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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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