NALC Health Benefit PlanHigh Option

2017 Prescription Benefits Overview

This booklet is a summary of some of the features of the NALC Health Benefit Plan High Option. Detailed information on the benefits for the 2017 NALC Health Benefit Plan High Option can be found in the official brochure. Before making a final decision, please read the Plan’s officially approved brochure (RI 71-009). All benefits are subject to the definitions, limitations, and exclusions set forth in the official brochure.

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Dear Plan Member,

Welcome to the NALC Health Benefit Plan High Option Plan. This booklet contains an overview of your prescription drug benefit which is administered by CVS/caremark. Be sure to take your ID card to your local NALC CareSelect pharmacy when you get a prescription filled for the first time. Use the ID number on your Health Insurance/Prescription Drug ID card to register at www.caremark.com, where you can order refills, check drug costs and coverage, print claim forms and more.

Here are some tips to help you save money on your prescriptions:

1. Ask for generics first. Generic drugs can cost up to 80% less than brand name drugs.

2. Remember the NALC Health Benefit Plan Formulary Drug List. If a generic isn’t available, ask your doctor to prescribe a drug on your plan’s formulary drug list, if appropriate.

3. Order 90-day supplies of long-term medications to save money. You can either sign up for CVS/caremark Mail Service to enjoy the convenience of having your medication shipped directly to you at no additional cost or visit your local CVS Pharmacy to obtain a 90-day supply through our Maintenance Choice Program.

4. Fill short-term prescriptions at a network pharmacy. You will pay more for short-term (30 days or less) prescriptions that are not filled at an NALC CareSelect Network pharmacy.

This booklet provides a summary of your prescription benefits and information that will help you get the most from your prescription drug benefits. If you have questions about your prescription drug coverage, please call CVS/caremark Customer Care at 800-933-NALC (6252), 7 days-a-week, 24 hours-a-day.

Sincerely,

Brian HellmanDirector

Retail coinsurance amounts shown are applicable for one fill/one refill of (up to) a 30-day supply of your medication purchased at a participating pharmacy in the NALC CareSelect network.

Your 2017 Drug Cost-Share When NALC is Primary Generic Drug*: You Pay:Network Retail up to 30 day supply 20% of Plan allowanceMail Order up to 60 day supply $8Mail Order 61-90 day supply $12

Formulary Brand Drug: You Pay:Network Retail up to 30 day supply 30% of Plan allowanceMail Order up to 60 day supply $43Mail Order 61-90 day supply $65

Non-Formulary Brand Drug: You Pay:Network Retail up to 30 day supply 45% of Plan allowanceMail Order up to 60 day supply $58Mail Order 61-90 day supply $80

Specialty Drugs**(Available only through CVS/specialtyTM Pharmacy Mail Order): You Pay:Mail Order up to 30 day supply $150 Mail Order 31-60 day supply $250 Mail Order 61-90 day supply $350

Your 2017 Drug Cost-Share When Medicare Part B is Primary Generic Drug*: You Pay:Network Retail up to 30 day supply 10% of Plan allowanceMail Order up to 60 day supply $4Mail Order 61-90 day supply $6

Formulary Brand Drug: You Pay:Network Retail up to 30 day supply 20% of Plan allowanceMail Order up to 60 day supply $37Mail Order 61-90 day supply $55

Non-Formulary Brand Drug: You Pay:Network Retail up to 30 day supply 30% of Plan allowanceMail Order up to 60 day supply $52Mail Order 61-90 day supply $70

Specialty Drugs** (Available only through CVS/specialtyTM Pharmacy Mail Order): You Pay:Mail Order up to 30 day supply $150 Mail Order 31-60 day supply $250 Mail Order 61-90 day supply $350

*Generic drug coverage shown above for those generic drugs not available at a reduced cost as listed on our NALCSelect, NALCPreferred, or NALCSenior Generic Drug Lists.

**All specialty drugs require prior authorization. Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs are generally defined as high-cost prescription drugs that treat complex conditions and require special handling and administration and can cost thousands of dollars for a single dose. NALC’s Advanced Control Specialty Formulary utilizes step therapy for certain specialty medications. Our Advanced Control Specialty Formulary focuses on biologic therapy classes that have multiple products with prescribing interchangeability based on safety and clinical efficacy. Examples include, but are not limited to, myelogenous leukemia (AML) cancer, Crohn’s disease, cystic fibrosis, growth hormone disorder, hemophilia, hepatitis C, HIV, immune deficiencies, multiple sclerosis, osteoarthritis, psoriasis and rheumatoid arthritis. Step therapy uses evidence-based protocols that require the use of a preferred drug(s) before non-preferred specialty drugs are covered. Call CVS/specialtyTM Pharmacy Services at 800-237-2767 to obtain prior approval.

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NALC Health Benefit Plan Formulary Drug ListWe use a formulary called the NALC Health Benefit Plan Formulary Drug List. Our formulary is a list of prescription drugs, both generic and name brand, that provide a safe, effective, and affordable alternative to other generic and brand name drugs that are available and have a higher cost-share. Our formulary is open and voluntary. The Plan’s formulary is updated quarterlyand lists commonly prescribed brand name and generic drugs. Please keep inmind it is not an all-inclusive list. Always call CVS/caremark at 800-933-NALC (6252) to verify your cost for any drug. This list represents brand name drugs in ALL CAPS and generic products in lower case italics.

When there is no generic available, there may be more than one brand namemedication to treat a condition. The brand name drugs listed on the formularylist identify products that are considered to be clinically appropriate and cost effective. When a brand name drug is required, your out-of-pocket cost will be less when you use a drug on the NALC Health Benefit Plan Formulary Drug List. Please note that the drugs listed on the NALC Health Benefit Plan Formulary Drug List may change. Please call CVS/caremark at 800-933-NALC (6252) to verify your cost-share for any drug.

Why use Generics?Generic drugs have the same active ingredients and are available in the samestrength and dosage as the equivalent brand name drug. Before a genericcan be labeled as equivalent to the brand name drug, it must meet stringentstandards set by the Food and Drug Administration (FDA). Generic drugsprovide the same therapeutic effects as their brand name equivalents.

Talk to your doctor or pharmacist about whether generic drugs are availablefor any brand name drugs you are currently being prescribed. The use of generic drugs adds value to your health care dollars. Based on averageingredient cost, generics can save as much as 80% over their brand namecounterparts. This means you pay much less for generic drugs.

Catastrophic Out-of-Pocket ProtectionCoinsurance amounts you pay for prescription drugs dispensed by an NALC CareSelect Network pharmacy and mail order copayment amounts count toward an individual $3,100 per person or $4,000 family annual prescription drug out-of-pocket maximum. When you have met this out-of-pocket maximum, network retail coinsurance amounts, specialty drug mail order copayment amounts, and mail order copayments are waived for the remainder of the calendar year.

Dispensing LimitationsThere are dispensing limitations for prescriptions purchased locally at NALCCareSelect pharmacies. You may obtain up to a 30-day fill and one refill ofmedication. We will waive the one 30-day fill and one refill limitation at retailfor patients confined to a nursing home, patients who are in the process of

Frequently Asked QuestionsWhat is a 4-Tier Prescription Drug Program?All covered prescription drugs fall into one of four tiers. The tiers represent the level of cost you will pay.

Tier 1 – Generic drugs. Your out-of-pocket costs are lowest when your doctor prescribes and you use generics.

Tier 2 – Formulary brand name drugs. If there is no generic medication available that is clinically appropriate for you treatment, ask your physician to prescribe a brand name drug on our Formulary Drug List. Your out-of-pocket costs are lower for brand name drugs that appear on our formulary.

Tier 3 – Non-formulary brand name drugs. Your out-of-pocket costs are higher for brand name drugs that do not appear on our formulary.

Tier 4 – Specialty drugs. You must purchase Specialty drugs through CVS/specialty™ Pharmacy Services. All specialty drugs require prior authorization.Specialty drugs generally include, but may not be limited to, drugs and biologics that may be complex to manufacture, can have routes of administration more challenging to administer, may have special handling requirements, may require special patient monitoring and may have special programs mandated by the FDA to control and monitor their use. These drugs are typically used to treat chronic, serious, or life-threatening conditions. Examples of such conditions include, but are not limited to, myelogenous leukemia (AML), cancer, Crohn’s disease, cystic

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having their medication regulated , or when state law prohibits the medicationfrom being dispensed in a quantity greater than 30-days. Call the Plan at 888-636-NALC (6252) to have additional refills at a network pharmacy authorized.

If you purchase more than two fills of a maintenance medication (limited to a 30-day supply) at a network pharmacy without prior Plan authorization, you will needto pay the full cost of the additional refills and file a paper claim to receive a 55%reimbursement. You will pay the difference in cost between the brand name drugand generic if you receive a brand name drug when a federally approved genericdrug is available, and your physician has not specified “Dispense as Written” forthe brand name drug.

Prior Authorization for Drugs The NALC Health Benefit Plan currently requires prior authorization for specialty and compound drugs. However, effective January 1, 2017, prior authorization and quantity/duration limits will be implemented for anti-narcolepsy and certain analgesic/opioid medications. This measure will ensure safe and clinically appropriate controlled substance medication therapy for our members. Please call CVS/caremark at 800-933-NALC (6252) for prior authorization and informa-tion on prior authorization requirements.

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fibrosis, growth hormone disorder, hemophilia, hepatitis C, HIV, immune defi-ciencies, multiple sclerosis, osteoarthritis, psoriasis and rheumatoid arthritis. Our benefit includes the Advanced Control Specialty Formulary that includes a step therapy program and uses evidence-based protocols that require the use of a preferred drug(s) before non-preferred specialty drugs are covered. The Advanced Control Specialty Formulary is designed as a specialty drug formulary that includes generics and clinically effective brands as determined through clini-cal evidence. The therapy classes chosen for the Advanced Control Specialty Formulary have multiple specialty drugs available that are considered therapeu-tically equivalent, thus providing the opportunity to utilize the lowest cost drug(s). Step therapy uses evidence-based protocols that require the use of a preferred drug(s) before non-preferred specialty drugs are covered. Categories, therapies and tiering changes could be updated every quarter and added to the formulary. Refer to the Advanced Control Specialty Formulary drug list for more information about the drugs and classes or call CVS/specialty™ Pharmacy Services at 800-237-2767. You may visit our website www.nalchbp.org to view the most current list of specialty drugs that may require step therapy.

Why isn’t my brand name drug on the NALC HBP Formulary Drug List?The NALC Health Benefit Plan Formulary is a list of commonly prescribed drugs identified by the CVS/caremark team of physicians and pharmacists (Pharmacy and Therapeutics Committee) to be the best overall value based on quality, safety, effectiveness, and cost. Drugs determined to be of equal therapeutic value and similar safety and efficacy are then evaluated on the basis of cost. Using lower cost formulary brand drugs provides you with a high quality, cost-effective prescription drug benefit.

Does the NALC Health Benefit Plan Formulary list all brand drugs available for the Tier 2 benefit level?No, our formulary is a list of commonly prescribed brand name drugs and is updated quarterly. It is not an all-inclusive list and you should always call CVS/caremark at 800-933-NALC (6252) to verify your cost-share for any drug.

Does the NALC Health Benefit Plan Formulary ever change? Yes, our formulary is subject to review and modifications throughout the year.Brand drugs may be added to, or removed from, the formulary for many reasons, such as:

• Many brand name medications lose their patents and generic versions become available.

• The FDA approves many new drugs throughout the year. These brand name drugs may be added to our formulary and may replace other medications currently listed.

• Medications may be withdrawn from the market or become available without a prescription.

Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Anitbiotic Generic lists are subject to change. Call the CVS/caremark Customer Service Representative at 800-933-NALC (6252) to verify the copayment amount of any generic drug.

NALC CareSelect PharmaciesThere are more than 68,500 participating NALC Network pharmacies,including major chain pharmacies and affiliated groups of independent community pharmacies, that accept your prescription benefit ID card. Please keep in mind that there are dispensing limitations for prescriptions purchased at local participating pharmacies. You may obtain up to a 30-day fill plus one refill of your covered medication at a local participating pharmacy. If your medication becomes maintenance, you can continue to fill up to a 90-day supply through our Maintenance Choice Program at your local participating CVS Pharmacy, paying the Mail Order Program copayment.

Pharmacies that participate in the NALC CareSelect networks are subject to change. Please call CVS/caremark at 800-933-NALC (6252) to verify a pharmacy’s participation.

NALCSenior Antibiotic Generic ListAvailable to Plan Members at NO COST When Medicare Part B is the primary payor (pays first).

Our NALCSenior Generic List offers the following prescription generic medications at no cost for (up to) a 30-day supply when filled at a local NALC CareSelect pharmacy and Medicare Part B is your primary payor. For generic medications not on the NALCSenior Antibiotic Generic List, regular retail coinsurance and mail order copayment amounts apply. At this printing, the NALCSenior Generic Antibiotic List includes:

Amoxicillin Capsule 500mgAmoxicillin Sus 250/5mlAmoxicillin Tablet 500mgAmoxicillin 875mg TabletAmoxicillin Sus 400mg/5mlAmoxicillin/Clavulanate 875/125mg TabletAmpicillin Capsule 500mgAzithromycin 250mgBacitracin Ointment OpCephalexin Capsule 250mgCephalexin 500mgCiprofloxacin 250mgCiprofloxacin 500mgCiprofloxacn Tablet 750mgErythromycin Gel 2%Erythromycin Ointment 5mg/GmErythromycin Ointment Op

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Erythromycin Solution 2%Gentak Ointment 0.3% OpGentamicin Cream 0.1%Gentamicin Inj 40mg/MlGentamicin Ointment 0.1%Gentamicin Ointment 0.3% OpGentamicin Solution 0.3% OpIlotycin Ointment OpIsoniazid Tablet 300mgLevofloxacin 500mgPenicillin Vk 250mgPenicillin Vk 500mgSodium Sulfacetamide Solution 10% OpSulfacetamide Sodium Solution 10% OpSulfamethoxazole/Trimethoprim 400/80mgSulfamethoxazole/Trimethoprim800/160mgTetracycline Capsule 250mgTetracycline Capsule 500mg

Acetazolamide Tablet 125mgAllopurinol Tablet 100mgAmiloride-Hydrochlorothiazide Tablet 5-50Amitriptyline Tablet 10mgAmitriptyline Tablet 25mgAmitriptyline Tablet 50mgAmmonium Lactate Cream 12%Amoxicillin Capsule 250mgAmpicillin Trihydrate Capsule 250mgAnucort-Hc Sup 25mgAcetaminophen-Codeine Tablet 300-15mgAcetaminophen-Codeine Tablet 300-30mgAtenolol Tablet 25mgAtenolol Tablet 50mgBenztropine Mesylate Tablet 1mgBetamethasone Valerate Cream 0.1%Betamethasone Valerate Ointment 0.1%Brimonidine Tartrate Solution 0.2% OpButalbital-Acetaminophen-Caffeine TabletCarbamazepine Chw 100mgCarteolol Solution 1% OpChlordiazepoxide Capsule 10mgChlordiazepoxide Capsule 25mgChlordiazepoxide Capsule 5mgChlorhexidine Gluconate Solution 0.12%Chlorothiazide Tablet 250mgChlorothiazide Tablet 500mgChlorpromazine Tablet 10mgChlorthalidone Tablet 25mgChlorthalidone Tablet 50mgClindamycin Phosphate Solution 1%Clonidine Tablet 0.1mgClotrimazole Solution 1%Codeine Sulfate Tablet 30mgColchicine Tablet 0.6mgCortisone Acetate Tablet 25mgCorvite Free TabletCovaryx H.S. TabletCyanocobalamin Injection Inj 1000mcgCyclopentolate Solution 1% OpCyproheptadine Tablet 4mgDexamethasone Tablet 0.5mgDexamethasone Tablet 0.75mgDexamethasone Tablet 1mgDexamethasone Tablet 2mgDexmethylphenidate Tablet 2.5mg

Dextroamphetamine Sulfate Tablet 5mgDialyvite TabletDiazepam Solution 1mg/MlDiazepam Tablet 10mgDiazepam Tablet 2mgDiazepam Tablet 5mgDiclofenac Sodium Solution 0.1% OpDigox Tablet 0.125mgDigox Tablet 0.25mgDigoxin Tablet 0.125mgDigoxin Tablet 0.25mgDiltiazem Er Capsule 120mg/24Doxepin Con 10mg/MlDoxycycline Hyclate Capsule 50mgEffer-K Tablet 25meq EfErythromycin Ointment OpErythromycin Solution 2%Estrogen & Methyltestosterone Tablet Mtest HsEstradiol Tablet 0.5mgEstradiol Tablet 1mgEstropipate Tablet 3mgFolic Acid-Vitamin B6-Vitamin B12 TabletFabb TabletFenofibrate Tablet 54mgFerocon CapsuleFerrocite Plus Tablet PlusFludrocortisone Acetate Tablet 0.1mgFluocinolone Acetonide Oil Oil 0.01%Fluocinonide Cream 0.05%Fluoride Chw 0.25mg FFluorometholone Sus 0.1% OpFluoxetine Solution 20mg/5mlFluphenazine Tablet 2.5mgFlurazepam Capsule 15mgFlurazepam Capsule 30mgFolbee TabletFolbee Plus Cz Tablet CzFolbic TabletFolic Acid Tablet 1mgFolplex 2.2 TabletFurosemide Solution 10mg/MlFurosemide Tablet 20mgFurosemide Tablet 40mgGavilyte-G SolutionGentak Ointment 0.3% OpGentamicin Sulfate Ointment 0.1%

NALCSelect GenericsThe amount you pay for a 90-day supply of an NALCSelect generic medication purchased through our Mail Order program or at a local participating CVS Pharmacy through our Maintenance Choice Program is only $5 or only $4 if Medicare Part B is your primary payor. Regular retail coinsurance and mail order copayment amounts apply for generic medication not on the NALCSelect Generic list. At this printing, the NALCSelect Generic list includes the following:

Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Anitbiotic Generic lists are subject to change. Call the NALC CVS/caremark Customer Service Representative at 800-933-NALC (6252) to verify the copayment amount of any generic drug.

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Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Anitbiotic Generic lists are subject to change. Call the NALC CVS/caremark Customer Service Representative at 800-933-NALC (6252) to verify the copayment amount of any generic drug.

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Levoxyl Tablet 112mcgLevoxyl Tablet 125mcgLevoxyl Tablet 137mcgLevoxyl Tablet 150mcgLevoxyl Tablet 175mcgLevoxyl Tablet 200mcgLevoxyl Tablet 25mcgLevoxyl Tablet 50mcgLevoxyl Tablet 75mcgLevoxyl Tablet 88mcgLidocaine Gel 2%Lidocaine Gel 2% JellyLidocaine Viscous Solution 2% ViscLithium Carbonate Capsule 150mgLithium Carbonate Capsule 300mgLithium Carbonate Capsule 600mgLithium Carbonate Tablet 300mgLithium Carbonate Er Tablet 450mg ErMeclizine Tablet 25mgMedroxyprogesterone Acetate Injection 150mg/MlMedroxyprogesterone Acetate Tablet 10mgMedroxyprogesterone Acetate Tablet 2.5mgMedroxyprogesterone Acetate Tablet 5mgMefloquine Tablet 250mgMethadone Tablet 10mgMethadone Tablet 5mgMethimazole Tablet 10mgMethimazole Tablet 5mgMethyldopa-Hydrochlorothiaz Tablet 250/25Methylphenidate Tablet 10mgMethylphenidate Er Tablet 10mg ErMethylphenidate Tablet 5mgMetipranolol Solution 0.3% OphMetoprolol Tartrate Tablet 25mgMetronidazole Tablet 250mgMetronidazole Tablet 500mgMorphine Sulfate Tablet 15mgMorphine Sulfate Tablet 30mgMultivitamin With Fluoride Chw 0.25mgMultivitamin With Fluoride Chw 0.5mgMultivitamin With Fluoride Chw 1mgMulti-Vitamin W-Fluoride Drop 0.25mgMulti-Vitamin W-Fluoride Drop 0.25mgMulti-Vitamin W-Fluoride Drop 0.5mg/MlMvc-Fluoride Chw 0.5mgSodium Chloride Neb 3%Neomycin-Polymyxin-Dexamethasone Ointment 0.1% OpNiacor Tablet 500mgNicardipine Capsule 20mgNp Thyroid Tablet 30mgNystatin Cream 100000Nystatin Ointment 100000Ofloxacin Drop 0.3% OpOfloxacin Drop 0.3%Otic

Glipizide Tablet 5mgGlipizide Er Tablet 2.5mgGlipizide Er Tablet 5mgGlipizide Xl Tablet 2.5mgGlipizide Xl Tablet 5mgGlyburide Ab 1.25mgHaloperidol Tablet 0.5mgHydrocortisone Butyrate Cream 0.1%Hydrocortisone Butyrate Ointment 0.1%Hydrocortisone Valerate Cream 0.2%Hematinic Plus Tablet Vit/MinHematinic With Folic Acid TabletHydrochlorothiazide Capsule 12.5mgHydrochlorothiazide Tablet 12.5mgHydrochlorothiazide Tablet 25mgHydrochlorothiazide Tablet 50mgHydrocortisone Cream 2.5%Hydrocortisone Ointment 2.5%Hydrocortisone Tablet 20mgHydrocortisone Tablet 5mgHydrocortisone Acetate Sup 25mgHydroxyzine Hydrochloride Tablet 10mgHydroxyzine Pamoate Capsule 50mgHypercare Solution 20%Icar-C Plus Plus TabletIsosorbide Dinitrate Tablet 10mgIsosorbide Dinitrate Tablet 20mgIsosorbide Dinitrate Tablet 30mgIsosorbide Dinitrate Tablet 5mgIsosorbide Mononitrate Tablet 10mgIsosorbide Mononitrate Er Tablet 60mg ErK Effervescent Tablet 25meq EfKetoconazole Sha 2%Klor-Con Pow 20meqKlor-Con 10 Tablet 10meq ErKlor-Con M10 Tablet 10meq ErKlor-Con M20 Tablet 20meq ErKlor-Con-Ef Tablet 25meq EfKlor-Con-Ef Tablet 25meq FrPotassium Bicarbonate Tablet 25meq EfLactic Acid Cream ELeucovorin Calcium Tablet 5mgLevothyroxine Sodium Tablet 100mcgLevothyroxine Sodium Tablet 112mcgLevothyroxine Sodium Tablet 125mcgLevothyroxine Sodium Tablet 137mcgLevothyroxine Sodium Tablet 150mcgLevothyroxine Sodium Tablet 175mcgLevothyroxine Sodium Tablet 200mcgLevothyroxine Sodium Tablet 25mcgLevothyroxine Sodium Tablet 300mcgLevothyroxine Sodium Tablet 50mcgLevothyroxine Sodium Tablet 75mcgLevothyroxine Sodium Tablet 88mcgLevoxyl Tablet 100mcg

Ondansetron Injection 40/20mlOto-End 10 SolutionOxybutynin Chloride Syrup 5mg/5mlOxycodone-Acetaminophen Tablet 5-325mgPantoprazole Sodium Tablet 40mgParoex Solution 0.12%Peg-3350 And Electrolytes SolutionPenicillin V Potassium Tablet 250mgPerphenazine-Amitriptyline Tablet 2-10mgPhenazopyridine Tablet 100mgPhenobarbital Elx 20mg/5mlPhenobarbital Tablet 100mgPhenobarbital Tablet 16.2mgPhenobarbital Tablet 30mgPhenobarbital Tablet 32.4mgPhenobarbital Tablet 60mgPhenobarbital Tablet 64.8mgPhenobarbital Tablet 97.2mgPhenytoin Sodium Extended Capsule 100mgPilocarpine Solution 1% OpPilocarpine Solution 2% OpPilocarpine Solution 4% OpPoly-Iron 150 Forte Capsule 150 FortPotassium Chloride Liq 10%Potassium Chloride Liq 20%Potassium Chloride Liq 20% SfPotassium Chloride Tablet 10meq CrPotassium Chloride Tablet 10meq ErPotassium Chloride Tablet 10meq CrPotassium Chloride Tablet 10meq ErPotassium Chloride Tablet 20meq ErPrednisolone Acetate Sus 1% OpPrednisone Tablet 2.5mgPrednisone Tablet 20mgPrednisone Tablet 50mgPrenaplus TabletPrenaTablets Fa TabletPrenaTablets Rx TabletPrenatal Plus Tablet PlusProctosol-Hc Cream 2.5%Proctozone-Hc Cream -Hc 2.5%Promethazine-Codeine Syrup 6.25-10Promethazine-Dm SyrupPropranolol Solution 20mg/5mlQuinidine Sulfate Tablet 200mgQuinidine Sulfate Tablet 300mg ErRenal Caps Capsule SoftgelRena-Vite Rx TabletReno Caps CapsuleSelenium Sulfide Sul Lot 2.5%Se-Tan Plus CapsuleSilver Sulfadiazine Cream 1%Sulfamethoxazole-Trimethoprim Tablet 800-160Sulfamethoxazole-Trimethoprim Sus 200-40/5Sulfamethoxazole-Trimethoprim Tablet 400-80mg

Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Anitbiotic Generic lists are subject to change. Call the CVS/caremark Customer Service Representative at 800-933-NALC (6252) to verify the copayment amount of any generic drug.

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Sodium Chloride Injection 0.9%Sodium Chloride Neb 0.9%Fluoride Chw 0.25mg FSodium Chloride Neb 3%Spironolactone-Hydrochlorothiazide Tablet 25/25Spironolactone Tablet 25mgSpironolactone Tablet 50mgWater InjectionSulfasalazine Tablet 500mgSulfatrim Sus 200-40/5Taztia Xt Capsule 120mg/24Temazepam Capsule 15mgTemazepam Capsule 30mgTheophylline Anhydrous Tablet 300mg ErThiamine Injection 100mg/MlThioridazine Tablet 100mgThiothixene Capsule 1mgTimolol Maleate Tablet 10mgTimolol Maleate Tablet 5mgTl Icon CapsuleTl-Hem 150 TabletTorsemide Tablet 5mgTrazodone Tablet 50mgTriamcinolone Acetonide Cream 0.025%Triamcinolone Acetonide Cream 0.1%Triamcinolone Acetonide Ointment 0.025%Triamcinolone Acetonide Ointment 0.1%Triamcinolone Acetonide Ointment 0.5%Triamterene-Hydrochlorothiazide Capsule 37.5-25Triamterene-Hydrochlorothiazide Tablet 37.5-25Triamterene-Hydrochlorothiazide Tablet 75-50mgTriazolam Tablet 0.125mgTriazolam Tablet 0.25mgTricon CapsuleTrifluoperazine Tablet 1mgTrihexyphenidyl Tablet 2mgTrihexyphenidyl Tablet 5mgTrimethoprim Tablet 100mgTriphrocaps Caps CapsuleTri-Vitamin With Fluoride Dro 0.25mgTriple-Vitamin W-Fluoride Dro 0.25mgUnithroid Tablet 100mcgUnithroid Tablet 112mcgUnithroid Tablet 125mcgUnithroid Tablet 175mcgUnithroid Tablet 200mcgUnithroid Tablet 50mcgUnithroid Tablet 75mcgUnithroid Tablet 88mcgV-C Forte CapsuleVerapamil Tablet 40mgVitamin D2 Capsule 50000untVol-Care Rx TabletZinc Sulfate Capsule 220mg

Sodium Chloride Injection 0.9%Sodium Chloride Neb 0.9%Fluoride Chw 0.25mg FSodium Chloride Neb 3%Spironolactone-Hydrochlorothiazide Tablet 25/25Spironolactone Tablet 25mgSpironolactone Tablet 50mgWater InjectionSulfasalazine Tablet 500mgSulfatrim Sus 200-40/5Taztia Xt Capsule 120mg/24Temazepam Capsule 15mgTemazepam Capsule 30mgTheophylline Anhydrous Tablet 300mg ErThiamine Injection 100mg/MlThioridazine Tablet 100mgThiothixene Capsule 1mgTimolol Maleate Tablet 10mgTimolol Maleate Tablet 5mgTl Icon CapsuleTl-Hem 150 TabletTorsemide Tablet 5mgTrazodone Tablet 50mgTriamcinolone Acetonide Cream 0.025%Triamcinolone Acetonide Cream 0.1%Triamcinolone Acetonide Ointment 0.025%Triamcinolone Acetonide Ointment 0.1%Triamcinolone Acetonide Ointment 0.5%Triamterene-Hydrochlorothiazide Capsule 37.5-25Triamterene-Hydrochlorothiazide Tablet 37.5-25Triamterene-Hydrochlorothiazide Tablet 75-50mgTriazolam Tablet 0.125mgTriazolam Tablet 0.25mgTricon CapsuleTrifluoperazine Tablet 1mgTrihexyphenidyl Tablet 2mgTrihexyphenidyl Tablet 5mgTrimethoprim Tablet 100mgTriphrocaps Caps CapsuleTri-Vitamin With Fluoride Dro 0.25mgTriple-Vitamin W-Fluoride Dro 0.25mgUnithroid Tablet 100mcgUnithroid Tablet 112mcgUnithroid Tablet 125mcgUnithroid Tablet 175mcgUnithroid Tablet 200mcgUnithroid Tablet 50mcgUnithroid Tablet 75mcgUnithroid Tablet 88mcgV-C Forte CapsuleVerapamil Tablet 40mgVitamin D2 Capsule 50000untVol-Care Rx TabletZinc Sulfate Capsule 220mg

Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Anitbiotic Generic lists are subject to change. Call the CVS/caremark Customer Service Representative at 800-933-NALC (6252) to verify the copayment amount of any generic drug.

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NALCPreferred Generics The Plan continues to make 90-day fills of thousands of generic drugs available through the CVS Maintenance Choice Program and through our CVS/caremark mail order program for only $7.99 when we are your primary payor, and for only $4 when Medicare Part B is the primary payor. At this printing, the NALCPreferred Generic list, which represents a summary of prescriptions, includes:

Acyclovir Capsule 200mgAlbuterol Sulfate Neb 0.5%Albuterol Sulfate 2mg/Ml SyrupAlbuterol Sulfate Neb 0.083%Alendronate Sodium Tablet 35mgAlendronate Sodium Tablet 70mgAllopurinol Tablet 300mgAmiodarone Tablet 200mgAmitriptyline Tablet 150mgAmitriptyline Tablet 75mgAmitriptyline Tablet 100mgAtenolol Tablet 100mgAtenolol-Chlorthalidone Tablet 100-25mgAtenolol-Chlorthalidone Tablet 50-25mgAtropine 1% Eye DropsBaclofen Tablet 10mgBenazepril Tablet 5mgBenazepril Tablet 10mgBenazepril Tablet 20mgBenazepril Tablet 40mgBenazepril-Hydrochlorothiazide Tablet 10-12.5Benazepril-Hydrochlorothiazide Tablet 20-12.5Benazepril-Hydrochlorothiazide Tablet 20-25mgBenztropine 0.5mg TabletBenztropine 2mg TabletBetamethasone Valerate Lot 0.1%Bisoprolol-Hydrochlorothiazide Tablet 5-6.25mgBisoprolol-Hydrochlorothiazide Tablet 10/6.25Bisoprolol-Hydrochlorothiazide Tablet 2.5/6.25Bumetanide Tablet 1mgBumetanide Tablet 2mgBumetanide Tablet 0.5mgBuspirone Tablet 5mgBuspirone Tablet 10mgBuspirone Tablet 15mgCaptopril Tablet 50mgCaptopril Tablet 100mgCaptopril-Hydrochlorothiazide Tablet 25-25mgCarbamazepine Tablet 200mgCartia Xt Capsule 120/24hrCarvedilol Tablet 25mgCarvedilol Tablet 12.5mgCarvedilol Tablet 3.125mgCarvedilol Tablet 6.25mgChlorpromazine Hydrochloride Tablet 25mgChlorpromazine Hydrochloride Tablet 50mgChlorzoxazone Tablet 500mg

Cimetidine Tablet 300mgCimetidine Tablet 400mgCimetidine Tablet 800mgCitalopram Hbr Tablet 10mgCitalopram Hbr Tablet 20mgCitalopram Hbr Tablet 40mgClonidine Hydrochloride Tablet 0.2mgClonidine Hydrochloride Tablet 0.3mgCyclobenzaprine Hydrochloride Tablet 10mgCyclobenzaprine Hydrochloride Tablet 5mgCytra-2 SolutionCytra-K SolutionDesonide Cream 0.05%Dexamethasone Tablet 4mgDiclofenac Sodium Tablet 50mg DrDiclofenac Sodium Tablet 75mg DrDicyclomine Hydrochloride Capsule 10mgDicyclomine Hydrochloride Tablet 20mgDiltiazem 24hr Cd Capsule 120mg CdDiltiazem 24hr Er Capsule 120mg ErDiltiazem Hydrochloride Tablet 30mgDiltiazem Hydrochloride Tablet 60mgDiltiazem Hydrochloride ablet 90mgDiltiazem Hydrochloride Tablet 120mgDoxazosin Mesylate Tablet 1mgDoxazosin Mesylate Tablet 2mgDoxazosin Mesylate Tablet 4mgDoxazosin Mesylate Tablet 8mgDoxepin Hydrochloride Capsule 10mgDoxepin Hydrochloride Capsule 25mgDoxepin Hydrochloride Capsule 50mgDoxepin Hydrochloride Capsule 75mgDoxepin Hydrochloride Capsule 100mgEnalapril Maleate Tablet 5mgEnalapril Maleate Tablet 10mgEnalapril Maleate Tablet 20mgEnalapril Maleate Tablet 2.5mgEnalapril-Hydrochlorothiazi Tablet 5-12.5mgEnalapril-Hydrochlorothiazi Tablet 10-25mgEstradiol Tablet 2mgEstropipate Tablet 0.75mgEstropipate Tablet 1.5mgFamotidine Tablet 20mgFamotidine Tablet 40mgFluconazole Tablet 100mgFluconazole Tablet 200mgFluocinolone Acetonide Cream 0.025%

Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Anitbiotic Generic lists are subject to change. Call the CVS/caremark Customer Service Representative at 800-933-NALC (6252) to verify the copayment amount of any generic drug.

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Fluocinolone Acetonide Oin 0.025%Fluoride Chw 0.5mg FFluoride Chw 0.5mg FFluoride Chw 1mg FFluoride Chw 1mg FFluoxetine Hydrochloride Capsule 10mgFluoxetine Hydrochloride Capsule 20mgFluoxetine Hydrochloride Capsule 40mgFluoxetine Hydrochloride Tablet 10mgFluphenazine Hydrochloride Tablet 1mgFluphenazine Hydrochloride Tablet 5mgFosinopril Sodium Tablet 10mgFosinopril Sodium Tablet 20mgFosinopril Sodium Tablet 40mgFurosemide Tablet 80mgGabapentin Capsule 100mgGlimepiride Tablet 1mgGlimepiride Tablet 2mgGlimepiride Tablet 4mgGlipizide Tablet 10mgGlyburide Tablet 5mgGlyburide Micronized Tablet 1.5mgGlyburide Micronized Tablet 3mgGlyburide Micronized Tablet 6mgGlyburide Tablet 2.5mgGlyburide-Metformin Hydrochloride Tablet 5-500mgGuanfacine Hydrochloride Tablet 1mgGuanfacine Hydrochloride Tablet 2mgHaloperidol Tablet 1mgHaloperidol Tablet 2mgHaloperidol Tablet 5mgHydralazine Hydrochloride Tablet 10mgHydralazine Hydrochloride Tablet 25mgHydroxyzine Hydrochloride Syp 10mg/5mlHydroxyzine Pamoate Capsule 25mgIbuprofen Tablet 400mgIbuprofen Tablet 600mgIbuprofen Tablet 800mgImipramine Tablet 10mgImipramine Tablet 25mgIndapamide Tablet 1.25mgIndapamide Tablet 2.5mgIndomethacin Capsule 25mgIndomethacin Capsule 50mgIpratropium Bromide Solution 0.02%InhIsoniazid Tablet 300mgIsosorbide Mononitrate Tablet 20mgIsosorbide Mononitrate Er Tablet 30mg ErJantoven Tablet 1mgJantoven Tablet 2mgJantoven Tablet 5mgJantoven Tablet 6mgJantoven Tablet 2.5mgKetoprofen Capsule 50mg

Ketoprofen Capsule 75mgLabetalol Tablet 100mgLactulose Solution 10gm/15Levobunolol Solution 0.5% OpLisinopril Tablet 5mgLisinopril Tablet 10mgLisinopril Tablet 20mgLisinopril Tablet 30mgLisinopril Tablet 40mgLisinopril Tablet 2.5mgLisinopril-Hydrochlorothiazide Tablet 10-12.5Lisinopril-Hydrochlorothiazide Tablet 20-12.5Lisinopril-Hydrochlorothiazide Tablet 20-25mgLovastatin Tablet 10mgLovastatin Tablet 20mgLovastatin Tablet 40mgLudent Fluoride Chw 0.5mg FMeclizine Tablet 12.5mgMegestrol Acetate Tablet 20mgMeloxicam Tablet 15mgMeloxicam Tablet 7.5mgMetformin Ab 1000mgMetformin Er 500mg ErMetformin Tablet 500mgMetformin Tablet 850mgMethocarbamol Tablet 500mgMethyldopa Tablet 250mgMethyldopa Tablet 500mgMethylprednisolone Tablet 4mgMetoclopramide Tablet 5mgMetoclopramide Tablet 10mgMetoclopramide Solution 5mg/5mlMetolazone Tablet 5mgMetolazone Tablet 2.5mgMetoprolol Tartrate Tablet 50mgMetoprolol Tartrate Tablet 100mgMirtazapine Tablet 15mgNadolol Tablet 20mgNadolol Tablet 40mgNaproxen Sodium Tablet 275mgNaproxen Sodium Tablet 550mgNaproxen Tablet 250mgNaproxen Tablet 375mgNaproxen Tablet 500mgNitroglycerin Capsule 2.5mg ErNitroglycerin Capsule 6.5mg ErNitro-Time Capsule 2.5mg CrNitro-Time Capsule 6.5mg CrNortriptyline Capsule 10mgNortriptyline Capsule 25mgNortriptyline Capsule 75mgNp Thyroid Tablet 60mgOxybutynin Chloride Tablet 5mgPacerone Tablet 200mg

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Ketoprofen Capsule 75mgLabetalol Tablet 100mgLactulose Solution 10gm/15Levobunolol Solution 0.5% OpLisinopril Tablet 5mgLisinopril Tablet 10mgLisinopril Tablet 20mgLisinopril Tablet 30mgLisinopril Tablet 40mgLisinopril Tablet 2.5mgLisinopril-Hydrochlorothiazide Tablet 10-12.5Lisinopril-Hydrochlorothiazide Tablet 20-12.5Lisinopril-Hydrochlorothiazide Tablet 20-25mgLovastatin Tablet 10mgLovastatin Tablet 20mgLovastatin Tablet 40mgLudent Fluoride Chw 0.5mg FMeclizine Tablet 12.5mgMegestrol Acetate Tablet 20mgMeloxicam Tablet 15mgMeloxicam Tablet 7.5mgMetformin Ab 1000mgMetformin Er 500mg ErMetformin Tablet 500mgMetformin Tablet 850mgMethocarbamol Tablet 500mgMethyldopa Tablet 250mgMethyldopa Tablet 500mgMethylprednisolone Tablet 4mgMetoclopramide Tablet 5mgMetoclopramide Tablet 10mgMetoclopramide Solution 5mg/5mlMetolazone Tablet 5mgMetolazone Tablet 2.5mgMetoprolol Tartrate Tablet 50mgMetoprolol Tartrate Tablet 100mgMirtazapine Tablet 15mgNadolol Tablet 20mgNadolol Tablet 40mgNaproxen Sodium Tablet 275mgNaproxen Sodium Tablet 550mgNaproxen Tablet 250mgNaproxen Tablet 375mgNaproxen Tablet 500mgNitroglycerin Capsule 2.5mg ErNitroglycerin Capsule 6.5mg ErNitro-Time Capsule 2.5mg CrNitro-Time Capsule 6.5mg CrNortriptyline Capsule 10mgNortriptyline Capsule 25mgNortriptyline Capsule 75mgNp Thyroid Tablet 60mgOxybutynin Chloride Tablet 5mgPacerone Tablet 200mg

Paroxetine Tablet 10mgParoxetine Tablet 20mgParoxetine Tablet 30mgParoxetine Tablet 40mgPerphenazine-Amitriptyline Tablet 4-25mgPhospha 250 Neutral Tablet NeutralPiroxicam Capsule 10mgPolymyxin B Sul-Trimethopri SolutionPravastatin Sodium Tablet 10mgPravastatin Sodium Tablet 20mgPravastatin Sodium Tablet 40mgPrazosin Capsule 1mgPrazosin Capsule 2mgPrazosin Capsule 5mgPrednisone 10mg Tablet DosepakPrednisone 5mgPrednisone 10mgPrednisone 1mgPrednisone 5 Mg Tablet DosepakProchlorperazine Maleate Tablet 5mgProchlorperazine Maleate Tablet 10mgPromethazine Syp 6.25/5mlPromethazine Tablet 25mgPromethazine Tablet 12.5mgPropranolol Tablet 10mgPropranolol Tablet 20mgPropranolol Tablet 40mgPropranolol Tablet 80mgPropranolol-Hydrochlorothiazide Tablet 40/25Propranolol-Hydrochlorothiazide Tablet 80/25Quinapril Tablet 5mgQuinapril Tablet 10mgQuinapril Tablet 20mgQuinapril Tablet 40mgRanitidine Tablet 150mgRanitidine Tablet 300mgSalsalate Tablet 500mgSertraline Tablet 25mgSodium Citrate & Citric Acid Sodium Fluoride Drop 0.5mg/MlSorine Tablet 80mgSotalol Tablet 80mgSotalol Af Tablet 80mgSynthroid Tablet 25mcgSynthroid Tablet 100mcgSynthroid Tablet 112mcgSynthroid Tablet 125mcgSynthroid Tablet 137mcgSynthroid Tablet 150mcgSynthroid Tablet 175mcgSynthroid Tablet 200mcgSynthroid Tablet 300mcgSynthroid Tablet 50mcgSynthroid Tablet 75mcg

Synthroid Tablet 88mcgTamoxifen Citrate Tablet 10mgTamoxifen Citrate Tablet 20mgTerazosin Capsule 1mgTerazosin Capsule 2mgTerazosin Capsule 5mgTerazosin Capsule 10mgTerbinafine Tablet 250mgTheophylline 100mg Tablet ErTheophylline Anhydrous Tablet 200mg CrThioridazine Tablet 25mgThioridazine Tablet 50mgThiothixene Capsule 2mgTimolol Maleate Solution 0.25% OpTimolol Maleate Solution 0.5% OpTizanidine Tablet 2mgTizanidine Tablet 4mgTorsemide Tablet 10mgTorsemide Tablet 20mgTrazodone Tablet 100mgTrazodone Tablet 150mgTriamcinolone 0.5% CreamVerapamil Tablet 80mgVerapamil Tablet 120mgVerapamil Er Tablet 180mg ErVerapamil Er Tablet 240mg ErWarfarin Sodium Tablet 1mgWarfarin Sodium Tablet 2mgWarfarin Sodium Tablet 3mgWarfarin Sodium Tablet 4mgWarfarin Sodium Tablet 5mgWarfarin Sodium Tablet 6mgWarfarin Sodium Tablet 10mgWarfarin Sodium Tablet 10mgWarfarin Sodium Tablet 2.5mgWarfarin Sodium Tablet 7.5mgZonisamide Capsule 25mg

Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Anitbiotic Generic lists are subject to change. Call the CVS/caremark Customer Service Representative at 800-933-NALC (6252) to verify the copayment amount of any generic drug.

NALC Advanced Control Specialty Formulary ListSpecialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs are generally defined as high-cost prescription drugs that treat complex conditions and require special handling and administration and can cost thousands of dollars for a single dose. NALC’s Advanced Control Specialty Formulary utilizes step therapy for certain specialty medications. Our Advanced Control Specialty Formulary focuses on biologic therapy classes that have multiple products with prescribing interchangeability based on safety and clinical efficacy. Step therapy uses evidence-based protocols that require the use of a preferred drug(s) before non-preferred specialty drugs are covered. Visit our website www.nalchbp.org to view the most current specialty drug lists that may require step therapy.

You must purchase specialty drugs through CVS/specialtyTM Pharmacy Services. Contact them at 800-237-2767 or visit www.cvscaremarkspecialtyrx.com.

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ANALGESICSVISCOSUPPLEMENTSGEL-ONE HYALGAN SUPARTZ FX

ANTI-INFECTIVES ANTIRETROVIRAL AGENTS§ ANTIRETROVIRAL COMBINATIONSlamivudine-zidovudineATRIPLACOMPLERAEPZICOMEVOTAZPREZCOBIX STRIBILDTRIUMEQ TRUVADA

FUSION INHIBITORSFUZEON

INTEGRASE INHIBITORSISENTRESSTIVICAY § NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORSnevirapinenevirapine ext-relEDURANT INTELENCE SUSTIVA

§ NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORSabacavir didanosine lamivudine stavudine zidovudine EMTRIVA

NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORSVIREAD

PROTEASE INHIBITORSKALETRA NORVIR PREZISTA REYATAZ

ANTIVIRALS§HEPATITIS B AGENTSentecavir tabletlamivudineBARACLUDE SOLUTION

§HEPATITIS C AGENTSribavirin HARVONI SOVALDI ANTINEOPLASTIC AGENTS§ ALKYLATING AGENTStemozolomide

§ANTIMETABOLITEScapecitabine

HORMONAL ANTINEOPLASTIC AGENTS§ ANTIANDROGENSZYTIGA

§ LUTEINIZING HORMONE RELEASING HORMONE (LHRH) AGONISTSleuprolide acetate LUPRON DEPOT TRELSTAR ZOLADEX

Medications eligible for the NALC Advanced Control Specialty Formulary List are subject to change. Call the CVS/specialtyTM Pharmacy Services at 800-237-2767. This is not an all-inclusive list.

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IMMUNOMODULATORSREVLIMID THALOMID

KINASE INHIBITORSimatinib mesylateAFINITOR BOSULIF NEXAVAR SPRYCEL SUTENT TARCEVA TYKERB VOTRIENT

§ MISCELLANEOUS bexarotene capsule ZOLINZA

CARDIOVASCULAR ANTILIPEMICSPCSK9 INHIBITORSREPATHA

PULMONARY ARTERIALHYPERTENSIONENDOTHELIN RECEPTOR ANTAGONISTSLETAIRIS TRACLEER

§ PHOSPHODIESTERASE INHIBITORSsildenafil

PROSTAGLANDIN VASODILATORSTYVASO VENTAVIS CENTRAL NERVOUS SYSTEM§ HUNTINGTON’S DISEASE AGENTStetrabenazine

§ MULTIPLE SCLEROSIS AGENTSglatiramerAUBAGIOBETSERONCOPAXONE 40 MG GILENYA REBIF TECFIDERA

ENDOCRINE AND METABOLICCALCIUM REGULATORS PARATHYROID HORMONES FORTEO

FERTILITY REGULATORS GNRH ILHRH ANTAGONISTSCETROTIDE

§OVULATION STIMULANTS, GONADOTROPINSchorionic gonadotropin -Novarel FOLLISTIM AQ OVIDREL

HUMAN GROWTH HORMONESHUMATROPE

HEMATOLOGICHEMATOPOIETIC GROWTH FACTORSARANESPNEULASTA

IMMUNOLOGIC AGENTSALLERGENIC EXTRACTS ORALAIR

BIOLOGIC DISEASE· MODIFYING AGENTS ENBRELHUMIRA

§ DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)RASUVO

IMMUNOSUPPRESSANTS§ANTIMETABOLITESmycophenolate mofetilMYFORTIC

§ CALCINEURIN INHIBITORScyclosporine cyclosporine, modified tacrolimus

§ RAPAMYCIN DERIVATIVESsirolimus tabletRAPAMUNE SOLUTION

TOPICALMOUTH /THROAT /DENTAL AGENTSPROTECTANTS MUGARD

Medications eligible for the NALC Advanced Control Specialty Formulary List are subject to change. Call the CVS/specialtyTM Pharmacy Services at 800-237-2767. This is not an all-inclusive list.

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If you are a plan member or health care provider, please contact CVS/specialtyTM Pharmacy toll-free at 800-237-2767 or visit www.cvscaremarkspecialtyrx.com.

* The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.§ Generics are available in this class and should be considered the first line of prescribing.1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.2 An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

Products distributed by CVS/specialtyTM Pharmacy, may change from time to time. This is not an all-inclusive list.

Call CVS/specialtyTM toll free at 800-237-2767 for specific medications available through CVS/specialtyTM Pharmacy, or to obtain prior approval.

Aabacavir AFINITOR ARANESP ATRIPLAAUBAGIO

BBARACLUDE SOLUTIONBETASERONbexarotene capsuleBOSULIF

CcapecitabineCETROTIDEchorionic gonadotropin - NovarelCOMPLERACOPAXONE 40 MGcyclosporine cyclosporine, modified

Ddidanosine

EEDURANTEMTRIVAENBRELentecavir tabletEPZICOMEVOTAZ

FFOLLISTIM AQFORTEOFUZEON

GGEL-ONEGILENYAglatiramer

HHARVONIHUMATROPEHUMIRAHYALGAN

Iimatinib mesylateINTELENCEISENTRESS

KKALETRA

Llamivudinelamivudine-zidovudineLETAIRISleuprolide acetateLUPRON DEPOT

MMUGARDmycophenolate mofetilMYFORTIC

NNEULASTA nevirapinenevirapine ext-relNEXAVARNORVIR

OORALAIROVIDREL

PPREZCOBIXPREZISTA

RRAPAMUNE SOLUTIONRASUVO

REBIFREPATHAREVLIMIDREYATAZribavirin

Ssildenafilsirolimus tabletSOVALDI SPRYCEL stavudineSTRIBILDSUPARTZ FXSUSTIVASUTENT

TtacrolimusTARCEVATECFIDERAtemozolomidetetrabenazineTHALOMIDTIVICAYTRACLEERTRELSTARTRIUMEQTRUVADATVKERBTYVASO

VVENTAVISVIREADVOTRIENT

ZzidovudineZOLADEXZOLINZAZYTIGA

SPECIALTY PHARMACY QUICK REFERENCE DRUG LIST