LOW-COST GENERIC DRUG LIST FOR HOME DELIVERY
The following list includes the generic prescription drugs that are
now only $9 for a 90-day supply through home delivery pharmacy
services from Express Scripts*. If your medications are not on the
list, please ask your doctor if there are alternatives you could use
that are on the list — this may result in a cost savings to you.
Some popular medications on the Low-Cost Generic Drug List
include medications for high blood pressure, high cholesterol,
diabetes, ulcers, osteoporosis, arthritis, asthma and hormone
replacement. This list is subject to change.
The quantities allowed for $9 are based on a manufacturerrecommended 90-day supply. If you are on a lower dosage, you will
pay less than $9; however, if you are on a higher dose, you will pay
more than $9.
Please contact an Express Scripts patient care advocate toll-free
at 866.685.2792 (non-Medicare enrollees) or 888.416.3326
(Medicare enrollees) with any questions. They will also assist in
getting a prescription from your doctor for home delivery.
By choosing medications on this list and using home delivery
pharmacy services from Express Scripts, you can save money and
help STRS Ohio extend the life of your health care program.
MEDICATION TYPE
GENERIC NAME
BRAND NAME
STRENGTH
FORM
QTY ALLOWED PER
$9 COPAYMENT
ARTHRITIS/PAIN (GOUT)
ALLOPURINOL
ZYLOPRIM®
100MG, 300MG
TABLET
90
ARTHRITIS/PAIN
BACLOFEN
LIORESAL®
10MG
TABLET
90
ARTHRITIS/PAIN
IBUPROFEN
MOTRIN®
400MG
TABLET
270
ARTHRITIS/PAIN
IBUPROFEN
MOTRIN®
600MG
TABLET
180
ARTHRITIS/PAIN
IBUPROFEN
MOTRIN®
800MG
TABLET
90
ARTHRITIS/PAIN
INDOMETHACIN
INDOCIN®
25MG
CAPSULE
180
ARTHRITIS/PAIN
MELOXICAM
MOBIC®
7.5MG, 15MG
TABLET
90
ASTHMA
ALBUTEROL
PROVENTIL®
2MG
TABLET
270
ASTHMA
ALBUTEROL
PROVENTIL®
4MG
TABLET
180
ASTHMA/COPD
IPRATROPIUM
ATROVENT®
0.2MG/ML
SOLUTION
225ML
CARDIAC
DIGOXIN
DIGITEK®/LANOXIN®
125MCG, 250MCG
TABLET
90
CARDIAC
DILTIAZEM
CARDIZEM®
120MG
TABLET
90
CARDIAC
DILTIAZEM
CARDIZEM®
30MG, 60MG, 90MG
TABLET
180
CARDIAC/HYPERTENSION
ATENOLOL
TENORMIN®
25MG, 50MG, 100MG
TABLET
90
CARDIAC/HYPERTENSION
ATENOLOL/ CHLORTHALIDONE
TENORETIC®
50-25MG, 100-25MG
TABLET
90
CARDIAC/HYPERTENSION
BENAZEPRIL
LOTENSIN®
5MG, 10MG, 20MG, 40MG
TABLET
90
CARDIAC/HYPERTENSION
BISAPROLOL/HCTZ
ZIAC®
2.5-6.25MG, 5-6.25MG, 10-6.25MG
TABLET
90
CARDIAC/HYPERTENSION
CAPTOPRIL
CAPOTEN®
12.5MG, 25MG, 50MG, 100MG
TABLET
180
CARDIAC/HYPERTENSION
CARVEDILOL
COREG®
3.125MG, 6.25MG, 12.5MG, 25MG
TABLET
180
CARDIAC/HYPERTENSION
CHLORTHALIDONE
HYGROTON®
25MG, 50MG
TABLET
90
CARDIAC/HYPERTENSION
CLONIDINE
CATAPRES®
0.1MG, 0.2MG
TABLET
90
CARDIAC/HYPERTENSION
ENALAPRIL
VASOTEC®
2.5MG, 5MG, 10MG, 20MG
TABLET
90
*Includes services provided by the Medco Pharmacy® and the Express Scripts PharmacySM.
MEDICATION TYPE
GENERIC NAME
BRAND NAME
STRENGTH
FORM
QTY ALLOWED PER
$9 COPAYMENT
CARDIAC/HYPERTENSION
FUROSEMIDE
LASIX®
20MG, 40MG, 80MG
TABLET
90
CARDIAC/HYPERTENSION
GUANFACINE
TENEX®
1MG
TABLET
90
CARDIAC/HYPERTENSION
HYDRALAZINE
APRESOLINE®
10MG, 25MG
TABLET
90
CARDIAC/HYPERTENSION
HYDROCHLOROTHIAZIDE
HYDRODIURIL®
12.5MG
CAPSULE
90
CARDIAC/HYPERTENSION
HYDROCHLOROTHIAZIDE
HYDRODIURIL®
25MG, 50MG
TABLET
90
CARDIAC/HYPERTENSION
LISINOPRIL
PRINIVIL®/ZESTRIL®
2.5MG, 5MG, 10MG, 20MG
TABLET
90
CARDIAC/HYPERTENSION
LISINOPRIL/HCTZ
PRINZIDE®/ ZESTORETIC®
10-12.5MG, 20-12.5MG, 20-25MG
TABLET
90
CARDIAC/HYPERTENSION
METHYLDOPA
ALDOMET®
250MG
TABLET
180
CARDIAC/HYPERTENSION
METHYLDOPA
ALDOMET®
500MG
TABLET
90
CARDIAC/HYPERTENSION
METOPROLOL
LOPRESSOR®
25MG, 50MG, 100MG
TABLET
180
CARDIAC/HYPERTENSION
NADOLOL
CORGARD®
20MG, 40MG
TABLET
90
CARDIAC/HYPERTENSION
PINDOLOL
VISKEN®
5MG, 10MG
TABLET
90
CARDIAC/HYPERTENSION
PRAZOSIN
MINIPRES®
1MG, 2MG, 5MG
CAPSULE
90
CARDIAC/HYPERTENSION
PROPRANOLOL
INDERAL®
10MG, 20MG, 40MG, 80MG
TABLET
180
CARDIAC/HYPERTENSION
SOTALOL
BETAPACE®
80MG
TABLET
90
CARDIAC/HYPERTENSION
SPIRONOLACTONE
ALDACTONE®
25MG
TABLET
90
CARDIAC/HYPERTENSION
TERAZOSIN
HYTRIN®
1MG, 2MG, 5MG, 10MG
CAPSULE
90
CARDIAC/HYPERTENSION
TRIAMTERENE/HCTZ
MAXIDE®
37.5-25MG, 75-50MG
TABLET
90
CARDIAC/HYPERTENSION
VERAPAMIL
CALAN®
80MG, 120MG
TABLET
90
CARDIOVASCULAR
WARFARIN
COUMADIN®
1MG, 2MG, 2.5MG, 3MG, 4MG, 5MG,
6MG, 7.5MG, 10MG
TABLET
90
CHOLESTEROL
LOVASTATIN
MEVACOR®
20MG, 40MG
TABLET
90
CHOLESTEROL
PRAVASTATIN
PRAVACHOL®
10MG, 20MG, 40MG
TABLET
90
DIABETES
CHLORPROPAMIDE
DIABINESE®
100MG
TABLET
90
DIABETES
GLIMEPIRIDE
AMARYL®
1MG, 2MG, 4MG
TABLET
90
DIABETES
GLIPIZIDE
GLUCOTROL®
10MG
TABLET
180
DIABETES
GLIPIZIDE
GLUCOTROL®
5MG
TABLET
90
DIABETES
GLIPIZIDE ER
GLUCOTROL XL®
5MG
TABLET
90
DIABETES
GLYBURIDE, MICRONIZED
GLYNASE PRESTAB®
3MG and 6MG
TABLET
90
DIABETES
METFORMIN
GLUCOPHAGE®
500MG, 850MG, 1000MG
TABLET
180
DIABETES
METFORMIN ER
GLUCOPHAGE XR®
500MG
SR TABLET
180
GASTROINTESTINAL
DICYCLOMINE
BENTYL®
10MG
CAPSULE
270
GASTROINTESTINAL
DICYCLOMINE
BENTYL®
20MG
TABLET
180
GASTROINTESTINAL
PROMETHAZINE
PHENERGAN®
25MG
TABLET
36
GASTROINTESTINAL
RANITIDINE
ZANTAC®
150MG
TABLET
180
GASTROINTESTINAL
RANITIDINE
ZANTAC®
300MG
TABLET
90
GLAUCOMA & EYE CARE
TIMOLOL
TIMOPTIC®
0.25%
DROPS
15mL
GLAUCOMA & EYE CARE
TIMOLOL
TIMOPTIC®
0.25%
DROPS
30mL
GLAUCOMA & EYE CARE
TIMOLOL
TIMOPTIC®
0.25%
DROPS
45mL
MEDICATION TYPE
GENERIC NAME
BRAND NAME
STRENGTH
FORM
QTY ALLOWED PER
$9 COPAYMENT
MENTAL HEALTH
AMITRIPTYLINE
ELAVIL®
10MG, 25MG, 50MG, 75MG, 100MG
TABLET
90
MENTAL HEALTH
BUSPIRONE
BUSPAR®
5MG, 10MG
TABLET
180
MENTAL HEALTH
FLUOXETINE
PROZAC®
10MG, 20MG, 40MG
CAPSULE
90
MENTAL HEALTH
FLUPHENAZINE
PROLIXIN®
1MG
TABLET
90
MENTAL HEALTH
NORTRIPTYLINE
PAMELOR®
10MG, 25MG
CAPSULE
90
MENTAL HEALTH
PAROXETINE
PAXIL®
10MG, 20MG
TABLET
90
MENTAL HEALTH
PROCHLORPERAZINE
COMPAZINE®
10MG
TABLET
90
MENTAL HEALTH
TRAZODONE
DESYREL®
50MG, 100MG, 150MG
TABLET
90
MENTAL HEALTH
TRIHEXYPHENIDYL
ARTANE®
2MG
TABLET
180
MUSCLE RELAXANT
CYCLOBENZAPRINE
FLEXERIL®
5MG, 10MG
TABLET
90
OTHER MEDICAL CONDITIONS
PREDNISONE
DELTASONE®
2.5MG, 5MG, 10MG, 20MG
TABLET
90
OVERACTIVE BLADDER
OXYBUTYNIN
DITROPAN®
5MG
TABLET
180
SEIZURE
CARBAMAZEPINE
TEGRETOL®
200MG
TABLET
180
SUPPLEMENT
FOLIC ACID
FOLVITE®
1MG
TABLET
90
THYROID
LEVOTHYROXINE
SYNTHROID®
25MCG, 50MCG, 75MCG, 88MCG,
TABLET
100MCG, 112MCG, 125MCG, 137MCG,
150MCG, 175MCG, 200MCG
90
WOMEN'S HEALTH
ESTRADIOL
ESTRACE®
0.5MG, 1MG, 2MG
TABLET
90
WOMEN'S HEALTH
ESTROPIPATE
OGEN®
0.75MG, 1.5MG
TABLET
90
WOMEN'S HEALTH
MEDROXYPROGESTERONE
PROVERA
10MG
TABLET
30
WOMEN'S HEALTH
MEDROXYPROGESTERONE
PROVERA®
2.5MG, 5MG
TABLET
90
WOMEN'S HEALTH
MEGESTROL
MEGACE
20MG
TABLET
90
®
®
List is subject to change
Effective 1/1/14
Start Saving Today – It’s Easy!
Let us do the work for you. Express Scripts will call your doctor to get a new prescription for home delivery pharmacy services
from Express Scripts. When you contact us, please have these items nearby:
Your ID number (found on the front of your prescription drug ID card)
Your doctor’s name and phone number
• Your current medications or medicine containers
•
•
Just visit: Express-Scripts.com
If you don’t have Internet access, call 877.331.3252 toll-free
(9 a.m. – 6 p.m. Eastern time, Monday-Friday)
By choosing medications on the Low-Cost Generic Drug List and using home delivery pharmacy services from Express Scripts,
you accomplish two very important objectives: saving money on your own prescription drugs now, and helping STRS Ohio
extend the life of your health care program.
© 2013 Express Scripts Holding Company. All Rights Reserved. CSSP 13-0671