September 2012 CVS Caremark Value Priced Generics List The CVS Caremark Value Priced Generics Drug List offers Capital Health Plan members access to a 30-day supply of
select maintenance generic medications under the member's prescription benefit plan and can be fil ed at any retail store in
the pharmacy network. Capital Health Plan members may receive a 90-day supply from a participating retail network
pharmacy for $9.99 plus a dispensing fee.
ARTHRITIS & PAIN Quantity DIABETES Quantity (30-day Supply) (30-day Supply) GASTROINTESTINAL HEALTH Quantity (30-day Supply)
INFECTIONS Quantity (30-day Supply) Quantity (30-day Supply)
ALBUTEROL SULFATE 2 MG/5 ML SYRUP 120 ML
CHOLESTEROL Quantity (30-day Supply)
GLAUCOMA & EYE CARE Quantity (30-day Supply)
HEART HEALTH & Quantity BLOOD PRESSURE (30-day Supply)
2012 Caremark. Al rights reserved. 106-22302a 091112
MENTAL HEALTH & CENTRAL NERVOUS Quantity (30-day Supply) OTHER MEDICAL Quantity CONDITIONS (30-day Supply)
2012 Caremark. Al rights reserved. 106-22302a 091112
WOMEN'S HEALTH Quantity (30-day Supply) SKIN CONDITIONS Quantity (30-day Supply)
VITAMINS & NUTRITIONAL Quantity (30-day Supply)
The Value Priced Generics Drug List was redacted from the CVS Caremark Value Priced Generics Drug List. The original list is available at www.caremark.com. This list
represents a summary of products included in Capital Health Plan's Value Generics Program which is administered by CVS Caremark. This is not an all inclusive list and
does not guarantee coverage. Products that are not represented on this list may be subject to plan-specific copayment. Void where prohibited by law. Your prescription
benefit plan design may apply restrictions, regardless of the drugs appearance in this document.
Copay means the amount a plan member is required to pay for a prescription in accordance with a Plan. Certain drugs or dosages may be subject to additional costs or
copays. The Value Priced Generics Drug List is based on commonly prescribed doses. This list is subject to change without notice.
CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to
brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark.
For questions, you may call the Member Services number on your identification card.
2012 Caremark. Al rights reserved. 106-22302a 091112
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