|
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 |