Pharmacy Savings Program

Transcription

1 Pharmacy Savings Program SELECT GENERICS DRUG LIST The Pharmacy Savings Program provides you with savings on select generic medications included on this list. The prices for these select generic medications are based on whether it is a 30-day supply* or 90-day supply* and its pricing tier: Tier 1 $5 for a 30-day supply and $10 for a 90-day supply Tier 2 $10 for a 30-day supply and, $20 for a 90-day supply Tier 3 $15 for a 30-day supply and $30 for a 90-day supply ALLERGIES & COLD AND FLU BENZONATATE 100 MG CAP BENZONATATE 200 MG CAP CYPROHEPTADINE HCL 2 MG/5 ML SYRUP DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID DIPHENHYDRAMINE HCL 50 MG CAP GUAIFEN/DEXTROMETHORPHAN/PE /1 DROPS HYDROXYZINE HCL 10 MG TAB HYDROXYZINE HCL 25 MG TAB HYDROXYZINE HCL 50 MG TAB With the Pharmacy Savings Program you will also receive: Discounts on other generic and brand name medications Flu Shots: $24.99 Discounts on select human-equivalent pet medications *The day supply is based upon the average dispensing patterns for the specific drug and strength. The Program, as well as the prices and the list of covered drugs, can be modified at any time without notice. HYDROXYZINE PAMOATE 25 MG CAP HYDROXYZINE PAMOATE 50 MG CAP LORATADINE 10 MG TAB PROMETHAZINE HCL 12.5 MG TAB PROMETHAZINE HCL 25 MG TAB PROMETHAZINE HCL 50 MG TAB PROMETHAZINE/DEXTROMETHORPHAN /5 SYRUP PHARMACY SAVINGS PROGRAM 1

2 ANTIBIOTIC & ANTI-INFECTIVE TREATMENTS ACYCLOVIR 200 MG CAP ACYCLOVIR 400 MG TAB AMOXICILLIN 125 MG TAB AMOXICILLIN 125 MG/5ML SUSP AMOXICILLIN 200 MG/5ML SUSP AMOXICILLIN 250 MG CAP AMOXICILLIN 250 MG/5ML SUSP AMOXICILLIN 400 MG/5ML SUSP AMOXICILLIN 500 MG CAP AMOXICILLIN 500 MG TAB AMOXICILLIN 875 MG TAB AMPICILLIN TRIHYDRATE 250 MG CAP AMPICILLIN TRIHYDRATE 500 MG CAP CEFADROXIL 500 MG CAP CEPHALEXIN 250 MG CAP CEPHALEXIN 500 MG CAP CIPROFLOXACIN HCL 250 MG TAB CIPROFLOXACIN HCL 500 MG TAB CLINDAMYCIN HCL 150 MG CAP CLINDAMYCIN HCL 300 MG CAP GENTAMICIN SULFATE 0.3 % DROPS ISONIAZID 100 MG TAB ISONIAZID 300 MG TAB METRONIDAZOLE 250 MG TAB METRONIDAZOLE 500 MG TAB MINOCYCLINE HCL 50 MG CAP PENICILLIN V POTASSIUM 125 MG/5ML SOLN PENICILLIN V POTASSIUM 250 MG TAB PENICILLIN V POTASSIUM 500 MG TAB POLYMYXIN B SULF/TRIMETHOPRIM /ML DROPS SMZ/TMP 400MG-80MG TAB SMZ/TMP MG TAB TOBRAMYCIN 0.3 % DROPS ARTHRITIS & PAIN CYCLOBENZAPRINE HCL 5 MG TAB CYCLOBENZAPRINE HCL 10 MG TAB FLURBIPROFEN 50 MG TAB IBUPROFEN 100 MG/5ML SUSP IBUPROFEN 400 MG TAB IBUPROFEN 600 MG TAB IBUPROFEN 800 MG TAB INDOMETHACIN 25 MG CAP INDOMETHACIN 50 MG CAP KETOPROFEN 50 MG CAP KETOPROFEN 75 MG CAP KETOROLAC TROMETHAMINE 30 MG/ML SYRINGE MELOXICAM 7.5 MG TAB MELOXICAM 15 MG TAB METHOCARBAMOL 500 MG TAB METHOCARBAMOL 750 MG TAB NAPROXEN 250 MG TAB PHARMACY SAVINGS PROGRAM 2

3 NAPROXEN 375 MG TAB NAPROXEN 375 MG TAB EC NAPROXEN 500 MG TAB TIZANIDINE HCL 4 MG TAB TRAMADOL HCL 50 MG TAB ASTHMA ALBUTEROL SULFATE 2 MG/5 ML SYRUP ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB IPRATROPIUM BROMIDE 0.2 MG/ML SOLN DIABETES GLIMEPIRIDE 1 MG TAB GLIMEPIRIDE 2 MG TAB GLIMEPIRIDE 4 MG TAB GLIPIZIDE 5 MG TAB GLIPIZIDE 10 MG TAB GLIPIZIDE ER 10 MG TAB GLIPIZIDE ER 5 MG TAB GLYBURIDE 2.5 MG TAB GLYBURIDE 5 MG TAB GLYBURIDE,MICRONIZED 1.5 MG TAB GLYBURIDE,MICRONIZED 3 MG TAB GLYBURIDE/METFORMIN HCL 5 MG-500MG TAB METFORMIN HCL 500 MG TAB METFORMIN HCL ER 500 MG TAB METFORMIN HCL 850 MG TAB METFORMIN HCL 1000 MG TAB FUNGAL INFECTIONS CLOTRIMAZOLE 1 % CRM FLUCONAZOLE 150 MG TAB TERBINAFINE HCL 250 MG TAB GASTROINTESTINAL HEALTH CIMETIDINE 300 MG TAB CIMETIDINE HCL 300 MG/5ML SOLN DICYCLOMINE HCL 10 MG CAP DICYCLOMINE HCL 20 MG TAB DOCUSATE SODIUM 100 MG CAP FAMOTIDINE 20 MG TAB FAMOTIDINE 40 MG TAB LACTULOSE 10 G/15 ML SOLN LACTULOSE 10 GM/15 ML SYRUP MECLIZINE HCL 12.5 MG TAB MECLIZINE HCL 25 MG TAB METOCLOPRAMIDE HCL 10 MG TAB METOCLOPRAMIDE HCL 10 MG/10ML SOLN METOCLOPRAMIDE HCL 5 MG TAB METOCLOPRAMIDE HCL 5 MG/5 ML SOLN NIZATIDINE 150 MG CAP OMEPRAZOLE 20 MG CAP PANTOPRAZOLE SODIUM 40 MG TAB PROCHLORPERAZINE MALEATE 5 MG TAB PROCHLORPERAZINE MALEATE 10 MG TAB RANITIDINE HCL 15 MG/ML SYRUP PHARMACY SAVINGS PROGRAM 3

4 RANITIDINE HCL 150 MG TAB RANITIDINE HCL 300 MG TAB GLAUCOMA AND EYE CARE FLUTICASONE PROPIONATE 50 MCG SUSP KETOROLAC TROMETHAMINE 0.5 % DROPS TIMOLOL MALEATE 0.25 % DROPS TIMOLOL MALEATE 0.5 % DROPS TROPICAMIDE 1 % DROPS HEART HEALTH & BLOOD PRESSURE AMIODARONE HCL 200 MG TAB AMLODIPINE BESYLATE 2.5 MG TAB AMLODIPINE BESYLATE 5 MG TAB AMLODIPINE BESYLATE 10 MG TAB AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-10 MG CAP AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG CAP ATENOLOL 25 MG TAB ATENOLOL 50 MG TAB ATENOLOL 100 MG TAB ATORVASTATIN CALCIUM 10 MG TAB ATORVASTATIN CALCIUM 20 MG TAB ATORVASTATIN CALCIUM 40 MG TAB ATORVASTATIN CALCIUM 80 MG TAB BENAZEPRIL HCL 5 MG TAB BENAZEPRIL HCL 10 MG TAB BENAZEPRIL HCL 20 MG TAB BENAZEPRIL HCL 40 MG TAB BISOPROLOL/HCTZ MG TAB BISOPROLOL/HCTZ MG TAB BISOPROLOL/HCTZ MG TAB CARVEDILOL MG TAB CARVEDILOL 6.25 MG TAB CARVEDILOL 12.5 MG TAB CARVEDILOL 25 MG TAB CLONIDINE HCL 0.1 MG TAB CLONIDINE HCL 0.2 MG TAB CLONIDINE HCL 0.3 MG TAB CLOPIDOGREL BISULFATE 75 MG TAB DILTIAZEM HCL 30 MG TAB DILTIAZEM HCL 120 MG CAP DIPYRIDAMOLE 25 MG TAB ENALAPRIL-HCTZ MG TAB ENALAPRIL-HCTZ MG TAB FOSINOPRIL SODIUM 20 MG TAB FOSINOPRIL SODIUM 40 MG TAB FUROSEMIDE 10 MG/ML SOLN FUROSEMIDE 20 MG TAB FUROSEMIDE 40 MG TAB FUROSEMIDE 80 MG TAB GEMFIBROZIL 600 MG TAB GUANFACINE HCL 1 MG TAB GUANFACINE HCL 2 MG TAB HCTZ 12.5 MG TAB PHARMACY SAVINGS PROGRAM 4

5 HYDRALAZINE HCL 10 MG TAB HYDRALAZINE HCL 25 MG TAB HYDRALAZINE HCL 50 MG TAB HYDROCHLOROTHIAZIDE 12.5 MG CAP HYDROCHLOROTHIAZIDE 25 MG TAB HYDROCHLOROTHIAZIDE 50 MG TAB INDAPAMIDE 1.25 MG TAB INDAPAMIDE 2.5 MG TAB ISOSORBIDE MONONITRATE 10 MG TAB ISOSORBIDE MONONITRATE 20 MG TAB ISOSORBIDE MONONITRATE 30 MG TAB ISOSORBIDE MONONITRATE 60 MG TAB LISINOPRIL 2.5 MG TAB LISINOPRIL 5 MG TAB LISINOPRIL 10 MG TAB LISINOPRIL 20 MG TAB LISINOPRIL 30 MG TAB LISINOPRIL 40 MG TAB LISINOPRIL-HCTZ MG TAB LISINOPRIL-HCTZ MG TAB LISINOPRIL-HCTZ MG TAB LOSARTAN POTASSIUM 25 MG TAB LOSARTAN POTASSIUM 50 MG TAB LOSARTAN POTASSIUM 100 MG TAB LOSARTAN/HCTZ MG TAB LOVASTATIN 10 MG TAB LOVASTATIN 20 MG TAB LOVASTATIN 40 MG TAB METHYLDOPA 250 MG TAB METHYLDOPA 500 MG TAB METOPROLOL TARTRATE 25 MG TAB METOPROLOL TARTRATE 50 MG TAB METOPROLOL TARTRATE 100 MG TAB PRAZOSIN HCL 1 MG CAP QUINAPRIL HCL 5 MG TAB QUINAPRIL HCL 40 MG TAB RAMIPRIL 1.25 MG CAP RAMIPRIL 2.5 MG CAP SIMVASTATIN 5 MG TAB SIMVASTATIN 10 MG TAB SIMVASTATIN 20 MG TAB SIMVASTATIN 40 MG TAB SIMVASTATIN 80 MG TAB SOTALOL HCL 160 MG TAB SPIRONOLACTONE 25 MG TAB SPIRONOLACTONE 50 MG TAB TERAZOSIN HCL 1 MG CAP TERAZOSIN HCL 2 MG CAP TERAZOSIN HCL 5 MG CAP TERAZOSIN HCL 10 MG CAP TORSEMIDE 10 MG TAB TORSEMIDE 20 MG TAB PHARMACY SAVINGS PROGRAM 5

6 TRANDOLAPRIL 1 MG TAB TRANDOLAPRIL 2 MG TAB TRIAMTERENE/HCTZ MG CAP TRIAMTERENE/HCTZ 75/50 TAB TRIAMTERENE-HCTZ MG TAB VERAPAMIL HCL 40 MG TAB VERAPAMIL HCL 80 MG TAB VERAPAMIL HCL 120 MG TAB WARFARIN SODIUM 2.5 MG TAB WARFARIN SODIUM 4 MG TAB MENS HEALTH FINASTERIDE 5 MG TAB MENTAL & NEURO HEALTH AMITRIPTYLINE HCL 10 MG TAB AMITRIPTYLINE HCL 25 MG TAB BENZTROPINE MESYLATE 2 MG TAB BUSPIRONE HCL 5 MG TAB BUSPIRONE HCL 10 MG TAB BUSPIRONE HCL 15 MG TAB CITALOPRAM HBR 10 MG TAB CITALOPRAM HBR 20 MG TAB CITALOPRAM HBR 40 MG TAB CLOZAPINE 25 MG TAB DIVALPROEX SODIUM 125 MG TAB DOXEPIN HCL 10 MG/ML ORAL CONC ESCITALOPRAM OXALATE 5 MG TAB ESCITALOPRAM OXALATE 10 MG TAB ESCITALOPRAM OXALATE 20 MG TAB FLUOXETINE HCL 10 MG CAP FLUOXETINE HCL 20 MG CAP FLUOXETINE HCL 20 MG/5 ML SOLN FLUOXETINE HCL 40 MG CAP FLUPHENAZINE HCL 1 MG TAB FLUPHENAZINE HCL 2.5 MG TAB FLUVOXAMINE MALEATE 25 MG TAB GABAPENTIN 100 MG CAP GABAPENTIN 300 MG CAP GABAPENTIN 400 MG CAP HALOPERIDOL 0.5 MG TAB HALOPERIDOL 1 MG TAB HALOPERIDOL LACTATE 2 MG/ML ORAL CONC IMIPRAMINE HCL 25 MG TAB LAMOTRIGINE 100 MG TAB LAMOTRIGINE 150 MG TAB LITHIUM CARBONATE 150 MG CAP LITHIUM CARBONATE 300 MG CAP LITHIUM CARBONATE 300 MG TAB LITHIUM CARBONATE 600 MG CAP MIRTAZAPINE 15 MG TAB MIRTAZAPINE 30 MG TAB NORTRIPTYLINE HCL 10 MG CAP NORTRIPTYLINE HCL 25 MG CAP PHARMACY SAVINGS PROGRAM 6

7 NORTRIPTYLINE HCL 75 MG CAP OXCARBAZEPINE 150 MG TAB PAROXETINE HCL 10 MG TAB PAROXETINE HCL 20 MG TAB PAROXETINE HCL 30 MG TAB PAROXETINE HCL 40 MG TAB PRAMIPEXOLE DI-HCL MG TAB PRAMIPEXOLE DI-HCL 0.25 MG TAB PRAMIPEXOLE DI-HCL 0.5 MG TAB PRIMIDONE 50 MG TAB RISPERIDONE 0.25 MG TAB RISPERIDONE 0.5 MG TAB RISPERIDONE 1 MG TAB ROPINIROLE HCL 0.25 MG TAB ROPINIROLE HCL 3 MG TAB SERTRALINE HCL 25 MG TAB SERTRALINE HCL 50 MG TAB SERTRALINE HCL 100 MG TAB THIORIDAZINE HCL 10 MG TAB TRAZODONE HCL 100 MG TAB TRAZODONE HCL 150 MG TAB TRAZODONE HCL 50 MG TAB TRIHEXYPHENIDYL HCL 2 MG TAB OTHER MEDICAL CONDITIONS CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH DEXAMETHASONE 0.75 MG TAB DEXAMETHASONE 1.5 MG TAB DEXAMETHASONE 4 MG TAB LIDOCAINE HCL 2 % SOLN LIDOCAINE HCL 40 MG/ML SOLN OXYBUTYNIN CHLORIDE 5 MG/5 ML SYRUP PREDNISOLONE 15 MG/5 ML SOLN PREDNISOLONE SOD PHOSPHATE 15 MG/5 ML SOLN PREDNISONE 2.5 MG TAB PREDNISONE 5 MG TAB PREDNISONE 10 MG TAB PREDNISONE 20 MG TAB SKIN CONDITIONS HYDROCORTISONE 1 % CRM HYDROCORTISONE 1 % OINT HYDROCORTISONE 2.5 % CRM HYDROCORTISONE 2.5 % OINT HYDROQUINONE 30 MG/ML SOLN MOMETASONE FUROATE 0.1 % OINT SALICYLIC ACID 6 % SHAMPOO TRIAMCINOLONE ACETONIDE % CRM TRIAMCINOLONE ACETONIDE 0.1 % CRM TRIAMCINOLONE ACETONIDE 0.1 % OINT TRIAMCINOLONE ACETONIDE 0.5 % CRM UREA 40 % LOTION DEXAMETHASONE 0.5 MG TAB PHARMACY SAVINGS PROGRAM 7

8 VITAMINS AND NUTRITIONAL HEALTH CYANOCOBALAMIN (VITAMIN B-12) 100 MCG TAB CYANOCOBALAMIN/FOLIC AC/VIT B MG TAB ERGOCALCIFEROL (VITAMIN D2) UNIT CAP FERROUS FUMARATE/FOLIC ACID 106 MG-1MG TAB FLUORIDE (SODIUM) 0.25(0.55) TAB FLUORIDE (SODIUM) 0.5(1.1)MG TAB FLUORIDE (SODIUM) 1.1 % CRM FLUORIDE (SODIUM) 1MG(2.2MG) TAB FOLIC ACID 1 MG TAB ESTRADIOL 0.5 MG TAB ESTRADIOL 1 MG TAB ESTRADIOL 2 MG TAB HYDROCORTISONE 5 MG TAB LETROZOLE 2.5 MG TAB MEDROXYPROGESTERONE 10 MG TAB MEDROXYPROGESTERONE 5 MG TAB MEDROXYPROGESTERONE 2.5 MG TAB MEGESTROL ACETATE 20 MG TAB PREVIFEM TAB FOLIC ACID/VIT BCOMP,C/CU/ZINC MG TAB IRON PS COMPLEX/B12/FOLIC ACID CAP IRON,CARB/VIT C/VIT B12/FOLIC TAB IRON/FOLIC AC/VIT BCOMP,C/MIN 106 MG-1MG TAB MAGNESIUM OXIDE 400 MG TAB PEDI MULTIVIT NO.17 W-FLUORIDE 1 MG TAB PNV/FERROUS FUM/FOLIC ACID/SEL 27 MG-1 MG TAB POTASSIUM CHLORIDE 10 MEQ TAB PRENATAL LOW IRON TAB PRENATAL PLUS TAB WOMEN S HEALTH ALENDRONATE SODIUM 10 MG TAB ALENDRONATE SODIUM 35 MG TAB ALENDRONATE SODIUM 70 MG TAB ANASTROZOLE 1 MG TAB CLOMIPHENE CITRATE 50 MG TAB This discount program is NOT health insurance and is not intended as a substitute for insurance. This program provides savings on a select group of prescription medications purchased from a participating pharmacy. This program is administered by Medical Security Card Company (MSC), LLC, 4911 E. Broadway Boulevard, Tucson, AZ 85711, and is marketed by your participating pharmacy. This program is not available in all states. This program does not make payments directly to any provider. You are obligated to pay for all services at the time of the service. This program is governed by the terms and conditions outlined on this website. MSC is not responsible for providing or guaranteeing service or for the quality of service rendered. Participating pharmacies are subject to change without notice and are not available in all areas. Prescriptions paid for in whole or in part by publicly funded health care programs, such as Medicare or Medicaid, are ineligible. Membership discount cannot be combined with any insurance. A0168_SS_PSP+BDC_DL_ PHARMACY SAVINGS PROGRAM 8