim to assure was incorrectly your health denied information or you is have properly questions protected. about CVS a processed Health is claim,committed call to 9 The following are examples that may require prior authorization for your prescription: meetingCVS Caremark both the Customer HIPAA and Care State at 1-844-460-8767 of Maryland guidelines. related to protecting your privacy. • Your doctor prescribes a medication not covered by the formulary • The medication prescribed is subject to age limits Privacy Your State of Maryland Benefit Plan meets the provisions of the Health Insurance Portability and Accountability • The medication is only covered for certain conditions Act of 1996 (HIPAA) to assure your health information is properly protected. CVS Health is committed to If the Prior Authorization is denied, written notification is sent to both you and your provider. You have If the Prior Authorization is denied, written notification is sent to both you and your provider. You have meeting both the HIPAA and State of Maryland guidelines related to protecting your privacy. the right to appeal the denial through the appeals process. The written notification of denial you receive provides instructions for filing an appeal. For more information on prior authorization, visit 10 https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767.

Quantity �limits For some medications, such as medications used to treat sleep disorders, your plan covers a limited 10 quantity within a specific time period. These limits are based on FDA-approved prescribing information, approved medical guidelines and/or the average utilization quantity for the drugs. Some medications with quantity limits have a prior authorization available if a greater quantity is medically necessary. For more information on quantity limits, visit https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767. Appeals If a prior authorization is denied, you or your representative may appeal the decision by proceeding with the Appeal procedure listed on the denial letter.

If you require an urgent review, call CVS Caremark Customer Care at 1-844-460-8767 for instructions. Please note that not all appeal requests are eligible for the urgent review process. Urgent appeals will be decided within 72 hours. If you choose to fill this prescription without prior authorization approval, you will be responsible for the full cost of the medication. You have a right to receive, upon written request and at no charge, information used to review your request. Appeals must be submitted within 180 calendar days after you receive the notice of a denial of a prior authorization.

If you require an urgent review, please call Customer Care at 1-844-460-8767 for instructions. Please note IfFor you more require information an urgent regarding review, Appeals, please callrefer Customer to the “Evidence Care at of 1-844-460-8767 Coverage” document for instructions. located on the Please DBM noteHealth that not all appeal requests are eligible for the urgent review process. Urgent appeals will be decided within thatBenefits not allPrescription appeal requests Drug Coverage are eligible page for (https://dbm.maryland.gov/benefits/Pages/CVS-Caremark.aspx). the urgent review process. Urgent appeals will be decided within 72 hours. If you choose to fill this prescription without prior authorization approval, you will be responsible for the full cost of the medication. You have a right to receive, upon written request and at no charge, information used to review your request. Please note: You must submit an appeal within 180 calendar days after you receive the notice of a denial of a prior authorization. Claims inquiry If you believe your claim was incorrectly denied or you have questions about a processed claim, call CVS Caremark Customer Care at 1-844-460-8767. Privacy Privacy10 Your State of Maryland Benefit Plan meets the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to assure your health information is properly protected. CVS Health is committed to meeting both the HIPAA and State of Maryland guidelines related to protecting your privacy.

10 How does the “generics preferred program” work? When your doctor prescribes a brand-name medication and a generic substitute is available, you will automatically receive the generic unless: • Your doctor writes “dispense as written” (DAW) on the prescription; or • You request the brand-name medication at the time you fill your prescription If you choose generic medications, you get high-quality, effective medication at the lowest cost. Your copayment for the generic medication will be less than the copayment for the brand-name medication.

If a generic is available, but you or your doctor request the brand-name medication, you will pay the brand The following are examples that may require prior authorization for your prescription: copayment PLUS the full difference in cost between the brand-name medication and the generic equivalent. • Your doctor prescribes a medication not covered by the formulary Getting• The medicationstarted prescribedwith mail is subject service to age limits You can• The begin medication using the is CVS only Caremarkcovered for Mail certain Service conditions Pharmacy for home delivery of your medications using For example: 30-day supply of medication Ifone the of Prior the followingAuthorization options: is denied, written notification is sent to both you and your provider. You have The following are examples that may require prior authorization for your prescription: the right to appeal the denial through the appeals process. The written notification of denial you Brand-name medication cost $120 • Your doctor prescribes a medication not covered by the formulary receive provides instructionsOnline for filing an appeal. For more information on prior authorization, visit https://info.caremark.com/stateofmaryland• The medication prescribed is subject or to call age CVS limits Caremark Customer Care at 1-844-460-8767. Generic medication cost $50 Register online at https://info.caremark.com/stateofmaryland to begin managing • The medication youris only prescriptions covered for online. certain You conditions can also download the CVS Caremark app to get Difference (ancillary fee) $70 QuantityIf the Prior Authorization �limits started is denied, with writtenmail service notification today. is sent to both you and your provider. You have the right to appeal the denial through the appeals process. The written notification of denial you Copayment $40 Please note: if your doctor requests you For some medications, such as medications used to treat sleep disorders, your plan covers a limited receive provides instructions for filing an appeal. For more information on prior authorization, visit take the brand-name medication due to quantity within a specific time period. These limits are based on FDA-approved prescribing information, Total cost $110 https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767. medical necessity, please call CVS approved medical guidelinesBy mail and/or the average utilization quantity for the drugs. Some medications with Ask your doctor to provide you with a written prescription for your medications. If you chose the generic medication, you would pay $10 Customer Care at 1-844-460-8767 and quantity limits have a prior authorization available if a greater quantity is medically necessary. For more request the Brand Exception Process. Quantityinformation on �limits quantitySign limits, in visitto caremark.com https://info.caremark.com to download/stateofmaryland and print a mail orservice call CVS form. Caremark Mail the prescription(s) along with a completed order form to the address below: ForCustomer some medications,Care at 1-844-460-8767. such as medications used to treat sleep disorders, your plan covers a limited CVS Caremark Step therapy quantity within a specific time period. These limits are based on FDA-approved prescribing information, approved medical guidelinesP.O. Box and/or 94467 the average utilization quantity for the drugs. Some medications with Step therapy is a process for finding the best treatment while ensuring you are receiving the most quantity limits have a priorPalatine, authorization IL 60094 available if a greater quantity is medically necessary. For more appropriate medication therapy and reducing prescription costs. Medications are grouped into two information on quantityPlease limits, visitnote https://info.caremark.com: to avoid delays in filling your/stateofmaryland prescription, beor callsure CVS to incl Caremarkude payment categories: Customer Care at 1-844-460-8767.with your order. Please do not send correspondence to this address. • First-line medications: These are the medications recommended for you to take first—usually generics, which have been proven safe and effective. You pay the lowest copayment for these. • Second-line medications: These are brand-name medications. They are recommended for you only if a first-line medication does not work. You may pay more for brand-name medications. By fax or electronic submission from your doctor Your doctor's office can fax or electronically send the prescription for a 90- These steps follow the most current and appropriate medication therapy recommendations. CVS Caremark day supply, plus the appropriate number of refills (maximum one-year will review your records for step therapy medications when you go to the pharmacy to fill a prescription. If supply). Your doctor's office will have the appropriate fax number. your prescription is for a step therapy medication, the pharmacy will search your prescription records for use of a first-line alternative. If you require an urgentImportant review, please notes: call Customer Care at 1-844-460-8767 for instructions. Please note that not all appeal requests- Faxes are musteligible be forsent the from urgent your review doctor’s process. office. Urgent Faxes appeals from other will locations, be decided such within If prior use of a first-line medication is not found, the second-line medication will not be covered. You will need 72 hours. 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Care Please at 1-844-460-8767 note: You must. submit an appeal within 180 calendar days after you guidelines and other criteria to determine if the plan will pay for certain medications. At the time you fill a receive the notice of a denial of a prior authorization. prescription, the pharmacist is informed of the Prior Authorization requirement through the pharmacy’s Privacy computer system and your doctor will need to contact CVS Caremark’s Prior Authorization department to ClaimsVacation overrides inquiry overrides provide justification for CVS Caremark’s consideration of why you should be on the prescribed medication. 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The following are examples that may require prior authorization for your prescription: 9 meetingCVS Caremark both the Customer HIPAA and Care State at 1-844-460-8767 of Maryland guidelines. related to protecting your privacy. • Your doctor prescribes a medication not covered by the formulary • The medication prescribed is subject to age limits Privacy • The medication is only covered for certain conditions Your State of Maryland Benefit Plan meets the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to assure your health information is properly protected. CVS Health is committed to If the Prior Authorization is denied, written notification is sent to both you and your provider. You have meeting both the HIPAA and State of Maryland guidelines related to protecting your privacy. the right to appeal the denial through the appeals process. The written notification of denial you receive provides instructions for filing an appeal. For more information on prior authorization, visit 10 https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767.

7 Quantity �limits For some medications, such as medications used to treat sleep disorders, your plan covers a limited quantity within a specific time period. These limits are based on FDA-approved prescribing information, 10 approved medical guidelines and/or the average utilization quantity for the drugs. Some medications with quantity limits have a prior authorization available if a greater quantity is medically necessary. For more information on quantity limits, visit https://info.caremark.com/stateofmaryland or call CVS Caremark Customer Care at 1-844-460-8767.

If you require an urgent review, please call Customer Care at 1-844-460-8767 for instructions. Please note that not all appeal requests are eligible for the urgent review process. Urgent appeals will be decided within 72 hours. If you choose to fill this prescription without prior authorization approval, you will be responsible for the full cost of the medication. You have a right to receive, upon written request and at no charge, information used to review your request. Please note: You must submit an appeal within 180 calendar days after you receive the notice of a denial of a prior authorization. CVS Caremark Customer Care ...... 1-844-460-8767 (TTY 711) CVS Specialty ...... 1-800-237-2767 Claims inquiry If you believe your claim was incorrectly denied or you have questions about a processed claim, call CVS Caremark Customer Care at 1-844-460-8767. Privacy 11 Your State of Maryland Benefit Plan meets the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to assure your health information is properly protected. CVS Health is committed to meeting both the HIPAA and State of Maryland guidelines related to protecting your privacy. 11

10 +Where allowed by law. In-store pick up is currently not available in Oklahoma. Puerto Rico requires 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. Copayment, copay or coinsurance means the amount a 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. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written permission from CVS Caremark. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. ©20112 8 CVS Caremark. All rights reserved. 106-42619A 072518