NALC Health Benefit PlanHigh Option

2018 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 2018 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 2018 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 2018 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 Spe-cialty™ 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,

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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 and/or quantity/duration limitations for specialty and compound drugs, anti-narcolepsy and certain analgesic/opioid medications. Effective January 1, 2018, prior authorization and/or quantity limitations will be implemented for ADD/ADHD 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 information on prior authorization requirements.

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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. 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 (Phar-macy and Therapeutics Committee) to be the best overall value based on qual-ity, 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 Antibiotic 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 68,550 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 500mgAmpicillin Trihydrate Capsule 500mgCephalexin Capsule 250mgCiprofloxacin Tablet 750mgCiprofloxacin Solution 0.3% OpthalmicErythrocin Stearate Tablet 250mgErythromycin Gel 2%Erythromycin Ointment 5mg/GmErythromycin Ointment OpErythromycin Solution 2%

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Erythromycin Tablet 250mg BsErythromycin Tablet 500mg BsGentak Ointment 0.3% OpGentamicin Sulfate Cre 0.1%Gentamicin Sulfate Injection 40mg/MlGentamicin Sulfate Ointment 0.1%Gentamicin Sulfate Ointment 0.3% OpGentamicin Sulfate Solution 0.3% OpIlotycin Ointment OpIsoniazid Tablet 300mgMinocycline HclOfloxacin Tablet 400mgSodium Sulfacet Solution 10% OpthalmicTobramycin Solution 0.3% Opthalmic

Acetic Acid Solution 2% OticAfeditab Tablet 30mg CrAllopurinol Tablet 100mgAltavera TabletAlyacen Tablet 1/35Amiloride-Hydrochlorothiazide Tablet 5-50Amitriptyline Tablet 10mgAmitriptyline Tablet 25mgAmitriptyline Tablet 50mgAmmonium Lactate Cream 12%Amoxicillin Capsule 250mgAmpicillin Trihydrate Capsule 250mgApri TabletAtenolol Tablet 25mgAtenolol Tablet 50mgAtropine Sulfate Solution 1% OpBenztropine Mesylate Tablet 0.5mgBenztropine Mesylate Tablet 1mgBenztropine Mesylate Tablet 2mgBetamethasone Dipropionate Lot 0.05%Betaxolol Tablet 10mgBisoprolol Fumarate Tablet 5mgBrimonidine Tartrate Solution 0.2% OpBupropion Tablet 75mgCalcitriol Capsule 0.25mcgCamila Tablet 0.35mgCarisoprodol Tablet 350mgCarteolol Solution 1% OpCartia Xt Capsule 180/24hrCephalexin Capsule 250mgChlordiazepoxide Capsule 10mgChlordiazepoxide Capsule 25mgChlordiazepoxide Capsule 5mgChlorhexidine Gluconate Solution 0.12%Chlorothiazide Tablet 250mgChlorothiazide Tablet 500mgChlorthalidone Tablet 25mgChlorthalidone Tablet 50mgClonazepam Tablet 0.5mgClonazepam Tablet 1mgClonidine Tablet 0.1mgClotrimazole Cream 1%Clotrimazole Cream 1% 2x45gCorvita 150 TabletCorvite Free TabletCromolyn Sodium Solution 4% OpthalmicCryselle Tablet 28 TabletsCyanocobalamin Injection 1000mcgCyclafem Tablet 1/35

Cyclopentolate Solution 1% OpDexamethason Elixir 0.5/5mlDexamethasone Phosphate Solution 0.1% OpthalmicDexamethasone Tablet 0.5mgDexamethasone Tablet 0.75mgDexamethasone Tablet 1mgDexamethasone Tablet 2mgDexmethylphenidate Tablet 2.5mgDialyvite TabletDiclofenac Sodium Solution 0.1% OpDigox Tablet 0.125mgDigox Tablet 0.25mgDigoxin Tablet 0.25mgDiltiazem Cd Capsule 180/24hrDiltiazem Er Capsule 120mg/24Diltiazem Er Capsule 180mg/24Diltiazem Xr Capsule 120mg/24Diltiazem Xr Capsule 180mg/24Diltiazem Xr Capsule 240mg/24Dilt-Xr Capsule 180mg/24Doxepin Con 10mg/MlEffer-K Tablet 25meq EfEmoquette TabletEnpresse TabletEnskyce TabletErrin Tablet 0.35mgErythromycin Ointment OpEstradiol Tablet 0.5mgEstradiol Tablet 1mgEstrogen & Methyltestosterone Tablet Mtest HsEstropipate Tablet 3mgEthambutol Tablet 100mgEtidronate Tablet 400mgFabb TabletFenofibrate Tablet 54mgFenofibric Tablet 35mgFerocon CapsuleFerrex 150 Capsule ForteFerrex 150 Capsule Forte PlFerrex 28 Ferrocite Plus Tablet PlusFludrocortisone Acetate Tablet 0.1mgFluoride Chew 0.25mg FFluoxetine Solution 20mg/5mlFluticasone Cream 0.05%Fluticasone Ointment 0.005%Folbee Plus Cz Tablet CzFolbee Plus TabletFolbee Tablet

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 Antibiotic 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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Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Antibiotic 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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Levothyroxine Sodium Tablet 150mcgLevothyroxine Sodium Tablet 175mcgLevothyroxine Sodium Tablet 200mcgLevothyroxine Sodium Tablet 25mcgLevothyroxine Sodium Tablet 300mcgLevothyroxine Sodium Tablet 50mcgLevothyroxine Sodium Tablet 88mcgLevoxyl Tablet 100mcgLevoxyl 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 Mdv 2%Lithium Carbonate Capsule 150mgLithium Carbonate Capsule 300mgLithium Carbonate Capsule 600mgLithium Carbonate Er Tablet 300mgLithium Carbonate Er Tablet 450mg ErLithium Carbonate Tablet 300mgLow-Ogestrel TabletLoxapine Capsule 10mgMarlissa Tablet 0.15/30Meclizine Tablet 25mgMedroxyprogesterone Acetate Tablet 10mgMedroxyprogesterone Acetate Tablet 2.5mgMedroxyprogesterone Acetate Tablet 5mgMethimazole Tablet 10mgMethimazole Tablet 5mgMethylprednisolone Tablet 32mgMethylprednisolone Tablet 4mg DpakMetipranolol Sol 0.3% OphMetoprolol Er Tablet Suc 25mgMetoprolol Er Tablet Suc 50mgMetoprolol Tablet Tar 37.5Metoprolol Tartrate Tablet 25mgMetoprolol/Hctz Tablet 50-25mgMetronidazole Tablet 250mgMetronidazole Tablet 500mgMicrogestin Fe Tablet Fe1.5/30Minocycline Capsule 75mgMinoxidil Tablet 2.5mgMoexipril Tablet 7.5mgMoexipril/Hctz Tablet 15-12.5mgMoexipril/Hctz Tablet 15-25mgMoexipril/Hctz Tablet 7.5-12.5mgMulti-Vitamin W-Fluoride Drop 0.25mgMulti-Vitamin W-Fluoride Drop 0.25mgMulti-Vitamin W-Fluoride Drop 0.5mg/MlMultivitamin With Fluoride Chew 0.25mgMultivitamin With Fluoride Chew 0.5mg

Folbic TabletFolic Acid Tablet 1mgFolic Acid-Vitamin B6-Vitamin B12 TabletFolplex 2.2 TabletFurosemide Solution 10mg/MlFurosemide Tablet 20mgFurosemide Tablet 40mgGavilyte-G SolutionGentak Ointment 0.3% OpGildess Fe Tablet 1.5/30Gildess Fe Tablet 1/20Gildess Tablet 1/20Glipizide Er Tablet 2.5mgGlipizide Er Tablet 5mgGlipizide Tablet 5mgGlipizide Xl Tablet 10mgGlipizide Xl Tablet 2.5mgGlipizide Xl Tablet 5mgGlyburide /Metformin Tablet 1.25-250Glyburide Ab 1.25mgHaloperidol Decanoate Amp 50mg/MlHaloperidol Tablet 0.5mgHeather Tablet 0.35mgHematinic Plus Tablet Vit/MinHematinic With Folic Acid TabletHydralazine Tablet 50mgHydrochlorothiazide Capsule 12.5mgHydrochlorothiazide Tablet 12.5mgHydrochlorothiazide Tablet 25mgHydrochlorothiazide Tablet 50mgHydrocortisone Cream 2.5%Hydrocortisone Ointment 2.5%Hydrocortisone Tablet 10mgHydrocortisone Tablet 5mgHydrocortisone Valerate Cream 0.2%Hydroxyzine Hydrochloride Tablet 10mgHydroxyzine Pamoate Capsule 50mgHypercare Solution 20%Ipratropium Spray .03% Isosorbide Mononitrate Er Tablet 60mg ErIsosorbide Mononitrate Tablet 10mgIvermectin Tablet 3mgJolivette Tablet 0.35mgJunel Fe Tablet 1.5/30Junel TabletKelnor 1-35 Tablet 1/35Ketoconazole Sha 2%Ketorolac Tablet 10mgKlor-Con M10 Tablet 10meq ErKlor-Con M20 Tablet 20meq ErLactic Acid Cream ELeucovorin Calcium Tablet 5mgLeucovorin Tablet 10mgLevora-28 Tablet 0.15/30Levothyroxine Sodium Tablet 100mcgLevothyroxine Sodium Tablet 112mcgLevothyroxine Sodium Tablet 125mcgLevothyroxine Sodium Tablet 137mcg

Multivitamin With Fluoride Chew 1mgMvc-Fluoride Chew 0.5mgMyzilra TabletNecon B 1/50-28Necon Tablet 1/35Neomycin-Polymyxin-Dexamethasone Ointment 0.1% OpNiacor Tablet 500mgNifedical Xl Tablet 30mg ErNifedipine Cc Tablet 30mg ErNifedipine Xl Tablet 30mg ErNora-Be Tablet 0.35mgNorethindrone Tablet 0.35mgNp Thyroid Tablet 15mgNp Thyroid Tablet 30mgNp Thyroid Tablet 90mgNystatin Cream 100000Nystatin Ointment 100000Ofloxacin Drop 0.3% OpOfloxacin Drop 0.3%OticOfloxacin Tablet 400mgOndansetron Injection 40/20mlOto-End 10 SolutionOxybutynin Chloride Syp 5mg/5mlParoex Solution 0.12%Peg-3350 And Electrolytes SolutionPhenylephrine Solution 2.5% OpthalmicPhenytoin Chewable 50mgPoly-Iron 150 Forte Capsule 150 FortPortia TabletPotassium Bicarbonate Tablet 25meq EfPotassium Bicarbonate/Cl Tablet 25meq EfPotassium Chloride Capsule 8meq ErPotassium Chloride Liq 10%Potassium Chloride Liq 20%Potassium Chloride Liq 20% SfPotassium Chloride Tablet 10meq CrPotassium Chloride Tablet 10meq CrPrednisolone Solution 15mg/5mlPrednisone Tablet 10mgPrednisone Tablet 1mgPrednisone Tablet 2.5mgPrednisone Tablet 20mgPrednisone Tablet 50mgPrednisone Tablet 5mgPrenaplus TabletPrenatabs Fa TabletPrenatabs Rx TabletPrenatal Plus Tablet PlusPrimidone Tablet 50mgProbenecid/Colchicine Tablet 500/.5mgPromethazine-Dm SypQuinapril/Hctz Tablet 10-12.5Quinapril/Hctz Tablet 20-25mgQuinidine Sulfate Tablet 200mgQuinidine Sulfate Tablet 300mg ErReclipsen Tablet

Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Antibiotic 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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Renal Caps Capsule SoftgelRena-Vite Rx TabletReno Caps CapsuleSelenium Sulfide Sul Lot 2.5%Se-Tan Plus CapsuleSilver Sulfadiazine Cream 1%Sodium Chloride Injection 0.9%Sodium Chloride Neb 0.9%Sodium Chloride Neb 3%Sodium Sulfacetamide Solution 10% OpthalmicSpironolactone Tablet 25mgSpironolactone Tablet 50mgSulfacetamide/Prednisolone Solution OpthalmicSulfamethoxazole-Trimethoprim Tablet 400-80mgSulfamethoxazole-Trimethoprim Tablet 800-160Sulfasalazine Tablet 500mgTaztia Xt Capsule 120mg/24Terconazole 3 Cream 0.8%Terconazole 7 Cream 0.4%Theophylline 24h Tablet 400mg ErTheophylline Anhydrous Tablet 100mg CrThiamine Injection 100mg/MlThioridazine Tablet 100mgTl Icon CapsuleTl-Hem 150 TabletTobramycin Solution 0.3% OpthalmicTorsemide Tablet 5mgTrandolapril Tablet 2mgTrandolapril Tablet 4mgTrazodone Tablet 50mgTriamcinolone Acetonide Cream 0.025%Triamcinolone Acetonide Cream 0.1%Triamcinolone Acetonide Cream 0.5%Triamcinolone Acetonide Ointment 0.025%Triamcinolone Acetonide Ointment 0.1%Triamcinolone Acetonide Ointment 0.5%Triamcinolone Lotion 0.025%Triamterene-Hydrochlorothiazide Capsule 37.5-25Triamterene-Hydrochlorothiazide Tablet 37.5-25Triamterene-Hydrochlorothiazide Tablet 75-50mgTricon CapsuleTrifluoperazine Tablet 1mgTrigels-F Capsule ForteTrihexyphenidyl Tablet 2mgTrihexyphenidyl Tablet 5mgTrimethoprim Tablet 100mgTriphrocaps Capsules CapsuleTriple-Vitamin W-Fluoride Drop 0.25mgTri-Vitamin With Fluoride Drop 0.25mgTrivora-28 TabletV-C Forte CapsuleVerapamil Tablet 40mgVitamin D2 Capsule 50000untVol-Care Rx TabletWater InjectionZinc Sulfate Capsule 220mgZovia 1-35e Tablet

Renal Caps Capsule SoftgelRena-Vite Rx TabletReno Caps CapsuleSelenium Sulfide Sul Lot 2.5%Se-Tan Plus CapsuleSilver Sulfadiazine Cream 1%Sodium Chloride Injection 0.9%Sodium Chloride Neb 0.9%Sodium Chloride Neb 3%Sodium Sulfacetamide Solution 10% OpthalmicSpironolactone Tablet 25mgSpironolactone Tablet 50mgSulfacetamide/Prednisolone Solution OpthalmicSulfamethoxazole-Trimethoprim Tablet 400-80mgSulfamethoxazole-Trimethoprim Tablet 800-160Sulfasalazine Tablet 500mgTaztia Xt Capsule 120mg/24Terconazole 3 Cream 0.8%Terconazole 7 Cream 0.4%Theophylline 24h Tablet 400mg ErTheophylline Anhydrous Tablet 100mg CrThiamine Injection 100mg/MlThioridazine Tablet 100mgTl Icon CapsuleTl-Hem 150 TabletTobramycin Solution 0.3% OpthalmicTorsemide Tablet 5mgTrandolapril Tablet 2mgTrandolapril Tablet 4mgTrazodone Tablet 50mgTriamcinolone Acetonide Cream 0.025%Triamcinolone Acetonide Cream 0.1%Triamcinolone Acetonide Cream 0.5%Triamcinolone Acetonide Ointment 0.025%Triamcinolone Acetonide Ointment 0.1%Triamcinolone Acetonide Ointment 0.5%Triamcinolone Lotion 0.025%Triamterene-Hydrochlorothiazide Capsule 37.5-25Triamterene-Hydrochlorothiazide Tablet 37.5-25Triamterene-Hydrochlorothiazide Tablet 75-50mgTricon CapsuleTrifluoperazine Tablet 1mgTrigels-F Capsule ForteTrihexyphenidyl Tablet 2mgTrihexyphenidyl Tablet 5mgTrimethoprim Tablet 100mgTriphrocaps Capsules CapsuleTriple-Vitamin W-Fluoride Drop 0.25mgTri-Vitamin With Fluoride Drop 0.25mgTrivora-28 TabletV-C Forte CapsuleVerapamil Tablet 40mgVitamin D2 Capsule 50000untVol-Care Rx TabletWater InjectionZinc Sulfate Capsule 220mgZovia 1-35e Tablet

Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Antibiotic 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 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%Acebutolol Capsule 200mgAcebutolol Capsule 400mgAfeditab Cr Tablet 60mg ErAlbuterol Syrup 2mg/5mlAlclometasone Cream 0.05%Amethyst (28) Tablet 0.09/20Amiloride Tablet 5mgAmitriptyline Tablet 75mgAmlodipine Tablet 10mgAmlodipine Tablet 2.5mgAmlodipine Tablet 5mgAmmonium Lactate Lotion 12% RxAtenolol Tablet 100mgAtenolol-Chlorthalidone Tablet 100-25mgAtenolol-Chlorthalidone Tablet 50-25mgBalziva Tablet 35/0.4B-Complex Via 100Benazepril Tablet 5mgBenazepril Tablet 10mgBenazepril Tablet 20mgBenazepril Tablet 40mgBenazepril Hctz Tablet 5-6.25mgBenazepril-Hydrochlorothiazide Tablet 10-12.5Benazepril-Hydrochlorothiazide Tablet 20-12.5Benazepril-Hydrochlorothiazide Tablet 20-25mgBetamethasone Valerate Lotion 0.1%Betamethasone Valerate Cream 0.1%Betamethasone Valerate Ointment 0.1%Betaxolol Tablet 20mgBisoprolol Tablet 5mgBisoprolol-Hydrochlorothiazide Tablet 5-6.25mgBisoprolol-Hydrochlorothiazide Tablet 10/6.25Bisoprolol-Hydrochlorothiazide Tablet 2.5/6.25Bumetanide Tablet 1mgBumetanide Tablet 0.5mgBupropion Tablet 100mgBuspirone Tablet 5mgCalcitriol Capsule 0.5mcgCaptopril-Hydrochlorothiazide Tablet 25-25mgCarbamazepine Chewable 100mgCarbidopa/Levodopa Odt 10-100mgCarbinoxamine Tablet 4mgCartia Xt Capsule 120/24hrCartia Xt Capsule 240/24hrCephalexin Capsule 500mgCetirizine Syp 5mg/5mlChlordiazepoxide/Amitriptyline Tablet 5-12.5mgChlorzoxazone Tablet 500mgCitalopram Hbr Tablet 10mgClindamycin Capsule 150mgClindamycin Pad 1%

Clindamycin Solution 1%Clonazepam Odt 0.25mgClonazepam Odt 0.5mgClonazepam Tablet 2mgClonidine Hydrochloride Tablet 0.2mgClonidine Hydrochloride Tablet 0.3mgCyproheptadine Tablet 4mgDesipramine Tablet 10mgDesipramine Tablet 25mgDexamethasone Tablet 4mgDexamethasone W Solution 0.5/5mlDicyclomine Hydrochloride Capsule 10mgDicyclomine Hydrochloride Tablet 20mgDigoxin Pediatric Solution 0.05/MlDigoxin Tablet 0.125mgDiltiazem 24hr Cd Capsule 120mg CdDiltiazem 24hr Er Capsule 120mg ErDiltiazem Cd Capsule 240/24hrDiltiazem Cd Capsule 300/24hrDiltiazem Er Capsule 240mg/24Diltiazem Er Capsule 300mg/24Diltiazem Er Capsule 360mg/24Diltiazem Er Capsule 420mg/24Diltiazem Hydrochloride Tablet 30mgDivalproex Tablet 125mg DrDorzolamide Solution 2% OpthalmicDorzolamide Solution Opthalmic 2%Doxazosin 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 100mgDoxycycline Hyclate Tablet 20mgDoxycycline Monohydrate Capsule 50mgEnalapril Maleate Tablet 5mgEnalapril Maleate Tablet 10mgEnalapril Maleate Tablet 2.5mgEnalapril-Hydrochlorothiazi Tablet 5-12.5mgEnalapril-Hydrochlorothiazi Tablet 10-25mgEstradiol Tablet 2mgEstropipate Tablet 0.75mgEstropipate Tablet 1.5mgEtodolac Capsule 200mgFelodipine Tablet 2.5mg ErFelodipine Tablet 5mg ErFenofibrate Capsule 43mgFenofibrate Tablet 160mgFenofibrate Tablet 48mgFlunisolide Spray 0.025%

Medications eligible for the NALCPreferred Generic, NALCSelect Generic and NALCSenior Antibiotic 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. 12

Fluocinolone Acetonide Cream 0.025%Fluoride Chew 0.5mg FFluoride Chew 1mg FFluphenazine Hydrochloride Tablet 1mgFluphenazine Hydrochloride Tablet 5mgFlurbiprofen Tablet 100mgFluticasone Spray 50mcgFosinopril Sodium Tablet 10mgFosinopril Sodium Tablet 20mgFosinopril Sodium Tablet 40mgFosinopril/Hctz Tablet 10/12.5Fosinopril/Hctz Tablet 20/12.5Furosemide Tablet 80mgFyavolv Tablet 1/5Gabapentin Capsule 100mgGenerlac Solution 10gm/15Gentamicin Cream 0.1%Glimepiride Tablet 1mgGlimepiride Tablet 2mgGlipizide Tablet 10mgGlipizide/Metform Tablet 2.5-250 MgGlyburide Tablet 5mgGlyburide Micronized Tablet 1.5mgGlyburide Micronized Tablet 3mgGlyburide Micronized Tablet 6mgGlyburide Tablet 2.5mgGuanfacine Hydrochloride Tablet 1mgGuanfacine Hydrochloride Tablet 2mgHaloperidol Tablet 1mgHaloperidol Tablet 2mgHaloperidol Tablet 5mgHydralazine Hydrochloride Tablet 10mgHydralazine Hydrochloride Tablet 25mgHydrocortisone Ointment 1%Hydrocortisone Tablet 20mgHydroxyurea Capsule 500mgHydroxyzine Hcl Tablet 25mgHydroxyzine Hcl Tablet 50mgHydroxyzine Hydrochloride Syp 10mg/5mlHydroxyzine Pamoate Capsule 25mgHydroxyzine Pamoate Capsule 100mgHyoscyamine Odt 0.125mgHyoscyamine Sub 0.125mgIbuprofen Tablet 400mgIbuprofen Tablet 600mgIbuprofen Tablet 800mgIcar-C Plus TabletImipramine Tablet 10mgImipramine Tablet 25mgImipramine Hcl Tablet 50mgIndapamide Tablet 1.25mgIndapamide Tablet 2.5mgIndomethacin Capsule 25mgIndomethacin Capsule 50mgIntrovale 91 Tablet 0.15/30Ipratropium Spray .06% 165Isoniazid Tablet 300mgIsosorbide Dinitrate Tablet 30mg IrIsosorbide Dinitrate Tablet 5mg IrIsosorbide Mononitrate Tablet 20mgIsosorbide Mononitrate Er Tablet 30mg ErIsoxsuprine Tablet 10mg

Jantoven Tablet 1mgJantoven Tablet 2mgJantoven Tablet 5mgJantoven Tablet 6mgJantoven Tablet 2.5mgJolessa (91) Tablet 0.15/30Klor-Con Spr Capsule Er 8meqKlor-Con/Ef Tablet 25meq FrLabetalol Tablet 100mgLabetalol Tablet 200mgLabetalol Tablet 300mgLatanoprost Solution .005% OpthalmicLeucovorin Calcium Tablet 15mgLevobunolol 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 20-25mgLosartan Tablet 25mgLovastatin Tablet 10mgLovastatin Tablet 20mgLoxapine Capsule 5mgLudent Fluoride Chew 0.5mg FMeclizine Tablet 12.5mgMefloquine Tablet 250mgMegestrol Acetate Tablet 20mgMetformin Er 500mg ErMetformin Tablet 500mgMetformin Tablet 850mgMetformin Er Tablet 750mg GpMethocarbamol Tablet 500mgMethocarbamol Tablet 750mgMethyclothiazide Tablet 5mgMethyldopa Tablet 250mgMethyldopa Tablet 500mgMethyldopa/Hctz Tablet 250/25Methylprednisolone Tablet 4mgMetoclopramide Tablet 5mgMetoclopramide Tablet 10mgMetoclopramide Solution 5mg/5mlMetolazone Tablet 5mgMetolazone Tablet 2.5mgMetoprolol Er Tablet Succinate 100mgMetoprolol Tartrate Tablet 50mgMetoprolol Tartrate Tablet 100mgMetoprolol/Hctz Tablet 100-25mgMinoxidil Tablet 10mgMoexipril Tablet 15mgMometasone Cream 0.1%Mometasone Lotion 0.1% TopMupirocin Ointment 2%Naproxen Dr Tablet 375mgNaproxen Tablet 250mgNaproxen Tablet 375mgNaproxen Tablet 500mgNeo/Poly/Dex Oin 0.1% OpthalmicNeo/Poly/Hc Sus 1% Otic

13

Jantoven Tablet 1mgJantoven Tablet 2mgJantoven Tablet 5mgJantoven Tablet 6mgJantoven Tablet 2.5mgJolessa (91) Tablet 0.15/30Klor-Con Spr Capsule Er 8meqKlor-Con/Ef Tablet 25meq FrLabetalol Tablet 100mgLabetalol Tablet 200mgLabetalol Tablet 300mgLatanoprost Solution .005% OpthalmicLeucovorin Calcium Tablet 15mgLevobunolol 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 20-25mgLosartan Tablet 25mgLovastatin Tablet 10mgLovastatin Tablet 20mgLoxapine Capsule 5mgLudent Fluoride Chew 0.5mg FMeclizine Tablet 12.5mgMefloquine Tablet 250mgMegestrol Acetate Tablet 20mgMetformin Er 500mg ErMetformin Tablet 500mgMetformin Tablet 850mgMetformin Er Tablet 750mg GpMethocarbamol Tablet 500mgMethocarbamol Tablet 750mgMethyclothiazide Tablet 5mgMethyldopa Tablet 250mgMethyldopa Tablet 500mgMethyldopa/Hctz Tablet 250/25Methylprednisolone Tablet 4mgMetoclopramide Tablet 5mgMetoclopramide Tablet 10mgMetoclopramide Solution 5mg/5mlMetolazone Tablet 5mgMetolazone Tablet 2.5mgMetoprolol Er Tablet Succinate 100mgMetoprolol Tartrate Tablet 50mgMetoprolol Tartrate Tablet 100mgMetoprolol/Hctz Tablet 100-25mgMinoxidil Tablet 10mgMoexipril Tablet 15mgMometasone Cream 0.1%Mometasone Lotion 0.1% TopMupirocin Ointment 2%Naproxen Dr Tablet 375mgNaproxen Tablet 250mgNaproxen Tablet 375mgNaproxen Tablet 500mgNeo/Poly/Dex Oin 0.1% OpthalmicNeo/Poly/Hc Sus 1% Otic

Nifedipine CC Tablet 30mg ErNitrofurantoin Mac Capsule 50mgNitroglycerin Capsule 2.5mg ErNitroglycerin Capsule 6.5mg ErNitro-Time Capsule 2.5mg CrNitro-Time Capsule 6.5mg CrNorgestimate And Ethinyl Estradiol Tablet 0.25/35Nortriptyline Capsule 10mgNortriptyline Capsule 25mgNp Thyroid Tablet 60mgNystatin Sus 100000uOgestrel(28) Tablet 0.5/50Oxybutynin Chloride Tablet 5mgPenicilln Vk Tablet 250mgPentoxifylline Tablet 400mg ErPerindopril Tablet 2mgPerphenazine/Amitriptyline Tablet 2-10mgPhenytoin Ex Capsule 100mgPhenytoin Ex Capsule 300mgPhenytoin Sus 125/5mlPhospha 250 Neutral Tablet NeutralPilocarpine Solution 1% OpthalmicPilocarpine Solution 2% OpthalmicPimozide Tablet 1mgPindolol Tablet 5mgPolymyxin B Sul-Trimethopri SolutionPrazosin Capsule 1mgPrazosin Capsule 2mgPrednisone Acetate Sus 1% OpthalmicPrimidone Tablet 250mgProbenecid Tablet 500mgProchlorperazine Maleate Tablet 5mgProchlorperazine Maleate Tablet 10mgPromethazine Syp 6.25/5mlPromethazine Tablet 25mgPromethazine Tablet 12.5mgPropanthelin Tablet 15mgPropranolol Tablet 10mgPropranolol Tablet 20mgPropranolol Tablet 40mgPropranolol Tablet 80mgPropranolol Capsule 60mg ErPropranolol Solution 20mg/5mlPropranolol-Hydrochlorothiazide Tablet 40/25Propranolol-Hydrochlorothiazide Tablet 80/25Propylthiouracil Tablet 50mgQuasense(91) Tablet 0.15/30Quinapril Tablet 5mgQuinapril Tablet 10mgQuinapril Tablet 20mgQuinapril Tablet 40mgQuinapril/Hctz Tablet 20-12.5Ramipril Capsule 1.25mgRamipril Capsule 2.5mgRamipril Capsule 5mgRanitidine Tablet 150mgRanitidine Capsule 150mgRea Lo 40 Lot 40%Simvastatin Tablet 5mgSodium Citrate & Citric Acid

Sodium Fluoride Drop 0.5mg/MlSorine Tablet 80mgSpironolactone Tablet 100mgSpironolactone/Hctz Tablet 25/25Sucralfate Tablet 1gmSulfamethoxazole Trimethoprim Cherry Suspension 200-40/5Sulfasalazine Tablet Ec 500mgSulindac Tablet 150mgSulindac Tablet 200mgSynthroid Tablet 25mcgSynthroid Tablet 100mcgSynthroid Tablet 112mcgSynthroid Tablet 125mcgSynthroid Tablet 137mcgSynthroid Tablet 150mcgSynthroid Tablet 175mcgSynthroid Tablet 200mcgSynthroid Tablet 300mcgSynthroid Tablet 50mcgSynthroid Tablet 75mcgSynthroid Tablet 88mcgTaztia Xt Capsule 240mg/24Terazosin Capsule 1mgTerazosin Capsule 2mgTerazosin Capsule 5mgTerazosin Capsule 10mgTheophylline 24h Tablet 600mg ErTheophylline Anhydrous Tablet 200mg CrThioridazine Tablet 25mgThioridazine Tablet 50mgThiothixene Capsule 2mgThiothixene Capsule 1mgThiothixene Capsule 5mgTimolol Mal Tablet 10mgTimolol Mal Tablet 5mgTimolol Maleate Solution 0.5% OpTorsemide Tablet 10mgTorsemide Tablet 20mgTrandolapril Tablet 1mgTrazodone Tablet 100mgTriamterene/Hctz Capsule 50-25mgTri-Lo Tablet EstaryllVerapamil Tablet 80mgVerapamil Tablet 120mgVerapamil Er Tablet 120mg12hVerapamil Pm Capsule 100mg24hVerapamil Sr Capsule 120mg24hVerapamil Sr Capsule 180mg24hVyfemla (28) Tablet 0.4-35Warfarin 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 Antibiotic 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 COMBINATIONSabacavir-lamivudinelamivudine-zidovudineATRIPLACOMPLERADESCOVYEVOTAZGENVOYAODEFSEYPREZCOBIX STRIBILDTRIUMEQ TRUVADA

FUSION INHIBITORSFUZEON

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

§ NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORSabacavir tablet didanosine lamivudine stavudine zidovudine

EMTRIVA

NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORSVIREAD

§ PROTEASE INHIBITORSlopinavir-ritonavir solutionKALETRA TABLETNORVIR PREZISTA REYATAZ

ANTIVIRALS§HEPATITIS B AGENTSentecavir tabletlamivudineBARACLUDE SOLUTIONVEMLIDY

§ HEPATITIS C AGENTSribavirin EPCLUSA (genotypes 2, 3)HARVONI (genotypes 1, 4, 5, 6)

ANTINEOPLASTIC AGENTS§ ALKYLATING AGENTStemozolomide

§ ANTIMETABOLITEScapecitabine

HORMONAL ANTINEOPLASTIC AGENTS§ ANTIANDROGENSZYTIGA

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

IMMUNOMODULATORSMedications 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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REVLIMID THALOMID

§ KINASE INHIBITORSimatinib mesylateAFINITOR BOSULIFCABOMETYX NEXAVAR SPRYCEL SUTENT TARCEVA TYKERB VOTRIENT

§ MISCELLANEOUS bexarotene capsule ZOLINZA

CARDIOVASCULAR ANTILIPEMICSMICROSOMAL TRIGLYCERIDE TRANFER PROTEIN INHIBITORSJUXTAPID

PCSK9 INHIBITORSREPATHA

PULMONARY ARTERIALHYPERTENSIONENDOTHELIN RECEPTOR ANTAGONISTSLETAIRIS TRACLEER

§ PHOSPHODIESTERASE INHIBITORSsildenafil

PROSTAGLANDIN VASODILATORSORENITRAM

CENTRAL NERVOUS SYSTEM§ HUNTINGTON’S DISEASE AGENTStetrabenazine

§ MULTIPLE SCLEROSIS AGENTSglatiramerAUBAGIOBETSERONCOPAXONE 40 MG GILENYA REBIF TECFIDERA

ENDOCRINE AND METABOLICACROMEGALY SOMATULINE DEPOTSOMAVERT

CALCIUM REGULATORS PARATHYROID HORMONES FORTEO

FERTILITY REGULATORS GNRH / LHRH ANTAGONISTSCETROTIDE

§ OVULATION STIMULANTS, GONADOTROPINSchorionic gonadotropin - Novarel FOLLISTIM AQ OVIDREL

HUMAN GROWTH HORMONESHUMATROPE

HEMATOLOGICHEMATOPOIETIC GROWTH FACTORSARANESPZARXIO

HEMOPHILIA AGENTSKOGENATE FSKOVALTRYNOVOEIGHTNUWIQ

HEREDITARY ANGIOEDEMARUCONEST

IMMUNOLOGIC AGENTSALLERGENIC EXTRACTS ORALAIR

BIOLOGIC DISEASE· MODIFYING AGENTS PSORIASISHUMIRASTELARA (after failure of HUMIRA)TALTZ (after failure of HUMIRA)

ALL OTHER CONDITIONSENBRELHUMIRA

§ DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)RASUVO

IMMUNOSUPPRESSANTS§ANTIMETABOLITESmycophenolate mofetilMYFORTIC

§ CALCINEURIN INHIBITORScyclosporine cyclosporine, modified tacrolimus

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 tabletabacavir-lamivudineAFINITOR ARANESP ATRIPLAAUBAGIO

BBARACLUDE SOLUTIONBETASERONBETHKISbexarotene capsuleBOSULIF

CCABOMETYXcapecitabineCETROTIDEchorionic gonadotropin - NovarelCOMPLERACOPAXONE 40 MGcyclosporine cyclosporine, modified

DDESCOVYdidanosineDUPIXENT

EEDURANTEMTRIVAENBRELentecavir tabletEPCLUSAESBRIET

SPECIALTY PHARMACY QUICK REFERENCE DRUG LIST

§ RAPAMYCIN DERIVATIVESsirolimus tabletRAPAMUNE SOLUTION

RESPIRATORY§ CYSTIC FIBROSIStobramycin inhalation solutionBETHKIS

PULMONARY FIBROSIS AGENTSESBRIET

OFEV

TOPICALDERMATOLOGYATOPIC DERMATITISDUPIXENT

MOUTH /THROAT /DENTAL AGENTSPROTECTANTS MUGARD

EVOTAZ

FFOLLISTIM AQFORTEOFUZEONGGEL-ONEGENVOYAGILENYAglatiramer

HHARVONIHUMATROPEHUMIRAHYALGAN

Iimatinib mesylateINTELENCEISENTRESS

JJUXTAPID

KKALETRA TABLETKOGENATE FSKOVALTRYLlamivudinelamivudine-zidovudineLETAIRISleuprolide acetatelopinavir-ritonavir solutionLUPRON DEPOT

MMUGARDmycophenolate mofetilmycophenolate sodium

Nnevirapinenevirapine ext-relNEXAVARNORVIRNOVOEIGHTNUWIQ

OODEFSEYOFEVORALAIRORENITRAMOVIDREL

PPREZCOBIXPREZISTA

RRAPAMUNE SOLUTIONRASUVOREBIFREPATHAREVLIMIDREYATAZribavirinRUCONEST

Ssildenafilsirolimus tablet

SOMATULINE DEPOTSOMAVERT SPRYCEL stavudineSTELARASTRIBILDSUPARTZ FXSUSTIVASUTENT

TtacrolimusTALTZTARCEVATECFIDERAtemozolomidetetrabenazineTHALOMIDTIVICAYtobramycin inhalation solutionTRACLEERTRELSTARTRIUMEQTRUVADATVKERB

VVEMLIDYVIREADVOTRIENT

ZZARXIOzidovudineZOLADEXZOLINZAZYTIGA