Getting Started with CVS Specialty®

Getting started with CVS Specialty 1 Welcome to a different kind of pharmacy

Whether you have a prescription for specialty medication or care for someone who does, CVS Specialty helps you make sense of it all. That’s because we do so much more than just provide your medication. We keep an eye on your condition and help you stay on track. We’ll also put you in touch with specialists who can help you sort out your insurance and look for financial assistance. We’re here to help you on your path to better health.

Let’s get started on the next page.

This guide goes hand-in-hand with ¿Español? your new prescription. It introduces Si prefiere recibir este material en español, you to CVS Specialty and how we comuníquese con su equipo CareTeam help you manage your condition as llamando a la línea gratuita que figura en la well as your health. etiqueta de su receta.

Getting started with CVS Specialty 2 Important steps to get started

The first thing to do is register with us – there are two easy ways 1 you can do this: • Go to CVSspecialty.com/newpatient • Or, text “START” to 28779 Fill in, sign and return the forms we’ll need to get you your 2 medication and submit claims – two ways to do this: • Online - after you register you can find them by clicking My Account, then complete and submit everything digitally • By mail - complete and print the forms on pages 29-33 and mail to: CVS Specialty, 105 Mall Boulevard, Monroeville, PA 15146

Be sure to sign and return the forms right away to avoid any delays. Because nothing is more important than getting you started on your treatment.

Getting started with CVS Specialty 3 All-around convenience

Digital tools make it easy to You can have your medication delivered manage your prescriptions anywhere nationwide, even if you’re on anytime, anywhere. vacation. Or you can pick it up at any CVS Pharmacy location.* You can manage your medications and stay on track at CVSspecialty.com or with our mobile app. Order and track We’re here for you 365 days a year. refills so you never miss a dose. Securely Have questions? Need answers? Our message your CareTeam on the go. pharmacists, nurses and insurance Make payments and view history day or specialists are here for you Monday night. You can also sign up to get refill through Friday 7:30 a.m. to 7:30 p.m. reminders, order status updates and local time. Need help after hours? Our more by email or text. on-call team is available 24/7. Call the phone number on your prescription We give you the choice of pick up label. Or send us a secure message at at CVS Pharmacy® or delivery CVSspecialty.com or on our mobile app. at home. We make it as easy as possible to get the medication you need, where you need it.

Text “iPHONE” or “ANDROID” to 28779 for a link to download our mobile app.**

Getting started with CVS Specialty 4 Specialized care and support

Our team of pharmacists and We help with insurance and more. nurses are specially trained We help you see if your medication is in your condition. covered. We file insurance claims for you We give you a CVS Specialty CareTeam and help you keep out-of-pocket costs as led by pharmacists and nurses that put low as possible. If your claim is denied, we you first. Count on us for personalized work to help you get the medication you support every step of the way. need. We also provide helpful resources during open enrollment. We’re here to look out for you. And, we keep you up to date on Your CVS Specialty CareTeam helps you payments and balances. manage your condition. We make sure you know how to take your medication We will send you a patient statement to correctly. And help you manage show if there is activity on your account, side effects. We check dosage and including any balance that you may still medication schedules. And remind you need to pay. Your insurer may also provide when it’s time to refill. Ask us anything, you with an Explanation of Benefits (EOB) anytime. We’re here 365 days a year report that describes the services that for you, no matter what. We also make were covered and how much was paid. it easy to learn about your condition. You can always find helpful resources, tips and more at CVSspecialty.com/ EducationCenter.

Worried about paying for your medication? Let us know. We’ll work hard to help you find the financial assistance you need.

Getting started with CVS Specialty 5 Medication delivery and more

Delivery times. Regular delivery is Change of address. Please tell your Monday through Friday, but some CareTeam if your address, phone shipments arrive on Saturday. Orders number or delivery preference changes. that need to be refrigerated arrive Tuesday through Friday. Emergency refills. Occasionally, you may need an emergency prescription or Delivery to remote areas. In remote refill. Just call the phone number on your areas, deliveries may be as late as 9 p.m. prescription label. Saturday delivery may not be available. Check delivery time with your CareTeam Lower-cost generics. Some states when placing your order. allow lower-cost generic medications. If your doctor prescribes a brand-name Late or missing deliveries. If you don’t medication, we may call him or her to receive your medication on schedule, see if a generic is right for you. This helps call us as soon as possible to avoid make sure your medications are both missing a dose. cost-effective and clinically effective.

Receiving your shipment. You or your insurance plan may require a signature for medication delivery. If that’s the case, we can’t leave your package at the door. We can always deliver it to another location, even when you’re on vacation. Or, you can pick it up at any CVS Pharmacy location.*

Getting started with CVS Specialty 6 Safety & storage

Always handle your medication safely.

Medication storage. medications or of medical waste, consult your local Department of Public Health Keep all medications and supplies out of agency or call your pharmacy. the reach of children and pets and away from other household or food items. If Source: U.S. Environmental Protection Agency your medication needs to be kept in the refrigerator, put it on a clean shelf or in Preventing infections. a drawer. Source: Center for Disease Control and Use soap and warm water to wash Prevention your hands. Rub your hands together, hard, for at least 20 seconds and scrub all surfaces. Rinse your hands under Waste disposal. running water and dry your hands using Do not flush unused medications or pour a paper towel or air dryer. If you cannot them down the sink. Utilizing local drug find soap and water, clean your hands take-back programs is the best way to with an alcohol-based hand sanitizer. Rub dispose of unwanted medications. Do the sanitizer all over your hands—this not recap needles after injections. Keep a includes under your nails and between rigid, puncture-proof, leak-proof container your fingers—until your hands are dry. close by for easy disposal of syringes and Emergency preparation. needles. Store the container upright and keep out of reach of children. When the Take enough medication and supplies to container is full, seal the lid with tape or last through the emergency. If you use an glue. To dispose of the container properly, infusion pump or other device, be sure to follow your county or city regulations. take that with you, too. Store temperature- Please do not send the container to sensitive medication in an ice-filled CVS Specialty. If you need more ice chest, and when you can, let your information on disposal of unused CareTeam know how you are and how to reach you.

Getting started with CVS Specialty 7 Medicare DMEPOS information DMEPOS is short for Durable Medical Equipment, Prosthetics, Orthotics and Supplies

Notification of warranty. Notification regarding capped CVS Specialty hereby notifies you that rental items and inexpensive or any manufacturer warranty coverage routinely purchased items. is described in the manufacturer Medicare has defined certain items as packaging that accompanies the being “capped rental items,” including product. We honor express and implied suction pumps, external infusion pumps, warranties under applicable state law hospital beds, wheelchairs, alternating and will repair or replace, free of charge, pressure pads, air-fluidized beds, Medicare-covered equipment that is mattress overlays, nebulizers, continuous covered under warranty. CVS Specialty airway pressure (CPAP) devices, patient itself does not provide a warranty lifts and trapeze bars. For these items, on any product it sells or rents and Medicare will pay a monthly rental fee disclaims any such warranty express for a period not to exceed 13 months, or implied, including any warranty of after which ownership of the equipment, merchantability or that the product as well as responsibility for repair or is fit for a particular purpose (unless servicing of the equipment, is transferred otherwise required by applicable to the Medicare beneficiary. state law). Medicare has defined certain items as “inexpensive or routinely purchased items,” including home blood glucose monitors, external infusion pump supplies, orthotics, respiratory care (oximeters, nebulizer), specialty incontinence items, wound care items and ostomy care items. A Medicare

Getting started with CVS Specialty 8 beneficiary may either rent or purchase these items, although CVS Specialty does not offer rental of items in this category. If rented from another supplier, the total amount paid for an item obtained on a monthly rental basis may not exceed the fee schedule purchase amount.

Right to consultation/education and training regarding DMEPOS. As a Medicare beneficiary, you have the right to be counseled about your DMEPOS prescription by a pharmacist, and trained and educated on the safe and effective use of the equipment, items and services. Training may include demonstrations of safe and effective operation and/or product use, troubleshooting and potential hazards associated with your purchase. Please ask to speak with a pharmacist for appropriate counseling and training.

Send us a secure message at CVSspecialty.com or on our mobile app.

? Or, call the phone number on your prescription label.

Getting started with CVS Specialty 9 Medicare DMEPOS supplier NOTE: This is an abbreviated version of the supplier standards all Medicare standards DMEPOS suppliers must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).

1. A supplier must be in compliance 5. A supplier must advise beneficiaries with all applicable Federal and State that they may rent or purchase licensure and regulatory requirements inexpensive or routinely purchased and cannot contract with an individual durable medical equipment, and of or entity to provide licensed services. the purchase option for capped rental equipment. 2. A supplier must provide complete and accurate information on the DMEPOS 6. A supplier must notify beneficiaries supplier application. Any changes to of warranty coverage and honor all this information must be reported to warranties under applicable State law, the National Supplier Clearinghouse and repair or replace free of charge within 30 days. Medicare covered items that are under warranty. 3. An authorized individual (one whose signature is binding) must sign the 7. A supplier must maintain a physical application for billing privileges. facility on an appropriate site. This standard requires that the location is 4. A supplier must fill orders from its own accessible to the public and staffed inventory, or must contract with other during posted hours of business. The companies for the purchase of items location must be at least 200-square necessary to fill the order. A supplier feet and contain space for storing may not contract with any entity that is records. currently excluded from the Medicare program, any State health care 8. A supplier must permit CMS, or its programs, or from any other Federal agents, to conduct on-site inspections procurement or non-procurement to ascertain the supplier’s compliance programs. with these standards. The supplier location must be accessible to beneficiaries during reasonable

Getting started with CVS Specialty 10 business hours, and must maintain 14. A supplier must maintain and replace a visible sign and posted hours of at no charge, or repair either directly operation. or through a service contract with another company, Medicare-covered 9. A supplier must maintain a primary items it has rented to beneficiaries. business telephone listed under the name of the business in a local 15. A supplier must accept returns directory, or a toll-free number of substandard (less than full available through directory assistance. quality for the particular item) or The exclusive use of a beeper, unsuitable items (inappropriate answering machine, answering service for the beneficiary at the time it or cell phone during posted business was fitted and rented or sold) from hours is prohibited. beneficiaries. 10. A supplier must have comprehensive 16. A supplier must disclose these liability insurance in the amount of supplier standards to each at least $300,000 that covers both beneficiary to whom it supplies a the supplier’s place of business and Medicare-covered item. all customers and employees of the 17. A supplier must disclose to the supplier. If the supplier manufactures government any person having its own items, this insurance must ownership, financial or control interest also cover product liability and in the supplier. completed operations. 18. A supplier must not convey or 11. A supplier must agree not to initiate reassign a supplier number (i.e., the telephone contact with beneficiaries, supplier may not sell or allow another with a few exceptions allowed. This entity to use its Medicare billing standard prohibits suppliers from number). contacting a Medicare beneficiary based on a physician’s oral order 19. A supplier must have a complaint unless an exception applies. resolution protocol established to address beneficiary complaints that 12. A supplier is responsible for delivery relate to these standards. A record of and must instruct beneficiaries on these complaints must be maintained use of Medicare-covered items, and at the physical facility. maintain proof of delivery. 20. Complaint records must include: the 13. A supplier must answer questions name, address, telephone number and respond to complaints of and health insurance claim number beneficiaries, and maintain of the beneficiary, a summary of the documentation of such contacts. complaint and any actions taken to resolve it.

Getting started with CVS Specialty 11 21. A supplier must agree to furnish CMS 26. All suppliers must meet the surety with any information required by the bond requirements specified in 42 Medicare statute and implementing C.F.R. 424.57(c). Implementation regulations. date: May 4, 2009. 22. All suppliers must be accredited 27. A supplier must obtain oxygen from a by a CMS-approved accreditation state-licensed oxygen supplier. organization in order to receive and 28. A supplier must maintain ordering retain a supplier billing number. and referring documentation The accreditation must indicate the consistent with provisions found in specific products and services for 42 C.F.R. 424.516(f). which the supplier is accredited in order for the supplier to receive 29. DMEPOS suppliers are prohibited payment for those specific from sharing a practice location with products and services (except for certain other Medicare providers and certain exempt pharmaceuticals). suppliers. Implementation date: 30. DMEPOS suppliers must remain October 1, 2009. open to the public for a minimum 23. All suppliers must notify their of 30 hours per week, with certain accreditation organization when a exceptions. new DMEPOS location is opened. 24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. 25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.

Getting started with CVS Specialty 12 Patient rights & responsibilities

As a CVS Specialty patient, or as a parent or guardian of a minor who is a CVS Specialty patient, you have the right to:

1. Be fully informed of all your rights of any person providing care and and responsibilities as a patient of service, and the name of the person CVS Specialty, or the parent or responsible for the coordination of guardian of a minor who is a patient your care. of CVS Specialty, and to exercise those 8. Refuse treatment and to be informed rights. of the consequences of your action. 2. Be treated with dignity and respect 9. Confidentiality and privacy in without discrimination on the basis of treatment and care, including any factor for which discrimination is confidential treatment of patient prohibited by law. health information. 3. Choose health care providers. 10. Be admitted for service only if 4. Receive information necessary to give CVS Specialty has the ability to informed consent prior to the start of provide safe and professional care any procedure or treatment. at the level of intensity prescribed. You have the right to reasonable 5. Receive information in a language or continuity of care and service form you can understand. provided by personnel who are 6. Make informed decisions about and qualified, through education and actively participate in the planning of experience, to perform the service for your care. which they are responsible. 7. Be informed about your illness and 11. Be informed within a reasonable treatment, when and how services will time of anticipated termination of be provided, the name and function services or plans for transfer to

Getting started with CVS Specialty 13 another agency, and participate in that 19. Be informed of the identity and job discharge or transfer process. title of the staff members of the pharmacy providing services to you, 12. Participate or refuse to participate in and to speak to a supervisor of the experimental treatment and research staff member if requested. with voluntary, informed consent documented without jeopardizing 20. Have cultural and personal values, access to care, treatment and beliefs and preferences respected. services unrelated to research. 21. Have a surrogate decision-maker 13. Issue voice complaints and whose decisions regarding care, grievances, suggest changes in treatment and services are respected, service staff, and be informed of including the right to refuse care, CVS Specialty procedures for treatment and services on your registering complaints without behalf, in accordance with law and reprisal, coercion, discrimination or regulation. unreasonable interruption in service 22. Give or withhold informed consent and the right to have your complaint for CVS Specialty to produce or use investigated. recordings, films, or other images of 14. Review your medical record. you, for internal or external purposes. 15. Formulate advance directives and be 23. Know about the philosophy and aware that CVS Specialty will honor characteristics of the CVS Specialty those directives. patient management program. 16. Participate in the consideration of 24. Receive information about the patient ethical issues in your care. management program. 17. Be advised of the availability of the 25. Decline participation, revoke toll-free state home health hotline. consent or disenroll in the patient management program at any time. 18. Refuse disclosure of your Protected Health Information (PHI) to 26. Speak to a health care professional. accrediting organizations for the purposes of quality management. To refuse disclosure of specialty pharmacy information and your PHI, please call the toll-free phone number of the pharmacy listed on your prescription label.

Getting started with CVS Specialty 14 As a CVS Specialty patient, or as a parent or guardian of a minor who is a CVS Specialty patient, you have the responsibility to:

1. Give accurate and complete health 8. Follow the plan of care and clinical information concerning past illnesses, instructions and use equipment hospitalizations, medications, allergies and supplies as prescribed by the and other pertinent information physician. necessary for CVS Specialty to render 9. Give information regarding concerns appropriate services. and problems you have to a staff 2. Assist in developing and maintaining member. a safe environment to give self 10. Advise CVS Specialty about any treatments according to infection changes in your insurance benefits, control guidelines. employment status or employer. 3. Advise CVS Specialty pharmacy staff 11. Fulfill financial obligations for services. about any change in physicians or in medical condition. 12. Treat CVS Specialty employees with courtesy and respect. 4. Inform the staff at CVS Specialty at least 24 hours in advance when you 13. Notify your treating provider of will not be able to keep a scheduled your participation in the patient appointment. management program. 5. Participate in the development and update of your plan of care. 6. Request further information concerning anything you do not Send us a understand. secure message at CVSspecialty.com or 7. Advise CVS Specialty if you are not on our mobile app.

willing to follow your established care ? Or, call the phone plan/services and accept responsibility number on your for those actions. prescription label.

Getting started with CVS Specialty 15 Notice of privacy practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This Notice of Privacy Practices (the It includes your name and contact “Notice”) describes the privacy practices information, as well as information of CVS Specialty (“CVS Health”) and about your health, medical conditions the members of its Affiliated Covered and prescriptions. It may relate to your Entity (“CVS ACE”). An Affiliated Covered past, present or future physical or Entity is a group of Covered Entities and mental health or condition, the provision Health Care Providers under common or health care products and services ownership or control that designates to you, or payment for such products itself as a single entity for purposes of or services. compliance with the Health Insurance We are required by law to protect the Portability and Accountability Act privacy of your PHI and to provide you (“HIPAA”). The members of the CVS ACE with this Notice explaining our legal will share Protected Health Information duties and privacy practices regarding (“PHI”) with each other for the treatment, your PHI. This Notice describes how we payment, and health care operations of may use and disclose your PHI. We have the CVS ACE and as permitted by HIPAA provided you with examples; however, and this Notice. For a complete list of not every permissible use or disclosure the members of the CVS ACE, please will be listed in this Notice. This Notice contact the CVS Health Privacy Office. also describes your rights and the PHI is information about you that we obligations we have regarding the use obtain to provide our services to you and and disclosure of your PHI. We and our that can be used to identify you. employees and workforce members are required to follow the terms of this

Getting started with CVS Specialty 16 Notice or any change to it that is in effect. • Disclose your PHI to other third parties, We are required to follow state privacy such as pharmacies, doctors, hospitals, laws when they are stricter (or more or other health care providers to assist protective of your PHI) than the federal them in providing care to you or for law. Note that some types of sensitive care coordination. In some instances, PHI, such as human immunodeficiency uses and disclosures of your PHI for virus (HIV) information, genetic these purposes may be made through a information, alcohol and/or substance Health Information Exchange or similar abuse records, and mental health shared system. records may be subject to additional • Contact you to provide treatment- confidentiality protections under state or related services, such as refill reminders, federal law. If you would like additional adherence communications, or information about state law protections treatment alternatives (e.g., available in your state, or additional use or generic products). disclosure restrictions that may apply to sensitive PHI, please contact the Payment: We may use and disclose your CVS Health Privacy Office. PHI to obtain payment for the services we provide to you and for other payment activities related to the services we Uses and disclosures of your PHI provide. For example, we may: for treatment, payment and health care operations • Share your PHI with your insurer, pharmacy benefit manager, or other We may use and disclose your PHI health care payor to determine for treatment, payment and health whether it will pay for your health care care operations without your written products and services you need and authorization. The following categories to determine the payment amount you describe and provide some examples may owe. of the different ways that may use and disclose your PHI for these purposes: • Contact you about a payment or balance due for prescriptions Treatment: We may use and disclose dispensed to you at CVS Pharmacy or your PHI to provide and coordinate the may disclose your PHI to other health treatment, medication and services you care providers, health plans or other receive. For example, we may: HIPAA Covered Entities who may need • Use and disclose your PHI to provide it for their payment activities. and coordinate the treatment, medication and services you receive at CVS Health.

Getting started with CVS Specialty 17 Health care operations: We may use Other uses and disclosures of and disclose your PHI for health care your PHI that do not require operations – those activities necessary authorization to operate our health care business. For We are also allowed or required to share example, we may: your PHI, without your authorization, • Use and disclose your PHI to monitor in certain situations or when certain the quality of our health care services, conditions have been met. to provide customer services to you, to Business associates: When we resolve complaints, and to coordinate contract with third parties to perform your care. certain services for us, such as • Transfer or receive your PHI if we buy or billing or consulting, these third party sell pharmacy locations. service providers, known as Business Associates, may need access to your • Use and disclose your PHI to contact PHI to perform these services. They are you about health-related products, required by law and their agreements services or opportunities that may with us to protect your PHI in the same interest you, such as programs for way we do. CVS Health patients. Individuals involved in your care • Disclose your PHI to other HIPAA or payment for your care: We may Covered Entities that have provided disclose your PHI to a friend, personal services to you so that they can representative, family member, or improve the quality and efficacy of the any other person you identify as a health care services they provide or for caregiver, who is involved in your care their health care operations. or the payment related to that care. For • Use your PHI to create de-identified example, we may provide prescriptions data, which no longer identifies you, and related information to your caregiver and which may used or disclosed for on your behalf. We may also make these analytics, business planning or other disclosures after your death unless purposes. doing so is inconsistent with any prior expressed preference documented by CVS Health. Upon your death, we may disclose your PHI to an administrator, executor, or other individual authorized under law to act on behalf of your estate. If you are a minor, we may release your PHI to your parents or legal guardians when permitted or required by law.

Getting started with CVS Specialty 18 Workers’ compensation: We may audits, investigations, inspections, disclose your PHI as necessary to licensure or disciplinary actions, or comply with laws related to workers’ civil, administrative, and criminal compensation or similar programs. proceedings, and as necessary for oversight of the health care system, Law enforcement: We may disclose government programs, or compliance your PHI to law enforcement officials with civil rights laws. as permitted or required by law. For example, we may use or disclose your Research: Under certain circumstances, PHI to report certain injuries or to report we may use or disclose your PHI for criminal conduct that occurred on our research purposes. For example, we premises. We may also disclose your PHI may use or disclose your PHI as part in response to a court order, subpoena, of a research study when the research warrant, or other similar written request has been approved by an institutional from law enforcement officials. review board and there is an established protocol to ensure the privacy of your Required by law: We will disclose your information. PHI when required to do so to comply with federal, state or local law. Coroners, medical examiners and funeral directors: We may disclose PHI Judicial and administrative to coroners, medical directors, or funeral proceedings: We may disclose your PHI directors so that they can carry out their in response to a court or administrative duties. order, subpoena, discovery request, or other lawful process. Organ or tissue donation: We may disclose your PHI to organ procurement Public health and safety purposes: organizations. We may disclose your PHI in certain situations to help with public health Notification: We may use or disclose and safety issues when we are required your PHI to notify or assist in notifying a or permitted to do so, for example family member, personal representative, to: prevent disease; report adverse or any other person responsible for your reactions to medications; report care regarding your location, general suspected abuse, neglect or domestic condition, or death. We may also disclose violence; or to prevent or reduce a threat your PHI to disaster relief organizations to anyone’s health or safety. so that your family or other persons responsible for your care can be notified Health oversight activities: We may of your location, general condition, or disclose your PHI to an oversight death. agency for certain activities including

Getting started with CVS Specialty 19 Correctional institution: If you are or Your revocation will be effective upon become an inmate of a correctional receipt; however, it will not undo any use institution, we may disclose your PHI to or disclosure of your PHI that occurred the institution or its agents to assist them before you notified us, or any actions in providing your health care, protecting taken based upon your authorization. your health and safety or the health and safety of others. Your health information rights Specialized government functions: We Written requests and additional may disclose your PHI to authorized information: You may request additional federal officials for the conduct of information about CVS Health’s privacy military, national security activities and practices or obtain forms for submitting other specialized government functions. written requests by contacting the CVS Health Privacy Officer: CVS Health Uses or disclosures for purposes Privacy Office, One CVS Dr., Woonsocket, that require your authorization RI 02895 or toll-free by telephone at (866) 443-0933. You can also visit Use and disclosure of your PHI for other CVSspecialty.com to obtain the forms to purposes may be made only with your submit written requests. written authorization and unless we have your authorization we will not: Obtain a copy of the notice: You have the right to obtain a paper copy of our • Use or disclose your PHI for marketing current Notice at any time. You may purposes. do so by going to the site where you • Sell your PHI to third parties (except obtain health care services from us or by for in connection with the transfer contacting the CVS Health Privacy Office. of a business to another health care Inspect and obtain a copy of your PHI: provider required to comply with With a few exceptions, you have the right HIPAA). to see and get a copy of the PHI • Share psychotherapy notes (to the we maintain about you. You may request extent we have any). access to your PHI electronically. To inspect or obtain a copy of your PHI, We will obtain your written authorization submit a written request to the before using or disclosing your PHI for CVS Health Privacy Office. You may also purposes other than those described in ask us to provide a copy of your PHI to this Notice or otherwise permitted by another person or entity. A reasonable law. You may revoke your authorization fee may be charged for the expense of at any time by submitting a written fulfilling your request as permitted under notice to the CVS Health Privacy Office. HIPAA and/or state law. We may deny

Getting started with CVS Specialty 20 your request to inspect and copy your Request confidential communications: record in certain limited circumstances. You have the right to request that we If we deny your request, we will notify communicate with you in a certain way you in writing and let you know if you or at a certain location. For example, you may request a review of the denial. may request that we contact you only in writing at a specific address. To request Request an amendment: If you feel confidential communication of your PHI, that the PHI we maintain about you submit a written request to the is incomplete or incorrect, you may CVS Health Privacy Office. Your request request that we amend it. For example, must state how, where, or when you if your date of birth is incorrect, you would like to be contacted. We will may request that the information be accommodate all reasonable requests. corrected. To request an amendment, submit a written request to the Request a restriction on certain uses CVS Health Privacy Office. You must and disclosures: You have the right to include a reason that supports your request additional restrictions on our use request. If we deny your request for an and disclosure of your PHI by sending amendment, we will provide with you a a written request to the CVS Health written explanation of why we denied it. Privacy Office. We are not required to agree to your request except where the Receive an accounting of disclosures: disclosure is to a health plan or insurer You have the right to request an for purposes of carrying out payment or accounting of disclosures we make health care operations, is not otherwise of your PHI for purposes other than required by law, and the PHI is related to treatment, payment, or health care a health care item or service for which operations. Please note that certain other you, or a person on your behalf, has paid disclosures need not be included in the in full out-of-pocket. If you do not want accounting we provide to you. To obtain a claim for payment submitted to your an accounting, submit a written request health plan on record, please discuss to the CVS Health Privacy Office. We will with the pharmacist or health care provide one accounting per 12-month provider when you check in for care or period free of charge, but you may be before your prescription is sent to the charged for the cost of any subsequent pharmacy. accountings. We will notify you in advance of the cost involved, and you Notification of breach: You have a right may choose to withdraw or modify your to be notified in the event there is a request at that time. breach of your unsecured PHI as defined by HIPAA.

Getting started with CVS Specialty 21 To report a problem Changes to this Notice Complaints: If you believe your privacy We reserve the right to make changes rights have been violated, you can file a to this Notice as permitted by law and complaint with the CVS Health Privacy to make the revised Notice effective for Officer or with the Secretary of the PHI we already have about you as well as United States Department of Health and any information we receive in the future, Human Services. All complaints must as of the effective date of the revised be submitted in writing. You will not be Notice. If we make material or important penalized or otherwise retaliated against changes to our privacy practices, we will in any way for filing a complaint. promptly revise our Notice. Upon request to the Privacy Office, CVS Health will provide a revised Notice to you. We will also post the revised Notice in our retail stores and on our website at https:// www.CVSspecialty.com/wps/portal/ specialty/company/privacy-policy/ and will make copies available at our facilities and locations where you receive health care products and services from us.

Send us a secure message at CVSspecialty.com or on our mobile app.

? Or, call the phone number on your prescription label.

Effective Date: This Notice is effective as of January 24, 2019.

Getting started with CVS Specialty 22 Customer care

Quality and care

If you have concerns about your care, Quality and care are important to us. please contact the pharmacy manager If you have a comment or concern at your dedicated CVS Specialty about the services you receive from pharmacy or call the phone number on CVS Specialty, you can call The your prescription label. If your specialty Accreditation Commission for Health pharmacy does not handle the issue Care (ACHC) at 1-855-937-2242 or The to your satisfaction, please call the Joint Commission at 1-800-994-6610, Specialty Escalation Line at or write to: 1-855-264-3240. The Office of Quality Monitoring The Joint Commission Returns One Renaissance Boulevard Oakbrook Terrace, IL 60181 CVS Specialty follows your doctor’s order carefully. You cannot return or exchange medications after they have been sold to you. Be sure to tell us the exact amount you have on hand when you schedule your next order. We cannot give credit for medication you do not use. Make sure you follow the treatment plan that your doctor gave you.

Getting started with CVS Specialty 23 Nondiscrimination and accessibility notice

(ACA § 1557)

CVS Specialty complies with applicable • Provides language services, free of Federal civil rights laws and does not charge, when necessary to provide discriminate on the basis of race, color, meaningful access to people whose national origin, age, disability or sex. primary language is not English, CVS Specialty does not exclude people such as: or treat them differently because of - Qualified interpreters race, color, national origin, age, - Information written in other languages disability or sex. If you need these services, contact CVS Specialty: Customer Care at 1-866-322-0984, • Provides certain aids and services, Monday through Friday 6:30 a.m. to free of charge, when necessary so that 8 p.m. (CST). TTY users should call 711. people with disabilities have an equal If you believe that CVS Specialty has opportunity to communicate effectively failed to provide these services or with us, such as: discriminated in another way on the - Auxiliary aids and services basis of race, color, national origin, - Written information in other formats age, disability or sex, you can file a (large print, audio, accessible grievance with: electronic formats, other formats) CVS Specialty Grievance Department Attn: Civil Rights Coordinator P.O. Box MC 1234 Woonsocket, RI 02895 Fax: 1-401-652-9935

Getting started with CVS Specialty 24 You can file a grievance by mail, or by fax. If you need help filing a grievance, the CVS Specialty Grievance Department’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/ lobby.jsf by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW., Send us a secure message at Room 509F, HHH Building CVSspecialty.com or Washington, DC 20201 on our mobile app. Phone: 1-800-368-1019, ? Or, call the phone 1-800-537-7697 (TDD) number on your prescription label. Complaint forms are available at http:// www.hhs.gov/ocr/office/file/index.html.

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SPANISHCHINESE al 小1-866-322-0984贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 (TTY: 711). CHINESE 1-866-322-0984 (TTY:小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 711). 1-866-322-0984 (TTY: 711). ATENCIÓN: Si usted habla español, tenemos servicios de asistencia lingüística disponibles paraCHINESE usted sin costo alguno. Llame 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 1-866-322-0984 (TTY:小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 711). VIETNAMESE 1-866-322-0984 (TTY: 711). al 1-866-322-0984 (TTY: 711). CHÚ小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ trợ giúp 1-866-322-0984 ngôn ngữ miễ (TTY:n phí dành711). cho quý vị. Hãy gọi số 1-866-322- CHINESEVIETNAMESE VIETNAMESE CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các0984 dịch (TTY: vụ tr ợ711). giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- VIETNAMESE 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨VIETNAMESE 1-866-322-0984 (TTY:CHÚ 711) Ý:. Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- CHINESE 0984 (TTY: 711). VIETNAMESE CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ trợ giúp ngôn ngữ miễn phíCHÚ dành Ý: N choếu quýquý vvịị .nói Hãy tiế gngọi sViốệ 1-866-322-t, thì có sẵn các0984 dịch (TTY: vụ trợ 711). giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 1-866-322-0984 (TTY: 711). KOREANCHÚ Ý: N ếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- 0984 (TTY: 711). VIETNAMESE 0984 (TTY: 711). GetKOREAN help in other languages 알림0984 (TTY:한국어를 711).하시는 경우 무료 통역 서비스가 준비되어 있습니다 로 연락주시기 바랍니다 CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịch: vụ trợ giúp ngôn ngữ mi ễn phí KOREAN dành cho quý vị. Hãy gọi số 1-866-322-. 1-866-322-0984 (TTY: 711) .

VIETNAMESEKOREAN If you0984알림 need (TTY:: 한국어를 help 711). or 하시는 speak 경우 a non-English 무료 통역KOREAN 서비스가 language, 준비되어 call 있습니다 1-866-322-0984. 1-866-322-0984 (TTY:알림 (TTY:711): 한국어를 711) 로하시는 연락주시기 경우 무료 바랍니다 통역 서비스가. 준비되어 있습니다. 1-866-322-0984 (TTY: 711)로 연락주시기 바랍니다. CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ trợ giúp ngôn ngữ miễn phí dành choKOREAN quý vị. Hãy gọi số 1-866-322- 알림: 한국어를 하시는 경우 무료 통역 서비스가 준비되어 있습니다. 1-866-322-0984알림 (TTY:: 한국어를 711)TAGALOG로 하시는 연락주시기 경우 무료 바랍니다 통역 서비스가. 준비되어 있습니다. 1-866-322-0984 (TTY: 711)로 연락주시기 바랍니다. 0984 (TTY: 711). and you will be connected to an interpreter Pansinin:who알림: will한국어를 Kungassist 하시는nagsasalita you at 경우 no ka무료cost. ng 통역 Tagalog, 서비스가 mga 준비되어serbisyo ng있습니다 tulong. sa1-866-322-0984 wika, nang walang (TTY: bayad, 711)로 ay 연락주시기 magagamit 바랍니다 sa iyo. Tawagan. KOREANTAGALOG TAGALOG Pansinin: Kung nagsasalita ka ng Tagalog, mgaang serbisyo 1-866-322-0984 ng tulong (TTY: sa wika, 711). nang walang bayad, ay magagamit sa iyo. Tawagan TAGALOG 알림: 한국어를 하시는 경우 무료 통역TAGALOG 서비스가 준비되어 있습니다. 1-866-322-0984Pansinin: (TTY: 711) Kung로 연락주시기nagsasalita 바랍니다ka ng Tagalog,. mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tawagan KOREAN ang 1-866-322-0984 (TTY: 711). TAGALOG Pansinin: Kung nagsasalita ka ng Tagalog,English mga serbisyo ng tulong sa wika, nangPansinin: walang bayad, KungRussian nagsasalitaay magagamit ka ngsa Tagalog,iyo. Tawagan mgaang serbisyo 1-866-322-0984 ng tulong sa(TTY: wika, 711). nang walang bayad, ay magagamit sa iyo. Tawagan 알림: 한국어를 하시는 경우 무료 통역 서비스가 준비되어 있습니다. 1-866-322-0984 (TTY: 711)RUSSIANPansinin:로 연락주시기 Kung nagsasalita 바랍니다. ka ng Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tawagan ang 1-866-322-0984 (TTY: 711). ATTENTION:TAGALOG If you speak English,ang 1-866-322-0984 (TTY: 711). RUSSIAN ВНИМАНИЕang 1-866-322-0984: Если вы (TTY: говорите 711). на русском языке, вам будут бесплатно предоставлены услуги переводчика. Звоните по Pansinin: Kung nagsasalita ka ng Tagalog, mga serbisyo ng tulong sa wika, nang walangRUSSIAN bayad, ay magagamit sa iyo. Tawagan languageВНИМАНИЕ assistance: Если services,вы говорите free на of русском языкетелефону , вам: 1-866-322-0984будут бесплатно (телетайп предоставлены: 711). услуги переводчика. Звоните по TAGALOGRUSSIAN ang 1-866-322-0984 (TTY: 711). RUSSIAN ВНИМАНИЕ: Если вы говорите на русском языке, вам будут бесплатно предоставлены услуги переводчика. Звоните по телефону: 1-866-322-0984 (телетайп: 711). RUSSIAN Pansinin:ВНИМАНИЕ Kung: Если nagsasalita вы говорите ka ng наTagalog, русскомcharge, mga языке serbisyo are, вам available ngбудут tulong бесплатно tosa you.wika, Call предоставленыnang ВНИМАНИЕ walang bayad, услуги: Если ay magagamitпереводчика вы говорите sa . на iyo.Звоните русском Tawagan по языке телефону , вам: будут1-866-322-0984 бесплатно ( телетайппредоставлены: 711). услуги переводчика. Звоните по ARABICВНИМАНИЕ : Если вы говорите на русском языке, вам будут бесплатно предоставлены услуги переводчика. Звоните по angтелефону 1-866-322-0984: 1-866-322-0984 (TTY: 711). (телетайп : 711).1-866-322-0984RUSSIAN (TTY: 711). телефону: 1-866-322-0984 (телетайп: 711). مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. اتصل .(711 :بالرقم телетайп) 0984-322-866-1 (من الھاتف0984-322-866-1 :النصي: 711телефону). ВНИМАНИЕARABIC : Если вы говорите на русском языке, вам будут бесплатно предоставленыARABIC услуги переводчика. Звоните по

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Zadzwoń pod numer 1-866-322- SPANISHATTENTION : Si vous parlez français, des services gratuits d’interprétation sont à votre disposition.PORTUGUESEPOLISH Veuillez UWAGA: appeler ATENÇÃO: Dla osób le 1-866 mówiSe -322-falaących português, po polsku estão dost disponíveisępna jest bezp serviçosłatna gratuitospomoc ję dezykowa. assistência Zadzwo linguísticań pod numer na sua 1-866-322- língua. 0984 (TTY: 711). al 1-866-322-0984 (TTY: 711).SPANISH 0984 (TTY: pou711). ou. Rele 1-866-322-0984 (TTY: 711). ATENCIÓN:0984 (TTY: Si usted 711). habla español, tenemos servicios小贴士：如果您说普通话，欢迎使用免费语PORTUGUESE de asistencia lingüísticaATENÇÃO: disponibles Se fala português, para ustedTelefone0984 estão sin (TTY: costodisponíveis para 711). alguno.1-866-322-0984 serviços Llame gratuitos (TTY: 711). de assistência linguística na sua língua. SPANISH POLISH UWAGA: 1-866-322-0984Dla osóbATENCIÓN: mówiących poSi ustedpolsku habla dostę español,pna jest bezptenemosłatna servicios pomoc jPORTUGUESE ędezykowa. asistencia Zadzwo lingüística ATENÇÃO:ń pod numer disponibles Se 1-866-322-fala português, para usted estão sin costo disponíveis alguno. serviçosLlame gratuitos de assistência linguística na sua língua. al 1-866-322-0984 (TTY: 711). 言协助服务。请拨Telefone para 1-866-322-0984 (TTY: 711). ATENCIÓN: Si usted habla español, tenemos serviciosPORTUGUESE de asistencia ATENÇÃO: lingüística disponiblesSe fala português, para0984 usted estão (TTY: sin disponíveis costo 711). alguno. serviços Llameal gratuitos1-866-322-0984 PORTUGUESE de assistência (TTY: ATENÇÃO:711). linguística Sena suafala língua.português, Telefone estão disponíveis para 1-866-322-0984 serviços gratuitos (TTY: de711). assistência linguística na sua língua. (TCHINESETY: 711). ITALIANPORTUGUESE ATENÇÃO: Se fala português, estão disponíveis serviços gratuitos de assistência linguística na sua língua. al 1-866-322-0984 (TTY: 711). POLISHTelefone UWAGA:para 1-866-322-0984 Dla osób mówi (TTY:ących 711). po polsku dostępna jest bezpłatna pomocTelefone językowa. para FrenchZadzwo 1-866-322-0984ń pod numer (TTY: 1-866-322- 711). CHINESE 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨ITALIAN ATTENZIONE:Telefone para 1-866-322-0984 1-866-322-0984 Se lei parla italiano,(TTY: (TTY: 711) sono 711).. disponibili servizi gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- 0984 (TTY: 711). PORTUGUESE ATENÇÃO:CHINESE Se fala português, estãoATTENTION: disponíveis Si serviçosvous parlez gratuitos français,ITALIAN de assistência des linguística na sua língua. 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 ATTENZIONE: Se lei parla italiano, .sono disponibili0984 (TTY: servizi 711). gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- CHINESE ITALIAN VietnameseTelefone para 1-866-322-0984 1-866-322-0984 (TTY:小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 (TTY: 711)ITALIAN 711). ATTENZIONE: 1-866-322-0984 Se lei parla (TTY: italiano, 711). sono disponibili servizi gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- 0984 (TTY: 711). services ITALIAN gratuits d’interprétation sont 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 PORTUGUESEATTENZIONE: 1-866-322-0984 Se ATENÇÃO: lei parla (TTY: italiano, Se fala 711) sonoportuguês,. disponibiliVIETNAMESE estão servizi disponíveis gratuiti serviços di assistenza gratuitos linguisticaATTENZIONE: de assistência nella suaSe linguística leilingua. parla Chiami italiano, na sua 1-866-3 língua.sono disponibili22- 0984 servizi(TTY: 711).gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- CHÚ Ý: Nếu quý vị nói tiếng Vi ệt, thì có sẵn các dịchàJAPANESEATTENZIONE: votre vụ trợ disposition. giúp お知らせ ngôn Se lei ng :parlaVeuillez ữ日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま mi ễitaliano,n phí appeler dành sono cho ledisponibili quý vị. Hãy servizi gọi gratuitisố 1-866-322- di assistenza linguistica nella sua す。電話番号 lingua. Chiami1-866-322- 1-866-322- VIETNAMESETelefone0984 (TTY: para 711). 1-866-322-0984 (TTY: 711). ITALIAN 0984 (TTY: 711). お知らせ: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれまVIETNAMESE 0984 (TTY: 711)711).までお問い合わせ下さい。 す。電話番号1-866-322- CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các d0984ịchATTENZIONE: vJAPANESE (TTY:ụ trợ giúp 711). ngôn Se leing ữparla miễ italiano,n phí dành sono cho disponibili quý v1-866-322-0984ị. Hãy servizi gọi sgratuitiố 1-866-322- di (TTY: assistenza 711). linguisticaJAPANESE nella お知らせsua lingua.: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま Chiami 1-866-322- す。電話番号1-866-322- VIETNAMESE までお問い合わせ下さい。CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- 0984 (TTY:ITALIANJAPANESE 711). お知らせ: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま09840984 (TTY: (TTY: 711). 711) JAPANESE お知らせ す。電話番号: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま1-866-322- 0984 (TTY: 711)までお問い合わせ下さい。 す。電話番号1-866-322- CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịchATTENZIONE: vụ trợ giúp ngôn Se ngleiữ parla miễn italiano, phí dành sono cho disponibili quýKOREAN vị. Hãy servizi gọi s ốgratuiti 1-866-322- di assistenza0984 (TTY: linguistica 711). nellaGERMANJAPANESE sua lingua. お知らせ Chiami :1-866-3 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま22- す。電話番号1-866-322- 0984 (TTY: 711)までお問い合わせ下さい。 0984 (TTY: 711)までお問い合わせ下さい。 0984 (TTY: 711). 0984 (TTY: 711). PolishBITTE BEACHTEN:までお問い合わせ下さい。 Wenn Sie Deutsch sprechen, stehen Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: KOREAN 알림:GERMAN 한국어를 お知らせ하시는 경우: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま 무료 통역 서비스가 준비되어0984 (TTY: 있습니다 711). 1-866-322-0984 (TTY:GERMAN 711) 로 연락주시기 す。電話番号 바랍니다1-866-322-. JAPANESE KOREAN 711) kostenlos zur Verfügung. GERMAN KoreanBITTE BEACHTEN:までお問い合わせ下さい。 Wenn Sie Deutsch sprechen,UWAGA: stehen Dla Ihnen osób unsere mówiących Dolmetscher poBITTE polsku unter BEACHTEN: der Nummer Wenn 1-866-322-0984 Sie Deutsch sprec(TTY:hen, stehen Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: KOREAN 알림: 한국어를 하시는 경우 무료 통역 서비스가 준비되어 0984 (TTY: 있습니다 711). 1-866-322-0984 (TTY:GERMAN 711) 로 연락주시기 바랍니다. JAPANESEBITTE BEACHTEN: お知らせ Wenn: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま Sie Deutsch sprechen,711) stehen kostenlos Ihnen zur unsere Verfügung. Dolmetscher알림: 한국어를 unter 하시는 derGERMAN Nummer경우 す。電話番号 무료 1-866-322-0984 통역 서비스가1-866-322- 준비되어(TTY: 711) 있습니다 kostenlos. 1-866-322-0984 zur Verfügung. (TTY: 711)로 연락주시기 바랍니다. 알림 한국어를 하시는 경우 무료 통역 서비스가 준비되어 있습니다 알림:TAGALOG로 연락주시기 한국어를 바랍니다 하시는 경우 무료 통역BITTE BEACHTEN:dostępna Wenn jest Siebezpłatna Deutsch pomoc sprechen, językowa. stehen Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: : 0984711) kostenlos(TTY: 711) .zur 1-866-322-0984までお問い合わせ下さい。 Verfügung. (TTY: 711) . FARSIBITTE BEACHTEN: Wenn Sie Deutsch sprechen, stehen Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: TAGALOG Pansinin:GERMAN Kung nagsasalita ka ng 1-866-322-Tagalog,711) mgakostenlos serbisyoZadzwoń zur ngVerfügung. tulongpod numer sa wika, 1-866-322-0984 nang walang bayad, ay magagamit sa iyo. Tawagan توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با Verfügung. (TTY: 711) 1-866-322-0984 تماس zur بگيريد. تماس kostenlos بگيريد(서비스가FARSI 준비되어 있습니다.TAGALOG .711 Pansinin: Kung nagsasalita ka ng Tagalog, mga serbisyoangBITTE 1-866-322-0984 ngBEACHTEN: tulong sa (TTY: wika, Wenn 711).nang Sie walangDeutsch bayad, sprec hen,ay magagamit stehen Ihnen sa iyo.unsere Tawagan Dolmetscher FARSI unter der Nummer 1-866-322-0984 (TTY: sa iyo. Tawagan توجهay :magagamitاگر به زبان,bayad فارسی walang گفتگو میnang کنيد، ,sa wika تسھيالت tulongزبانی ng بصورت serbisyo رايگان mga برای شما فراھم,Tagalog می ka ngباشد .(711. با :TTY:Pansinin: 711) 바랍니다. 1-866-322-0984 Kung nagsasalita (TTY) تماس로 연락주시기 بگيريد. (711 تماس :TTY) بگيريد.TAGALOG GERMAN 0984 توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد. ang 1-866-322-0984FARSI (TTY: 711). 711) kostenlos zur Verfügung. FARSI Pansinin: Kung nagsasalita ka ng Tagalog, mga serbisyoBITTE ng BEACHTEN: tulong sa wika, Wenn nang Sie walang Deutsch bayad, sprec ayhen, magagamit stehen Ihnen sa iyo. unsere Tawagan Dolmetscherang 1-866-322-0984 unter der FARSI(TTY: Nummer 711). 1-866-322-0984 (TTY: توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با توجه: اگر به زبان 0984-322-866-1 فارسی(711 گفتگو :TTY) می تماسکنيد، بگيريد. تسھيالت تماس زبانی بگيريد.بصورت رايگان برای شما فراھم می باشد . با TTY: 711) 1-866-322-0984RUSSIAN) تماس بگيريد. تماس بگيريد. توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد. ang 1-866-322-0984 (TTY: 711). 711) kostenlos zur Verfügung. Tagalog ВНИМАНИЕFARSI : Если вы говорите на русском языке, вам будут бесплатно предоставлены услуги переводчика. Звоните по RUSSIAN Pansinin: Kung nagsasalitaRUSSIAN ka ng توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت по رايگان برای شما Звоните .فراھم می باشد. با TTY: предоставлены (телетайп 711) 1-866-322-0984: 711). услуги переводчика) تماس бесплатно بگيريد. будут: 1-866-322-0984تماس вам ,بگيريد.ВНИМАНИЕ: Если вы говорите на русском языкетелефону RUSSIAN FARSI Tagalog, mga serbisyo ng ВНИМАНИЕtulong sa wika,: Если вы говорите на русском языке, вам будут бесплатно предоставлены услуги переводчика. Звоните по ВНИМАНИЕ: Если вы говорите на русском телефонуязыке, вам: 1-866-322-0984будут бесплатно (телетайп предоставлены: 711). услуги переводчика. Звоните по توجه: اگر به زبان .(711 :فارسی گفتگو میтелетайп ) کنيد، تسھيالت زبانی 0984-322-866-1 :بصورت رايگانтелефону برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984ARABIC) تماس بگيريد. تماس بگيريد. телефону: 1-866-322-0984 (телетайп: 711). nang walang bayad, ay magagamit مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. اتصل بالرقم 0984-322-866-1 (من الھاتف النصي: 711). ARABIC sa iyo. Tawagan ang 1-866-322-0984 ARABIC مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. اتصل بالرقم 0984-322-866-1 (من الھاتف النصي: 711). مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. اتصل بالرقم 0984-322-866-1 (من الھاتف النصي: ARABIC (TTY:FRENCH 711). CREOLE .(711 مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. اتصل بالرقم 0984-322-866-1 (من الھاتف النصي: 711). FRENCH CREOLE ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-322-0984 (TTY: 711). FRENCH CREOLE FRENCH CREOLE ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratisATANSYON: pou ou. Rele Si 1-866-322-0984 w pale Kreyòl Ayisyen, (TTY: 711). gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-322-0984 (TTY: 711). FRENCH ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-322-0984Getting started with (TTY: CVS 711). Specialty 26 FRENCH ATTENTION : Si vous parlez français, des services gratuits d’interprétation sont à votre disposition. Veuillez appeler le 1-866-322- 0984 (TTY: 711). FRENCH FRENCH ATTENTION : Si vous parlez français, des services gratuits d’interprétation sontATTENTION à votre disposition. : Si vous Veuillez parlez français,appeler le des 1-866 services-322- gratuits d’interprétation sont à votre disposition. Veuillez appeler le 1-866-322- 0984 (TTY: 711). ATTENTION : Si vous parlez français, des services gratuits d’interprétation sont à votre disposition.POLISH Veuillez UWAGA: appeler Dla leosób 1-866 mówi0984-322-ących (TTY: po 711). polsku dostępna jest bezpłatna pomoc językowa. Zadzwoń pod numer 1-866-322- 0984 (TTY: 711). UWAGA: Dla osób mówiących po polsku0984 dost (TTY:ępna jest711). bezp łatna pomoc językowa. Zadzwoń pod numer 1-866-322- POLISH POLISH UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomoc językowa. Zadzwoń pod numer 1-866-322- 0984 (TTY: 711). POLISH UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomoc językowa. ZadzwoPORTUGUESEń pod numer ATENÇÃO: 1-866-322- Se0984 fala (TTY: português, 711). estão disponíveis serviços gratuitos de assistência linguística na sua língua. 0984 (TTY: 711). ATENÇÃO: Se fala português, estãoTelefone disponíveis para 1-866-322-0984 serviços gratuitos (TTY: de 711). assistência linguística na sua língua. PORTUGUESE PORTUGUESE ATENÇÃO: Se fala português, estão disponíveis serviços gratuitos de assistência linguística na sua língua. Telefone para 1-866-322-0984 (TTY: 711). PORTUGUESE ATENÇÃO: Se fala português, estão disponíveis serviços gratuitos de assistênciaITALIAN linguística na sua língua. Telefone para 1-866-322-0984 (TTY: 711). Telefone para 1-866-322-0984 (TTY: 711). ATTENZIONE: Se lei parla italiano, sono disponibili servizi gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- ITALIAN ITALIAN ATTENZIONE: Se lei parla italiano, sono disponibili0984 servizi (TTY: gratuiti 711). di assistenza linguistica nella sua lingua. Chiami 1-866-322- ITALIAN ATTENZIONE: Se lei parla italiano, sono disponibili servizi gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- ATTENZIONE: Se lei parla italiano, sono disponibili0984 (TTY: servizi 711). gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- JAPANESE お知らせ: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま0984 (TTY: 711). す。電話番号1-866-322- 0984 (TTY: 711). お知らせ 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま0984 (TTY: 711)までお問い合わせ下さい。 す。電話番号 JAPANESE : お知らせ : 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま1-866-322- す。電話番号1-866-322- JAPANESE JAPANESE お知らせ: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま0984 (TTY: 711)までお問い合わせ下さい。 す。電話番号1-866-322- までお問い合わせ下さい。 GERMAN 0984 (TTY: 711) 0984 (TTY: 711)までお問い合わせ下さい。 GERMAN BITTE BEACHTEN: Wenn Sie Deutsch sprechen, stehen Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: 711) kostenlos zur Verfügung.GERMAN GERMAN BITTE BEACHTEN: Wenn Sie Deutsch sprechen, stehen Ihnen unsere DolmetscherBITTE unterBEACHTEN: der Nummer Wenn 1-866-322-0984 Sie Deutsch sprec (TTY:hen, stehen Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: 711) kostenlos zur Verfügung. BITTE BEACHTEN: Wenn Sie Deutsch sprechen, stehen Ihnen unsere Dolmetscher unter der FARSINummer 1-866-322-0984 (TTY:711) kostenlos zur Verfügung. 711) kostenlos zur Verfügung. توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد. FARSI FARSI توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با توجه: اگر به زبان 0984-322-866-1 فارسی (711 گفتگو می :TTY) کنيد، تماس تسھيالتبگيريد . زبانیتماس بگيريد.بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد. FARSI توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد.

Get Help in Other Languages Get Help in Other Languages If you need help or speak a non-English language, call 1-866-322-0984 (TTY: 711) and you will be connected to an interpreter If you need help or speak a non-Englishwho will language, assist you call at 1-866-322-0984 no cost. (TTY: 711) and you will be connected to an interpreter Get Help in Other Languages If you need help or speak a non-English language,who will call assist 1-866-322-0984 you at no cost. (TTY: 711) and you will be connected to an interpreter Get Help in Other Languages ENGLISH who will assist you at no cost. If you need help or speak a non-English language, call 1-866-322-0984 (TTY: 711) and you will be connected to an interpreterATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-866-322-0984 (TTY: ENGLISH who will assist you at no cost. ATTENTION: If you speak English,711). language assistance services, free of charge, are available to you. Call 1-866-322-0984 (TTY: ENGLISH ATTENTION: If you speak English, language711). assistance services, free of charge, are available to you. Call 1-866-322-0984 (TTY: SPANISH ENGLISH 711). ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-866-322-0984ATENCIÓN: (TTY: Si usted habla español, tenemos servicios de asistencia lingüística disponibles para usted sin costo alguno. Llame SPANISH 711). ATENCIÓN: Si usted habla español,al 1-866-322-0984tenemos servicios (TTY: de asistencia 711). lingüística disponibles para usted sin costo alguno. Llame SPANISH

ATENCIÓN: Si usted habla español, tenemosal servicios1-866-322-0984 de asistencia (TTY: lingüística711). disponibles para usted sin costo alguno. Llame CHINESE SPANISH al 1-866-322-0984 (TTY: 711). ATENCIÓN: Si usted habla español, tenemos servicios de asistencia lingüística disponibles para usted sin costo alguno. Llame小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 1-866-322-0984 (TTY: 711). CHINESE al 1-866-322-0984 (TTY: 711). CHINESE 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 1-866-322-0984 (TTY: 711).

小 VIETNAMESE. CHINESE 贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 1-866-322-0984 (TTY:CHÚ Ý:711) Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- VIETNAMESE 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 1-866-322-0984 (TTY: 711)CHÚ. Ý: Nếu quý vị nói tiếng Việt, thì0984 có s(TTY:ẵn các 711). dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- VIETNAMESE

CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn 0984các d ị(TTY:ch vụ 711).trợ giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322- KOREAN VIETNAMESE 0984 (TTY: 711). CHÚ Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ trợ giúp ngôn ngữ miễn phí dành cho quý vị. Hãy gọi số 1-866-322-알림: 한국어를 하시는 경우 무료 통역 서비스가 준비되어 있습니다. 1-866-322-0984 (TTY: 711)로 연락주시기 바랍니다. KOREAN 0984 (TTY: 711). KOREAN 알림: 한국어를 하시는 경우 무료 통역 서비스가 준비되어 있습니다. 1-866-322-0984 (TTY: 711)로 연락주시기 바랍니다.

TAGALOG KOREAN 알림: 한국어를 하시는 경우 무료 통역 서비스가 준비되어 있습니다. 1-866-322-0984Pansinin: (TTY: Kung 711) nagsasalita로 연락주시기 ka ng 바랍니다 Tagalog,. mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tawagan TAGALOG 알림: 한국어를 하시는 경우 무료 통역 서비스가 준비되어 있습니다. 1-866-322-0984 (TTY:Pansinin: 711)로 Kung연락주시기 nagsasalita 바랍니다 ka ng. PortugueseTagalog,ang 1-866-322-0984 mga serbisyo (TTY: ng tulong 711). sa wika, nang walang bayad, ay magagamit sa iyo. Tawagan TAGALOG

Pansinin: Kung nagsasalita ka ng Tagalog, mgaang serbisyo1-866-322-0984 ng tulong (TTY: sa wika, 711). nang ATENÇÃO: walang bayad, Se fala ay português,magagamit sa estão iyo. Tawagan RUSSIAN TAGALOG ang 1-866-322-0984 (TTY: 711). Pansinin: Kung nagsasalita ka ng Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. TawagandisponíveisВНИМАНИЕ :serviços Если вы gratuitosговорите на de русском языке, вам будут бесплатно предоставлены услуги переводчика. Звоните по RUSSIAN ang 1-866-322-0984 (TTY: 711). ВНИМАНИЕ: Если вы говорите наassistênciaтелефону русском: языке1-866-322-0984 linguística, вам будут na (suaтелетайп бесплатно língua.: 711). предоставлены услуги переводчика. Звоните по RUSSIAN

ВНИМАНИЕ: Если вы говорите на русскомтелефону языке, вам: 1-866-322-0984 будут бесплатно (телетайп предоставленыTelefone: 711). para услуги 1-866-322-0984 переводчика .(TTY: Звоните 711). по ARABIC RUSSIAN телефону: 1-866-322-0984 (телетайп: 711). مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. اتصل بالرقم 0984-322-866-1 (من الھاتف النصي: ВНИМАНИЕ: Если вы говорите на русском языке, вам будут бесплатно предоставленыARABIC услуги переводчика. Звоните.(711 по телефону: 1-866-322-0984 (телетайп: 711). Italian مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. اتصل بالرقم 0984-322-866-1 (من الھاتف النصي: ARABIC .(711 ATTENZIONE:FRENCH CREOLE Se lei parla italiano, sono مالحظة: إذا كنت تتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. اتصل بالرقم 0984-322-866-1 (من الھاتف النصي: 711). ARABIC ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-322-0984 (TTY: 711). FRENCH CREOLE disponibili servizi gratuiti di assistenza .(Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-322-0984 (TTY: 711 مالحظة: إذا كنت :ATANSYONتتحدث العربية، تتوفر خدمات المساعدة اللغوية مجان أجلك. اتصل بالرقم 0984-322-866-1 (من الھاتف النصي: 711). FRENCH CREOLE linguistica nella sua lingua. Chiami FRENCH ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-322-0984 (TTY: 711). 1-866-322-0984ATTENTION : Si vous (TTY: parlez 711). français, des services gratuits d’interprétation sont à votre disposition. Veuillez appeler le 1-866-322- FRENCH CREOLE FRENCH ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. ATTENTIONRele 1-866-322-0984 : Si vous (TTY: parlez 711). français, 0984 des (TTY: services 711). gratuits d’interprétation sont à votre disposition. Veuillez appeler le 1-866-322- FRENCH

ATTENTION : Si vous parlez français, des se0984rvices (TTY: gratuits 711). d’interprétation sontJapanese à votre disposition. Veuillez appeler le 1-866-322- POLISH UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomoc językowa. Zadzwoń pod numer 1-866-322- FRENCH 0984 (TTY: 711). ATTENTION : Si vous parlez français, des services gratuits d’interprétation sont à votre disposition. Veuillez appeler le 1-866お知らせ:0984-322- (TTY: 日本語での対応を望まれる方に 711). POLISH UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomoc językowa. Zadzwoń pod numer 1-866-322- 0984 (TTY: 711). 0984 (TTY: 711). POLISH UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomocは、無料で通訳サービスをご利用になれま językowa. Zadzwoń pod numer 1-866-322- PORTUGUESE ATENÇÃO: Se fala português, estão disponíveis serviços gratuitos de assistência linguística na sua língua. 0984 (TTY: 711). す。電話番号 1-866-322-0984 (TTY: 711)ま UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomoc językowa. Zadzwoń pod numer 1-866-322-Telefone para 1-866-322-0984 (TTY: 711). POLISH PORTUGUESE ATENÇÃO: Se fala português, estão disponíveis serviços gratuitos de assistência linguística na sua língua. 0984 (TTY: 711). Telefone para 1-866-322-0984 (TTY:でお問い合わせ下さい。 711). PORTUGUESE ATENÇÃO: Se fala português, estão disponíveis serviços gratuitos de assistência linguística na sua língua. ITALIAN Telefone para 1-866-322-0984 (TTY: 711). ATENÇÃO: Se fala português, estão disponíveis serviços gratuitos de assistência linguística na sua língua.ATTENZIONE: Se lei parla italiano, sono disponibili servizi gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- PORTUGUESE ITALIAN German Telefone para 1-866-322-0984 (TTY: 711). ATTENZIONE: Se lei parla italiano,0984 sono (TTY: disponibili 711). servizi gratuiti di assistenza linguistica nella sua lingua. Chiami 1-866-322- ITALIAN BITTE BEACHTEN: Wenn Sie Deutsch 0984 (TTY: 711). ATTENZIONE: Se lei parla italiano, sono disponibili servizi gratuiti di assistenza linguistica nellaお知らせ sua lingua.日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま Chiami 1-866-322- す。電話番号 sprechen,JAPANESE stehen Ihnen: unsere 1-866-322- ITALIAN 0984 (TTY: 711). ATTENZIONE: Se lei parla italiano, sono disponibili servizi gratuiti di assistenza linguistica nella sua lingua.お知らせ Chiami日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま 1-866-3098422- (TTY: 711)までお問い合わせ下さい。 す。電話番号 JAPANESE : Dolmetscher unter der Nummer 1-866-322- 0984 (TTY: 711). までお問い合わせ下さい。 お知らせ: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま0984 (TTY: 711) 1-866-322-0984 (TTY:す。電話番号 711) kostenlos1-866-322- JAPANESE GERMAN 0984 (TTY: 711)までお問い合わせ下さい。 zur Verfügung. JAPANESE お知らせ: 日本語での対応を望まれる方には、無料で通訳サービスをご利用になれま す。電話番号1-866-322-BITTE BEACHTEN: Wenn Sie Deutsch sprechen, stehen Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: GERMAN 0984 (TTY: 711)までお問い合わせ下さい。 BITTE BEACHTEN: Wenn Sie Deutsch711) kostenlossprechen, zur stehen Verfügung. Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: GERMAN Farsi BITTE BEACHTEN: Wenn Sie Deutsch sprec711)hen, kostenlos stehen Ihnen zur Verfügung. unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY: FARSI GERMAN 711) kostenlos zur Verfügung. توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد.:BITTE BEACHTEN: Wenn Sie Deutsch sprechen, stehen Ihnen unsere Dolmetscher unter der Nummer 1-866-322-0984 (TTY FARSI 711) kostenlos zur Verfügung. توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد. FARSI توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد. FARSI

توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با TTY: 711) 1-866-322-0984) تماس بگيريد. تماس بگيريد.

Getting started with CVS Specialty 27 Authorization Forms Fill out, sign and return these forms right away.

Submit forms online. Or print and mail them to: CVS Specialty, 105 Mall Boulevard, Monroeville, PA 15146

Assignment and authorization form

I hereby authorize Caremark Rx, L.L.C. and its affiliated specialty pharmacies (collectively, “CVS Specialty”) to: • Submit claims directly to my insurance company or Medicare and bill me for any items not covered by my insurance or Medicare, which includes deductibles, copayments, coinsurance and all other beneficiary obligations; • Seek direct payment for claims under this assignment; • Release and receive medical information to or from my physician, insurance company, Medicare or other health care providers as needed to coordinate my pharmaceutical needs; • To contact me directly concerning providing and delivering my medication and/or supply order(s); and • To bill me directly for any special shipping needs I may request that are outside CVS Specialty’s normal business delivery practices to the extent permitted. Your signature on this form will enable us to provide you with prompt medication delivery and billing service.

Please sign this form (page 29). If we do not receive this form within seven days, you may be required to pay for your medications directly and submit claims to your insurance company or other payor yourself. If you are a Medicare patient, CVS Specialty is not permitted to submit a claim to Medicare without this form signed by you.

Getting started with CVS Specialty 28 SIGNATURE REQUIRED: Please sign and date this form.

Patient’s Name (Please Print) Date

Signature of Patient or Guardian Date

If the patient is physically or mentally unable to sign, an authorized representative may sign on the patient’s behalf.

Representative’s Signature Relationship to Patient

Representative’s Name (Please Print)

Representative’s Address: Street

City State Zip Code

Please state reason patient cannot sign

Name of Policyholder (If different from patient) Date

©2019 CVS Specialty. All rights reserved. 75-PCM4488 072919

Getting started with CVS Specialty 29 Formulario de asignación y autorización

Por el presente autorizo a Caremark Rx, L.L.C. y sus farmacias afiliadas (colectivamente, “CVS Specialty”) a: • Presentar reclamos directamente a mi compañía de seguro o Medicare y enviarme la cuenta por cualquier artículo que no esté cubierto por mi seguro o por Medicare, y que pueda incluir deducibles, co-pagos, co-seguro y todas las otras obligaciones del beneficiario; • Buscar el pago directo para los reclamos bajo esta asignación; • Compartir y obtener la información médica con o de mi médico, compañía de seguro, Medicare o otros proveedores de servicios de salud, cuando se necesario, para coordinar mis necesidades farmacéuticas; • Contactarme directamente en relación a la provisión y entrega de mis medicamentos y/o pedidos desuministros; y • Enviarme la cuenta directamente por cualquier necesidad de envío especial que yo pueda requerir fuera de las prácticas normales de entrega ofrecidas por CVS Specialty, hasta el punto necesario. Su firma en este formulario permitirá que nosotros podamos proveerle a tiempo el medicamento y su cuenta.

Por favor, firme este formulario (página 31). Si nosotros no recibimos este formulario dentro de siete días, es posible que se le requiera que usted mismo pague sus medicamentos directamente y presente los reclamos a su compañía de seguro u otro pago pertinente. Si usted es un paciente de Medicare, a CVS Specialty no se le permite presentar un reclamo a Medicare sin que este formulario sea firmado por usted.

Getting started with CVS Specialty 30 FIRMA REQUERIDA: Por favor, firme y coloque la fecha en este formulario.

Nombre del Paciente (Por favor, en letra de molde) Fecha

Firma del Paciente o Guardián Fecha

Si el paciente no es capaz de físicamente o mentalmente firmar, un representante autorizado puede firmar en el nombre del paciente.

Firma del Representante Relación con el Paciente

Nombre del Representante (Por favor, en letra de molde)

Dirección del Representante: Calle

Ciudad Estado Postal

Por favor, mencione la razón por la cual el paciente no puede firmar

Nombre del Dueño de la Póliza (Si es diferente al paciente) Fecha

©2019 CVS Specialty. Todos los derechos reservados. 75-PCM4488 072919

Getting started with CVS Specialty 31 Pharmacy patient authorization form

Section A: Pharmacy Patient Information Pharmacy Patient Name: Pharmacy Patient Date of Birth: Street Address: City State Zip Code Phone Number: Primary Cardholder ID Number: Email Address (optional): Pharmacy Patient Social Security Number: Section B: Information about Me that May Be Used and/or Disclosed The Personal Health Information about me that may be used and/or disclosed includes, but is not limited to, any information held by CVS Specialty® for any time period about my: • Treating providers of care (e.g., pharmacies, prescribing physicians); • Prescription records (e.g., drug names, dispensing dates, costs); • Demographic information (e.g., address); • Eligibility information (e.g., dates of coverage, deductibles). • Other specific information: Section C: Purpose This authorization is made at my request. OR other purpose: Person or Entity Authorized to Receive and Use Personal Health Information About Me: Name: Phone Number: Address: Relationship to Me: Section D: Expiration and Revocation This authorization will automatically expire: (1) one year after (date) OR (2) if no date is specified in (1) one year following the termination of my participation in a pharmacy benefit plan or drug discount card, as applicable, managed by CVS Caremark. I understand that I have the right to revoke this authorization at any time, but that my revocation will not apply to any action that CVS Specialty has already taken in reliance on this authorization prior to receipt of my revocation. I understand that in order to revoke this authorization, I must send a written notice of revocation to the CVS Specialty contact listed below:

Contact Information: CVS Specialty, 105 Mall Boulevard, Monroeville, PA 15146

Section E: Signature/Authorization I understand that the information used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy law. I acknowledge that my authorization is voluntary. I understand that CVS Specialty may not condition any treatment, payment, enrollment or eligibility for benefits on whether I sign this form. I have had full opportunity to read and consider the content of this Authorization Form. I understand that, by signing this form, I am authorizing CVS Specialty to use and/or disclose my personal health information as described in Section B above to the person or entity named in Section C for the purposes described above.

Signature: Date: Note: If signed by someone other than the above-named pharmacy patient, please describe your legal authority to act on behalf of the pharmacy patient and, if applicable, attach support legal documentation. PLEASE RETURN THE SIGNED AUTHORIZATION FORM TO THE CONTACT PERSON LISTED IN SECTION D. YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION FORM AFTER YOU SIGN IT.

©2019 CVS Specialty. All rights reserved. 75-PCM4422 072919 32 Formulario de autorización del paciente de farmacia

Sección A: Información del Paciente de Farmacia Nombre del Paciente de Farmacia: Fecha de Nacimiento del Paciente de Farmacia: Dirección: Cuidad Estado Código Postal Número Telefónico: Número de ID del Tarjeta-habiente Primario: Dirección de Correo Electrónico (opcional): Número del Seguro Social del Paciente de Farmacia: Sección B: Información acerca de Mí que se pueda Usar y/o Compartir La Información de Salud Personal acerca de mi persona que se pueda usar y/o compartir incluye, pero no se limita a, cualquier información retenida por CVS Specialty® durante cualquier periodo de tiempo acerca de: • Mis proveedores del cuidado del tratamiento (e.g., farmacias, médicos que recetan el medicamento); • Mi récord de las recetas (e.g., nombres del medicamento, fechas en que se proveyó, costos); • Mi información demográfica (e.g., dirección); • Mi información de elegibilidad (e.g., fecha de cobertura, deducibles). • Otra información específica: Sección C: Propósito Esta autorización se hace bajo mi solicitud. O con otro propósito: Persona o Entidad Autorizada para Recibir y Usar la Información de Salud Personal Acerca de Mí: Nombre: Número Telefónico: Dirección: Relación Conmigo: Sección D: Vencimiento y Revocación Esta autorización automáticamente va a vencer: (1) un año después de (fecha) O (2) si no se especifica la fecha, en un (1) año siguiente a la terminación de mi participación en un plan de beneficios de farmacia o tarjeta de descuento para medicamentos, como corresponda, administrado por CVS Caremark. Comprendo que tengo el derecho de revocar esta autorización en cualquier momento, pero que mi revocación no se aplicará a cualquier medida que CVS Specialty ya haya tomado basándose en esta autorización antes de que reciba mi revocación. Comprendo que con el propósito de revocar esta autorización, debo enviar un aviso por escrito de la revocación a la información de contacto de CVS Specialty mencionada abajo:

Información de Contacto: CVS Specialty, 105 Mall Boulevard, Monroeville, PA 15146 Sección E: Firma / Autorización Comprendo que la información usada y/o compartida de acuerdo con esta autorización puede ser compartida de nuevo por el recipiente y posiblemente ya no sea protegida por la ley federal de privacidad. Reconozco que mi autorización es voluntaria. Comprendo que CVS Specialty no pondrá esto como condición para el tratamiento, el pago, registro, o elegibilidad para los beneficios si firmo o no este formulario. Se me ha dado toda la oportunidad de leer y considerar el contenido de este Formulario de Autorización. Comprendo que al firmar el mismo, autorizo a CVS Specialty para que use y/o comparta mi información personal de salud, como se describió en la Sección B, arriba, con la persona o entidad nombrada en la Sección C, para los propósitos arriba mencionados. Firma: Fecha: Nota: Si es firmado por alguien a diferencia del paciente de farmacia arriba mencionado, por favor, describa su autoridad legal para actuar a nombre del paciente de farmacia y, si corresponde, anexe el documento legal que lo respalde. POR FAVOR, REGRESE EL FORMULARIO DE AUTORIZACIÓN FIRMADO A LA PERSONA DE CONTACTO QUE SE MENCIONA EN LA SECCIÓN D. USTED TIENE EL DERECHO DE RECIBIR UNA COPIA DE ESTA AUTORIZACIÓN DESPUÉS QUE LA FIRME.

©2019 CVS Specialty. Todos los derechos reservados. 75-PCM4422 072919 33 Want to know more about managing your condition?

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*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. **Message and data rates may apply. This CVS Specialty New Patient Guide is intended to supplement the expertise and judgment of your doctor, pharmacist or other health care provider. It should not replace their instructions or decisions. It does not suggest that the use of any medication is safe, helpful or right for you. CVS Specialty does not operate all the websites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CVS Specialty. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.

©2020 CVS Specialty. All rights reserved. 75-10324B 032520