NALC Health Benefit Plan Prescription Drug Lists High Option Your 2021 Drug Cost-Share When NALC is Primary

Generic Drug*: You Pay: Network Retail up to 30 day supply 20% of cost (10% of cost for asthma, diabetes & hypertension) Mail Order up to 60 day supply $10 Mail Order 61-90 day supply $15 ($8 generic for asthma, diabetes & hypertension)

Formulary Brand Drug: You Pay: Network Retail up to 30 day supply 30% of cost Mail Order up to 60 day supply $60 Mail Order 61-90 day supply $90 ($50 Formulary brand for asthma, diabetes & hypertension)

Non-Formulary Brand Drug: You Pay: Network Retail up to 30 day supply 50% of cost Mail Order up to 60 day supply $84 Mail Order 61-90 day supply $125 ($70 Non-formulary brand for asthma, diabetes & hypertension)

Specialty Drugs** : You Pay: (Available only through CVS SpecialtyTM Mail Order) Mail Order up to 30 day supply $200 Mail Order 31-60 day supply $300 Mail Order 61-90 day supply $400

*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. We require the use of preferred drugs before non-preferred specialty drugs are covered. 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. Call CVS SpecialtyTM at 800-237-2767 to obtain prior approval. NALCSelect Generics The 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:

Acetic Acid Otic Solution 2% Chlorthalidone Tablet 25 mg Albuterol Sulfate Syrup 2 mg/5ml Ciprofloxacin Hcl Ophth Solution 0.3% Allopurinol Tablet 100 mg Ciprofloxacin Hcl Tablet 750 mg (Base Equiv) Allopurinol Tablet 300 mg Ciprofloxacn Tablet 250 mg Aluminum Chloride Solution 20% Ciprofloxacn Tablet 500 mg Amiloride & Hydrochlorothiazide Tablet 5-50 mg Clonazepam Tablet 0.5 mg Aminophylline Oral Solution 105 mg/5 ml Clonidine Hcl Tablet 0.1 mg Aminophylline Powder Clonidine Hcl Tablet 0.2 mg Aminophylline Tablet 200 mg Clonidine Hcl Tablet 0.3 mg Amitriptyline Hcl Tablet 10 mg Colchicine Powder Amitriptyline Hcl Tablet 25 mg Cyanocobalamin (Bulk) Crystals Amoxicillin (Trihydrate) Capsule 250 mg Cyanocobalamin (Bulk) Powder Amoxicillin (Trihydrate) Capsule 500 mg Cyanocobalamin Crystals Amoxicillin (Trihydrate) Tablet 500 mg Cyanocobalamin Inj 1000 mcg/ml Amoxicillin Tablet 875 mg Cyanocobalamin Powder (For Compounding) Ampicillin Capsule 250 mg Cyanocobalamin Tablet 100 mcg Ampicillin Capsule 500 mgAtenolol Tablet 25 mg Cyanocobalamin Tablet 1000 mcg Atenolol Tablet 50 mg Cyclopentolate Hcl Ophth Solution 1% Atropine Sulfate Monohydrate Powder Dexamethasone Sodium Phosphate Inj 10 mg/ml Atropine Sulfate Powder Dexamethasone Sodium Phosphate Inj 100 mg/10 ml Azithromycin Tablet 250 mg Dexamethasone Tablet 0.5 mg Bacitracin Micronized (Bulk) Powder Dexamethasone Tablet 0.75 mg Bacitracin Ointment 500 Unit/Gm Dexamethasone Tablet 1 mg Bacitracin Powder Dexamethasone Tablet 2 mg Bacitracin Zinc Ointment 500 Unit/gm Dexmethylphenidate Hcl Tablet 2.5 mg B-Complex W/ C & Folic Acid Capsule 1 mg Diclofenac Sodium (Pf) Ophth Solution 0.1% B-Complex W/ C & Folic Acid Tablet 1 mg Diclofenac Sol 0.1% Opthalmic B-Complex W/ C & Folic Acid Tablet 5 mg Dicyclomine Hcl Oral Solution 10 mg/5 ml B-Complex W/ C-Biotin-Minerals & Folic Acid Tablet 5 mg Digoxin (Bulk) Powder B-Complex W/ C-Min-Fe & Folic Acid Tablet 106-1 mg Digoxin Tablet 0.5 mg Belladonna Alkaloids-Phenobarbital Tablet 16.2 mg Diltiazem Hcl Capsule Er 24hr 120 mg Benzoyl Peroxide Gel 5% Diltiazem Hcl Extended Release Beads Capsule Sr 24hr 120 mg Benztropine Mesylate Powder Diphenhydramine Hcl (Sleep) Tablet 25 mg Benztropine Mesylate Tablet 0.5 mg Diphenhydramine Hcl (Sleep) Tablet 50 mg Benztropine Mesylate Tablet 1 mg Diphenhydramine Hcl Capsule 50 mg Benztropine Mesylate Tablet 2 mg Diphenhydramine Hcl Liquid 12.5 mg/5 ml Betamethasone Valerate Powder Diphenhydramine Hcl Powder Betaxolol Hcl Tablet 10 mg Diphenhydramine Hcl Tablet 25 mg Brimonidine Tartrate Ophth Solution 0.2% Diphenhydramine-Zinc Acetate Cream 2-0.1% Brom/Pse/Dm Syrup 2-30-10 Doxycycline Mono Capsule 100 mg Calcitriol Capsule 0.25 mcg Doxycycline Tablet 50 mg Carteolol Hcl Ophth Solution 1% Ergocalciferol Capsule 50000 Unit Cartia Xt Capsule 120/24hr Erythromycin Ophth Ointment 5 mg/gm Cefadroxil Capsule 500 mg Estradiol Micronized (Bulk) Powder Cephalexin Capsule 250 mg Estradiol Micronized Powder Cephalexin Capsule 500 mg Estradiol Tablet 0.5 mg Chlordiazepoxide Hcl Capsule 10 mg Estradiol Tablet 1 mg Chlordiazepoxide Hcl Capsule 25 mg Estradiol Tablet 2 mg Chlordiazepoxide Hcl Capsule 5 mg Ethambutol Hcl Tablet 100 mg Chlorhexidine Gluconate Solution 0.12% Ethyl Chloride Aerosol Spray Chlorothiazide Tablet 250 mg Etidronate Disodium Tablet 400 mg Chlorpheniramine Maleate Powder FE Asp Gly-Fe Polysacch-Succ Ac-C-Threon Ac-B12-Fa Capsule Chlorpheniramine Maleate Tablet 4 mg FE Asparto Gly-Fe Fum-B12-Fa-C-Succinic Ac Tablet Ther Pack Chlorpheniramine Maleate Tablet Cr 8 mg FE Fumarate-Vit C-Vit B12-Fa Capsule 460 (151 Fe)-60-0.01-1 mg FE Fum-Iron Polysacch Complex-Fa-B Cmplx-C-Zn-Mn-Cu Capsule Indomethacin Capsule 25 mg Fenofibrate Micronized Capsule 67 mg Iron Polysacch Complex-Vit B12-Fa Capsule 150-0.025-1 mg Fenofibrate Tablet 54 mg Iron-Docusate-B12-Folic Acid-C-E-Cu-Biotin Tablet 150-1 mg Fenofibric Acid Tablet 35 mg Isoniazid Powder Ferrous Fumarate-Fa-B Complex-C-Zn-Mg-Mn-Cu Tablet 106-1 mg Isoniazid Tablet 300 mg Ferrous Fumarate-Folic Acid Tablet 324-1 mg Isoniazid Tablet 100 mg Ferrous Sulfate Capsule Cr 250 mg Isosorbide Dinitrate SL Tablet 5 mg Ferrous Sulfate Dried Tablet 200 mg (65 mg Elemental Fe) Isosorbide Mononitrate Tablet 10 mg Ferrous Sulfate Dried Tablet Cr 160 mg (50 mg Fe Equivalent) Ivermectin Tablet 3 mg Ferrous Sulfate Elixir 220 mg/5ml (44 mg/5 ml Elemental Fe) Ketoconazole Shampoo 2% Ferrous Sulfate Granules Klor-Con 10 Tablet 10meq Er Ferrous Sulfate Powder Lactic Acid W/ Vitamin E Cream 10%-3500 Unit/30 gm Ferrous Sulfate Solution 75 mg/0.6ml (15 mg/0.6 ml Elemental Fe) Leucovorin Calcium Tablet 5 mg Ferrous Sulfate Solution 75 mg/ml (15 mg/ml Elemental Fe) Levobunolol Hcl Ophth Solution 0.25% Ferrous Sulfate Syrup 300 mg/5ml (60 mg/5 ml Elemental Fe) Levofloxacin Tablet 250 mg Ferrous Sulfate Tablet 134 mg (27 mg Elemental Fe) Levofloxacin Tablet 500 mg Ferrous Sulfate Tablet 28 mg (Elemental Fe) Levofloxacin Tablet 750 mg Ferrous Sulfate Tablet 324 mg Levothyroxine Sodium (Bulk) Powder Ferrous Sulfate Tablet 325 mg (65 mg Elemental Fe) Levothyroxine Sodium Tablet 300 mcg Ferrous Sulfate Tablet 83 mg Lisinopril & Hydrochlorothiazide Tablet 10-12.5 mg Ferrous Sulfate Tablet Ec 324 mg (65 mg Fe Equivalent) Lisinopril & Hydrochlorothiazide Tablet 20-25 mg Ferrous Sulfate Tablet Ec 325 mg (65 mg Fe Equivalent) Lisinopril Tablet 10 mg Ferrous Sulfate-Vit C-Folic Acid Tablet Cr 105-500-0.8 mg Lisinopril Tablet 2.5 mg Fexofenadine Hcl Tablet 30 mg Lisinopril Tablet 20 mg Fludrocortisone Acetate Tablet 0.1 mg Lisinopril Tablet 5 mg Fluorometholone (Bulk) Powder Lithium Carbonate Capsule 150 mg Folic Acid Tablet 1 mg Lithium Carbonate Capsule 300 mg Folic Acid-Pyridoxine-Cyanocobalamin Tablet 2.5-25-2 mg Lithium Carbonate Capsule 600 mg Folic Acid-Vitamin B6-Vitamin B12 Tablet 2.2-25-0.5 mg Lithium Carbonate Tablet 300 mg Folic Acid-Vitamin B6-Vitamin B12 Tablet 2.2-25-1 mg Lithium Carbonate Tablet Cr 450 mg Folic Acid-Vitamin B6-Vitamin B12 Tablet 2.5-25-1 mg Lithium Carbonate Tablet Er 300 mg Furosemide Oral Solution 10 mg/ml Magnesium Sulfate Granules Furosemide Oral Solution 8 mg/ml Magnesium Sulfate Powder Furosemide Powder Meclizine Hcl Tablet 25 mg Furosemide Tablet 20 mg Medroxyprogesterone Acetate Micronized (Bulk) Powder Furosemide Tablet 40 mg Medroxyprogesterone Acetate Tablet 10 mg Gentamicin Sol 0.3% Opthalmic Medroxyprogesterone Acetate Tablet 2.5 mg Gentamicin Sulfate Ophth Ointment 0.3% Medroxyprogesterone Acetate Tablet 5 mg Glimepiride Tablet 1 mg Medroxyprogesterone Micronized Powder Glipizide Tablet 10 mg Metaproterenol Sulfate Syrup 10 mg/5 ml Glipizide Tablet 5 mg Methimazole Tablet 10 mg Glipizide Tablet Sr 24hr 2.5 mg Methimazole Tablet 5 mg Glipizide Tablet Sr 24hr 5 mg Methotrexate Powder Glyburide Tablet 1.25 mg Methotrexate Sodium Tablet 2.5 mg (Antirheumatic) Glyburide Tablet 2.5 mg Methyldopa Tablet 250 mg Haloperidol Decanoate Im Solution 50 mg/ml Methylprednisolone Tablet 32 mg Haloperidol Tablet 0.5 mg Metipranolol Ophth Solution 0.3% Homatropine Hbr Ophth Solution 5% Metoclopramide Hcl Tablet 10 mg (Base Equivalent) Hydrochlorothiazide Capsule 12.5 mg Metoclopramide Hcl Tablet 5 mg (Base Equivalent) Hydrochlorothiazide Powder Metoprolol Succinate Tablet Er 24hr 25 mg (Tartrate Equiv) Hydrochlorothiazide Solution 50 mg/5ml Metoprolol Tartrate Tablet 25 mg Hydrochlorothiazide Tablet 12.5 mg Metronidazole Tablet 250 mg Hydrochlorothiazide Tablet 25 mg Minocycline Capsule 100 mg Hydrochlorothiazide Tablet 50 mg Minocycline Capsule 50 mg Hydrocortisone Cream 1% Minoxidil Tablet 2.5 mg Hydrocortisone Cream 2.5% Moexipril-Hydrochlorothiazide Tablet 15-25 mg Hydrocortisone Ointment 2.5% Mometasone Sol 0.1% Topical Hydrocortisone Tablet 5 mg Multiple Vitamins W/ Iron Tablet Hydroxyzine Hcl Syrup 10 mg/5 ml Multiple Vitamins W/ Minerals Capsule Hydroxyzine Hcl Tablet 10 mg Multiple Vitamins W/ Minerals Tablet Hydroxyzine Pamoate Capsule 50 mg Neomycin Tablet 500 mg Hyosyne Elixir 0.125/5 Niacin Capsule Cr 500 mg Niacin Tablet 500 mg Prenatal Vit W/ Iron Carbonyl-Fa Tablet 29-1 mg Nitroglyc Sl 0.6 mg 1/100 Primidone Tablet 50 mg Nitroglycerin Capsule Cr 9 mg Prochlorperazine Maleate Tablet 5 mg (Base Equivalent) Nitroglycerin Sl Tablet 0.3 mg Propranolol Hcl Powder Nitroglycerin Sl Tablet 0.4 mg Quinapril-Hydrochlorothiazide Tablet 20-25 mg Nystatin Cream 100000 Unit/gm Quinidine Sulfate Tablet 200 mg Nystatin Ointment 100000 Unit/gm Quinidine Sulfate Tablet 300 mg Ofloxacin Ophth Solution 0.3% Quinidine Sulfate Tablet Cr 300 mg Ofloxacin Tablet 400 mg Selenium Sulfide Lotion 2.5% Oxybutynin Chloride Syrup 5 mg/5 ml Silver Sulfadiazine Cream 1% Oxybutynin Chloride Syrup 5 mg/5 ml Sodium Bicarbonate (Bulk) Powder *Pediatric Multiple Vitamins W/ Fl-Fe Drops 0.25-10 mg/ml Sodium Bicarbonate Powder *Pediatric Multiple Vitamins W/ Fluoride Chew Tablet 0.25 mg Sodium Bicarbonate Tablet 325 mg *Pediatric Multiple Vitamins W/ Fluoride Chew Tablet 0.5 mg Sodium Bicarbonate Tablet 650 mg *Pediatric Multiple Vitamins W/ Fluoride Chew Tablet 1 mg Sodium Chloride Solution Nebu 0.9% *Pediatric Multiple Vitamins W/ Fluoride Solution 0.25 mg/ml Sodium Chloride Solution Nebu 3% *Pediatric Multiple Vitamins W/ Fluoride Solution 0.5 mg/ml Sodium Fluoride Chew Tablet 0.25 mg F (From 0.55 mg Naf) *Pediatric Vitamins Acd W/ Fluoride Solution 0.25 mg/ml Sodium Fluoride-Potassium Nitrate Paste 1.1-5% Penicilln Vk Tablet 250 mg Spironolactone Tablet 25 mg Penicilln Vk Tablet 500 mg Spironolactone Tablet 50 mg Perphenazine-Amitriptyline Tablet 4-10 mg Sulfacetamide Sodium-Prednisolone Ophth Solution 10-0.23 Phenobarbital Tablet 100 mg (0.25)% Phenobarbital Tablet 15 mg Sulfamethoxazole-Trimethoprim Tablet 400-80 mg Phenobarbital Tablet 16.2 mg Sulfamethoxazole-Trimethoprim Tablet 800-160 mg Phenobarbital Tablet 30 mg Sulfasalazine Tablet 500 mg Phenobarbital Tablet 60 mg Tetracycline Hcl Powder Phenylephrine Hcl Ophth Solution 2.5% Thyroid Powder Phenytoin Chew Tablet 50 mg Thyroid Tablet 15 mg (1/4 Grain) Pilocarpine Hcl Ophth Solution 0.5% Thyroid Tablet 30 mg (1/2 Grain) Pilocarpine Hcl Ophth Solution 3% Thyroid Tablet 300 mg (5 Grain) Pilocarpine Hydrochloride Crystals Tobramycin Ophth Solution 0.3% Pilocarpine Hydrochloride Powder Torsemide Tablet 5 mg Polymyxin B-Trimethoprim Ophth Solution 10000 Unit/ml-0.1% Triamcinolone Acetonide Cream 0.025% Polysaccharide Iron-Fa-Vit B12 Capsule 150 mg-1 mg-25 mcg Triamcinolone Acetonide Cream 0.1% Potassium Bicarbonate-Citric Acid Effer Tablet 10 Meq Triamcinolone Acetonide Lotion 0.025% Potassium Bicarbonate-Citric Acid Effer Tablet 20 Meq Triamcinolone Acetonide Ointment 0.025% Potassium Chloride Crystals Triamcinolone Acetonide Ointment 0.1% Potassium Chloride Granules Triamterene & Hydrochlorothiazide Capsule 37.5-25 mg Potassium Chloride Microencapsulated Crys Cr Tablet 10 Meq Triamterene & Hydrochlorothiazide Tablet 37.5-25 mg Potassium Chloride Microencapsulated Crys Cr Tablet 20 Meq Triamterene & Hydrochlorothiazide Tablet 75-50 mg Potassium Chloride Oral Liq 10% (20 Meq/15 ml) Trifluoperazine Hcl Tablet 1 mg Potassium Chloride Oral Liq 20% (40 Meq/15 ml) Trihexyphenidyl Hcl Tablet 2 mg Potassium Chloride Powder (For Compounding) Trihexyphenidyl Hcl Tablet 5 mg Potassium Chloride Tablet Er 20 Meq (1500 mg) Trimethoprim Tablet 100 mg Potassium Chloride Tablet Er 8 Meq (600 mg) Tropicamide Ophth Solution 1% Pramoxine-Hc-Chloroxylenol Otic Solution 10-10-1 mg/ml Verapamil Hcl Tablet 40 mg Prednisolone Powder Warfarin Sodium Tablet 1 mg Prednisolone Sod Phosphate Oral Solution 15 mg/5ml (Base Equiv) Warfarin Sodium Tablet 10 mg Prednisone Powder Warfarin Sodium Tablet 2 mg Prednisone Tablet 1 mg Warfarin Sodium Tablet 2.5 mg Prednisone Tablet 10 mg Warfarin Sodium Tablet 3 mg Prednisone Tablet 2.5 mg Warfarin Sodium Tablet 4 mg Prednisone Tablet 20 mg Warfarin Sodium Tablet 5 mg Prednisone Tablet 5 mg Warfarin Sodium Tablet 6 mg Prednisone Tablet 5 mg Dose Pack Warfarin Sodium Tablet 7.5 mg Prednisone Tablet 50 mg Zinc Capsule 50 mg Prenatal Vit W/ Dss-Fe Fumarate-Fa Tablet 29-1 mg Zinc Sulfate Capsule 220 mg (50 mg Elemental Zn) Prenatal Vit W/ Dss-Iron Carbonyl-Fa Tablet 90-1 mg Zinc Sulfate Granules Prenatal Vit W/ Fe Fumarate-Fa Chew Tablet 29-1 mg Zinc Sulfate Powder Prenatal Vit W/ Fe Fumarate-Fa Tablet 27-1 mg Zinc Sulfate Tablet 220 mg (50 mg Zinc Equivalent) Prenatal Vit W/ Fe Fumarate-Fa Tablet 28-0.8 mg Zinc Sulfate Tablet Cr 220 mg (50 mg Elemental Zinc) Prenatal Vit W/ Fe Fumarate-Fa Tablet 29-1 mg 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:

Acebutolol Hcl Cap 200 mg Carisoprodol Tablet 350 mg Acetic Acid Irrigation Solution 0.25% Carvedilol Acyclovir Carvedilol Tablet 12.5 mg Albuterol Sulfate Carvedilol Tablet 25 mg Albuterol Sulfate Syrup 2 mg/5 ml Carvedilol Tablet 3.125 mg Allopurinol Carvedilol Tablet 6.25 mg Amiloride & Hydrochlorothiazide Cefaclor Capsule 250 mg Amiloride Hcl Tablet 5 mg Cetirizine Hcl Oral Solution 1 mg/ml (5 mg/5 ml) Amitriptyline Hcl Tablet 50 mg Chlorhexidine Gluconate (Mouth-Throat) Amitriptyline Hcl Tablet 75 mg Chlorothiazide Tablet 500 mg Amlodipine Besylate Tablet 2.5 mg Chlorpheniramine & Phenylephrine Liquid 1-3.5 mg/ml Amlodipine Besylate Tablet 5 mg Chlorpropamide Tablet 100 mg Amoxicillin Tablet 875 mg Chlorthalidone Tablet 25 mg Atenol/Chlor Tablet 100-25 mg Chlorthalidone Tablet 50 mg Atenolol & Chlorthalidone Citalopram Hydrobromide Atenolol & Chlorthalidone Tablet 50-25 mg Citalopram Tablet 10 mg Atenolol Tablet 100 mg Citalopram Tablet 20 mg Atropine Sulfate (Ophthalmic) Citalopram Tablet 40 mg Atropine Sulfate Ophth Solution 1% Clindamycin Phosphate (Topical) B-Complex Vitamin Inj Clindamycin Sol 1% Belladonna Alkaloids-Phenobarbital Tablet 16.2 mg Clonazepam Orally Disintegrating Tablet 0.5 mg Benazepril Hcl Tablet 10 mg Clonazepam Orally Disintegrating Tablet 2 mg Benazepril Hcl Tablet 20 mg Clonazepam Tablet 2 mg Benazepril Hcl Tablet 40 mg Clonidine Hcl Benazepril Hcl Tablet 5 mg Clotrimazole Cream 1% Benazepril Hct Tablet 10-12.5 Corvita 150 Tablet Benazepril Hct Tablet 20-12.5 Corvita Tablet Benazepril/Hctz Tablet 20-25 mg Cyclobenzaprine Tablet 10 mg Benztropine Mesylate Cyclopentol Sol 2% Opthalmic Benztropine Mesylate Tablet 0.5 mg Cyclopentolate Hcl (Pf) Ophth Solution 1% Benztropine Mesylate Tablet 2 mg Cyclopentolate Hcl Ophth Solution 1% Betamethasone Dipropionate Lotion 0.05% Cyproheptad Syp 2 mg/5 ml Betamethasone Val Lot 0.1% Cyproheptadine Hcl Betamethasone Valerate Cyproheptadine Hcl Tablet 4 mg Betamethasone Valerate Desonide Betamethasone Valerate Ointment 0.1% (Base Equivalent) Desonide Cre 0.05% Betaxolol Hcl Tablet 20 mg Dexamethasone Tablet 0.5 mg Bisoprl/Hctz Tablet 2.5/6.25 Dexamethasone Tablet 0.75 mg Bisopro/Hctz Tablet 10/6.25 Dexamethasone Tablet 4 mg Bisopro/Hctz Tablet 5-6.25 mg Dexamethasone Tablet 6 mg Bisoprolol & Hydrochlorothiazide Dicyclomine Capsule 10 mg Bumetanide Dicyclomine Hcl Bumetanide Tablet 0.5 mg Dicyclomine Hcl Bumetanide Tablet 1 mg Dicyclomine Hcl Tablet 20 mg Bumetanide Tablet 2 mg Digoxin Bupropion Hcl Tablet 100 mg Digoxin Tablet 125 mcg (0.125 mg) Buspirone Hcl Tablet 5 mg Digoxin Tablet 250 mcg (0.25 mg) Captopril & Hydrochlorothiazide Tablet 25-25 mg Diltiazem Cd Capsule 300/24hr Carbamazepin Tablet 200 mg Diltiazem Hcl Carbamazepine Diltiazem Hcl Capsule Er 24hr 180 mg Carbidopa & Levodopa Orally Disintegrating Tablet 10-100 mg Diltiazem Hcl Capsule Er 24hr 240 mg Carbinoxamine Maleate Tablet 4 mg Diltiazem Hcl Coated Beads Capsule Er 24hr 180 mg Diltiazem Hcl Coated Beads Capsule Er 24hr 240 mg Glyburide Tablet 5 mg Diltiazem Hcl Extended Release Beads Capsule Er 24hr 240 mg Glyburide-Metformin Tablet 1.25-250 mg Diltiazem Tablet 120 mg Guanfacine Hcl Diltiazem Tablet 30 mg Guanfacine Hcl Tablet 1 mg Diltiazem Tablet 60 mg Haloperidol Tablet 0.5 mg Diltiazem Tablet 90 mg Haloperidol Tablet 1 mg Dorzolamide Hcl Ophth Solution 2% Haloperidol Tablet 2 mg Doxazosin Mesylate Haloperidol Tablet 5 mg Doxazosin Mesylate Tablet 1 mg Hydralazine Hcl Tablet 10 mg Doxazosin Mesylate Tablet 2 mg Hydralazine Hcl Tablet 25 mg Doxazosin Mesylate Tablet 4 mg Hydralazine Hcl Tablet 50 mg Doxazosin Mesylate Tablet 8 mg Hydrochlorothiazide Doxepin Hcl Capsule 10 mg Hydrochlorothiazide Tablet 50 mg Doxepin Hcl Capsule 25 mg Hydrocort Cream 1% Rectal Doxepin Hcl Capsule 50 mg Hydrocortisone Cream 1% Enalapril Maleate Hydrocortisone Cream 2.5% Enalapril Maleate & Hydrochlorothiazide Tablet 10-25 mg Hydrocortisone Ointment 2.5% Enalapril Maleate & Hydrochlorothiazide Tablet 5-12.5 mg Hydrocortisone Tablet 10 mg Enalapril Maleate Tablet 2.5 mg Hydrocortisone Tablet 20 mg Enalapril Tablet 10 mg Hydroxyurea Capsule 500 mg Enalapril Tablet 20 mg Hydroxyzine Hcl Enalapril Tablet 5 mg Hydroxyzine Hcl Tablet 25 mg Erythromycin Solution 2% Hydroxyzine Hcl Tablet 50 mg Estradiol Hydroxyzine Pamoate Capsule 25 mg Estropipate Tablet 0.75 mg Ibuprofen Susp 100 mg/5 ml Estropipate Tablet 1.5 mg Ibuprofen Tablet 400 mg FE Fumarate W/ B12-Vit C-Fa-Ifc Capsule 110-0.015-75- Ibuprofen Tablet 600 mg 0.5-240 mg Imipramine Hcl Tablet 10 mg Felodipine Tablet Er 24hr 2.5 mg Imipramine Hcl Tablet 25 mg Felodipine Tablet Er 24hr 5 mg Indapamide Fenofibrate Capsule 134mg Indapamide Tablet 1.25 mg Fenofibrate Tablet 48 mg Indapamide Tablet 2.5 mg Fenofibric Capsule 45 mg Dr Indomethacin Fluocinolone Acetonide Indomethacin Capsule 50 mg Fluoxetin(P) Capsule 10 mg Ipratrop.02% Sol Inh 30’s Fluoxetin(P) Capsule 20 mg Ipratropium Bromide Fluoxetin(P) Capsule 40 mg Iron-Vit C-Vit B12-Folic Acid Tablet 100-250-0.025-1 mg Fluoxetine Hcl Isoniazid Tablet 300 mg Fluoxetine Hcl (Pmdd) Isosorbide Dinitrate Tablet 5 mg Flurbiprofen Sodium Isosorbide Mononitrate Tablet 20 mg Fluticasone Propionate Cream 0.05% Isosorbide Mononitrate Tablet Sr 24hr 30 mg Fluticasone Propionate Ointment 0.005% Isosorbide Mononitrate Tablet Sr 24hr 60 mg Folic Acid Tablet 1 mg Ketoprofen Fosinopril Sodium Labetalol Hcl Tablet 100 mg Fosinopril Sodium & Hydrochlorothiazide Tablet 10-12.5 mg Lactic Acid (Ammonium Lactate) Cream 12% Fosinopril Sodium & Hydrochlorothiazide Tablet 20-12.5 mg Lactic Acid (Ammonium Lactate) Lotion 12% Fosinopril Sodium Tablet 40 mg Lactulos Orl Sol 10 gm/15 Furosemide Tablet 80 mg Lactulose Gabapentin Capsule 100 mg Latanoprost (Pf) Ophth Solution 0.005% Glimepiride Levobunolol Hcl (Pf) Ophth Solution 0.5% Glimepiride Tablet 2 mg Levobunolol Hcl Ophth Solution 0.5% Glipizide Levonorgestrel & Ethinyl Estradiol (91-Day) Tablet 0.15-0.03 mg Glipizide Tablet Sr 24hr 5 mg Lidocaine Hcl Viscous Solution 2% Glipizide Xl Tablet 10mg Lidocaine/Prilocaine Cream 2.5-2.5% Glipizide-Metformin Hcl Tablet 2.5-250 mg Lisinopril Glyburide Lisinopril & Hydrochlorothiazide Glyburide Micronized Lisinopril & Hydrochlorothiazide Tablet 20-12.5 mg Glyburide Micronized Tablet 1.5 mg Lisinopril Tablet 30 mg Glyburide Micronized Tablet 3 mg Lisinopril Tablet 40 mg Glyburide Micronized Tablet 6 mg Lithium Carbonate Capsule 300 mg Losartan Potassium Tablet 25 mg Oxybutynin Tablet 5 mg Lovastatin Tablet 10 mg Oxybutynin Chloride Loxapine Succinate Capsule 10 mg Oxybutynin Chloride Tablet 5 mg Meclizine Hcl Tablet 12.5 mg Paroxetine Hcl Medroxyprogesterone Acetate Paroxetine Tablet 10 mg Hcl Medroxyprogesterone Acetate Im Susp Prefilled Syr 150 mg/ml Paroxetine Tablet 20 mg Hcl Mefloquine Hcl Tablet 250 mg Paroxetine Tablet 30 mg Hcl Megestrol Acetate Tablet 20 mg Paroxetine Tablet 40 mg Hcl Meloxicam Pediatric Multiple Vitamins W/ Fl-Fe Drops 0.25-10 mg/ml Meloxicam Tablet 15 mg Pediatric Vitamins Acd Fluoride & Iron Meloxicam Tablet 7.5 mg Penicillin V Potassium Tablet 250 mg Metformin Hcl Pentoxifylline Tablet 400 mg Er Metformin Hcl Tablet 500 mg Perindopril Erbumine Tablet 2 mg Metformin Hcl Tablet Er 24hr 750 mg Phenobarbital Tablet 32.4 mg Metformin Tablet 1000 mg Phenobarbital Tablet 64.8 mg Metformin Tablet 850 mg Phenobarbital Tablet 97.2 mg Methenamine Tablet 500 mg Pilocarpine Hcl Ophth Solution 2% Methocarbamol Tablet 500 mg Pindolol Tablet 5 mg Methocarbamol Tablet 750 mg Polymyxin B-Trimethoprim Methyclothiazide Tablet 5 mg Pot Bicarbonate & Chloride Effer Tablet 25 Meq Methyldopa Pot Chloride Sol 10% Org Methyldopa Tablet 500 mg Pot Chloride Sol 20% Org Methylprednisolone Tablet 4 mg Pot Citrate Sol Citr Acd Methylprednisolone Tablet Therapy Pack 4 mg (21) Pot Phos Monobasic W/Sod Phos Di & Monobas Tablet 155-852- Metoclopramide Hcl 130 mg Metoclopramide Hcl Solution 5 mg/5 ml (10 mg/10 ml) Potassium Chloride Metoclopramide Hcl Solution 5 mg/5 ml (10 mg/10 ml) Potassium Chloride Cap Er 10 Meq (Salt Equiv) Potassium Chloride Cap Er 8 Meq Metolazone Tablet 2.5 mg Potassium Chloride Inj 1.5 Meq/ml Metoprolol & Hydrochlorothiazide Tablet 50-25 mg Potassium Chloride Microencapsulated Crys Cr Tablet 10 Meq Metoprolol Er Tablet Suc100 mg Potassium Chloride Oral Solution 10% (20 Meq/15 ml) Metoprolol Succinate Tablet Er 24hr 50 mg (Tartrate Equiv) Potassium Citrate-Citric Acid Metoprolol Tartrate Tablet 100 mg Potassium Phosphate Monobasic W/ Sod Phosphate Dibasic & Metoprolol Tartrate Tablet 25 mg Monobasi Metoprolol Tartrate Tablet 50 mg Prazosin Hcl Metronidazole Tablet 500 mg Prazosin Hcl Cap 1 mg Moexipril Hcl Tablet 15 mg Prazosin Hcl Cap 5 mg Moexipril Hcl Tablet 7.5 mg Prednisolone Acetate Ophth Susp 1% Moexipril-Hydrochlorothiazide Tablet 15-12.5 mg Prednisone Moexipril-Hydrochlorothiazide Tablet 7.5-12.5 mg Prednisone Tablet 1 mg Mometasone Furoate Cream 0.1% Prednisone Tablet 10 mg Mometasone Ointment 0.1% Prednisone Tablet 2.5 mg Multiple Vitamins W/ Minerals Prednisone Tablet 5 mg Multiple Vitamins W/ Minerals Capsule Prednisone Tablet Therapy Pack 10 mg (21) Mupirocin Ointment Prednisone Tablet Therapy Pack 10 mg (48) Naproxen Prednisone Tablet Therapy Pack 5 mg (21) Naproxen Tablet 250 mg Prednisone Tablet Therapy Pack 5 mg (21) Naproxen Tablet 375 mg Prednisone Tablet Therapy Pack 5 mg (48) Naproxen Tablet 500 mg Prenatal Vit W/ Dss-Iron Carbonyl-Fa Tablet 90-1 mg Neo/Poly/Dex Sus 0.1% Opthalmic Prenatal Vit W/ Fe Fumarate-Fa Tablet 27-1 mg Neomycin-Polymyxin-Dexamethasone Ophth Ointment 0.1% Prenatal Vit W/ Iron Carbonyl-Fa Tablet 29-1 mg Nifedipine Tablet Er 24hr 30 mg Primidone Tablet 250 mg Nifedipine Tablet Er 24hr Osmotic Release 30 mg Prochlorperazine Maleate Nitroglycerin Capsule Cr 2.5 mg Promethazine Hcl Norethindrone & Ethinyl Estradiol Tablet 0.4 mg-35 mcg Promethazine Hcl Tablet 12.5 mg Norgestimate & Ethinyl Estradiol Tablet 0.25 mg-35 mcg Promethazine Hcl Tablet 25 mg Norgestrel & Ethinyl Estradiol Tablet 0.5 mg-50 mcg Propran/Hctz Tablet 80/25 Nortriptyline Hcl Capsule 10 mg Propranolol & Hydrochlorothiazide Np Thyroid Tablet 90 mg Propranolol & Hydrochlorothiazide Tablet 40-25 mg Nystatin (Topical) Propranolol Hcl Tablet 10 mg Propranolol Hcl Tablet 20 mg Theophylline Tablet Er 24hr 600 mg Propranolol Hcl Tablet 40 mg Theophylline Tablet Sr 12hr 100 mg Propranolol Hcl Tablet 80 mg Theophylline Tablet Sr 12hr 200 mg Quinapril Hcl Thioridazine Hcl Tablet 10 mg Quinapril Hcl Tablet 10 mg Thioridazine Hcl Tablet 25 mg Quinapril Hcl Tablet 20 mg Thyroid Tablet 60 mg (1 Grain) Quinapril Hcl Tablet 40 mg Timolol Maleate Ophth Solution 0.25% Quinapril Tablet 5 mg Timolol Maleate Ophth Solution 0.5% Quinapril-Hydrochlorothiazide Tablet 10-12.5 mg Timolol Tablet 20 mg Quinapril-Hydrochlorothiazide Tablet 20-12.5 mg Torsemide Tablet 10 mg Ramipril Cap 1.25 mg Torsemide Tablet 20 mg Ramipril Cap 2.5 mg Trandolapril Tablet 1 mg Selenium Sulfide Lotion 2.5% Trandolapril Tablet 2 mg Sodium Fluoride Chew Tablet 0.5 mg F (From 1.1 mg Naf) Trandolapril Tablet 4 mg Sodium Fluoride Chew Tablet 1 mg F (From 2.2 mg Naf) Trazodone Hcl Tablet 100 mg Sodium Fluoride Rinse 0.2% Trazodone Hcl Tablet 50 mg Sodium Fluoride Solution 0.5 mg/ml F (From 1.1 mg/ml Naf) Triamcinolon Lotion 0.1% Spironolactone & Hydrochlorothiazide Tablet 25-25 mg Triamcinolone Acetonide (Topical) Spironolactone Tablet 100 mg Triamcinolone Acetonide Cream 0.5% Spironolactone Tablet 25 mg Triamcinolone Acetonide Ointment 0.1% Sulfacetamide Sodium Ophth Solution 10% Triamcinolone Acetonide Ointment 0.5% Sulfasalazine Tablet Delayed Release 500 mg Triamterene & Hydrochlorothiazide Cap 37.5-25 mg Sulindac Tablet 150 mg Triamterene & Hydrochlorothiazide Cap 50-25 mg Tamoxifen Citrate Triamterene & Hydrochlorothiazide Tablet 37.5-25 mg Terazosin Cap 2 mg Trifluoperazine Tablet 2 mg Terazosin Hcl Trihexyphenidyl Hcl Tablet 2 mg Terazosin Hcl Cap 1 mg (Base Equivalent) Urea Lotion 40% Terazosin Hcl Cap 10 mg (Base Equivalent) Verapamil Er Tablet 120 mg 12h Terazosin Hcl Cap 5 mg (Base Equivalent) Verapamil Er Tablet 240 mg Terbinafine Hcl Verapamil Hcl Tablet 120 mg Terbinafine Tablet 250 mg Verapamil Hcl Tablet 80 mg Terconazol 3 Cre 0.8% Warfarin Sodium Terconazole Vaginal Cream 0.4% Zonisamide Cap 25 mg Theophylline Tablet Er 24hr 400 mg

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. NALCSenior Antibiotic Generic List

Available 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/Clavula Tablet 500/125 Doxycycline Hyc Tablet 100 mg Amoxicillin/Clavula Tablet 875-125 Doxycycline Hyc Tablet 20 mg Amoxicillin/Clavula Tablet 875 mg Doxycycline Mono Capsule 50 mg Amoxicillin (Trihydrate) Capsule 500 mg Doxycycline Mono Tablet 100 mg Amoxicillin (Trihydrate) for Suspension Doxycycline Monohydrate Capsule 100 mg 125mg/5ml Doxycycline Monohydrate Tablet 50 mg Amoxicillin (Trihydrate) Tablet 875 mg Doxycycline Tablet 20 mg Amoxicillin Suspension 250/5ml Erythromycin Stearate Tablet 500 mg Amoxicillin Suspension 200/5ml Gentamicin Sulfate Ophth Solution 0.3% Azithromycin Tablet 250 mg Isoniazid Tablet 100 mg Cefadroxil Capsule 500 mg Isoniazid Tablet 300 mg Cefdinir Capsule 300 mg Levofloxacin Tablet 250 mg Cefuroxime Tablet 250 mg Levofloxacin Tablet 500 mg Cefuroxime Tablet 250 mg Levofloxacin Tablet 750 mg Cefuroxime Tablet 500 mg Minocycline Hcl Capsule 100 mg Cephalexin Capsule 250 mg Minocycline Hcl Capsule 50 mg Cephalexin Capsule 500 mg Ofloxacin Tablet 400 mg Ciprofloxacin Hcl Tablet 250 mg (Base Equiv) Penicillin V Potassium Tablet 250 mg Ciprofloxacin Hcl Tablet 500 mg (Base Equiv) Penicillin V Potassium Tablet 500 mg Ciprofloxacin Hcl Tablet 750 mg (Base Equiv) Sulfamethoxazole-Trimethoprim Tablet 400-80 mg Doxycycline Hyc Capsule 100 mg Sulfamethoxazole-Trimethoprim Tablet 800-160 mg Doxycycline Hyc Capsule 50 mg

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.