Everyday Low Cost Generics

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QTY LIMIT COPAY (30 DAY/90 DAY) BENIGN PROSTATIC HYPERPLASIA FINASTERIDE $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8

Appendix 1: Interactions

2019 Preventive Drug List

2017 Formulary Changes Year to Date

Transcription:

Antibiotics Antifungal Antiviral Arthritis/ Pain 30 Day Qty* Free AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE) AMOXICILLIN 200 MG/5 ML (100 ML BOTTLE) 100 AMOXICILLIN 200 MG/5 ML (75 ML BOTTLE) 75 AMOXICILLIN 200 MG/5 ML (50 ML BOTTLE) 50 AMOXICILLIN 250 MG CAPSULES 30 AMOXICILLIN 250 MG/5 ML (150 ML BOTTLE) AMOXICILLIN 250 MG/5 ML (100 ML BOTTLE) AMOXICILLIN 250 MG/5 ML (80 ML BOTTLE) AMOXICILLIN 400 MG/5 ML (100 ML BOTTLE) 100 AMOXICILLIN 400 MG/5 ML (75 ML BOTTLE) 75 AMOXICILLIN 400 MG/5 ML (50 ML BOTTLE) 50 AMOXICILLIN 500 MG CAPSULES 30 CEPHALEXIN 250 MG CAPSULES 30 CEPHALEXIN 500 MG CAPSULES 30 CIPROFLOXACIN 250 MG TABLETS 20 CIPROFLOXACIN 500 MG TABLETS 20 PENICILLIN V Pot 125/5 100 ML (100 ML BOTTLE) PENICILLIN VK 250 MG TABLETS- 28 COUNT SULFAMETH/TRIMETH 400/80 MG TABLETS- 28 COUNT SULFAMETH/TRIMETH 800/160 MG TABLETS- 20 COUNT FLUCONAZOLE 150 MG TABLETS 1 3 TERBINAFINE 250 MG TABLETS 30 90 ACYCLOVIR 200 MG CAPSULES 30 90 ALLOPURINOL 100 MG TABLETS 30 90 IBUPROFEN 400 MG TABLETS 90 270 IBUPROFEN 600 MG TABLETS 60 180 IBUPROFEN 800 MG TABLETS 30 90 INDOMETHACIN 25 MG CAPSULES 60 180 MELOXICAM 15 MG TABLETS 30 90 MELOXICAM 7.5 MG TABLETS 30 90 NAPROXEN 375 MG TABLETS 60 180 NAPROXEN 500 MG TABLETS 60 180 $8.00 $24.00 BACLOFEN 10 MG TABLETS 30 90 DICLOFENAC SOD DR 50 MG TABLETS 60 180 DICLOFENAC SOD DR 75 MG TABLETS 60 180 Asthma/Resp/Allergies ALBUTEROL 2 MG/5 ML SYRUP 120 473 ALBUTEROL SULFATE 0.083 % NEB SOLN 75 225 IPRATROPIUM BROMIDE 0.02% AMPULE 75 225 LORATADINE 10 MG TABLETS 30 90

Cholesterol CNS Cough Diabetes Ear/Eye Gastrointestinal LOVASTATIN 10 MG TABLETS 30 90 LOVASTATIN 20 MG TABLETS 30 90 DRUG NAME $8.00 $22.00 BENZTROPINE 2 MG TABLETS 30 90 BENZONATATE 100 MG CAPSULES 15 45 PROMETHAZINE/DM 15-6.25 MG/5 ML SYRUP 120 360 PROMETHAZINE 6.25/5 ML SYRUP* 120 360 30 Day Qty* Free GLIMEPIRIDE 1 MG TABLETS 30 90 GLIMEPIRIDE 2 MG TABLETS 30 90 GLIMEPIRIDE 4 MG TABLETS 30 90 GLIPIZIDE 10 MG TABLETS 60 180 GLIPIZIDE 5 MG TABLETS (DIABETA) 60 180 GLYBURIDE 1.25 MG TABLETS 30 90 GLYBURIDE 2.5 MG TABLETS 30 90 GLYBURIDE 5 MG TABLETS 30 90 METFORMIN 1000 MG TABLETS- UP TO 225 TABLETS METFORMIN 500 MG TABLETS- UP TO 360 TABLETS METFORMIN 850 MG TABLETS- UP TO 270 TABLETS METFORMIN ER 500 MG TABLETS 60 180 $8.00 $20.00 GLYBURIDE 5 MG TABLETS (MICRONASE) 30 90 GLYBURIDE MCR 3 MG TABLETS 30 90 GLYBURIDE MCR 6 MG TABLETS 30 90 CIPROFLOXACIN 0.3% OPTHALMIC SOL 5 15 GENTAMICIN SUL 0.3% OPTHALMIC SOL 5 15 TIMOLOL MAL 0.25% OPTHALMIC SOL (5 ML) 5 N/A TIMOLOL MAL 0.5% OPTHALMIC SOL (5 ML or 15 ML) 5 15 TOBRAMYCIN 0.3% OPHTHALMIC SOLUTION 5 15 TRIMETHOPRIM-POLY B OPTHALMIC SOL 10 30 $8.00 $24.00 TIMOLOL MAL 0.5% OPTHALMIC SOL (10 ML) 10 N/A FAMOTIDINE 20 MG TABLETS 60 180 METOCLOPRAMIDE 10 MG TABLETS 60 180 METOCLOPRAMIDE 5 MG/5 ML SYRUP 240 PROMETHAZINE 25 MG TABLETS 12 36 $4.00 $12.00 LACTULOSE 10 MG/15 ML SOLUTION 240 960 $8.00 $24.00 DICYCLOMINE 10 MG CAPSULES 90 270 DICYCLOMINE 20 MG TABLETS 60 180 RANITIDINE 150 MG TABLETS 60 180 RANITIDINE 300 MG TABLETS 30 90

Heart and Blood Pressure 30 Day Qty* Free ATENOLOL 100 MG TABLETS 30 90 ATENOLOL 25 MG TABLETS 30 90 ATENOLOL 50 MG TABLETS 30 90 BENAZEPRIL 10 MG TABLETS 30 90 BENAZEPRIL 20 MG TABLETS 30 90 BENAZEPRIL 40 MG TABLETS 30 90 BENAZEPRIL 5 MG TABLETS 30 90 BISOPROLOL/HCTZ 10/6.25 TABLETS 30 90 BISOPROLOL/HCTZ 5/6.25 TABLETS 30 90 BISOPROLOL/HCTZ 2.5/6.25 TABLETS 30 90 CARVEDILOL 12.5 MG TABLETS 60 180 CARVEDILOL 25 MG TABLETS 60 180 CARVEDILOL 3.125 MG TABLETS 60 180 CARVEDILOL 6.25 MG TABLETS 60 180 CLONIDINE 0.1 MG TABLETS 60 180 CLONIDINE 0.2 MG TABLETS 60 180 ENALAPRIL/HCTZ 5/12.5 MG 30 90 FUROSEMIDE 20 MG TABLETS 30 90 FUROSEMIDE 40 MG TABLETS 30 90 FUROSEMIDE 80 MG TABLETS 30 90 GUANFACINE 1 MG TABLETS 30 90 HYDRALAZINE 10 MG TABLETS 60 180 HYDRALAZINE 25 MG TABLETS 60 180 HYDROCHLOROTHIAZIDE 12.5 MG CAPSULES 30 90 HYDROCHLOROTHIAZIDE 25 MG TABLETS 30 90 HYDROCHLOROTHIAZIDE 50 MG TABLETS 30 90 LISINOPRIL 10 MG TABLETS- UP TO 180 TABLETS LISINOPRIL 2.5 MG TABLETS- UP TO 180 TABLETS LISINOPRIL 20 MG TABLETS- UP TO 180 TABLETS LISINOPRIL 5 MG TABLETS- UP TO 180 TABLETS LISINOPRIL 30 MG TABLETS- UP TO 180 TABLETS LISINOPRIL 40 MG TABLETS- UP TO 180 TABLETS LISINOPRIL-HCTZ 10-12.5 MG TABLETS 30 90 LISINOPRIL-HCTZ 20-12.5 MG TABLETS 30 90 LISINOPRIL-HCTZ 20-25 MG TABLETS 30 90 METHYLDOPA 250 MG TABLETS 60 180 METOPROLOL TART 100 MG TABLETS 60 180 METOPROLOL TART 25 MG TABLETS 60 180 METOPROLOL TART 50 MG TABLETS 60 180 SOTALOL HCL 80 MG TABLETS 30 90 SPIRONOLACTONE 25 MG TABLETS 30 90 TERAZOSIN 10 MG CAPSULES 30 90 TERAZOSIN 1 MG CAPSULES 30 90 TERAZOSIN 2 MG CAPSULES 30 90 TERAZOSIN 5 MG CAPSULES 30 90 TRIAMTERENE/HCTZ 37.5-25 TABLETS 30 90

Heart and Blood Pressure VERAPAMIL 120 MG TABLETS 30 90 VERAPAMIL 80 MG TABLETS 30 90 WARFARIN 10 MG TABLETS 30 90 WARFARIN 1 MG TABLETS 30 90 WARFARIN 2.5 MG TABLETS 30 90 WARFARIN 2 MG TABLETS 30 90 WARFARIN 3 MG TABLETS 30 90 WARFARIN 4 MG TABLETS 30 90 WARFARIN 5 MG TABLETS 30 90 WARFARIN 6 MG TABLETS 30 90 WARFARIN 7.5 MG TABLETS 30 90 $8.00 $22.00 ISOSORBIDE MONONITRATE ER 30 MG TABLETS 30 90 ISOSORBIDE MONONITRATE ER 60 MG TABLETS 30 90 TRIAMTERENE/HCTZ 75-50 MG TABLETS 30 90 $10.00 $30.00 INDAPAMIDE 1.25 MG TABLETS 30 90 INDAPAMIDE 2.5 MG TABLETS 30 90 Mental Health BUSPIRONE 5 MG TABLETS 60 180 BUSPIRONE 10 MG TABLETS 60 180 CITALOPRAM 20 MG TABLETS 30 90 CITALOPRAM 40 MG TABLETS 30 90 FLUOXETINE 10 MG CAPSULES 30 90 FLUOXETINE 20 MG CAPSULES 30 90 FLUOXETINE 40 MG CAPSULES 30 90 LITHIUM CARBONATE 300 MG CAPSULES 90 270 NORTRIPTYLINE 10 MG CAPSULES 30 90 NORTRIPTYLINE 25 MG CAPSULES 30 90 PAROXETINE 10 MG TABLETS 30 90 PAROXETINE 20 MG TABLETS 30 90 PROCHLORPERAZINE 10 MG TABLETS 30 90 TRAZODONE 100 MG TABLETS 30 90 TRAZODONE 150 MG TABLETS 30 90 TRAZODONE 50 MG TABLETS 30 90 DRUG NAME $8.00 $22.00 AMITRIPTYLINE 10 MG TABLETS 30 90 AMITRIPTYLINE 25 MG TABLETS 30 90 $12.00 $36.00 AMITRIPTYLINE 50 MG TABLETS 30 90 $24.00 $65.00 AMITRIPTYLINE 75 MG TABLETS 30 90 AMITRIPTYLINE 100 MG TABLETS 30 90

Muscle Relaxants Other Skin CYCLOBENZAPRINE 10 MG TABLETS 30 90 CYCLOBENZAPRINE 5 MG TABLETS 30 90 CHLORHEXADINE GLUCOSE 0.12% SOLN 480 DEXAMETHASONE.5 MG TABLETS 12 36 DEXAMETHASONE 0.75 MG TABLETS 12 36 DEXAMETHASONE 4 MG TABLETS 6 18 PREDNISONE 2.5 MG TABLETS 30 90 PREDNISONE 5 MG TABLETS 30 90 HYDROCORTISONE 1% CREAM 30 GM 30 90 HYDROCORTISONE 2.5% CREAM 30 GM 30 90 TRIAMCINOLONE 0.025% 15 GM (tube) CREAM 15 45 TRIAMCINOLONE 0.1% 15 GM (tube) CREAM 15 45 $8.00 $18.00 SILVER SULFADIAZINE 1% (50 GM) CREAM 50 TRIAMCINOLONE 0.025% 15 GM (tube) OINTMENT 15 45 TRIAMCINOLONE 0.025% 80 GM (tube) CREAM 80 240 TRIAMCINOLONE 0.025% 80 GM (tube) OINTMENT 80 240 TRIAMCINOLONE 0.1% 15 GM (tube) OINTMENT 15 45 TRIAMCINOLONE 0.1% 80 GM (tube) CREAM 80 240 TRIAMCINOLONE 0.1% 80 GM (tube) OINTMENT 80 240 TRIAMCINOLONE 0.5% 15 GM (tube) CREAM 15 45 TRIAMCINOLONE 0.5% 15 GM (tube) OINTMENT 15 45 Thyroid DRUG NAME $12.00 $36.00 LEVOTHYROXINE 25 MCG TABLETS 30 90 LEVOTHYROXINE 50 MCG TABLETS 30 90 LEVOTHYROXINE 75 MCG TABLETS 30 90 LEVOTHYROXINE 88 MCG TABLETS 30 90 LEVOTHYROXINE 100 MCG TABLETS 30 90 LEVOTHYROXINE 112 MCG TABLETS 30 90 LEVOTHYROXINE 125 MCG TABLETS 30 90 LEVOTHYROXINE 137 MCG TABLETS 30 90 LEVOTHYROXINE 150 MCG TABLETS 30 90 LEVOTHYROXINE 175 MCG TABLETS 30 90 LEVOTHYROXINE 200 MCG TABLETS 30 90 Vitamins/ Nutritional FOLIC ACID 1 MG TABLETS 30 90 LUDENT CHEW FL 0.5 MG TABLETS 120 360 LUDENT CHEW FL 1 MG TABLETS 120 360 MAG-OXIDE 400 MG TABLETS 60 180 Womens Health ESTRADIOL 0.5 MG TABLETS 30 90 ESTRADIOL 1 MG TABLETS 30 90 ESTRADIOL 2 MG TABLETS 30 90 MEDROXYPROGESTERONE AC 10 MG TABLETS 30 90 MEDROXYPROGESTERONE AC 2.5 MG TABLETS 30 90 MEDROXYPROGESTERONE AC 5 MG TABLETS 30 90

Womens Health DRUG NAME $9.00 $24.00 ALENDRONATE SOD 35 MG TABLETS 4 12 ALENDRONATE SOD 70 MG TABLETS 4 12 CLOMIPHENE 50 MG TABLETS 5 15 28- Day* 84- Day* $9.00 $27.00 APRI 0.15-30 MG-MCG TABLETS 28 84 CYCLAFEM 1/35 MG-MCG TABLETS 28 84 CYCLAFEM 7/7/7 TABLETS 28 84 LEVONOR/ETH ESTRADIOL 0.15-30 MG-MCG TABLETS 28 84 LEVONOR/ETH ESTRADIOL 0.1-20 MG-MCG TABLETS (A1 & A2) 28 84 NORETHINDRONE 0.35 MG (A1) 28 84 NORETHINDRONE 0.35 MG (A2) 28 84 PREVIFEM 28 TABLETS 28 84 TRI-PREVIFEM TABLETS 28 84