Tier 1 CO-PAY MEDICATION LIST
Tier 1 CO-PAY MEDICATION LIST 2020
Arthritis & Pain
Aspirin buffered tablet Aspirin chewable tablet Aspirin enteric coated tablet Allopurinol tablet Celecoxib capsule Diclofenac tablet Ibuprofen tablet Meloxicam tablet Naproxen tablet
Blood Thinners & Platelet Inhibitors
Clopidogrel Bisulfate tablet Warfarin Sodium tablet
Bone Health
Alendronate tablet
Cholesterol
Atorvastatin tablet Gemfibrozil tablet Lovastatin tablet Pravastatin tablet Rosuvastatin CA tablet Simvastatin tablet
Dementia
Donepezil tablet
Diabetes
Glimepiride tablet Glipizide tablet Metformin HCL tablet
Diabetes (cont.)
Metformin HCL 24hr (SA) tablet Pioglitazone HCL tablet
Dizziness (Vertigo)
Meclizine HCL tablet Meclizine HCL chewable tablet
Electrolyte Supplement
Potassium SA tablet Potassium SA Dispersible tablet
Gastrointestinal Health
Omeprazole EC capsule Pantoprazole Sodium EC capsule Ranitidine tablet
Glaucoma & Eye Care
Diclofenac 0.1% solution Dorzolamide 2%/Timolol 0.5% sol Latanoprost 0.005% solution PEG-400 0.4%/Propylene Glycol
0.3% solution
Heart Health & Blood Pressure
Amlodipine tablet Amiodarone HCL tablet Aspirin (see Arthritis & Pain) Atenolol tablet Benazepril tablet Carvedilol tablet
Tier 1 CO-PAY MEDICATION LIST 2020
Heart Health & Blood Pressure (cont.)
Chlorthalidone tablet Clonidine tablet Diltiazem 24HR capsule Diltiazem HCL tablet Enalapril Maleate tablet Furosemide tablet Hydrochlorothiazide cap/tab Hydrochlorothiazide/Lisinopril tablet Hydrochlorothiazide/Losartan tablet Hydrochlorothiazide/Triamterene cap/tab Isosorbide Mononitrate SA tablet Lisinopril tablet Losartan tablet Metoprolol Succinate SA tablet Metoprolol Tartrate tablet Nifedipine SA tablet Nitroglycerin sublingual tablet Prazosin HCL capsule Propranolol HCL tablet Spironolactone tablet Verapamil HCL tablet Verapamil HCL SA tablet
Mental Health
Amitriptyline HCL tablet Bupropion HCL tablet Bupropion HCL SA (12HR-SR) tablet Bupropion HCL SA (24HR-XL) tablet Citalopram Hydrobromide tablet Duloxetine HCL EC capsule Escitalopram Oxalate tablet Fluoxetine cap/tab Lithium Carbonate cap/tab
Mental Health (cont.)
Mirtazapine tablet Paroxetine HCL tablet Sertraline HCL tablet Trazodone tablet
Respiratory Condition
Montelukast NA tablet
Seizures
Gabapentin cap/tab Lamotrigine tablet Topiramate tablet
Thyroid Conditions
Levothyroxine Sodium tablet
Urologic (Bladder & Prostate) Health
Alfuzosin HCL SA tablet Doxazosin Mesylate tablet Finasteride tablet Sildenafil tablet Tamsulosin HCL capsule Terazosin HCL capsule
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