Prescription Advantage Program Drug List for 2021

Tier I: $9 / 30 and $16 / 90 Tier II: $75 / per unit dose Antiviral Gastrointestinal Health Men's Health Heart Health & Blood Pressure Acyclovir 200mg capsule Famotidine 20mg tablet Finasteride 5mg tablet Eliquis 2.5mg tablet- 60ct Acyclovir 400mg capsule Famotidine 40mg tablet Mental & Neuro Health Eliquis 5mg tablet- 60ct Arthritis & Pain Treatments Omeprazole 20mg capsule Amitriptyline 10mg tablet Xarelto 10mg tablet- 30ct Allopurinol 100mg tablet Omeprazole 40mg capsule Buspirone 10mg tablet Xarelto 20mg tablet- 30ct Allopurinol 300mg tablet Ondansetron 4mg tablet Citalopram 10mg tablet Diabetes Treatments Cyclobenzaprine 10mg tablet Pantoprazole 40mg tablet Citalopram 20mg tablet Humalog Vial 100unit/ml- 10ml Gabapentin 300mg capsule Heart Health & Blood Pressure Citalopram 40mg tablet Naloxone Ibuprofen 600mg tablet Amlodipine 2.5mg tablet Escitalopram 10mg tablet Naloxone 2mg/2ml- 4ml kit Meloxicam 7.5mg tablet Amlodipine 5mg tablet Fluoxetine 10mg capsule Respiratory Meloxicam 15mg tablet Amlodipine 10mg tablet Fluoxetine 20mg capsule Fluticasone-Salmeterol 100-50 Cholesterol Treatments Atenolol 25mg tablet Hydroxyzine 25mg tablet Fluticasone-Salmeterol 250-50 Atorvastatin 10mg tablet Atenolol 50mg tablet Lamotrigine 25mg tablet Fluticasone-Salmeterol 500-50 Atorvastatin 40mg tablet Atenolol 100mg tablet Lamotrigine 100mg tablet Ventolin HFA Lovastatin 10mg tablet Carvedilol 25mg tablet Mirtazapine 15mg tablet Lovastatin 20mg tablet Clonidine 0.1mg tablet Mirtazapine 30mg tablet Lovastatin 40mg tablet Clonidine 0.2mg tablet Paroxetine 10mg tablet Simvastatin 10mg tablet Clopidogrel 75mg tablet Paroxetine 20mg tablet Simvastatin 20mg tablet Furosemide 20mg tablet Sertraline 25mg tablet Simvastatin 40mg tablet Hydrochlorothiazide 12.5mg capsule Sertraline 50mg tablet Simvastatin 80mg tablet Hydrochlorothiazide 25mg tablet Sertraline 100mg tablet Diabetes Treatments Hydrochlorothiazide 50mg tablet Topiramate 25mg tablet Glimepiride 1mg tablet Isosorbide Mononitrate 20mg Topiramate 50mg tablet Glimepiride 2mg tablet Lisinopril 2.5mg tablet Topiramate 100mg tablet Glimepiride 4mg tablet Lisinopril 5mg tablet Trazodone 50mg tablet Glipizide 5mg tablet Lisinopril 10mg tablet Trazodone100mg tablet Glipizide 10mg tablet Lisinopril 20mg tablet Skin Conditions Glyburide 2.5mg tablet Lisinopril 30mg tablet Hydrocortisone 2.5% ointment 20gm Metformin 500mg tablet Lisinopril 40mg tablet Triamcinolone 0.1% ointment 15gm Metformin 850mg tablet Lisinopril-HCTZ 20-12.5mg tablet Triamcinolone 0.1% cream 15gm Metformin 1000mg tablet Lisinopril-HCTZ 20-25mg tablet Women's Health Meftormin ER 500mg tablet Losartan 25mg tablet Estradiol 1mg tablet Eye Care Losartan 50mg tablet Prenatal Plus 27-1mg tablet Timolol 0.25% 5ml Losartan 100mg tablet Folic Acid 1mg Timolol 0.5% 5ml Metoprolol Tartrate 25mg tablet Tobramycin 0.3% 5ml Metoprolol Tartrate 50mg tablet Fluoride Treatments Spirololactone 25mg Sodium Fluoride 0.5mg Triamterene HCTZ 37.5-25mg tablets Sodium Fluoride 1mg Warfarin 2.5mg tablet Warfarin 5mg tablet