generic formulary copay · calcipotriene (cream/ointment/solution) $10 candesartan $10 captopril...
TRANSCRIPT
Drugs NOT listed here will either be: (1) Non-formulary copay of $40+10% coinsurance or
GENERIC FORMULARY Copay
Abacavir $10
Abacavir/Lamivudine $10
Acetaminophen/Codeine $10
Acyclovir (Tablets/Capsules/Ointment/Cream) $10
Adefovir (Tablet) $10
Albuterol (Metered Dose Inhalers/Tablets/Syrup/Nebules) $10
Alendronate Sodium $10
Alfuzosin $10
Allopurinol $10
Alprazolam IR/ER $10
Amiodarone $10
Amitriptyline $10
Amlodipine $10
Amlodipine/Benzapril $10
Amoxicillin $10
Amoxicillin/Clavulanate $10
Amphetamine Salts $10
Aripiprazole $10
Ampicillin $10
Atazanavir $10
Atenolol $10
Atomoxetine $10
Atorvastatin $10
Azathioprine $10
Azithromycin (Tablet/Powder Suspension) $10
Baclofen $10
Benazepril $10
Benzonatate $10
Benzoyl Peroxide/Clindamycin $10
Benzoyl Peroxide/Eythromycin $10
Betamethasone Dipropionate $10
Betamethasone Valerate (Lot/Cream/Ointment/Foam) $10
Brimonidine $10
Bromocriptine $10
Budesonide (Respules/Nasal Spray) $10
Bupropion IR/SR/XL $10
CampusCare Drug Formulary for Summer Semester (Effective 5/18/2020- 8/15/2020)
Formulary Generics drugs are $10
Formulary Brand drugs are $20
(2) Not covered or excluded by plan
See the Certificate of Coverage for further explanation of your prescription coverage
Buspirone $10
Butalbital/Acetaminophen/Caffeine 50/325/40 $10
Cabergoline $10
Calcipotriene (Cream/Ointment/Solution) $10
Candesartan $10
Captopril $10
Carbamazepine IR/ER $10
Carbidopa/Levodopa $10
Cefadroxil $10
Cefpodoxime $10
Cephalexin $10
Chlorzoxazone $10
Cholestyramine $10
Ciprofloxacin (Tablet/Ophthalmic) $10
Citalopram $10
Claravis (Branded Generic for Accutane) $10
Clindamycin (Oral/Topical Gel/Lotion/Solution/Vag Cream) $10
Clonazepam $10
Clonidine (Tablets Only) $10
Clopidogel $10
Clotrimazole/Betamethasone $10
Colchicine $10
Cromolyn Nebules $10
Cyclobenzaprine $10
Delestrogen (Injection) $10
Desvenlafaxine $10
Dex/Neo/Poly 0.1% (Ophthalmic Suspension/Ointment) $10
Dextroamphetamine $10
Dexamethasone $10
Diazepam $10
Diclofenac DR/ER (Not Topical) $10
Dicloxacillin $10
Dicyclomine $10
Diflorasone (Cream) $10
Digoxin $10
Diltiazem $10
Diphenoxylate/Atropine $10
Divalproex $10
Dorzolamide/Timolol $10
Doxazosin $10
Doxycycline $10
Duloxetine $10
Econazole (Cream) $10
Efavirenz $10
Eletriptan $10
Enalapril $10
Enoxaparin (Injection) $10
Epinastine $10
Epinepherine (0.3g/0.15mg) (Jr) (Injection) $10
Erythromycin (Oral/Topical) $10
Erythromycin Ethylsuccinate $10
Escitalopram $10
Estradiol (Oral Tablets/Injection/Topical Patches) $10
Etodolac $10
Ezetimibe $10
Ezetimibe/Simvastatin $10
Famciclovir $10
Felodipine $10
Fenofibrate $10
Finasteride (5mg Only) (1mg is Excluded From Coverage) $10
Fluconazole (Tablets/Oral Suspension) $10
Fluocinolone $10
Fluticasone/Salmeterol (Diskus/Inhaler) $10
Fluoxetine $10
Fluvoxamine $10
Fosamprenavir $10
Furosemide $10
Gabapentin $10
Galantamine (Tablet) $10
Gemfibrozil $10
Gentamycin (Ophthalmic) $10
Glipizide $10
Glyburide $10
Glyburide/Metformin $10
Glycopyrrolate $10
Griseofulvin (Suspension) $10
Griseofulvin (Tabets/Oral Suspension) $10
Haloperidol $10
Hydralazine $10
Hydrochlorothiazide $10
Hydrochlorothiazide/Losartan Potassium $10
Hydrocodone/Acetaminophen $10
Hydrocodone Bitartate/Ibuprofen $10
Hydrocortisone (Topical/Rectal) $10
Hydroxychloroquine $10
Hydroxyzine $10
Hyoscyamine $10
Ibuprofen $10
Imipramine $10
Imiquimod 5% (Cream Only) $10
Indomethacin $10
Isoniazid $10
Isoniazid/Rifampin $10
Isosorbide Dinitrate $10
Isosorbide Mononitrate $10
Itraconazole $10
Ketoconazole (Cream/Shampoo) $10
Ketoconazole (Oral) $10
Ketorolac (Ophthalmic) $10
Labetalol $10
Lactulose $10
Lamivudine $10
Lamotrigine $10
Lansoprazole/Amoxicillin/Clarithromycin $10
Lansoprazole (30mg Only) $10
Latanoprost $10
Levalbuterol $10
Levetiracetam $10
Levodopa/Carbidopa $10
Levofloxacin $10
Levothyroxine $10
Lidocaine (Topical/Oral) $10
Lisinopril $10
Lithium Carbonate/Lithium Citrate $10
Lorazepam $10
Losartan $10
Loxapine $10
Mebendazole $10
Medoxyprogesterone Acetate $10
Mesalamine (Tablets) $10
Metformin IR/ER $10
Methimazole $10
Methotrexate $10
Methyldopa $10
Methylphenidate-Hydrochloride IR/SR/ER (Oral Only) $10
Methylprednisolone $10
Metoclopramide $10
Metolazone $10
Metoprolol IR/XL $10
Metronidazole (Oral/Cream/Lotion/Gel/Vaginal) $10
Minocycline $10
Minoxidil (Oral Only) $10
Mirtazapine $10
Misoprostol $10
Mometasone (Cream/Ointment/Nasal Spray) $10
Montelukast $10
Mupirocin (Ointment/Cream) $10
Myorisan (Branded Generic for Accutane) $10
Mycophenolate $10
Naproxen (375mg/500mg Only) $10
Nefazodone $10
Neomycin/Polymyxn B/Gramicidin (Ophthalmic) $10
Neomycin/Polmyxin/Hydrocortisone 1% Otic $10
Neostigmine Bromide $10
Niacin ER (Tablet) $10
Nifedipine $10
Nitrofurantoin $10
Nitroglycerin $10
Nortriptyline $10
Nystatin (Suspension/Ointment/Cream) $10
Nystatin/Triaminolone (Cream) $10
Ofloxacin $10
Olanzapine $10
Omeprazole (40mg Only) $10
Ondansetron (Tabs/Orally Disinegrating ODT) $10
Oseltamivir $10
Oxcarbazepine $10
Oxybutynin $10
Oxycodone/Acetaminophen $10
Pantoprazole $10
Paroxetine IR/CR $10
Penicillin V Potassium $10
Pentoxifylline $10
Permethrin (Cream) $10
Phenazopyridine $10
Phenobarbital $10
Phenytoin $10
Pimecroliumus $10
Pilocarpine $10
Pindolol $10
Pioglitazone $10
Podofilox (Solution) $10
Polyethylene Glycol-Electrolyte (Solution/Powder) $10
Potassium Chloride (Tablet) $10
Pramipexole $10
Prazosin $10
Prednisolone (Oral/Ophthalmic) $10
Prednisone $10
Prenatal Vitamins with Folic Acid $10
Primidone $10
Probenecid $10
Procainamide $10
Prochlorperazine $10
Progesterone (Micronized Oral Cap) $10
Promethazine $10
Propranolol (Tabs/Capsules) $10
Propylthiouracil $10
Pyrazinamide $10
Pyridostigmine $10
Quetiapine $10
Quinapril $10
Quinine Sulfate $10
Ramelteon $10
Ramipril $10
Rifampin $10
Risperidone $10
Ritonavir $10
Rivastigmine (Capsules) $10
Rizatriptan $10
Ropinirole $10
Salsalate $10
Selenium Sulfifide 2.25% and 2.5% (Shampoo/Lotion) $10
Sertraline $10
Simvastatin $10
Siroliumus $10
Sorbitol $10
Sotalol $10
Sotret (Branded Generic For Accutane) $10
Spironolactone $10
Spironolactone/HCTZ $10
Sucralfate $10
Sulfacetamide Sodium $10
Sulfacetamide/Prednisolone $10
Sulfadiazine (Tablet) $10
Sulfasalazine $10
Sulindac $10
Sumatriptan $10
Tacrolimus (Capsules/Topical) $10
Tamoxifen $10
Tamsulosin $10
Tenofovir Disoproxil Fumarate $10
Terazosin $10
Terbinafine $10
Terbutaline Sulfate $10
Terconazole $10
Testosterone (Topical/Injection) $10
Theophylline $10
Timolol Maleate 5% GFS (Ophthalmic Solution) $10
Tobramycin 0.3%/Dexamethasone 0.1% $10
Tolterodine $10
Topiramate $10
Tramadol $10
Trazodone $10
Tretinoin $10
Triamcinolone (Topical) $10
Triamterene/Hydrochlorothiazide $10
Trifluridine 1% (Ophthalmic Solution) $10
Trimethoprim/Sulfamethoxazole $10
Trimethoprim/Polymyxin $10
Ursodiol $10
Valacyclovir $10
Valproic Acid (Capsules/Syrup) $10
Valsartan $10
Venlafaxine IR/XR $10
Verapamil $10
Vitamin D (Ergocalciferol D2) $10
Warfarin $10
Ziprasidone $10
Zolpidem $10
BRAND FORMULARY Copay
Depo Testosterone $20
Apidra (Vial/Solostar pen) $20
Arnuity Ellipta (Inhaler) $20
Asmanex (Twisthaler) $20
Atrovent (HFA) $20
Basaglar $20
Ciprodex Otic $20
Cipro HC Otic $20
Coumadin (Exception to Brand alternative) $20
Descovy $20
Emtriva $20
Flovent (HFA) $20
Genvoya $20
Glucagon (1mg Kit) $20
Humalog (Vial/Kwikpen) $20
Humalog Mix 50/50 (Vial/Kwikpen) $20
Humalog Mix 75/25 (Vial/Kwikpen) $20
Humulin 70/30 (Vial/Pen) $20
Humulin N (Vial/Pen) $20
Humulin R $20
Incruse Ellipta $20
Insulins (ALL) $20
Isentress $20
Lantus (Vial/Solostar Pen) $20
Levemir (Vial/Flexpen) $20
Levoxyl (Exception to Brand Alternative) $20
Narcan $20
Novolin 70/30 $20
Novolin N $20
Novolin R $20
NovoLog Mix 70/30 (Vial/Flexpen) $20
NovoLog (Vial/Flexpen) $20
Pred-G (Ophthalmic) $20
Premarin $20
Prempro $20
Prezista $20
Proctofoam HC $20
Pulmicort (Flexhaler) $20
Spiriva $20
Symbicort (Inhaler) $20
Synthroid (Exception to Brand alternative) $20
Tecfidera $20
Tivicay $20
Toujeo $20
Triumeq $20
Truvada $20
Vemlidy $20
Victoza $20
Vyvanse $20
Xarelto $20
OTC Copay
Aspirin (Men age 45-79 years old & Women age 55-79) $0
Folic Acid (0.4mg- 0.8mg) $0
Iron Supplementation (Infants 6-12 months old) $0
Birth Control & Emergency Contraception Copay
Coverage is for Dependents with CampusCare Coverage for Students are under Student Health Service Fee
Generic for Alesse (Tablets) $0
Generic for Ortho-Cyclen (Tablets) $0
Generic for Ortho-tri-cyclen (Tablets) $0
Generic for Ortho Novum7/7/7 (Tablets) $0
Generic for Ortho Novum 1/35 (Tablets) $0
Generic for Micronor (Progesterone Only-Tablets) $0
Generic for Loestrin Fe 1/20 (Tablets) $0
Generic for Depo-Provera (Injection) $0
Generic for Ortho Evra (Patch) $0
Brand for Ortho Tri Cyclen Lo (Tablets) $0
Emergency Contraception (Ella/Plan B/My Way) $0
Nuvaring $0
GENERIC FORMULARY Copay
ACE Inhibitors
Benazepril $10
Captopril $10
Enalapril $10
Lisinopril $10
Quinapril $10Ramipril $10
Acne Agents
Benzoyl Peroxide/Clindamycin $10
Benzoyl Peroxide/Eythromycin $10
Claravis (Branded Generic For Accutane) $10
Clindamycin (Topical Gel/Lotion/Solution) $10
Myorisan (Branded Generic For Accutane) $10
Sotret (Branded Generic For Accutane) $10
Actinic Keratosis
Imiquimod 5% (Cream Only) $10
ADHD Agents
Amphetamine salts $10
Atomoxetine $10
Clonidine (Tablets Only) $10
Dextroamphetamine $10Methylphenidate-Hydrochloride IR/SR/ER (Oral Only) $10
Alzheimer's Agents
DRUGS LISTED BY CLASS
Galantamine (Tablet) $10Rivastigmine (Capsules) $10
Anaphylaxis Treatment Agents
Epinepherine (0.3g/0.15mg) (Jr) (Injection) $10
Androgens
Testosterone (Topical/Injection) $10
Anesthetics
Lidocaine (Topical/Oral) $10
Angiotensin Blockers
Amlodipine/Benzapril $10
Candesartan $10
Hydrochlorothiazide/Losartan Potassium $10
Losartan $10Valsartan $10
Antibiotics
Amoxicillin $10
Amoxicillin/Clavulanate $10
Ampicillin $10
Azithromycin (Tablet/Powder Suspension) $10
Cefadroxil $10
Cefpodoxime $10
Cephalexin $10
Ciprofloxacin (Tablet/Ophthalmic) $10
Clindamycin (Oral/Vag Cream) $10
Dicloxacillin $10
Doxycycline $10
Erythromycin (Oral/Topical) $10
Erythromycin Ethylsuccinate $10
Levofloxacin $10
Metronidazole (Oral/Cream/Lotion/Gel/Vaginal) $10
Minocycline $10
Mupirocin (Ointment/Cream) $10
Nitrofurantoin $10
Ofloxacin $10
Penicillin V Potassium $10
Sulfacetamide Sodium $10
Sulfadiazine (Tablet) $10Trimethoprim/Sulfamethoxazole $10
Anticoagulants
Enoxaparin (Injection) $10Warfarin $10
Anticonvulsants
Carbamazepine IR/ER $10
Clonazepam $10
Diazepam $10
Divalproex $10
Gabapentin $10
Lamotrigine $10
Levetiracetam $10
Oxcarbazepine $10
Phenobarbital $10
Phenytoin $10
Primidone $10
Topiramate $10Valproic Acid (Capsules/Syrup) $10
Antidepressants
Amitriptyline $10
Bupropion IR/SR/XL $10
Citalopram $10
Desvenlafaxine $10
Duloxetine $10
Escitalopram $10
Fluoxetine $10
Fluvoxamine $10
Imipramine $10
Mirtazapine $10
Nefazodone $10
Nortriptyline $10
Paroxetine IR/CR $10
Sertraline $10
Trazodone $10Venlafaxine IR/XR $10
Antiemetic/Antivertigo Agents
Metoclopramide $10
Ondansetron (Tabs/Orally Disinegrating ODT) $10
Prochlorperazine $10Promethazine $10
Antifungals
Clotrimazole/Betamethasone $10
Econazole (Cream) $10
Fluconazole (Tablets/Oral Suspension) $10
Griseofulvin (Suspension) $10
Griseofulvin (Tabets/Oral Suspension) $10
Ketoconazole (Cream/Shampoo) $10
Ketoconazole (Oral) $10
Nystatin (Suspension/Ointment/Cream) $10
Nystatin/Triaminolone (Cream) $10
Selenium Sulfifide 2.25% and 2.5% (Shampoo/Lotion) $10
Terbinafine $10Terconazole $10
Antimyasthenic Agents
Pyridostigmine $10
Antimycobacterials
Isoniazid $10
Isoniazid/Rifampin $10
Pyrazinamide $10Rifampin $10
Antineoplastics
Methotrexate $10Tamoxifen $10
Antiparasitic Agents
Hydroxychloroquine $10
Mebendazole $10Quinine Sulfate $10
Antiparkinson Agents
Bromocriptine $10
Carbidopa/Levodopa $10
Levodopa/Carbidopa $10
Pramipexole $10Ropinirole $10
Antipsoriatics
Calcipotriene (Cream/Ointment/Solution) $10
Antipsychotics
Aripiprazole $10
Haloperidol $10
Loxapine $10
Olanzapine $10
Quetiapine $10
Risperidone $10Ziprasidone $10
Antiretrovirals
Abacavir $10
Abacavir/Lamivudine $10
Atazanavir $10
Efavirenz $10
Fosamprenavir $10
Lamivudine $10
Tenofovir Disoproxil Fumarate $10Ritonavir $10
Antispasticity Agents
Baclofen $10
Antivirals
Acyclovir (Tablets/Capsules/Ointment/Cream) $10
Famciclovir $10
Itraconazole $10
Oseltamivir $10Valacyclovir $10
Anxiolytics
Alprazolam IR/ER $10
Buspirone $10
Clonazepam $10
Hydroxyzine $10Lorazepam $10
Beta-Adrenergic Agents
Albuterol (Metered Dose Inhalers/Tablets/Syrup/Nebules) $10
Fluticasone/Salmeterol (Diskus/Inhaler) $10
Levalbuterol $10Terbutaline Sulfate $10
Beta-Adrenergic Receptor Blocking Agents
Atenolol $10
Labetalol $10
Metoprolol IR/XL $10
Pindolol $10
Propranolol (Tabs/Capsules) $10
Sotalol $10
Bone Resorption Suppression & Related Agents
Alendronate Sodium $10
Benign Prostatic Hyperplasia Agents
Alfuzosin $10
Doxazosin $10
Finasteride (5mg Only) (1mg is Excluded From Coverage) $10
Tamsulosin $10Terazosin $10
Bipolar Agents
Lithium Carbonate/Lithium Citrate $10
Calcium Channel Blockers
Amlodipine $10
Diltiazem $10
Felodipine $10
Nifedipine $10
Prazosin $10Verapamil $10
Cardiovascular Agents
Amiodarone $10
Digoxin $10
Hydralazine $10
Isosorbide Dinitrate $10
Isosorbide Mononitrate $10
Methyldopa $10
Minoxidil (Oral Only) $10
Pentoxifylline $10Procainamide $10
Corticosteroids
Betamethasone dipropionate $10
Betamethasone Valerate (Lot/Cream/Ointment/Foam) $10
Diflorasone (Cream) $10
Fluocinolone $10
Hydrocortisone (Topical/Rectal) $10
Triamcinolone (Topical) $10
Cough
Benzonatate $10
Diabetes
Glipizide $10
Glyburide $10
Glyburide/Metformin $10
Metformin IR/ER $10Pioglitazone $10
Diuretics
Furosemide $10
Hydrochlorothiazide $10
Metolazone $10
Sorbitol $10
Spironolactone $10
Spironolactone/HCTZ $10
Triamterene/Hydrochlorothiazide $10
Dysuria
Phenazopyridine $10
Electrolytes, Minerals, & Vitamins
Potassium Chloride (Tablet) $10
Prenatal Vitamins with Folic Acid $10Vitamin D (Ergocalciferol D2) $10
Gastrointestinal Agents
Dicyclomine $10
Diphenoxylate/Atropine $10
Glycopyrrolate $10
Hyoscyamine $10
Lansoprazole/Amoxicillin/Clarithromycin $10
Misoprostol $10
Polyethylene Glycol-Electrolyte (Solution/Powder) $10
Sucralfate $10Ursodiol $10
Genital warts
Podofilox (Solution) $10
Glucocorticoids
Methylprednisolone $10
Prednisolone (Oral) $10Prednisone $10
Gout
Allopurinol $10
Colchicine $10Probenecid $10
Hepatitis B
Adefovir (Tablet) $10Lamivudine $10
Hormonal Agents, Suppressant
Cabergoline $10
Medoxyprogesterone Acetate $10
Methimazole $10Propylthiouracil $10
Hormones-estrogens
Delestrogen (Injection) $10Estradiol (Oral Tablets/Injection/Topical Patches) $10
Immunosuppressive Agents
Azathioprine $10
Methotrexate $10
Mycophenolate $10
Pimecroliumus $10
Siroliumus $10Tacrolimus (Capsules/Topical) $10
Inhaled Anticholinergics
Fluticasone/Salmeterol (Diskus/Inhaler) $10
Insomnia agents
Ramelteon $10
Zolpidem $10
Laxatives
Lactulose $10
Leukotriene Anatagonists
Montelukast $10
Lice Treatment
Permethrin (Cream) $10
Lipotropics
Atorvastatin $10
Cholestyramine $10
Ezetimibe $10
Ezetimibe/Simvastatin $10
Fenofibrate $10
Gemfibrozil $10
Niacin ER (Tablet) $10Simvastatin $10
Migraine
Eletriptan $10
Rizatriptan $10Sumatriptan $10
Miscellaneous
Neostigmine Bromide $10
Musculoskeletal Therapy Agents
Chlorzoxazone $10Cyclobenzaprine $10
Nasal Steroids
Budesonide (Respules/Nasal Spray) $10Mometasone (Cream/Ointment/Nasal Spray) $10
Nitrates
Nitroglycerin $10
NSAIDs-Nonsteroidal anti-inflammatory drugs
Diclofenac DR/ER (Not Topical) $10
Etodolac $10
Ibuprofen $10
Indomethacin $10
Naproxen (375mg/500mg Only) $10
Salsalate $10Sulindac $10
Opioids
Acetaminophen/Codeine $10
Butalbital/Acetaminophen/Caffeine 50/325/40 $10
Hydrocodone/Acetaminophen $10
Hydrocodone Bitartate/Ibuprofen $10
Oxycodone/Acetaminophen $10Tramadol $10
Ophthalmics
Brimonidine $10
Ciprofloxacin (Tablet/Ophthalmic) $10
Dexamethasone $10
Dex/Neo/Poly 0.1% (Ophthalmic Suspension/Ointment) $10
Dorzolamide/Timolol $10
Epinastine $10
Gentamycin (Ophthalmic) $10
Ketorolac (Ophthalmic) $10
Latanoprost $10
Ofloxacin $10
Pilocarpine $10
Prednisolone (Ophthalmic) $10
Sulfacetamide Sodium $10
Sulfacetamide/Prednisolone $10
Timolol Maleate 5% GFS (Ophthalmic Solution) $10
Tobramycin 0.3%/Dexamethasone 0.1% $10
Trifluridine 1% (Ophthalmic Solution) $10Trimethoprim/Polymyxin $10
Otic
Neomycin/Polmyxin/Hydrocortisone 1% Otic $10
Neomycin/Polymyxn B/Gramicidin (Ophthalmic) $10
Ofloxacin $10
Platelet Aggregation Inhibitors
Clopidogel $10
Progesterone/Hydroxyprogesterone
Progesterone (Micronized Oral Cap) $10
Proton Pump Inhibitors
Lansoprazole (30mg Only) $10
Omeprazole (40mg Only) $10Pantoprazole $10
Respiratory Agents
Cromolyn Nebules $10Theophylline $10
Retinoids
Tretinoin $10
Thyroid Supplements
Levothyroxine $10
Ulcerative Colitis
Mesalamine (Tablets) $10Sulfasalazine $10
Urinary Incontinence
Oxybutynin $10
Tolterodine $10
BRAND FORMULARY Copay
ADHD Agents/Stimulants
Vyvanse $20
Androgens
Depo Testosterone $20
Anticoagulants
Coumadin (Exception to Brand Alternative) $20Xarelto $20
Antiretrovirals
Descovy $20
Emtriva $20
Genvoya $20
Isentress $20
Prezista $20
Tivicay $20
Triumeq $20
Truvada $20Vemlidy $20
Diabetes
Glucagon (1mg Kit) $20
Victoza $20
Hemorrhoids Treatment
Proctofoam HC $20
Hormone Replacement Therapy
Premarin $20Prempro $20
Inhaled Anticholinergics
Atrovent (HFA) $20Spiriva $20
Inhaled Long-Acting Muscarinic Antagonist
Incruse Ellipta $20
Inhaled Steroids
Arnuity Ellipta (Inhaler) $20
Asmanex (Twisthaler) $20
Flovent (HFA) $20
Pulmicort (Flexhaler) $20Symbicort (Inhaler) $20
Insulins
Apidra (Vial/Solostar pen) $20
Basaglar $20
Humalog (Vial/Kwikpen) $20
Humalog Mix 50/50 (Vial/Kwikpen) $20
Humalog Mix 75/25 (Vial/Kwikpen) $20
Humulin 70/30 (Vial/Pen) $20
Humulin N (Vial/Pen) $20
Humulin R $20
Insulins (ALL) $20
Lantus (Vial/Solostar Pen) $20
Levemir (Vial/Flexpen) $20
Novolin 70/30 $20
Novolin N $20
Novolin R $20
NovoLog Mix 70/30 (Vial/Flexpen) $20
NovoLog (Vial/Flexpen) $20Toujeo $20
Multiple Sclerosis Agents
Tecfidera $20
Opioid Overdose Emergency Agent
Narcan $20
Ophthalmics
Pred-G (Ophthalmic) $20
Otic
Ciprodex Otic $20Cipro HC Otic $20
Thyroid Supplements
Levoxyl (Exception to Brand Alternative) $20
Synthroid (Exception to Brand Alternative) $20
Birth Control & Emergency Contraception Copay
Coverage is for Dependents with CampusCare Coverage for Students are under Student Health Service Fee
Generic for Alesse (Tablets) $0
Generic for Ortho-Cyclen (Tablets) $0
Generic for Ortho-tri-cyclen (Tablets) $0
Generic for Ortho Novum7/7/7 (Tablets) $0
Generic for Ortho Novum 1/35 (Tablets) $0
Generic for Micronor (Progesterone Only-Tablets) $0
Generic for Loestrin Fe 1/20 (Tablets) $0
Generic for Depo-Provera (Injection) $0
Generic for Ortho Evra (Patch) $0
Brand for Ortho Tri Cyclen Lo (Tablets) $0
Emergency Contraception (Ella/Plan B/My Way) $0
Nuvaring $0
OTC Copay
Aspirin (Men age 45-79 years old & Women age 55-79) $0
Folic Acid (0.4mg- 0.8mg) $0
Iron Supplementation (Infants 6-12 months old) $0
(2) Not covered or excluded by plan
See the Certificate of Coverage for further explanation of your prescription coverage