Health : Prescription Drug

Prescription
Drug

CVS Caremark

	Basic HSA	HSA Plus	Basic PPO	Classic PPO
	In-Network	In-Network	In-Network	In-Network
Calendar Year Deductible (Integrated with Medical)
Individual	$2,500	$1,750	$1,250	$900
Family	$5,000	$3,500	$2,500	$1,800
Calendar Year Out-of-Pocket Maximum (Includes Deductible and Integrated with Medical)
Individual	$5,000	$5000	$5000	$5000
Family	$10,000	$10,000	$10,000	$10,000
	You pay	You pay	You pay	You pay
Retail (30-Day Supply)
Generic	$10 maximum after deductible		$10 maximum, no deductible
Brand Formulary	30% after deductible (minimum $35; maximum $70)		30%; no deductible (minimum $35; maximum $70)
Brand Non-Formulary	50% after deductible (minimum $70; maximum $140)		50%; no deductible (minimum $70; maximum $140)
Mail Order (90-Day Supply)
Generic	$25 copay after deductible		$25 copay; no deductible
Brand Formulary	30% after deductible (minimum $90; maximum $180)		30%; no deductible (minimum $90; maximum $180)
Brand Non-Formulary	50% after deductible (minimum $175; maximum $350)		50%; no deductible (minimum $175; maximum $350)

PrudentRx – CVS will monitor employee medications and reach out if they are eligible to receive their specialty medications at no cost
(NEW) Cost Saver Rx Program – Employees that elect an XPO medical plan will pay a lower out-of-pocket cost if they fill a qualifying prescription at an in-network pharmacy. This program is powered by GoodRx and allows employees to have automatic access to GoodRx pricing for generic drugs when employees present their card at the pharmacy.
(NEW) RxSavingsPlus Program – This program allows employees to purchase medications not covered by the prescription plan at a lower price by providing manufacturer’s discounts on certain medications. Please note discounts can be changed at any time and the prescription does not run through the XPO medical plan and will not count towards deductibles or out-of-pocket maximums.
Transform Diabetes Care (TDC) Rx Program – CVS offers ongoing support for members with diabetes. Through the TDC program members have access to low/no cost diabetic monitoring equipment.

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XPO Benefit Center

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For those employees represented by a union, all the items, statements, terms and conditions referred to in this website are subject to collective bargaining and will be negotiated with your union. To the extent that different terms and conditions are agreed upon and included in a collective bargaining agreement, those terms supersede the terms contained in this website and will govern your terms of employment. If any of the items, statements, terms and conditions referred to in this website conflict with applicable law, such applicable law shall supersede and shall govern. The company reserves the right to revise or delete this program, the plans or any benefits described here. If there is any discrepancy between the information included here and the official Plan Documents or contracts, the official document or contracts will decide plan provisions and how benefits are paid. The program, plans and benefit provision do not create a contract of employment, expressed or implied. Notwithstanding any provision on this website, employment is at-will employment, unless a written agreement states otherwise.

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