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RESPIRATORY
Antihistamines (Oral)
| Covered Drug/Strength |
Quantity |
Your Price |
| Clarinex 5mg | 30 | $76.00 |
| Clarinex 5mg | 90 | $222.00 |
| Clarinex Repitabs 5mg | 30 | $75.00 |
ALLERGY SPRAYS
| Covered Drug/Strength |
Quantity |
Your Price |
| Nasonex Spray | 17 | $71.00 |
ASTHMA INHALATION THERAPY
| Covered Drug/Strength |
Quantity |
Your Price |
| Altrovent Inh | 14.7 | $68.00 |
| Combivent | 15 | $90.00 |
| Foradil Aerolizer | 60 | $98.00 |
| Proventil HFA | 6.7 | $41.00 |
CARDIOVASCULAR
Ace Inhibitors
| Covered Drug/Strength |
Quantity |
Your Price |
| Aceon 2mg | 30 | $39.00 |
| Aceon 2mg | 90 | $111.00 |
| Aceon 4mg | 30 | $45.00 |
| Aceon 4mg | 90 | $129.00 |
| Aceon 8mg | 30 | $57.00 |
| Aceon 8mg | 90 | $163.00 |
| Altace 1.25mg | 30 | $37.00 |
| Altace 2.5mg | 30 | $40.00 |
| Altace 5mg | 30 | $46.00 |
| Altace 10mg | 30 | $54.00 |
Angiotensin II Blockers (ARB)
| Covered Drug/Strength |
Quantity |
Your Price |
| Micardis 20mg | 28 | $46.00 |
| Micardis 40mg | 28 | $50.00 |
| Micardis 80mg | 28 | $53.00 |
| Micardis HCT 40-12.5mg | 28 | $58.00 |
| Micardis HCT 80-12.5mh | 28 | $65.00 |
Potassium Supplement
| Covered Drug/Strength | Quantity |
Your Price |
| K-Dur 10mg |
30 |
$14.00 |
| K-Dur 20mg | 30 | $22.00 |
Thyroid Agents
| Covered Drug/Strength | Quantity |
Your Price |
| Levoxyl 25mcg |
100 |
$31.00 |
| Levoxyl 50mcg | 100 | $35.00 |
| Levoxyl 75mcg | 100 | $36.00 |
| Levoxyl 88mcg | 100 | $39.00 |
| Levoxyl 100mcg | 100 | $39.00 |
| Levoxyl 112mcg | 100 | $45.00 |
| Levoxyl 125mcg | 100 | $46.00 |
| Levoxyl 137mcg | 100 | $46.00 |
| Levoxyl 150mcg | 100 | $47.00 |
| Levoxyl 175mcg | 100 | $55.00 |
| Levoxyl 200mcg | 100 | $55.00 |
| Levoxyl 300mcg |
100 |
$74.00 |
Antiarthritics
| Covered Drug/Strength |
Quantity |
Your Price |
| Mobic 7.5mg |
30 |
$95.00 |
| Mobic 15mg | 30 | $143.00 |
| Trexall 5mg | 5 | $35.00 |
| Trexall 7.5mg | 5 | $51.00 |
| Trexall 10mg | 5 | $66.00 |
| Trexall 15mg | 5 | $98.00 |
Skeletal Muscle Relaxant
| Covered Drug/Strength |
Quantity |
Your Price |
| Skelaxin 400mg | 30 | $40.00 |
| Skelaxin 800mg | 30 | $83.00 |
Osteoporosis
| Covered Drug/Strength |
Quantity |
Your Price |
| Actonel 5mg | 30 | $78.00 |
| Actonel 30mg | 4 | $76.00 |
| Actonel 35mg | 4 | $76.00 |
BPH
| Covered Drug/Strength |
Quantity |
Your Price |
| Flomax cap 0.4mg | 30 | $68.00 |
Anticoagulant
| Covered Drug/Strength |
Quantity |
Your Price |
| Aggrenox cap 200-25mg | 60 | $131.00 |
Cholesterol Lowering
| Covered Drug/Strength |
Quantity |
Your Price |
| Advicor 20-500mg |
30 |
$78.00 |
| Advicor 20-750mg | 30 | $83.00 |
| Advicor 20-1000mg | 30 | $89.00 |
| Altoprev 10mg | 30 | $78.00 |
| Altoprev 20mg | 30 | $82.00 |
| Altoprev 40mg | 30 | $89.00 |
| Altoprev 60mg | 30 | $95.00 |
| Niaspan 500mg | 30 | $57.00 |
| Niaspan 750mg | 30 | $79.00 |
| Niaspan 1000mg | 30 | $93.00 |
Diabetes (Injectable)
| Covered Drug/Strength |
Quantity |
Your Price |
| Novolin 10ml vial | 10 | $32.00 |
| Novolin Innolet | 15 | $66.00 |
| Novolin Penfill 3ml | 15 | $90.00 |
| Novolog vial | 10 | $69.00 |
| Novolog cartridge | 15 | $129.00 |
| Novolog Mix 70/30 Penfill | 15 | $133.00 |
| Novolog Mix 70/30 FlexPen | 15 | $138.00 |
| Novofine 30 Mis Dispos | 100 | $29.00 |
| Novofine 31 Mis Dispos | 100 | $32.00 |
Diabetes (Oral)
| Covered Drug/Strength |
Quantity |
Your Price |
| Prandin 0.5mg | 30 | $39.00 |
| Prandin 0.5mg | 90 | $109.00 |
| Prandin 1mg | 30 | $39.00 |
| Prandin 1mg | 90 | $109.00 |
| Prandin 2mg | 30 | $39.00 |
| Prandin 2mg | 90 | $109.00 |
Women's Health
Hormonal Replacement Therapy (HRT)
| Covered Drug/Strength |
Quantity |
Your Price |
| Activella 1-0.5mg | 28 | $40.00 |
| Cenestin 0.3mg | 30 | $38.00 |
| Cenestin 0.3mg | 90 | $106.00 |
| Cenestin .625mg | 30 | $34.00 |
| Cenestin .625mg | 90 | $96.00 |
| Cenestin 0.9mg | 30 | $37.00 |
| Cenestin 0.9mg | 90 | $105.00 |
| Cenestin 1.25mg | 30 | $37.00 |
| Cenestin 1.25mg | 90 | $105.00 |
| Climara Pro Dis Weekly | 4 | $39.00 |
Oral Contraceptives
| Covered Drug/Strength |
Quantity |
Your Price |
| Yasmin 28 | 28 | $35.50 |
| Seasonale | 91 | $135.00 |
Antibiotics
| Covered Drug/Strength |
Quantity |
Your Price |
| Cipro XR 500mg | 3 | $29.00 |
| Cipro XR 1000mg | 3 | $32.00 |
Antibiotic-Eardrops
| Covered Drug/Strength |
Quantity |
Your Price |
| Floxin 0.3% | 5 | $50.00 |
| Floxin 0.3% | 10 | $87.00 |
Opthalmic Drops
| Covered Drug/Strength |
Quantity |
Your Price |
| Alrex Susp 0.2% | 5 | $45.00 |
| Alrex Susp 0.2% | 10 | $86.00 |
| Lotemax Susp 0.5% | 5 | $37.00 |
| Lotemax Susp 0.5% | 10 | $63.00 |
Topical Medications
| Covered Drug/Strength |
Quantity |
Your Price |
| Diprolene Lotion | 30 | $53.00 |
| Diprolene AF Cream | 15 | $47.00 |
| Elecon Cream | 15 | $31.00 |
| Elecon Lotion | 30 | $34.00 |
| Elecon Oint | 15 | $31.00 |
| Lotrisone Lotion | 30 | $62.00 |
COSTS WILL VARY BASED ON QUANTITY, AND YOUR CO-PAY IS SUBJECT TO CHANGE DUE TO MANUFACTURER PRICE CHANGES TO PHARMACIES.
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