Summary Plan Description Medical (Health Net of California and Kaiser Permanente) Prescription (CaremarkPCS Health) Dental (Aetna DMO) Vision Benefits (Vision Service Plan) Employee Assistance Plan (LifeScope) Legal (Hyatt Legal Plans) For California Employees Effective June 1, 2011 California Introduction CVS Pharmacy, Inc. (“CVS”) maintains The CVS Caremark Welfare Benefit Plan (the “Plan”) for the exclusive benefit of and to provide welfare benefits to its eligible employees, their spouses, and eligible dependents. The welfare benefits under the Plan include medical, prescription, dental insurance through the Aetna DMO, vision insurance, an Employee Assistance Plan (EAP), and a prepaid legal plan offered to eligible CVS employees in California. This Summary describes your prescription (Rx), vision, EAP benefits, and prepaid legal benefits. In addition, this Summary is being distributed with the medical and dental insurance booklets and/or policies in order to supplement the information contained in those documents (for example, the Plan’s eligibility rules are contained in this Summary) in order to provide you with a complete description of the Plan. ERISA Summary Plan Description This document, produced by CVS, combined with the medical insurance booklets and/or policies (referred to as the “Evidence of Coverage”) issued by Kaiser Permanente and Health Net of California (“Health Net”), and the dental insurance booklet-certificate provided by Aetna Life insurance Company, constitute your Summary Plan Description with respect to the insured benefits offered under the Plan, as required under the Employee Retirement Income Security Act (“ERISA”). The Summary Plan Description is a resource you can reference when you have a question about your medical, prescription, dental (through the Aetna DMO), vision, EAP or prepaid legal benefits under the Plan. Note that while the Plan also includes disability and life insurance benefits (insured with Unum) and dental benefits (administered by Delta Dental of RI), the eligibility, enrollment and benefit provisions that apply to those benefits are addressed in separate documents. If you would like a copy of these documents, call myHR at 1-888-MY-HR-CVS (1-888-694-7287). Because this Summary is intended to “supplement” the Evidence of Coverage (i.e. insurance certificates) provided to you by Kaiser Permanente, Health Net of California, and Aetna Life Insurance Company please note that: • This Summary does not fully describe your medical or dental benefit coverages. For details on these benefit coverages, please refer to the Evidence of Coverage documents issued by Kaiser Permanente, Health Net, and/or Aetna Life Insurance Company, as applicable. The Evidence of Coverage documents issued by these Insurance Companies represent the binding document between the Insurance Company (as applicable) and its members. • A Plan physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat your medical condition. The services and supplies must be provided, prescribed, authorized, or directed by a Plan physician. You must receive the services and supplies at a Plan facility or skilled nursing facility inside our Service Area, except where specifically noted to the contrary in the Evidence of Coverage. • For details on the benefit and claims review and adjudication procedures, please refer to the Evidence of Coverage or insurance certificates issued by Kaiser Permanente, Health Net or Aetna Life insurance Company, as applicable. 2 • If there are any discrepancies between benefits included in this Summary and the Evidence of Coverage (EOC) and/or insurance certificates issued by the Insurance Companies named above, the Insurance Company’s document (EOC or insurance certificate) will prevail in determining the medical services provided under the Plan. However, the EOC or insurance certificate will not prevail in determining the Plan’s eligibility rules. ERISA Plan Document Portions of this document, together with the insurance contracts entered into between CVS and the applicable insurance company constitute the written Plan document with respect to the insured benefits offered under the Plan. Certain benefits under the Plan (such as medical and dental benefits) are provided pursuant to insurance contracts which, together with this Summary, constitute the governing plan document adopted by CVS. For purposes of determining medical and dental services covered under the Plan, the terms of the insurance contract or Evidence of Coverage (EOC) will control in the event of a conflict with this Summary. However, if any of the other rules (including the eligibility rules) set forth in this Summary conflict with the terms of such insurance contract or any other document, then the terms of this Summary shall control, unless otherwise required by law. 3 Table of Contents Eligibility .............................................................................................................................. 7 Your Eligibility ........................................................................................................................ 7 Dependent Eligibility .............................................................................................................. 7 How to Enroll and When Your Coverage Begins ............................................................. 11 New Hire ............................................................................................................................... 12 Annual Enrollment ................................................................................................................. 12 Special Enrollment ................................................................................................................ 12 Level of Coverage ................................................................................................................. 14 Paying for Coverage ............................................................................................................. 14 Changing Your Coverage ...................................................................................................... 15 When Coverage Ends ........................................................................................................... 16 Rescissions of Coverage ...................................................................................................... 17 Loss of Benefits ..................................................................................................................... 17 Erroneous Claims and Administrative Errors ........................................................................ 18 Disclaimer ............................................................................................................................. 18 Medical Plan ........................................................................................................................ 18 Primary Care Provider ........................................................................................................... 18 Obstetrical and Gynecological Care ...................................................................................... 19 The Pharmacy (Rx) Plan ..................................................................................................... 19 How the Prescription (Rx) Plan Works .................................................................................. 20 Retail Pharmacy Service ....................................................................................................... 20 Mail Service Pharmacy ......................................................................................................... 20 Covered Medications ............................................................................................................ 20 Preventive Care Services ...................................................................................................... 21 Preferred Drug List ................................................................................................................ 21 Reducing Health Care Costs with Generics .......................................................................... 21 Paying For Brand Drugs ........................................................................................................ 21 High Performance Formulary ................................................................................................ 22 Quantity Restrictions on Covered Medications ..................................................................... 22 Prior Authorizations (PA) ....................................................................................................... 22 Prescription Plan Definitions ................................................................................................. 22 Excluded Drugs and Items .................................................................................................... 23 Dental Plan (Aetna DMO Plan) .......................................................................................... 23 Vision Services Plan (VSP) ................................................................................................ 24 Cost of Coverage .................................................................................................................. 24 In-Network and Out-of-Network Coverage ...........................................................................