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Available through your mail-order prescription benefit
$10 for 90 days of 400+ generic drugs

You’ll pay just $10 or less* for a 90-day supply† of more than 400 generic drugs when you use
Medco Pharmacy®, which is now partof the Express Scripts family of pharmacies. Plus you’ll get:
> 24/7 access to specialist pharmacists who are experts in the medications used to treat a specific condition, such as diabetes, asthma, or heart disease Expert care from
Specialist Pharmacists
> Safety checks that help to protect you from potential drug interactions is available 24/7.
> Convenient delivery to you with free standard shipping
*If your plan’s mail-order cost share for generics is less than $10, you’ll pay the lower amount. †The price of $10 or less is for a supply of medication in the quantities listed below. If your prescription is for a greater quantity, your cost may be higher. If your prescription is for a lesser quantity, your cost may be lower. Drug list and pricing are subject to change without notice. Coverage of medications may depend on your plan.
Antibiotics/antifungals/antivirals
Anticoagulants
Acyclovir 200mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 4mg, 5mg, 6mg, 7.5mg, 10mg tablet . . . . . . . . . . . . . . . . . . . . . . . .90 250mg/5mL suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240mLAmoxicillin Trihydrate 200mg/5mL, Antiseizure medications
400mg/5mL suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150mL Carbamazepine 200mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Amoxicillin Trihydrate 250mg, 500mg capsule . . . . . . . . . . . . .90 Amoxicillin Trihydrate 500mg tablet . . . . . . . . . . . . . . . . . . . . . . .90 32.4mg, 64.8mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Amoxicillin Trihydrate 50mg/mL drops . . . . . . . . . . . . . . . . . .90mL Phenobarbital 97.2mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Cephalexin Monohydrate 250mg capsule . . . . . . . . . . . . . . . . . .84 Zinc Sulfate 220(50)mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Cephalexin Monohydrate 500mg capsule . . . . . . . . . . . . . . . . . .90 Arthritis/pain
Ciprofloxacin HCl 250mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Diclofenac Sodium 75mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Ciprofloxacin HCl 500mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . .60 Ibuprofen 100mg/5mL suspension . . . . . . . . . . . . . . . . . . . . .360mL Doxycycline Hyclate 100mg tablet . . . . . . . . . . . . . . . . . . . . . . . . .90 Ibuprofen 400mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .270 Doxycycline Hyclate 50mg, 100mg capsule . . . . . . . . . . . . . . . . .90 Ibuprofen 600mg, 800mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .180 Erythromycin Base 250mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . .84 Indomethacin 25mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Erythromycin Stearate 250mg capsule . . . . . . . . . . . . . . . . . . . . .120 Meloxicam 7.5mg, 15mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Fluconazole 150mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Naproxen 375mg, 500mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Isoniazid 100mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 Piroxicam 20mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Isoniazid 300mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Salsalate 500mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Metronidazole 250mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84Metronidazole 500mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Asthma/respiratory
Penicillin V potassium 125mg/5mL suspension . . . . . . . . .600mL Albuterol Sulfate 2.5mg/3mL inhalant solution . . . . . . . . .225mL Penicillin V potassium 250mg tablet . . . . . . . . . . . . . . . . . . . . . . . .84 Albuterol Sulfate 2mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .270 Penicillin V potassium 250mg/5mL suspension . . . . . . . .300mL Albuterol Sulfate 2mg/5mL syrup . . . . . . . . . . . . . . . . . . . . .1440mL Albuterol Sulfate 4mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 5 suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .360mL Albuterol Sulfate 5mg/mL inhalant solution . . . . . . . . . . . .60mL Sulfamethoxazole/Trimethoprim 400mg-80mg tablet . . . . .84 Aminophylline 100mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Sulfamethoxazole/Trimethoprim 800-160mg DS tablet . . .60 Aminophylline 200mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .270 Terbinafine HCl 250mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Ipratropium Bromide 0.2mg/mL inhalant solution . . . . . .225mL Tetracycline HCl 250mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . .180Tetracycline HCl 500mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 2012 Express Scripts Holding Company. All rights reserved.
If your medication isn’t listed here, log on to My Health Planfor other potential lower-cost alternatives.
Member Services toll-free at (800) 417-1961.
Blood pressure/heart health
Cold and allergy therapy
Amiloride/Hydrochlorothiazide 5mg-50mg tablet . . . . . . . . .90 Benzonatate 100mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Atenolol 25mg, 50mg, 100mg tablet . . . . . . . . . . . . . . . . . . . . . . .90 Diphenhydramine HCl 50mg capsule . . . . . . . . . . . . . . . . . . . . . .90 Atenolol/Chlorthalidone 100mg-25mg tablet . . . . . . . . . . . . . .90 Diphenhydramine HCl 50mg/mL vial . . . . . . . . . . . . . . . . . . . .10mL Atenolol/Chlorthalidone 50mg-25mg tablet . . . . . . . . . . . . . . .90 D-methorphan HB/PE/Chlorphenir 15-12.5-4, Benazepril HCl 5mg, 10mg, 20mg, 40mg tablet . . . . . . . . . . . .90 15-6-2mg/5 syrup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .360mL Bisoprolol/Hydrochlorothiazide 10-6.25mg tablet . . . . . . . . . .90 D-Methorphan HB/P-EPD HCl/BPM 30-60-4/5 syrup . . .180mL Bisoprolol/Hydrochlorothiazide 2.5-6.25mg tablet . . . . . . . . . .90 D-Methorphan HB/Prometh HCl 15-6.25/5 syrup . . . . . . .360mL Bisoprolol/Hydrochlorothiazide 5-6.25mg tablet . . . . . . . . . . .90 Guaifenesin/D-Methorphan HB 600mg-30mg tablet . . . . .180 Bumetanide 0.5mg, 1mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Guaifenesin/Dyphylline 100-100/15 elixer . . . . . . . . . . . . . .240mL Captopril 12.5mg, 25mg, 50,mg, 100mg tablet . . . . . . . . . . . . .180 Guaifenesin/P-Ephed HCl 600mg-60mg tablet . . . . . . . . . . . .90Hydroxyzine Pam 25mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 Carvedilol 3.125mg, 6.25mg, 12.5mg, 25mg tablet . . . . . . . . . . .180 Loratadine 10mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Chlorothiazide 250mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Phenylephrine HCl/Chlor-Mal 3.5-1mg/mL drops . . . . . . . .90mL Chlorthalidone 25mg, 50mg tablet . . . . . . . . . . . . . . . . . . . . . . . . .90 Phenylephrine/Chlor-Mal/Scop 10-2-0.625 drops . . . . . .480mL Clonidine HCl 0.1mg, 0.2mg tablet . . . . . . . . . . . . . . . . . . . . . . . . .180 Phenylephrine/Hydrocodone/CP 5-2.5-2 drops . . . . . . . . .240mL Digoxin 125mcg, 250mcg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Promethazine HCl 25mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Diltiazem HCl 30mg, 60mg, 90mg, 120mg tablet . . . . . . . . . .180 Promethazine HCl 6.25mg/5mL syrup . . . . . . . . . . . . . . . . . .540mL Doxazosin Mesylate 1mg, 2mg, 4mg, 8mg tablet . . . . . . . . . . .90Enalapril Maleate 2.5mg, 5mg, 10mg, 20mg tablet . . . . . . . . .90 Diabetes
Enalapril/Hydrochlorothiazide 5-12.5mg tablet . . . . . . . . . . . . .90 Chlorpropamide 100mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Furosemide 20mg, 40mg, 80mg tablet . . . . . . . . . . . . . . . . . . . .90 Glimepiride 1mg, 2mg, 4mg tablet . . . . . . . . . . . . . . . . . . . . . . . . .90 Guanfacine HCl 1mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Glipizide 10mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Hydralazine HCl 10mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Glipizide 5mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Hydralazine HCl 25mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Glyburide 2.5mg, 5mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Hydrochlorothiazide 12.5mg capsule . . . . . . . . . . . . . . . . . . . . . . .90 Glyburide, Micronized 3mg, 6mg tablet . . . . . . . . . . . . . . . . . . . .90 Hydrochlorothiazide 25mg, 50mg tablet . . . . . . . . . . . . . . . . . . .90 Metformin HCl 500mg ER tablet . . . . . . . . . . . . . . . . . . . . . . . . . .180 Indapamide 1.25mg, 2.5mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .90 Metformin HCl 500mg, 850mg, 1000mg tablet . . . . . . . . . . .180 Isosorbide DN 10mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .270Isosorbide DN 5mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Ear health
Isosorbide Mononitrate 30mg, 60mg tablet . . . . . . . . . . . . . . .90 Acetic Acid/Aluminum Acetate 2% drops . . . . . . . . . . . . . . . .60mL Lisinopril 2.5mg, 5mg, 10mg, 20mg tablet . . . . . . . . . . . . . . . . . .90 Antipyrine/Benzocaine/Glycerin 5.4%-1.4% drops . . . . . . .30mL Lisinopril/Hydrochlorothiazide 10-12.5mg, 20-12.5mg, Phenylephrine/Antipy/B-Caine 0.25-5-5% drops . . . . . . . . . .15mL 20-25mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Methyldopa 250mg, 500mg tablet . . . . . . . . . . . . . . . . . . . . . . . .180 Eye health
Metoprolol Tartrate 25mg, 50mg, 100mg tablet . . . . . . . . . . .180 Atropine Sulfate 1% drops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15mL Nadolol 20mg, 40mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Atropine Sulfate 1% ointment . . . . . . . . . . . . . . . . . . . . . . . . . . . .4gm Niacin 500mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Bacitracin 500 unit/g ointment . . . . . . . . . . . . . . . . . . . . . . . . . .4gm Nitroglycerin 0.3mg, 0.4mg, 0.6mg SL tablet . . . . . . . . . . . . . .300 Cyclopentolate 1% drops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15mL Pindolol 5mg, 10mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Erythromycin Base 5mg/g ointment . . . . . . . . . . . . . . . . . . . . . .4gm Prazosin HCl 1mg, 2mg, 5mg capsule . . . . . . . . . . . . . . . . . . . . . . .90 Gentamicin Sulfate 0.3% drops . . . . . . . . . . . . . . . . . . . . . . . . . .15gm Propranolol HCl 10mg, 20mg, 40mg, 80mg tablet . . . . . . . . .180 Levobunolol HCl 0.5% drops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15mL Propranolol HCl 40mg/5mL solution . . . . . . . . . . . . . . . . . . . .30mL Naphazoline 0.1%HCl drops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15mL Sotalol HCl 80mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Neo/Polymyx B Sulf/Dexameth 0.1% drops . . . . . . . . . . . . . .15mL Spironolactone 25mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Neo/Polymyx B Sulf/Dexameth 3.5-10k-1 ointment . . . . . . .4gm Terazosin HCl 1mg, 2mg, 5mg, 10mg capsule . . . . . . . . . . . . . . . .90 Neomy Sulf/Bacitra/Polymyxin B 3.5mg-400 ointment . . .4gm Triamterene/Hydrochlorothiazide 37.5-25mg capsule . . . . . . .90 Neomy Sulf/Bacitrac ZN/Poly/HC 3.5-10k-1 ointment . . . . .4gm Phenylephrine HCl 2.5%, 10% drops . . . . . . . . . . . . . . . . . . . . . .15mL 37.5-25mg, 75-50mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Pilocarpine HCl 0.5%, 3% drops . . . . . . . . . . . . . . . . . . . . . . . . . . .15mL Verapamil HCl 80mg, 120mg tablet . . . . . . . . . . . . . . . . . . . . . . . .180 Pilocarpine HCl 1%, 2% drops . . . . . . . . . . . . . . . . . . . . . . . . . . . .45mL If your medication isn’t listed here, log on to My Health Plan for other potential lower-cost alternatives.
Member Services toll-free at (800) 417-1961.
Pilocarpine HCl 4% drops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30mL Lactulose 10g/15mL solution . . . . . . . . . . . . . . . . . . . . . . . . . . .960mL Polymyxin B Sulfate/TMP 10k u-0.1% drops . . . . . . . . . . . . . .30mL Metoclopramide HCl 10mg tablet . . . . . . . . . . . . . . . . . . . . . . . . .180 Sulfacetamide Sodium 10% drops . . . . . . . . . . . . . . . . . . . . . . . .15mL Metoclopramide HCl 5mg/5mL solution . . . . . . . . . . . . . . . .180mL Timolol Maleate 0.25%, 0.5% drops . . . . . . . . . . . . . . . . . . . . . . .15mL Prochlorperazine Maleate 10mg tablet . . . . . . . . . . . . . . . . . . . . .90 Tobramycin Sulfate 0.3% drops . . . . . . . . . . . . . . . . . . . . . . . . . . .15mLTropicamide 1% drops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15mL Other medications
Allopurinol 100mg, 300mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .90 Heartburn/ulcer
Atropine Sulfate 1mg/mL vial . . . . . . . . . . . . . . . . . . . . . . . . . . . .15mL Cimetidine 800mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Bacteriostatic Water Vial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90mL Famotidine 20mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Chlorhexidine Gluconate 0.12% solution . . . . . . . . . . . . . . .1419mL Ranitidine HCl 150mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Citric Acid/Sodium Citrate 334-500mg solution . . . . . . . .540mL Ranitidine HCl 300mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Colchicine 0.6mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Dexamethasone 0.5mg, 0.75mg tablet . . . . . . . . . . . . . . . . . . . . .90 High cholesterol
Dexamethasone 4mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Lovastatin 10mg, 20mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Dexamethasone Sodium Phosphate 4mg/mL vial . . . . . . .10mL Pravastatin Sodium 10mg, 20mg, 40mg tablet . . . . . . . . . . . . .90 Methylprednisolone 4mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . .63Methylprednisolone 4mg, dose pak . . . . . . . . . . . . . . . . . . . . . . . .63 Mental health
Oxybutynin Chloride 5mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .180 Alprazolam 0.25mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Phenazopyridine HCl 100mg, 200mg tablet . . . . . . . . . . . . . . . .90 Alprazolam 0.5mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 Prednisolone 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Amitriptyline HCl 10mg, 25mg, 50mg, 75mg,100mg tablet . . .90 Prednisone 10mg tablet, dose pak . . . . . . . . . . . . . . . . . . . . . . . . . .40 Buspirone HCl 5mg, 10mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .180 Prednisone 2.5mg, 5mg, 10mg, 20mg tablet . . . . . . . . . . . . . . . .90 Citalopram Hydrobromide 20mg, 40mg tablet . . . . . . . . . . . . .90 Prednisone 50mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Diazepam 2mg, 5mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Prednisone 5mg tablet, dose pak . . . . . . . . . . . . . . . . . . . . . . . . . . .63 Doxepin HCl 10mg, 25mg, 50mg, 75mg, 100mg capsule . . . .90Fluoxetine HCl 10mg tablets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Parkinson’s disease
Fluoxetine HCl 10mg, 20mg, 40mg capsules . . . . . . . . . . . . . . .90 Benztropine Mesylate 2mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .90 Fluphenazine Decanoate 25mg/mL vial . . . . . . . . . . . . . . . . . . .5mL Trihexyphenidyl HCl 2mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Fluphenazine HCl 1mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180Haloperidol 0.5mg, 1mg, 2mg, 5mg tablet . . . . . . . . . . . . . . . . . .90 Skin conditions
Lithium Carbonate 300mg capsule . . . . . . . . . . . . . . . . . . . . . . . .270 Betamethasone Dipropionate 0.05% cream . . . . . . . . . . . .135gm Nortriptyline HCl 10mg, 25mg capsule . . . . . . . . . . . . . . . . . . . . .90 Betamethasone Dipropionate 0.05% ointment . . . . . . . . .60gm Paroxetine HCl 10mg, 20mg tablet . . . . . . . . . . . . . . . . . . . . . . . . .90 Betamethasone Valerate 0.1% cream . . . . . . . . . . . . . . . . . . .135gm Perphen-Amitrip 2mg-10mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Betamethasone Valerate 0.1% lotion . . . . . . . . . . . . . . . . . . .120gm Thioridazine HCl 25mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Betamethasone Valerate 0.1% ointment . . . . . . . . . . . . . . . .135gm Thioridazine HCl 50mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Fluocinolone 0.025% cream . . . . . . . . . . . . . . . . . . . . . . . . . . . .60gm Thiothixene 2mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Fluocinolone 0.025% ointment . . . . . . . . . . . . . . . . . . . . . . . . .60gm Trazodone HCl 50mg, 100mg, 150mg tablet . . . . . . . . . . . . . . . .90 Fluocinolone Acetonide 0.01% cream . . . . . . . . . . . . . . . . . . .60gmFluocinolone Acetonide 0.01% solution . . . . . . . . . . . . . . . . .180mL Muscle relaxants
Fluocinonide 0.05% cream . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90gm Baclofen 10mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Gentamicin Sulfate 0.1%, cream . . . . . . . . . . . . . . . . . . . . . . . . .45gm Cyclobenzaprine HCl 5mg, 10mg tablet . . . . . . . . . . . . . . . . . . . . .90 Gentamicin Sulfate 0.1%, ointment . . . . . . . . . . . . . . . . . . . . . .45gmHydrocortisone 1%, 2.5% cream . . . . . . . . . . . . . . . . . . . . . . . . .90gm Other GI drugs
Hydrocortisone 2.5% ointment . . . . . . . . . . . . . . . . . . . . . . . . .60gm Belladonna Alkaloids/Phenobarb 16.2mg . . . . . . . . . . . . . . . . . .180 Hydroquinone 30mg/mL solution . . . . . . . . . . . . . . . . . . . . . . .30mL Belladonna Alkaloids/Phenobarb 16.2mg/5mL elixir . . .480mL Lidocaine HCl 20mg/mL solution . . . . . . . . . . . . . . . . . . . . . .300mL Dicyclomine HCl 10mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . .270 Nystatin 100000u/g cream . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90gm Dicyclomine HCl 20mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Nystatin 100000u/g ointment . . . . . . . . . . . . . . . . . . . . . . . . .90gm Hydrocortisone Acetate 25mg suppository . . . . . . . . . . . . . . . . .36 Nystatin/Triamcin 100000u-0.1 cream . . . . . . . . . . . . . . . . .90gm Hyoscyamine Sulfate 0.125mg/mL drops . . . . . . . . . . . . . . . . .45mL Nystatin/Triamcin 100000u-0.1 ointment . . . . . . . . . . . . . . .45gm If your medication isn’t listed here, log on to My Health Plan for other potential lower-cost alternatives.
Member Services toll-free at (800) 417-1961.
Selenium Sulfide 2.5% shampoo . . . . . . . . . . . . . . . . . . . . . . .360mL Potassium Chloride 10meq sustained release tablet . . . . . . . .90 Triamcinolone Acetonide 0.025% ointment . . . . . . . . . . . . .80gm Triamcinolone Acetonide 0.025%, 0.1% cream . . . . . . . . .240gm 40meq/15mL solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1440mL Triamcinolone Acetonide 0.1%, ointment . . . . . . . . . . . . . .240gm Potassium Chloride 20meq/15mL solution . . . . . . . . . . . .1440mL Triamcinolone Acetonide 0.5% cream . . . . . . . . . . . . . . . . . . .45gm Potassium Chloride 8meq, 10meq sustained action tablet . .90 Triamcinolone Acetonide 0.5% ointment . . . . . . . . . . . . . . . .45gm Prenatal Rx1 tablet 60-1mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Prenatal Rx tablet 27-0.5mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Thyroid therapy
29mg-1mg, 60mg-1mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 137mcg, 150mcg, 175mcg, 200mcg tablet . . . . . . . . . . . . . . . . . . .90 Prenatal Vit/Fe Fumarate/Fa/Se 27-1mg tablet . . . . . . . . . . . . .90 Pyridoxine HCl 25mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 75mcg, 88mcg, 100mcg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Sodium Fluoride 0.25mg, 0.5mg, 1mg chewable tablet . . . . .90 Thyroid 32.5mg, 65mg, 130mg, 195mg tablet . . . . . . . . . . . . . . .90 Sodium Fluoride 0.5mg/mL drops . . . . . . . . . . . . . . . . . . . . . . .50mLTherapeutic Multivitamins with Folic Acid, Vitamins and electrolytes
27-0.8mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Tri-Vit-Fluor-Iron 0.25mg/mL drops . . . . . . . . . . . . . . . . . . . . .100mL 0.5mg, 1mg chewable tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Vitacon Forte 1mg capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Fluoride Ion/Multivitamins 0.25mg/mL, 0.5mg/mL drops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100mL Vitamin B Comp W-C, tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Fluoride Ion/Multivits W-Fe 0.5mg/mL drops . . . . . . . . . . .100mL Women’s health
Fluoride Ion/Vitamins A,C & D 0.25mg, 0.5mg drops . . . .50mL Estradiol 0.5mg, 1mg, 2mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Folic Acid 0.4mg, 0.8mg, 1mg tablet . . . . . . . . . . . . . . . . . . . . . . . .90 Estropipate 0.75mg, 1.5mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Folic Acid/Vitamin B Comp W-C 1-100mg tablet . . . . . . . . . . . .90 Medroxyprogesterone Acet 10mg tablet . . . . . . . . . . . . . . . . . . . .42 Magnesium Chloride 64mg tablet . . . . . . . . . . . . . . . . . . . . . . . .180 Medroxyprogesterone Acet 2.5mg, 5mg tablet . . . . . . . . . . . . .90 Magnesium Oxide 400mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . .90 Megestrol Acetate 20mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Natalcare PIC 60mg-1mg tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . .90Polyvit-Iron-FL 0.25mg/mL drops . . . . . . . . . . . . . . . . . . . . . . .100mL If your medication isn’t listed here, log on to My Health Plan for other potential lower-cost alternatives.
Member Services toll-free at (800) 417-1961.

Source: http://www.ercoh.com/uploads/3/2/3/0/3230294/10_drug_list.pdf

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Welcome to NGC. Skip directly to:,,. Brief Summary GUIDELINE TITLE Evidence-based guidelines for the management of Lyme disease. BIBLIOGRAPHIC SOURCE(S) Evidence-based guidelines for the management of Lyme disease. Expert Rev Anti Infect Ther 2004;2(1 Suppl):S1-13. [66references] GUIDELINE STATUS This is the current release of the guideline. ** REGULATORY ALERT ** FDA WARNIN

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