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Lifestyle members enjoy additional out-of-pocket savings for common generic medications with a $1 copay!

prescription benefits overviewTIER 1 GENERIC MEDICATION FORMULARY

As a unique feature of our Lifestyle Health Plans Rx Program, the generic medications listed below are now available for a $1 copay. Other generic medications, not included on this list or excluded by the Summary Plan Document (SPD), are considered Tier 2 and are available at a low $15 copay.

Formulary Effective Date: 01/01/2017 - 12/31/2017Version: 1st Quarter 2017

Arthritis & Pain Asthma Antibiotics Cont... Antibiotics Cont... Diabetes Cont... Glaucoma & Eye Care Heart Health & Blood Pressure

Allopurinol 100mg tab Albuterol 2mg tab Amoxicillin 200mg/5ml susp (100ml bottle)

SMZ-TMP DS 800mg-160mg tab Metformin 500mg tab Erythromycin op oint-

ment (35gm tube) Atenolol 25mg tab

Allopurinol 300mg tab Albuterol 4mg tab Amoxicillin 250mg/5ml susp (80ml bottle) Metformin 850mg tab Gentak 03% op soln Atenolol 50mg tab

Baclofen 10mg tab Albuterol 2mg/5ml syrup

Amoxicillin 250mg/5ml susp (100ml bottle) Cholesterol Metformin 1000mg tab Gentamicin 03% op soln

(5ml bottle) Atenolol 100mg tab

Cyclobenzaprine 5mg tab

Albuterol 0083% nebu-lizer soln (25x3ml vials)

Amoxicillin 250mg/5ml susp (150ml bottle) Lovastatin 10mg tab Metformin 500mg

ER tab Levobunolol 05% op soln (5ml bottle) Benazepril 5mg tab

Cyclobenzaprine 10mg tab

Albuterol 05% nebulizer soln (20ml bottle)

Amoxicillin 400mg/5ml susp (50ml bottle) Lovastatin 20mg tab Neomycin/Polymyxin/

Dexamethasone Benazepril 10mg tab

Dexamethasone 05mg tab

Ipratropium 002% nebulizer soln (25x25ml vials)

Amoxicillin 400mg/5ml susp (75ml bottle) Gastrointestinal Health 01% op ointment (35gm

tube) Benazepril 20mg tab

Dexamethasone 075mg tab

Amoxicillin 400mg/5ml susp (100ml bottle) Diabetes Dicyclomine 10mg cap Neomycin/Polymyxin/

Dexamethasone Benazepril 40mg tab

Dexamethasone 4mg tab Allergies & Cold and Flu Amoxicillin 250mg cap Glimepiride 1mg tab Dicyclomine 20mg tab 01% op susp (5ml

bottle)† Bisoprolol-HCTZ 25mg-625mg tab

Diclofenac DR 75mg tab Benzonatate 100mg cap Amoxicillin 500mg cap Glimepiride 2mg tab Famotidine 20mg tab Pilocarpine 1% op soln (15ml bottle)

Bisoprolol-HCTZ 5mg-625mg tab

Ibuprofen 100mg/5ml susp Loratadine 10mg tab Cephalexin 250mg cap Glimepiride 4mg tab Lactulose syrup Polymyxin Sulfate/TMP

op soln (10ml bottle) Carvedilol 3125mg tab

Ibuprofen 400mg tab Promethazine DM syrup Cephalexin 500mg cap Glipizide 5mg tab Metoclopramide 10mg tab

Sulfacet Sodium 10% op soln (15ml bottle) Carvedilol 625mg tab

Ibuprofen 600mg tab Ciprofloxacin 250mg tab Glipizide 10mg tab Metoclopramide syrup Timolol Maleate 025% op soln (5ml bottle) Carvedilol 125mg tab

Ibuprofen 800mg tab Antibiotic Treatments Ciprofloxacin 500mg tab Glyburide 25mg tab Promethazine 25mg tab Timolol Maleate 05% op soln (5ml bottle) Carvedilol 25mg tab

Indomethacin 25mg cap Amoxicillin 125mg/5ml susp (80ml bottle) Penicillin VK 250mg tab Glyburide 5mg tab

(blue) Promethazine plain syrup

Tobramycin 03% op soln (5ml bottle) Clonidine 01mg tab

Meloxicam 75mg tab Amoxicillin 125mg/5ml susp (100ml bottle)

Penicillin VK 125mg/5ml susp (100ml bottle)

Glyburide 5mg tab (green) Ranitidine 150mg tab 01% op susp (5ml

bottle) Clonidine 02mg tab

Meloxicam 15mg tab Amoxicillin 125mg/5ml susp (150ml bottle)

Penicillin VK 125mg/5ml susp (200ml bottle)

Glyburide, micronized 3mg tab Ranitidine 300mg tab Enalapril-HCTZ 5mg-

125mg tab

Naproxen 375mg tab Amoxicillin 200mg/5ml susp (50ml bottle)

SMZ-TMP 400mg-80mg tab

Glyburide, micronized 6mg tab Furosemide 20mg tab

Naproxen 500mg tab Amoxicillin 200mg/5ml susp (75ml bottle)

SMZ-TMP DS 800mg-160mg tab Furosemide 40mg tab

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TIER 1 GENERICS

V123116

prescription benefits overviewTIER 1 GENERIC MEDICATION FORMULARY

TIER 1 GENERICS CONT...

Formulary Effective Date: 01/01/2017 - 12/31/2017 Version: 1st Quarter 2017

Heart Health & Blood Pressure Cont...

Heart Health & Blood Pressure Cont...

Heart Health & Blood Pressure Cont... Mental Health Mental Health Viruses Other Medical

Conditions

Furosemide 80mg tab Lisinopril 10mg tab Warfarin 2mg tab Buspirone 5mg tab Prochlorperazine 10mg tab

Levothyroxine 200mcg tab

Chlorhexidine Gluco-nate 012% soln (473ml bottle)

Guanfacine 1mg tab Lisinopril 20mg tab Warfarin 25mg tab Buspirone 10mg tab Trazodone 50mg tab Acyclovir 200mg cap Isoniazid 300mg tab

Hydralazine 10mg tab Methyldopa 250mg tab Warfarin 3mg tab Citalopram 20mg tab Trazodone 100mg tab Megestrol 20mg tab

Hydralazine 25mg tab Metoprolol Tartrate 25mg tab Warfarin 4mg tab Citalopram 40mg tab Trazodone 150mg tab Vitamins & Nutritional

Health Prednisone 25mg tab

Hydrochlorothia-zide(HCTZ)125mg cap

Metoprolol Tartrate 50mg tab Warfarin 5mg tab Fluoxetine 10mg cap Trihexyphenidyl 2mg

tab Folic Acid 1mg tab Prednisone 5mg tab

Hydrochlorothiazide (HCTZ) 25mg tab

Metoprolol Tartrate 100mg tab Warfarin 6mg tab Fluoxetine 10mg tab Mag 64 64mg tab Medroxyprogesterone

Acetate 10mg tab

Hydrochlorothiazide (HCTZ) 50mg tab Sotalol HCL 80mg tab Warfarin 75mg tab Fluoxetine 20mg cap Thyroid Conditions Magnesium Oxide

400mg tab

Naproxen 375mg tab Spironolactone 25mg tab Warfarin 10mg tab Fluoxetine 40mg cap Levothyroxine 25mcg

tab Prenatal Plus qty 30

Indapamide 125mg tab Terazosin 1mg cap Haloperidol 05mg tab Levothyroxine 50mcg tab

Sodium Fluoride 25mg chewable (120ct bottle)

Indapamide 25mg tab Terazosin 2mg cap Men’s Health Haloperidol 1mg tab Levothyroxine 75mcg tab

Isosorbide Mononitrate 30mg ER tab Terazosin 5mg cap Finasteride 5mg Haloperidol 2mg tab Levothyroxine 88mcg

tab Women’s Health

Isosorbide Mononitrate 60mg ER tab Terazosin 10mg cap Haloperidol 5mg tab Levothyroxine 100mcg

tab Estradiol 05mg tab

Lisinopril-HCTZ 10mg-125mg tab

Triamterene-HCTZ 75mg-50mg tab Mental Health Lithium Carbonate

300mg cap Levothyroxine 112mcg tab Estradiol 1mg tab

Lisinopril-HCTZ 20mg-125mg tab

Triamterene-HCTZ 375mg-25mg tab Amitriptyline 50mg tab Nortriptyline 10mg cap Levothyroxine 125mcg

tab Estradiol 2mg tab

Lisinopril-HCTZ 20mg-25mg tab Verapamil 80mg tab Amitriptyline 75mg tab Nortriptyline 25mg cap Levothyroxine 137mcg

tab Medroxyprogestero-neAcetate 25mg tab

Lisinopril 25mg tab Verapamil 120mg tab Amitriptyline 100mg tab Paroxetine 10mg tab Levothyroxine 150mcg

tab Medroxyprogesterone Acetate 5mg tab

Lisinopril 5mg tab Warfarin 1mg tab Benztropine 2mg tab Paroxetine 20mg tab Levothyroxine 175mcg tab

Medroxyprogesterone Acetate 10mg tab

IMPORTANT NOTE: Medications on this list are available in a 30 days supply for the Tier 1 copay. Only the specific strength listed applies to the Tier 1 copay. Any medication with a specific package size listed (e.g., 50ml bottle), is only available in that specific package size for the Tier 1 copay, regardless of the days supply. Our Tier 1 Generic Listing is reviewed and updated quarterly. Only medications that are a federal legend drug will be covered. Some of the medications and categories on this list may NOT be covered by your plan. Their presence on this list does NOT guarantee coverage. Please consult your group’s Summary Plan Document (SPD) for specific information regarding included and excluded medications. In the event of any inconsistency, the SPD will govern. Consult your Lifestyle Health Plans sales representative for more detail on your group’s plan.

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