TIER 3 (Retail)
$50.00 Co-Pay
UP TO 30 DAYS SUPPLY 

Medication

Generic for

Aceon 2mg, 4mg

Aceon

Activella 1-0.5mg

Activella

Alrex Drops 0.2%

Alrex

Altace 1.25mg, 2.5mg, 5mg

Altace

Atrovent Nasal Solution 0.06%

Atrovent

Creon 5

Creon

Diltiazem ER-XR 240mg

Cardizem CD

Diprolene Lotion 0.5%

Diprolene

Diprolene AF Cream 0.05%

Diprolene AF

Elocon Lotion 0.1%

Elocon

Famotidine 40mg

Pepcid

Flomax 0.4mg

Flomax

Floxin Otic Drops 0.3%

Floxin Otic

Isosorbide Mononitrate 10mg, 20mg

Ismo, Monoket

Labetolol 200mg, 300mg

Trandate

Lotemax Drops 0.5%

Lotemax

Lovastatin 20mg

Mevacor

Metormin 1000mg

Glucophage

Nasonex Spray 50mcg

Nasonex

Niaspan 500mg

Niaspan

Proventil Aerosol 90mcg

Proventil

Provenil HFA Inhaler

Proventil HFA

Yasmin 28

Yasmin