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Formulary

200+ Drugs Available at Zero Co-pay

GCN Drug Description Max Quantity per fill Category
Retail Mail Order
45155 Acetaminophen with Codeine 120mg-12mg/5 Solution 6 18 Cold
9630 Acyclovir 200mg capsule 25 75 Asthma
5032 Albuterol Sulfate Syrup 2mg/5mL Syrup 1 3 Cold
47381 Alendronate Sodium 35mg tablet 4 12 Womens Health
2535 Allopurinol 100mg tablet 30 90 Gout
3774 Alprazolam 0.5mg tablet 30 90 Mental Health
3775 Alprazolam 1mg tablet 30 90 Mental Health
16927 Amlodipine 10mg tablet 30 90 BP
16925 Amlodipine 2.5mg tablet 30 90 BP
16926 Amlodipine 5mg tablet 30 90 BP
Amlodipine Besylate 10mg tablet 30 90 BP
Amlodipine Besylate 2.5mg tablet 30 90 BP
Amlodipine Besylate 5mg tablet 30 90 BP
50519 Amlodipine Besylate/Benazepril 10mg-20mg capsule 30 90 BP
23770 Amlodipine Besylate/Benazepril 2.5mg-10mg capsule 30 90 BP
60722 Amlodipine Besylate/Benazepril 5mg-40mg capsule 30 90 BP
8997 Amoxicillin 125mg-5mL suspension for reconstitution 1 3 Cold
42684 Amoxicillin 200mg/5mL suspension for reconstitution 1 3 Cold
8995 Amoxicillin 250mg 10 30 Cold
8998 Amoxicillin 250mg/5mL suspension for reconstitution 1 3 Cold
42683 Amoxicillin 400mg/5mL suspension for reconstitution 1 3 Cold
8996 Amoxicillin 500mg 10 30 Cold
26720 Amoxicillin/Potassium Clav 200mg-28.5mg/5mL suspension for reconstitution 1 3 Cold
25898 Amoxicillin/Potassium Clav 400-57mg/5mL suspension for reconstitution 1 3 Cold
4376 Aspirin 325mg tablet 10 30 Pain
15864 Atenolol 25mg tablet 30 90 BP
5139 Atenolol 50mg tablet 30 90 BP
29967 Atorvastatin Calcium 10mg tablet 30 90 Cholesterol
29968 Atorvastatin Calcium 20mg tablet 30 90 Cholesterol
4680 Baclofen 20mg tablet 30 90 Pain
46236 Bupropion 75mg Tablet 1 3 Pain
4557 Carbamazepine 100mg/5mL suspension 1 3 Diabetic
48963 Carbinoxamine Maleate 4mg/5mL liquid 1 3 Allergy
4663 Carisoprodol 350mg tablet 30 90 Pain
19293 Carvedilol 25mg tablet 30 90 BP
9043 Cephalexin 500mg capsule 10 30 AntiBiotics
9042 Cephalexin 500mg capsule 10 30 AntiBiotics
21687 Cetirizine HCL 1mg/mL Solution 1 3 Allergy
17037 Cetirizine HCL 10mg tablet 30 90 Allergy
3734 Chlodiazepoxide HCL 10mg capsule 15 45 Mental health
3736 Chlodiazepoxide HCL 5mg capsule 15 45 Mental health
39551 Ciprofloxacin HCL 250mg/5mL suspension, Microcapsule Recon 45 135 AntiBiotics
46203 Citalopram Hydrobromide 20mg tablet 30 90 Mental Health
Clindamycin Phosphate/D5W 300mg/50mL Piggyback 30 90 AntiBiotics
4560 Clonazepam 0.5mg tablet 30 90 Mental Health
4561 Clonazepam 1mg tablet 30 90 Mental Health
4562 Clonazepam 2mg tablet 30 90 Mental Health
346 Clonidine HCL 0.1mg tablet 30 90 BP
347 Clonidine HCL 0.2mg tablet 30 90 BP
38164 Clopidogrel Bisulfate 75mg tablet 30 90 BP
4681 Cyclobenzaprine HCL 10mg tablet 30 90 Pain
4010 Cyproheptadine HCL 2mg/5mL Syrup 30 90 Allergy
6784 Dexamethasone 0.5mg tablet 30 90 Corticosteroid
6780 Dexamethasone 0.5mg/5mL Elixir 30 90 Corticosteroid
3766 Diazepam 10mg tablet 30 90 Mental Health
3767 Diazepam 2mg tablet 30 90 Mental Health
3768 Diazepam 5mg tablet 30 90 Mental Health
4918 Dicyclomine HCL 10mg capsule 30 90 Gastrointestinal
4924 Dicyclomine HCL 20mg tablet 30 90 Gastrointestinal
11583 Diphenydramine HCL 50mg capsule 30 90 Allergy
46092 Doxepin HCL 10mg/mL concentrate 30 90 Insomnia
46214 Fluoxetine HCL 20mg capsule 1 3 Mental Health
2366 Floci Acid 1mg tablet 30 90 Womens Health
8206 Furosemide 10mg/mL Solution (oral) 30 90 BP
8208 Furosemide 20mg tablet 30 90 BP
8209 Furosemide 40mg tablet 30 90 BP
21413 Gabapentin 100mg capsule 30 90 Pain
21414 Gabapentin 300mg capsule 30 90 Pain
25180 Glimepiride 2mg tablet 30 90 Diabetes
25181 Glimepiride 4mg tablet 30 90 Diabetes
43463 Glipizide 2.5mg tablet 24-Hour ER 30 90 Diabetes
1777 Glipizide 5mg tablet 30 90 Diabetes
21840 Glipizide 5mg tablet 24-Hour ER 30 90 Diabetes
1773 Glyburide 1.25mg tablet 30 90 Diabetes
16665 Glyburide, micronized 1.5mg tablet 15 45 Diabetes
16666 Glyburide, micronized 3mg tablet 15 45 Diabetes
761 Guaifenesin 200mg tablet 10 30 Cold
22210 Guaifenesin Liquid 100mg /5mL 1 3 Cold
652 Guaifenesin/Dextromethorphan 100-10mg/5 liquid 1 3 Cold
284 Hydralazine HCL 10mg tablet 30 90 BP
286 Hydralazine HCL 25mg tablet 30 90 BP
8182 Hydrochlorothiazide 25mg tablet 30 90 BP
8183 Hydrochlorothiazide 50mg tablet 30 90 BP
7545 Hydrocortisone 2.5% CREAM 1 3 Pain
6705 Hydrocortisone 5mg tablet 30 90 Pain
0.04 Hydroxyzine HCL 10mg/5mL Solution 1 3 Allergy
3729 Hydroxyzine HCL 50mg tablet 20 60 Allergy
3731 Hydroxyzine Pamoate 25mg capsule 20 60 Allergy
3732 Hydroxyzine Pamoate 50mg capsule 20 60 Allergy
12080 Ibuprofen 100mg/5mL suspension 1 3 Pain
8346 Ibuprofen 200mg tablet 20 60 Pain
8348 Ibuprofen 400mg tablet 20 60 Pain
46068 Imipramine HCL 10mg tablet 30 90 Mental Health
8336 Indomethacin 25mg capsule 20 60 Pain
48018 Ipratropium/Albuterol Sulfate 0.5-3mg/3 Solution for Nebulization 90 180 COPD
44905 Iron PS CMPLX/VIT B12/FA 150-25-1 capsule 30 90 Anemia
9544 Ketoconazole 200mg tablet 20 60 Antifungal
39500 Ketorolac Tromethamine 30mg/mL(1) Solution 1 3 Pain
3143 Lactulose 10g/15mL (15 mL) Solution 1 3 Laxative
Lactulose 20g/30mL Solution 1 3 Laxative
22551 Lamotrigine 200mg tablet 30 90 Mental Health
17872 Lamotrigine 25mg tablet 30 90 Mental Health
44632 Levetiracetam 250mg tablet 30 90 Mental health
6655 Levothyroxine Sodium 175 MCG tablet 15 45 Thyroid
6648 Levothyroxine Sodium 25 MCG tablet 15 45 Thyroid
3411 Lidocaine HCL 2% Solution 1 3 Pain
Lidocaine HCL 5mg/mL Solution 30 90 Pain
Lidocaine HCL/Epinephrine 2%-1:100K Solution 20 60 Pain
Lidocaine HCL/Epinephrine BIT 2%-1:100K CARTRIDGE 30 90 Pain
Lidocaine HCL/PF 10mg/mL Solution 5 15 Pain
390 Lisinopril 10mg tablet 30 90 BP
17266 Lisinopril 2.5mg tablet 30 90 BP
391 Lisinopril 20mg tablet 30 90 BP
392 Lisinopril 40mg tablet 30 90 BP
393 Lisinopril 5mg tablet 30 90 BP
389 Lisinopril/Hydrochlorothiazide 20mg-25mg tablet 30 90 BP
388 Lisinopril/Hydrochlorothiazide 20mg-12.5mg tablet 30 90 BP
4000 Lithium Corbonate 150mg capsule 30 90 Mental Health
4001 Lithium Corbonate 300mg capsule 30 90 Mental Health
4004 Lithium Corbonate 300mg tablet ER 30 90 Mental Health
4002 Lithium Corbonate 600mg capsule 30 90 Mental Health
3757 Lorazepam 0.5mg tablet 30 90 Mental Health
3758 Lorazepam 1mg tablet 30 90 Mental Health
38686 Losartan Potassium 100mg tablet 30 90 BP
23381 Losartan Potassium 25mg tablet 30 90 BP
23382 Losartan Potassium 50mg tablet 30 90 BP
40923 Losartan/Hydrochlorothiazide 100mg-25mg tablet 30 90 BP
59919 Losartan/Hydrochlorothiazide 100mg-12.5mg tablet 30 90 BP
23465 Losartan/Hydrochlorothiazide 50mg-12.5mg tablet 30 90 BP
4731 Meclizine HCL 12.5mg tablet 20 60 Cold
4732 Meclizine HCL 25mg tablet 20 60 Cold
3272 Medroxyprogesterone Acetate 2.5mg tablet 30 90 Womens Health
29157 Meloxicam 15mg tablet 30 90 Pain
29156 Meloxicam 7.5mg tablet 30 90 Pain
13318 Metformin HCL 500mg tablet 30 90 Diabetes
46754 Metformin HCL ER 500mg tablet 24-Hour ER 30 90 Diabetes
4240 Methadone HCL 10mg tablet 30 90 Mental Health
50631 Metoprolol Tartrate 25mg tablet 30 90 BP
38451 Montelukast Sodium 10mg tablet 30 90 Allergy
21980 Naproxen Sodium 220mg tablet 30 90 Pain
46060 Nortriptyline HCL 25mg capsule 30 90 Mental health
46062 Nortriptyline HCL 75mg capsule 30 90 Mental Health
50289 Olmesartan Medoxomil 20mg tablet 30 90 BP
50290 Olmesartan Medoxomil 40mg tablet 30 90 BP
43136 Omeprazole 10mg capsule DR/EC 30 90 Gastrointestinal
33530 Omeprazole 20mg capsule DR/EC 30 90 Gastrointestinal
43137 Omeprazole 40mg capsule DR/EC 30 90 Gastrointestinal
13467 Oxycodone HCL 10mg tablet 30 90 Pain
27462 Pantoprazole Sodium 40mg tablet DR/EC 30 90 Gastrointestinal
46222 Paroxetine HCL 10mg tablet 30 90 Mental Health
46223 Paroxetine HCL 20mg tablet 30 90 Mental Health
46224 Paroxetine HCL 30mg tablet 30 90 Mental Health
46225 Paroxetine HCL 40mg tablet 30 90 Mental Health
5170 Phendimetrazine Tartrate 35mg tablet 30 90 Weight loss
6748 Prednisone 1mg tablet 30 90 Pain
6750 Prednisone 2.5mg tablet 30 90 Pain
6751 Prednisone 20mg tablet 30 90 Pain
6753 Prednisone 5mg tablet 30 90 Pain
3876 Promethazine HCL 6.25mg/5mL Syrup 30 90 Gastrointestinal
48489 Promethazine HCL/Codeine 6.25mg-10mg/5mL Syrup 30 90 Gastrointestinal
48493 Promethazine/Dextromethorphan 6.25mg-15mg/5mL Syrup 30 90 Gastrointestinal
5089 Pseudoephedrine HCL 30mg tablet 10 90 Cold
46229 Sertraline HCL 100mg tablet 30 90 Mental Health
46227 Sertraline HCL 25mg tablet 30 90 Mental Health
46228 Sertraline HCL 50mg tablet 30 90 Mental Health
16577 Simvastatin 10mg tablet 30 90 Chlesterol
16578 Simvastatin 20mg tablet 30 90 Chlesterol
16579 Simvastatin 40mg tablet 30 90 Chlesterol
6817 Spironolactone 25mg tablet 30 90 BP
9396 Sulfamethoxazole/Trimethoprim 800-160mg tablet 10 30 Cold
22649 Terazosin HCL 1mg capsule 30 90 BP
22652 Terazosin HCL 10mg capsule 30 90 BP
22650 Terazosin HCL 2mg capsule 30 90 BP
22651 Terazosin HCL 5mg capsule 30 90 BP
27447 Tizanidine HCL 2mg tablet 30 90 Pain
30274 Tizanidine HCL 4mg tablet 30 90 Pain
23139 Tramadol HCL 50mg tablet 30 90 Pain
46241 Trazodone HCL 50mg tablet 30 90 Insomnia
Triamcinolone Acetonide 0.5% ointment 1 3 Psoriasis
8176 Triamterene/Hydrochlorothiazide 37.5/25mg tablet 30 90 BP
3694 Triazolam 0.25mg tablet 30 90 Sleep
50805 Valsartan 40mg tablet 30 90 BP
38925 Valsartan/Hydrochlorothiazide 160mg-12.5mg tablet 30 90 BP
50256 Valsartan/Hydrochlorothiazide 160mg-25mg tablet 30 90 BP
60780 Valsartan/Hydrochlorothiazide 320mg-25mg tablet 30 90 BP
37354 Valsartan/Hydrochlorothiazide 80mg-12.5mg tablet 30 90 BP
564 Verapamil HCL 120mg tablet 30 90 BP
565 Verapamil HCL 40mg tablet 30 90 BP
14198 Warfarin Sodium 1mg tablet 30 90 BP
18080 Warfarin Sodium 3mg tablet 15 45 BP

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