IMPORTANT PLAN INFORMATION Long-Term Care (LTC) Pharmacy If you reside in an LTC facility, you pay the same as at a network retail pharmacy. LTC pharmacies must dispense brand-name drugs in amounts of 14 days or less at a time. They may also dispense less than a one month’s supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Out-of-Network Coverage You must use Express Scripts Medicare network pharmacies to fill your prescriptions. Covered Medicare Part D drugs are available at out-of-network pharmacies only in special circumstances, such as illness while traveling outside of the plan’s service area where there is no network pharmacy. You generally have to pay the full cost for drugs received at an out-of-network pharmacy at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. Please contact the plan or the Retiree Customer Service Center for more details. Additional Information About This Coverage  The service area for this plan is all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. You must live in one of these areas to participate in this plan.  The amount you pay may differ depending on what type of pharmacy you use; for example, retail, home infusion, LTC or home delivery.  To find a network pharmacy near you, visit our website at www.Express-Scripts.com.  Your plan uses a formulary – a list of covered drugs. The amount you pay depends on the drug’s tier and on the coverage stage that you’ve reached. From time to time, a drug may move to a different tier. If a drug you are taking is going to move to a higher (or more expensive) tier, or if the change limits your ability to fill a prescription, Express Scripts will notify you before the change is made.  To access your plan’s list of covered drugs, visit our website at www.Express- Scripts.com.  The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.  Your healthcare provider must get prior authorization from Express Scripts Medicare for certain drugs.  If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.  Each month, you may need to pay a monthly premium amount to continue your participation in this plan. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party, even if your Medicare Part D plan premium is $0. Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal. © 2018 Express Scripts Holding Company. All Rights Reserved.