Intro
Formulary
Body
Pharmacy Formulary
The pharmacy's formulary (medication list) includes products that are approved by the McKinley Pharmacy and Therapeutics Committee. Many drugs are covered by the Health Service Fee at low cost or no cost. However, certain drugs, due to their high acquisition cost, may be on the formulary at a percentage of the cost. Restrictions may apply to brands of drugs and amounts dispensed.
McKinley Pharmacy does not accept insurance. You may want to check coverage with your private insurance prior to purchasing medication at McKinley as it may save you money in some instances on your prescription.
OTC = over-the-counter, available at McKinley pharmacy
SCS = available at Self-Care Stations (ACES, Grainger, MHC, SDRP, Union)
SCS*=only MHC and Union basement
SL=supplylimit, restrictions apply to the amount dispensed
Covered Medications
Analgesics
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Pain | ||
| Acetaminophen 325mg tab | no charge | OTC, SCS, SL |
| Acetaminophen 650mg suppository | $5 | |
| Acetaminophen Extra-Strength liquid | $5 | |
| Acet/ASA/Caffeine 250/250/65mg (generic Excedrin ExtraStrgth) | $5 | |
| Acetaminophen/Codeine 120mg/12mg/5ml | $5 | |
| Acetaminophen/Codeine 300mg/30mg tab | $5 | |
| Tramadol 50mg tab | $5 | |
| Drugs for Pain and Inflammation | ||
| Acet/ASA/Caffeine 250/250/65mg (generic Excedrin ExtraStrgth) | $5 | |
| Celecoxib 200mgcap | 100% of cost | |
| Dexamethasone 0.5mg, 4mg tab | $5 | |
| Diclofenac EC 75mg tab | $5 | |
| Diclofenac 1% Topical Gel100gm | $5 | |
| Ibuprofen 100mg/5ml liquid | $5 | |
| Ibuprofen OTC200mg tab | no charge | OTC, SCS, SL |
| Ibuprofen 400mg,600mg, 800mg tab | no charge | |
| Indomethacin 25mg,50mg cap | $5 | |
| Ketorolac 10mgtab | $5 | |
| Meloxicam 7.5mg, 15mg tab | $5 | |
| Methylprednisolone dose pak | $5 | |
| Naproxen 250mg,500mg tab | $5 | |
| Naproxen Sodium550mg tab | $5 | |
| Prednisone 1mg, 5mg, 10mg, 20mg tab | $5 | |
| Salonpas External Pain Patch #20 | no charge | |
| Sulindac 150mg,200mg tab | $5 | |
Antibacterials
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs For Infections | ||
| Amoxicillin 250mg, 500mg, 875mg cap/tab | $5 | |
| Amoxicilin 250mg/5ml Oral Susp. 150ml | 100% of cost | |
| Amox/Clav. 500/125mg, 875/125mg tab | $5 | |
| Ampicillin 500mg cap | $5 | |
| Azithromycin pak 250mg 6tabs | $5 | |
| Azithromycin pak 500mg 3tabs | $5 | |
| Cefaclor 500mg cap | $5 | |
| Cefdinir 300mg cap | $5 | |
| Cefuroxime 250mg, 500mg tab | $5 | |
| Cephalexin 250mg, 500mg cap | $5 | |
| Ciprofloxacin 250mg, 500mg tab | $5 | |
| Clarithromycin 500mg tab | $5 | |
| Clindamycin 150mg, 300mgcap | $5 | |
| Clindamycin 2% VaginalCream | $5 | |
| Dicloxacillin 250mg, 500mgcap | $5 | |
| Doxycycline Hyclate 50mg cap | $5 | |
| Doxycycline Hyclate/Monohydrate 100mg cap | $5 | |
| Levofloxacin 500mg, 750mg tab | $5 | |
| Metronidazole 250mg, 500mg tab | $5 | |
| Metronidazole 0.75% Vaginal gel | $5 | |
| Minocycline 50mg, 100mg cap | 100% of cost | |
| Moxafloxicin 400mg | $15 | |
| Nitrofurantoin Macro 100mg cap | $5 | |
| Penicillin VK 250mg, 500mg tab | $5 | |
| Penicillin VK 250mg/5ml Oral Susp. 100ml | 100% of cost | |
| Sulfamethoxazole/Trimethoprim 400/80mg tab | $5 | |
| Sulfamethoxazole/Trimethoprim 800/160mg tab | $5 | |
| Tetracycline 500mg cap | $15, 100% of cost | $15 H. Pylori only |
| Vancomycin 125mg, 250mg cap | 70% of cost | |
Anticoagulants
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs to Treat or Prevent Blood Clots | ||
| Aspirin chewable & entericcoated 81mg tab | no charge | |
| Warfarin 1mg, 2mg, 5mg tab | 100% of cost | |
Anticonvulsants
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Seizures | ||
| Carbamazepine 100mg, 200mg tab | $5 | |
| Divalproex DR 125mg, 250mg, 500mg tab | $5 | |
| Divalproex ER 250mg, 500mg tab | $5 | |
| Divalproex Sprinkle 125mg cap | $5 | |
| Gabapentin 100mg, 300mg, 400mg, 600mg | $5 | |
| Lamotrigine 25mg, 100mg, 150mg, 200mg tab | $5 | |
| Lamotrigine ER 25mg, 50mg, 100mg, 200mg, 250mg, 300mg tab | $10 | |
| Levetiracetam 250mg, 500mg, 750mg, 1000mg tab | 100% of cost | |
| Oxcarbazepine 150mg, 300mg, 600mg tab | $5 | |
| Topiramate 25mg, 50mg, 100mg tab | $5 | |
Antidepressants
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Depression | ||
| Amitriptyline HCl 10mg, 25mg, 50mg tab | $5 | |
| Bupropion 75mg, 100mg tab | $5 | |
| Bupropion SR 100mg, 150mg, 200mg tab | $5 | |
| Bupropion XL/ER 150mg, 300mg tab | $5 | |
| Citalopram 10mg, 20mg, 40mg tab | $5 | |
| Desipramine 10mg, 25mg tab | $5 | |
| Desvenlafaxine ER 25mg, 50mg, 100mg | $10 | |
| Doxepin 10mg, 25mg cap | $5 | |
| Duloxetine 20mg, 30mg, 60mg Capsule | $5 | |
| Escitalopram 5mg, 10mg, 20mg tab | $5 | |
| Fluoxetine 10mg, 20mg, 40mg cap | $5 | |
| Fluoxetine 10mg tab | $5 | |
| Fluvoxamine 25mg, 50mg, 100mg tab | $5 | |
| Mirtazapine 7.5mg, 15mg, 30mg, 45mg tab | $5 | |
| Nortriptyline 10mg, 25mg cap | $5 | |
| Paroxetine 10mg, 20mg, 30mg, 40mg tab | $5 | |
| Sertraline 25mg, 50mg, 100mg tab | $5 | |
| Trazodone 50mg, 100mg tab | $5 | |
| Venlafaxine 25mg, 37.5mg, 75mg tab | $5 | |
| Venlafaxine ER 37.5mg, 75mg, 150mg cap | $5 | |
| Vilazodone 10mg, 20mg, 40mg tab | $5 | |
Antiemetics
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Nausea and Vomiting | ||
| Dexamethasone 0.5mg, 4mg tab | $5 | |
| Ondansetron ODT 4mg, 8mg tab | $5 | |
| Prochlorperazine 5mg tab | $5 | |
| Prochlorperazine 25mg suppository | $5 | |
| Promethazine 25mg tab | $5 | |
| Scopalamine Transdermal Patch | 100% of cost | |
Antifungals
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Fungal Infections | ||
| Clotrimazole 10mg Troche | 100% of cost | |
| Fluconazole 100mg, 150mg tab | $5 | |
| Miconazole 2% Vaginal Cream | no charge | |
| Miconazole 3 Vaginal Combo. Pack | no charge | OTC, SCS*, SL |
| Nystatin 100,000 units/ml Oral Susp. | $5 | |
| Terbinafine 250mg tab | $5 | |
| Terconazole 0.4%, 0.8% VaginalCream | $5 | |
| Terconazole 80mg Vaginal Suppository | $5 | |
Antigout
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Gout | ||
| Allopurinol 100mg, 300mg tab | $5 | |
| Colchicine 0.6mg tab | 100% of cost | |
Antimigraine
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Migraines | ||
| Butalbital/Acetaminophen/Caffeine 50/325/40mg tab | $5 | |
| Eletriptan 20mg, 40mg tab #6 | $15 | SL |
| Rizatriptan 5mg, 10mg tablet #9 | $15 | SL |
| Rizatriptan ODT 5mg, 10mg tablet #9 | $15 | SL |
| Sumatriptan 25mg, 50mg, 100mg tab #9 | $5 | SL |
| Zolmitriptan 2.5mg tab #6, 5mg #3 tab | $15 | SL |
| Zolmitriptan ODT 2.5mg #6, 5mg tab #3 | $15 | SL |
Antiparasitic
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Parasitic Infections | ||
| Permethrin 1% Cream Rinse | no charge | |
| Permethrin 5% Topical Cream | $5 | |
| Ivermectin 3mg tab | 100% of cost | |
Antipsychotics
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Mood Disorders | ||
| Aripiprazole 2mg, 5mg, 10mg, 15mg, 20mg,30mg tab | $5 | |
| Haloperidol 0.5mg, 1mg, 5mg | $5 | |
| Lurasidone 20mg, 40mg, 60mg, 80mg, 120mg tab | $5 | |
| Olanzapine 2.5mg, 5mg, 10mg, 15mg tab | $5 | |
| Quetiapine 25mg, 50mg, 100mg, 200mg, 300mg, 400mg tab | $5 | |
| Quetiapine ER 50mg, 150mg, 200mg, 300mg, 400mg | $5 | |
| Risperidone 0.25mg. 0.5mg, 1mg, 2mg, 3mg, 4mg tab | $5 | |
Antitubercular
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Tuberculosis | ||
| Ethambutol 400mg tab | $5 | |
| Isoniazid 300mg tab | $5 | |
| Rifampin 150mg, 300mg cap | $5 | |
Antivirals
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Viral Infections | ||
| Acyclovir 200mg, 400mg, 800mg cap/tab | $5 | |
| Emtricitabine/Tenofivir DF (Truvada) 200mg/300mg tab | $15 | |
| Oseltamivir 75mg cap #10 | $15 | |
| Valacyclovir 500mg, 1000mg tab | $5 | |
Antixiolytics
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Anxiety | ||
| Alprazolam 0.25mg, 0.5mg, 1mg tab | $5 | |
| Buspirone 5mg, 10mg, 15mg tab | $5 | |
| Clonazepam 0.5mg, 1mg tab | $5 | |
| Diazepam 2mg, 5mg tab | $5 | |
| Lorazepam 0.5mg, 1mg tab | $5 | |
| Drugs For Mood Disorders | ||
| Lithium 150mg cap, 300mg cap/tab, 600mg cap | $5 | |
| Lithium ER 300mg, 450mg tab | $5 | |
Cardiovascular/Heart Disease
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for High Blood Pressure | ||
| Amlodipine 2.5mg, 5mg, 10mg tab | $5 | |
| Atenolol 25mg, 50mg, 100mgtab | $5 | |
| Captopril 25mg, 50mg tab | $5 | |
| Carvedilol 3.125mg, 6.25mg, 25mg tab | $5 | |
| Clonidine 0.1mg tab | $5 | |
| Diltiazem 30mg, 60mg, | $5 | |
| Diltiazem CD 120mg,180mg cap | 70% of cost | |
| Enalapril 5mg, 10mg, 20mg tab | $5 | |
| Furosemide 20mg, 40mg tab | $5 | |
| Hydrochlorothiazide 25mg tab | no charge | |
| Lisinopril 5mg, 10mg, 20mg, 30mg, 40mg tab | $5 | |
| Lisinopril/HCTZ 10/12.5mg, 20/12.5mg, 20/25mg tab | $5 | |
| Losartan 25mg, 50mg, 100mg tab | $5 | |
| Metoprolol 25mg, 50mg tab | $5 | |
| Metoprolol ER 25mg, 50mg tab | $5 | |
| Prazosin 1mg, 2mg, 5mg cap | $5 | |
| Propranolol 10mg, 20mg, 40mg, 60mg, 80mg tab | $5 | |
| Propranolol ER 60mg, 80mg, 120mg cap | 70% of cost | |
| Triamterene/Hydrochlorothiazide 37.5/25mg cap | $5 | |
| Verapamil 80mg tab | $5 | |
| Verapamil ER 120mg, 180mg, 240mg tab | $5 | |
| Drugs For High Cholesterol | ||
| Atorvastatin 10mg, 20mg, 40mg tab | $5 | |
| Cholestyramine for oral susp. USP | $5 | |
| Cholestyramine Light for oral susp. USP | $5 | |
| Ezetimibe 10mg | $5 | |
| Gemfibrozil 600mg tab | $5 | |
| Niacin ER 500mgtab | $5 | |
| Rosuvastatin 5mg, 10mg, 20mg, 40mg tab | $5 | |
| Simvastatin 10mg, 20mg, 40mg tab | $5 | |
Central Nervous System
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Attention Deficit Disorder | ||
| Atomoxetine 10mg, 18mg, 25mg,40mg, 60mg, 80mg, 100mg tab | $5 | |
| Guanfacine 1mg tab | 100% of cost | |
| Guanfacine ER 1mg, 2mg, 3mg, 4mg tab | $5 | |
| Drugs For Sleep Disorder | ||
| Temazepam 15mg cap | $5 | |
| Zaleplon 5mg cap | $5 | |
| Zolpidem 5mg, 10mg tab | $5 | |
Dermatology
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Acne | ||
| Adapalene 0.1% Gel 15gm, 45gm | 100% of charge | *Differin |
| Benzoyl Peroxide 5%, 10% Gel 42.5gm | no charge | |
| Clindamycin 1.2%-Benzoyl Peroxide 5% Gel 45gm (Duac) | $15 | |
| Tretinoin 0.025%, 0.05%,0.1% Cream 20gm, 45gm | 70% of cost | |
| Tretinoin 0.01%, 0.025% Gel 15gm, 45gm | 70% of cost | |
| Drugs For Inflammatory Skin Conditions - Corticosteroids | ||
| Very High Potency | ||
| Betamethasone Dip. Augmented 0.05% Oint 15gm | $15 | SL |
| Clobetasol 0.05% Cream15gm, 60gm | $5 | SL |
| Clobetasol 0.05% Lotion25ml, 50ml | $5 | SL |
| Clobetasol 0.05% Ointment 15gm | $5 | SL |
| High Potency | ||
| Betamethasone Dip. Augmented 0.05% Cream 15gm, 50gm | $5 | SL |
| Betamethasone Dipropionate 0.05% Cream 15gm, 45gm | $5 | SL |
| Betamethasone Dipropionate 0.05% Ointment 15gm, 45gm | $5 | SL |
| Betamethasone Valerate 0.1% Ointment 15gm, 45gm | $5 | SL |
| Mometasone Furoate 0.1% Ointment 15gm, 45gm | $5 | SL |
| Medium Potency | ||
| Mometasone Furoate 0.1% Cream 15gm, 45gm | $5 | SL |
| Mometasone Furoate 0.1% Topical Sol./Lotion 30mg, 60ml | $5 | SL |
| Triamcinolone 0.1% Cream 15gm, 80gm, 454gm | $5 | SL |
| Triamcinolone 0.1% Ointment 15gm, 80gm, 454gm | $5 | SL |
| Lower-Mid Potency | ||
| Betamethasone Dipropionate 0.05% Lotion 60ml | $5 | SL |
| Betamethasone Valerate 0.1% Cream 15gm, 45gm | $5 | SL |
| Desonide 0.05% Ointment 15gm, 60gm | $5 | SL |
| Low Potency | ||
| Betamethasone Valerate 0.1% Lotion 60ml | $5 | SL |
| Desonide 0.05% Cream15gm, 60gm | $5 | SL |
| Least Potent | ||
| Hydrocortisone 0.5% Cream 28gm | no charge | OTC, SL |
| Hydrocortisone 1% Ointment 28gm | no charge | OTC, SL |
| Hydrocortisone 1.0% Cream 28gm | no charge | OTC, SL |
| Hydrocortisone 2.5% Cream 20gm | $5 | SL |
| Hydrocortisone 2.5% Ointment 20gm | $5 | SL |
| Drugs for Bacterial Skin Conditions | ||
| Bacitracin Topical Ointment 30gm | no charge | |
| Clindamycin 1% TopicalLotion 60ml | $15 | |
| Clindamycin 1% Topical Solution 60ml | $5 | |
| Clindamycin 1% Gel60gm | $15 | |
| Erythromycin 2% Topical Solution 60ml | $15 | |
| Hibiclens | 100% of cost | |
| Hydrogen Peroxide | no charge | |
| Metronidazole 0.75% Topical Cream 45gm | 100% of cost | |
| Metronidazole 0.75% Topical Gel 45gm | 100% of cost | |
| Mupirocin 2% Ointment 22gm | $5 | |
| Povidone/Iodine 10% Topical Solution | $5 | |
| Silver Sulfadiazine 1% Cream 25gm | $5 | |
| Drugs for Fungal Skin Infections | ||
| Ciclopirox 8% NailLacquer 6.6ml | 100% of cost | |
| Clotrimazole 1% Cream28gm | no charge | OTC, SL |
| Clotrimazole 1% Topical Solution 10ml | 100% of cost | |
| Clotrimazole 1% / Betamethasone 0.05% Cream 15gm, 45gm | $5 | |
| Econazole 1% Cream30gm | $5 | |
| Ketoconazole 2% Shampoo 120ml | $5 | |
| Ketoconazole 2% Cream 30gm | 100% of cost | |
| Miconazole 2% Cream 30gm | no charge | |
| Nystatin 100,000 USP units/gm Powder 15gm | 100% of cost | |
| Nystatin 100,000 USP units per gm/Triamcinolone 0.1% Cream 30gm | 70% of cost | |
| Nystatin 100,000USP units per gm/Triamcinolone 0.1% Oint. 15gm | 70% of cost | |
| Selenium Sulfide 2.5%Shampoo 118ml | $5 | |
| Terbinafine 1% Cream 30gm | no charge | |
| Tolnaftate 1% Cream 14gm | no charge | |
| Miscellaneous | ||
| Aluminum Chloride Hexahydrate 20% Top. Sol. 60ml | 100% of cost | *Drysol |
| Ammonium Lactate 12% Cream 140gm | 100% of cost | |
| Ammonium Lactate 12% Lotion 226gm, 396gm | 100% of cost | |
| Domeboro | no charge | |
| Imiquimod 5% Cream 12x0.25gm | $5 | SL |
| Lidocaine 5% Ointment 35.44g | $5 | |
| Podofilox 0.5% Topical Solution 3.5ml | $15 | |
| Salacylic Acid 17%topical Gel 7gm | no charge | |
| Salacylic Acid 40% topical pad2x3in pad | no charge | |
Dental & Oral Care
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Mouth and Throat Conditions | ||
| Chlorhexidine Oral Rinse 0.12% | $5 | |
| Lidocaine Viscous 2% | $5 | |
| Sodium Fluoride 5000 1.1% Dental Paste | 100% of cost | |
| Triamcinolone 0.1% Dental Paste | $5 | |
Diabetes
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Blood Glucose Monitoring & Supplies | ||
| All brands of test strips - call in advance for special ordering | 70% of cost | *covered 100% at outside pharmacy with insurance |
| OneTouch Delica PlusLancing Device | 70% of cost | |
| OneTouch Verio Reflect Blood Glucose Monitoring kit (includes glucometer, 25 strips, 100 lancets, lancet device & control solution) | no charge | |
| OneTouch Verio Test Strips | 70% of cost | |
| OneTouch Ultra Test Strips | 70% of cost | |
| Pen Needle Short 31g x 8mm #100 | $5 | |
| Pen Needle Mini 31g x 5mm #100 | $5 | |
| Pen Needle Nano 32g x 4mm #100 | $5 | |
| Pen Needle Orig 29g x 12.7mm #100 | $5 | |
| Insulin | ||
| Humalog 100 units/ml 10ml vial | $5 | *Insulin Lispro, SL |
| Humalog KwikPen 100 units/ml 5x3ml | $5 | SL |
| Humulin N 100 units/ml 10ml vial | $5 | SL |
| Humulin R 100 units/ml 10ml vial | $5 | SL |
| Lantus Solostar Pens 100 units/ml 5x3ml | $5 | SL |
| Novolin 70/30 100 units/ml 10ml vial | $15 | SL |
| Novolin R 100 units/ml 10ml vial | $15 | SL |
| Novolin R 100 units/ml 10ml vial | $15 | SL |
| Non-Insulin Agents | ||
| Glimepiride 1mg, 2mg, 4mg tabs | $5 | |
| Glucagon Emergency Kit | $15 | SL = 1 every12mos |
| Metformin 500mg, 850mg, 1000mg tab | $5 | |
| Metformin ER 500mg, 750mg tab | $5 | |
Gastrointestinal Agents
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Acid Reflux and Ulcer | ||
| Antacid/Anti-Gas suspension | no charge |
|
| Calcium Carbonate 500mgtab | no charge | OTC, SL |
| Famotidine 20mg, 40mg tab | $5 | |
| Omeprazole 20mg, 40mg cap | $5 | |
| Pantoprazole DR 20mg, 40mg tab | $5 | |
| Sucralfate 1gm tab | $5 | |
| Drugs for Bowel, Intestine and Stomach Conditions | ||
| Benefiber SF | $5 | |
| Bisacodyl 5mg tab | no charge | |
| Bisacodyl 10mg suppository | no charge | |
| Bismuth Subsalicylate suspension | no charge | |
| Bismuth Subsalicylate tab | no charge | OTC, SL |
| Dicyclomine 10mg cap | $5 | |
| Dicyclomine 20mg tab | $5 | |
| Docusate Sodium 100mg cap | no charge | |
| Enema-Ready to use Saline | no charge | |
| Hyoscyamine 0.125mg tab/SL | $5 | |
| Hyoscyamine ER 0.375mg tab | $5 | |
| Loperamide 2mg cap | $5 | |
| Loperamide 2mg caplet (#12 tabs/box) | no charge | OTC, SL |
| Methylcellulose Fiber | no charge | |
| Metoclopramide 10mg tab | $5 | |
| Milk of Magnesia Suspension | no charge | |
| Polyethylene Glycol 3350 Powder 238gm, 510gm | $5 | |
| Psyllium Fiber | no charge | |
| Simethicone 125mg cap | no charge | OTC, SL, *Gas Relief |
Genitourinary Agents
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Bladder, Genital, Kidney & Prostate Conditions | ||
| Finasteride 1mg, 5mg tab | $5 | |
| Oxybutynin 5mg tab | $5 | |
| Oxybutynin ER 10mg, 15mg tab | 100% of cost | |
| Phenazopyridine 95mg | $5 | |
| Tamsulosin 0.4mg cap | $5 | |
Hormonal Agents
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Anti-Androgen | ||
| Spironolactone 25mg, 50mg, 100mg tab | $5 | |
| Finasteride 1mg, 5mg tab | $5 | |
| Hormone Replacement & Birth Control | ||
| Apri (Desogen generic) | no charge | SL |
| Aviane (Alesse generic) | no charge | SL |
| Cryselle (Lo-Ovral generic) | no charge | SL |
| Emergency Contraceptive Pill (Levonorgestrel 1.5mg) | no charge | SL |
| Enpresse (Tri-Levlen generic) | no charge | SL |
| Errin (Ortho Micronor generic) | no charge | SL |
| Estradiol 0.5mg, 1mg, 2mg tab | $5 | |
| Junel Fe 1/20(LoEstrin, Gildess generic) | no charge | SL |
| Junel Fe 1.5/30(LoEstrin, Gildess generic) | no charge | SL |
| Junel Fe 24 | no charge | SL |
| Kelnor 1/35 (Demulen, Zoviageneric) | no charge | SL |
| Levonorgestrel 1.5mg (Plan B generic) | no charge | OTC, SCS, SL |
| Loryna (Yaz generic) | no charge | SL |
| Medroxyprogesterone 2.5mg, 10mg tab | $5 | |
| Medroxyprogesterone 150mg Inj. (Dep-Provera generic) | $55 | |
| Nexplanon | 100% of cost | |
| Nortrel 0.5/35 (Ortho Novum generic) | no charge | SL |
| Nortrel 1/35 (Ortho Novum generic) | no charge | SL |
| Nortrel 7/7/7 (Ortho Novum generic) | no charge | SL |
| Ocella (Yasmin generic) | no charge | SL |
| OPill Daily OralContraceptive | 100% of cost | OTC, SL |
| Plan B One-Step Brand Name | $30 | |
| Portia (Nordette generic) | no charge | SL |
| Progesterone 100mg, 200mg cap | $5 | |
| Sprintec (Ortho Cyclen generic) | no charge | SL |
| Tri-LO-Marzia (Ortho Tri-Cyclen LO generic) | no charge | SL |
| Tri-Sprintec (Ortho Tri-Cyclen generic) | no charge | SL |
| Velivet (Cyclessa generic) | no charge | SL |
| Volnea (Kariva, Mircette generic) | no charge | SL |
| Systemic Corticosteroids | ||
| Dexamethasone 0.5mg, 4mg tab | $5 | |
| Methylprednisolone dose pak | $5 | |
| Prednisone 1mg, 5mg, 10mg, 20mg tab | $5 | |
| Testosterone Replacement | ||
| Testosterone Cyp. 200mg/ml injection 1ml | $5 | |
| Thyroid Agents | ||
| Levothyroxine 25mcg, 50mcg, 75mcg tab | $5 | |
| Levothyroxine 88mcg, 100mcg, 112mcg tab | $5 | |
| Levothyroxine 125mcg, 137mcg, 150mcg tab | $5 | |
| Levothyroxine 175mcg, 200mcg tab | $5 | |
| Liothyronine 5mg, 25mg tab | $5 | |
| Methimazole 5mg, 10mg tab | $5 | |
| Propylythiouracil 50mg tab | $5 | |
| Thyroid Armour 1/4gr, 1/2gr, 1gr, 1-1/2gr, 2gr tab | $5 | |
Immunological Agents
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Immune Suppression | ||
| Azathioprine 50mg tab | $5 | |
| Methotrexate 2.5mg tab | 100% of cost | |
Inflammatory Conditions
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Rheumatoid Arthritis, Crohns Disease, Ulcerative Colitis | ||
| Azathioprine 50mg tab | $5 | |
| Hydrocortisone Rectal 2.5% Cream | $5 | |
| Hydrocortisone Rectal 25mg Suppository | $15 | SL |
| Hydroxychloroquine 200mg tab | $15 | |
| Methotrexate 2.5mg tab | 100% of cost | |
| Prednisone 1mg, 5mg, 10mg, 20mg tab | $5 | |
| Preparation-H Ointment | $5 | |
| Sulfasalazine 500mg tab | $5 | |
Miscellaneous
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Oral Dose Syringe | no charge | |
| Pill Splitter | no charge | |
| Hand Held Nebulizer | 100% of cost |
Ophthalmic Conditions
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Eye Allergy, Infection and Inflammation | ||
| Artificial Tears | no charge | OTC, SL |
| Bacitracin/Polymyxin-B Ophth. Ointment | $5 | |
| Ciprofloxacin 0.3% Ophth. Solution | $5 | |
| Dexamethasone 0.1% Ophth. Solution | 70% of cost | |
| Erythromycin 0.5% Ophth. Ointment | $5 | |
| Gentamicin 0.3% Ophth. Solution | $5 | |
| Ketorolac 0.5% Ophth. Solution | $5 | |
| Ketotifen 0.025% Ophth. Solution | $5 | |
| Naphazoline 0.025%/Pheniramine 0.3% Ophth. (*Visine equiv.) | no charge | |
| Neo/Poly/Bac/HC (Cortisporin) Ophth. Oint. | 100% of cost | |
| Neo/Poly/Bac/HC (Cortisporin) Ophth. Solution | 100% of cost | |
| Neo/Poly/Bac (Neosporin) Ophth. Ointment | 100% of cost | |
| Neo/Poly/Gramicidin (Neosporin) Ophth.Sol. | 100% of cost | |
| Neo/Poly/Dex (Maxitrol) Ophth. Ointment | 100% of cost | |
| Neo/Poly/Dex (Maxitrol) Ophth. Susp. | 70% of cost | |
| Ofloxacin 0.3% Ophth. Sol. | $5 | |
| Olopatadine 0.1% Ophth. Solution (*Pataday twice/day) | 100% of cost | |
| Olopatadine 0.2% Ophth. Solution (*Pataday once/day) | 100% of cost | |
| Polymyxin B/Trimethoprim Ophth. Sol. | $5 | |
| Prednisolone 1% Ophth. Solution | $15 | |
| Sulfacetamide/Prednisolone Ophth. Sol. | $5 | |
| Sulfacetamide 10% Ophth Sol. | $5 | |
| Systane Original | 100% of cost | |
| Systane Original PF | 100% of cost | |
| Tobramycin 0.3% Ophth. Sol. | $5 | |
| Tobra 0.3%/Dex 0.1% (TobraDex) Ophth. Susp. | 70% of cost | |
| Visine Advanced (generic equivalent) | no charge | |
Otic Agents
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Ear Conditions | ||
| Acetic Acid Otic 2% Solution | $5 | |
| Earwax Removal Aid (Carbamide peroxide) | no charge | OTC, SL |
| Lidocaine 4% Otic Topical Analgesic | $5 | |
| Neo/Poly/HC Otic Suspension | $5 | |
Respiratory Agents
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Drugs for Anaphylaxis | ||
| Epinephrine Auto-Injector 0.3mg | $15 | SL = 1 every12mos |
| Drugs for Allergies, Cough or Cold | ||
| Benzonatate 100mg cap | $5 | |
| Budesonide 32mcg NasalSpray 8.43ml | 70% of cost | |
| Cetirizine 10mg tab | $5 | |
| Cetirizine/Pseudoephedrine ER 5/120mg #24 tab | 70% of cost | SL |
| Chlorpheniramine 4mg tab | no charge | |
| Cough Drop | no charge | OTC, SCS, SL |
| Cyproheptadine 4mg tab | $5 | |
| Desloratadine 5mg | 70% of cost | |
| Diabetic Guaifenesin liquid | no charge | |
| Diabetic Guaifenesin DM liquid | no charge | |
| Diphenhydramine 25mg cap | no charge | OTC, SCS*, SL |
| Diphenhydramine 12.5mg/5ml Elixer | no charge | |
| Fexofenadine 60mg, 180mg tab | $5 | |
| Fexofenadine/Pseudoephedrine 12hr #20 tab | 70% of cost | |
| Fexofenadine/Pseudoephedrine 24hr #10 tab | 70% of cost | |
| Flunisolide 0.025% NasalSolution 25ML | 70% of cost | |
| Fluticasone 50mcg NasalSpray 16gm | $5 | |
| Guaifenesin 400mg tab | no charge | OTC, SL |
| Guaifenesin 200mg/10ml syrup | no charge | OTC, SL |
| Guaifenesin w/Codeine 100mg/10mg/5ml | $5 | |
| Guaifenesin DM 200mg/20mg/20ml syrup | no charge | |
| Hydroxyzine HCl 10mg, 25mg tab | $5 | |
| Hydroxyzine Pamoate 25mg, 50mg cap | $5 | |
| Levocetirizine 5mg tab | $5 | |
| Loratadine 10mg tab | no charge | OTC, SCS, SL |
| Meclizine 12.5mg tab | $5 | |
| Mometasone 50mcg Nasal Spray 17gm | 70% of cost | |
| Oxymetazoline 0.05% Nasal Spray | no charge | |
| Promethazine/Codeine 62.5/10mg/5ml Syrup | 100% of cost | |
| Pseudoephedrine 30mg, 60mg | no charge | SL |
| Sinus Rinse/Nasal Irrigation Kit | no charge | |
| Sodium Chloride 0.65%Nasal Spray | no charge | OTC, SCS*, SL |
| Sore Throat Spray | no charge | OTC, SL |
| Throat Lozenges | no charge | OTC, SL |
| Triamcinolone 55mcg Nasal Spray 17ml | 70% of cost | |
| Drugs for Asthma & COPD | ||
| Advair Diskus 100/50, 250/50, 500/50 mcg x 60doses | $15 | SL, *Wixela |
| Albuterol 0.083% nebulizer sol. 3ml vialx25doses | $5 | |
| Albuterol HFA MDI 8.5gm 200doses | $5 | SL |
| Budesonide/Formoterol MDI 80/4.5, 160/4.5 mcg x 120doses | $15 | SL |
| Dexamethasone 0.5mg, 4mg tab | $5 | |
| Fluticasone HFA MDI 44mcg, 110mcg, 220mcg x 120doses | $15 | SL |
| Ipratropium 0.02% Nebulizer Sol. 2.5ml vialx25doses | $5 | |
| Ipratrop. 0.5mg/Albuterol 3mg Neb Sol 3mlx25doses | $5 | |
| Methylprednisolone dose pak | $5 | |
| Monteleukast 10mg tab | $5 | |
| OptiChamber Spacer | no charge | |
| Peak Flow Meter (Mini-Wright) | $5 | |
| Prednisone 1mg, 5mg, 10mg, 20mg tab | $5 | |
Sexual Health Agents
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Condoms | no charge | OTC, SCS, SL |
| Diaphragm latex free | $5 | *Caya |
| Emergency Contraceptive Pill (Levonorgestrel 1.5mg) | no charge | OTC, SCS, SL |
| OPill Daily OralContraceptive | 100% of cost | OTC, SL |
| Pregnancy Test (*Accu-Home) | no charge | OTC, SCS*, SL |
| Sildenafil 50mg, 100mg tab | 100% of cost | |
| Surgilube | no charge | OTC, SCS*, SL |
Skeletal Muscle Relaxants
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Musculoskeletal | ||
| Baclofen 10mg, 20mg tab | $5 | |
| Cyclobenzaprine 5mg, 10mg tab | $5 | |
| Methocarbamol 500mg, 750mg | $5 | |
Smoking Cessation
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Bupropion SR 150mg tab(generic Zyban) | $5 | |
| Nicotine Transdermal Patch 7mg, 14mg, 21mg #7 | 100% of cost | |
| Nicotine Gum 4mg #110 | 100% of cost |
Supplements
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Calcium 500mg/Vit. D3 400iutab | no charge | |
| Cyanocobalamine 1mg/ml Injection 1ml | 100% of cost | |
| Ferrous Gluconate 324mg tab | no charge | |
| Ferrous Sulfate 325mg tab | no charge | |
| Folic Acid 1mg tab | $5 | |
| Melatonin 1mg, 3mg, 5mg, 15mg | no charge | |
| Prenatal Vitamin tablet | no charge | |
| Pyridoxine 50mg tab | no charge | |
| Vitamin B12 1000 mcg tab | $5 | |
| Vitamin D3 1000 i.u. tab | no charge | |
| Vitamin D3 5,000 i.u. cap | 100% of cost | |
| Vitamin D3 50,000 i.u. cap | $5 |
Syringes
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| BD PrecisionGLide Needle21gx25mm(1in) | $5 | |
| BD PrecisionGLide Needle23gx25mm(1in) | $5 | |
| BD Luer-lok Syringe 1cc | $5 | |
| BD Syringe 31g x 8mm(5/16in) x 1/2cc | $5 | |
| BD Syringe 31g x 8mm(5/16in) x 3/10cc | $5 | |
| BD Syringe 30g x 12.7mm(1/2in) x 1cc | $5 | |
| BD Syringe 22g x 40mm (1-1/2in) x 3cc | $5 |
Tropical Disease/Travel Agents
| Drug Name | CoPay | Limits & Requirements |
|---|---|---|
| Acetazolamide 125mg tab | 100% of cost | |
| Atovaquone-Proguanil 250-100mg tab | 100% of cost | |
| Chloroquine 500mg tab | 100% of cost | |
| Mefloquine 250mg | 100% of cost | |
| Typhoid Oral Vaccine | $91 |