generic formulary copay - campuscare...methylphenidate-hydrochloride ir/sr/er (oral only) $10...

Drugs NOT listed here will either be: (1) Non-formulary copay of $40+10% coinsurance or

GENERIC FORMULARY Copay

Abacavir $10

Abacavir/Lamivudine $10

Acetaminophen/Codeine $10

Acyclovir (Tablets/Capsules/Ointment/Cream) $10

Adefovir (Tablet) $10

Albuterol (Metered Dose Inhalers/Tablets/Syrup/Nebules) $10

Alendronate Sodium $10

Alfuzosin $10

Allopurinol $10

Alprazolam IR/ER $10

Amiodarone $10

Amitriptyline $10

Amlodipine $10

Amlodipine/Benzapril $10

Amoxicillin $10

Amoxicillin/Clavulanate $10

Amphetamine Salts $10

Aripiprazole $10

Ampicillin $10

Atazanavir $10

Atenolol $10

Atomoxetine $10

Atorvastatin $10

Azathioprine $10

Azithromycin (Tablet/Powder Suspension) $10

Baclofen $10

Benazepril $10

Benzonatate $10

Benzoyl Peroxide/Clindamycin $10

Benzoyl Peroxide/Eythromycin $10

Betamethasone Dipropionate $10

Betamethasone Valerate (Lot/Cream/Ointment/Foam) $10

Brimonidine $10

Bromocriptine $10

Budesonide (Respules/Nasal Spray) $10

Bupropion IR/SR/XL $10

CampusCare Drug Formulary for Summer Semester (Effective 1/1/2020- 5/17/2020)

Formulary Generics drugs are $10

Formulary Brand drugs are $20

(2) Not covered or excluded by plan

See the Certificate of Coverage for further explanation of your prescription coverage

Buspirone $10

Butalbital/Acetaminophen/Caffeine 50/325/40 $10

Cabergoline $10

Calcipotriene (Cream/Ointment/Solution) $10

Candesartan $10

Captopril $10

Carbamazepine IR/ER $10

Carbidopa/Levodopa $10

Cefadroxil $10

Cefpodoxime $10

Cephalexin $10

Chlorzoxazone $10

Cholestyramine $10

Ciprofloxacin (Tablet/Ophthalmic) $10

Citalopram $10

Claravis (Branded Generic for Accutane) $10

Clindamycin (Oral/Topical Gel/Lotion/Solution/Vag Cream) $10

Clonazepam $10

Clonidine (Tablets Only) $10

Clopidogel $10

Clotrimazole/Betamethasone $10

Colchicine $10

Cromolyn Nebules $10

Cyclobenzaprine $10

Delestrogen (Injection) $10

Desvenlafaxine $10

Dex/Neo/Poly 0.1% (Ophthalmic Suspension/Ointment) $10

Dextroamphetamine $10

Dexamethasone $10

Diazepam $10

Diclofenac DR/ER (Not Topical) $10

Dicloxacillin $10

Dicyclomine $10

Diflorasone (Cream) $10

Digoxin $10

Diltiazem $10

Diphenoxylate/Atropine $10

Divalproex $10

Dorzolamide/Timolol $10

Doxazosin $10

Doxycycline $10

Duloxetine $10

Econazole (Cream) $10

Efavirenz $10

Eletriptan $10

Enalapril $10

Enoxaparin (Injection) $10

Epinastine $10

Epinepherine (0.3g/0.15mg) (Jr) (Injection) $10

Erythromycin (Oral/Topical) $10

Erythromycin Ethylsuccinate $10

Escitalopram $10

Estradiol (Oral Tablets/Injection/Topical Patches) $10

Etodolac $10

Ezetimibe $10

Ezetimibe/Simvastatin $10

Famciclovir $10

Felodipine $10

Fenofibrate $10

Finasteride (5mg Only) (1mg is Excluded From Coverage) $10

Fluconazole (Tablets/Oral Suspension) $10

Fluocinolone $10

Fluticasone/Salmeterol (Diskus/Inhaler) $10

Fluoxetine $10

Fluvoxamine $10

Fosamprenavir $10

Furosemide $10

Gabapentin $10

Galantamine (Tablet) $10

Gemfibrozil $10

Gentamycin (Ophthalmic) $10

Glipizide $10

Glyburide $10

Glyburide/Metformin $10

Glycopyrrolate $10

Griseofulvin (Suspension) $10

Griseofulvin (Tabets/Oral Suspension) $10

Haloperidol $10

Hydralazine $10

Hydrochlorothiazide $10

Hydrochlorothiazide/Losartan Potassium $10

Hydrocodone/Acetaminophen $10

Hydrocodone Bitartate/Ibuprofen $10

Hydrocortisone (Topical/Rectal) $10

Hydroxychloroquine $10

Hydroxyzine $10

Hyoscyamine $10

Ibuprofen $10

Imipramine $10

Imiquimod 5% (Cream Only) $10

Indomethacin $10

Isoniazid $10

Isoniazid/Rifampin $10

Isosorbide Dinitrate $10

Isosorbide Mononitrate $10

Itraconazole $10

Ketoconazole (Cream/Shampoo) $10

Ketoconazole (Oral) $10

Ketorolac (Ophthalmic) $10

Labetalol $10

Lactulose $10

Lamivudine $10

Lamotrigine $10

Lansoprazole/Amoxicillin/Clarithromycin $10

Lansoprazole (30mg Only) $10

Latanoprost $10

Levalbuterol $10

Levetiracetam $10

Levodopa/Carbidopa $10

Levofloxacin $10

Levothyroxine $10

Lidocaine (Topical/Oral) $10

Lisinopril $10

Lithium Carbonate/Lithium Citrate $10

Lorazepam $10

Losartan $10

Loxapine $10

Mebendazole $10

Medoxyprogesterone Acetate $10

Mesalamine (Tablets) $10

Metformin IR/ER $10

Methimazole $10

Methotrexate $10

Methyldopa $10

Methylphenidate-Hydrochloride IR/SR/ER (Oral Only) $10

Methylprednisolone $10

Metoclopramide $10

Metolazone $10

Metoprolol IR/XL $10

Metronidazole (Oral/Cream/Lotion/Gel/Vaginal) $10

Minocycline $10

Minoxidil (Oral Only) $10

Mirtazapine $10

Misoprostol $10

Mometasone (Cream/Ointment/Nasal Spray) $10

Montelukast $10

Mupirocin (Ointment/Cream) $10

Myorisan (Branded Generic for Accutane) $10

Mycophenolate $10

Naproxen (375mg/500mg Only) $10

Nefazodone $10

Neomycin/Polymyxn B/Gramicidin (Ophthalmic) $10

Neomycin/Polmyxin/Hydrocortisone 1% Otic $10

Neostigmine Bromide $10

Niacin ER (Tablet) $10

Nifedipine $10

Nitrofurantoin $10

Nitroglycerin $10

Nortriptyline $10

Nystatin (Suspension/Ointment/Cream) $10

Nystatin/Triaminolone (Cream) $10

Ofloxacin $10

Olanzapine $10

Omeprazole (40mg Only) $10

Ondansetron (Tabs/Orally Disinegrating ODT) $10

Oseltamivir $10

Oxcarbazepine $10

Oxybutynin $10

Oxycodone/Acetaminophen $10

Pantoprazole $10

Paroxetine IR/CR $10

Penicillin V Potassium $10

Pentoxifylline $10

Permethrin (Cream) $10

Phenazopyridine $10

Phenobarbital $10

Phenytoin $10

Pimecroliumus $10

Pilocarpine $10

Pindolol $10

Pioglitazone $10

Podofilox (Solution) $10

Polyethylene Glycol-Electrolyte (Solution/Powder) $10

Potassium Chloride (Tablet) $10

Pramipexole $10

Prazosin $10

Prednisolone (Oral/Ophthalmic) $10

Prednisone $10

Prenatal Vitamins with Folic Acid $10

Primidone $10

Probenecid $10

Procainamide $10

Prochlorperazine $10

Progesterone (Micronized Oral Cap) $10

Promethazine $10

Propranolol (Tabs/Capsules) $10

Propylthiouracil $10

Pyrazinamide $10

Pyridostigmine $10

Quetiapine $10

Quinapril $10

Quinine Sulfate $10

Ramelteon $10

Ramipril $10

Rifampin $10

Risperidone $10

Ritonavir $10

Rivastigmine (Capsules) $10

Rizatriptan $10

Ropinirole $10

Salsalate $10

Selenium Sulfifide 2.25% and 2.5% (Shampoo/Lotion) $10

Sertraline $10

Simvastatin $10

Siroliumus $10

Sorbitol $10

Sotalol $10

Sotret (Branded Generic For Accutane) $10

Spironolactone $10

Spironolactone/HCTZ $10

Sucralfate $10

Sulfacetamide Sodium $10

Sulfacetamide/Prednisolone $10

Sulfadiazine (Tablet) $10

Sulfasalazine $10

Sulindac $10

Sumatriptan $10

Tacrolimus (Capsules/Topical) $10

Tamoxifen $10

Tamsulosin $10

Tenofovir Disoproxil Fumarate $10

Terazosin $10

Terbinafine $10

Terbutaline Sulfate $10

Terconazole $10

Testosterone (Topical/Injection) $10

Theophylline $10

Timolol Maleate 5% GFS (Ophthalmic Solution) $10

Tobramycin 0.3%/Dexamethasone 0.1% $10

Tolterodine $10

Topiramate $10

Tramadol $10

Trazodone $10

Tretinoin $10

Triamcinolone (Topical) $10

Triamterene/Hydrochlorothiazide $10

Trifluridine 1% (Ophthalmic Solution) $10

Trimethoprim/Sulfamethoxazole $10

Trimethoprim/Polymyxin $10

Ursodiol $10

Valacyclovir $10

Valproic Acid (Capsules/Syrup) $10

Valsartan $10

Venlafaxine IR/XR $10

Verapamil $10

Vitamin D (Ergocalciferol D2) $10

Warfarin $10

Ziprasidone $10

Zolpidem $10

BRAND FORMULARY Copay

Depo Testosterone $20

Apidra (Vial/Solostar pen) $20

Arnuity Ellipta (Inhaler) $20

Asmanex (Twisthaler) $20

Atrovent (HFA) $20

Basaglar $20

Ciprodex Otic $20

Cipro HC Otic $20

Coumadin (Exception to Brand alternative) $20

Descovy $20

Emtriva $20

Flovent (HFA) $20

Genvoya $20

Glucagon (1mg Kit) $20

Humalog (Vial/Kwikpen) $20

Humalog Mix 50/50 (Vial/Kwikpen) $20


Humulin 70/30 (Vial/Pen) $20

Humulin N (Vial/Pen) $20

Humulin R $20

Incruse Ellipta $20

Insulins (ALL) $20

Isentress $20

Lantus (Vial/Solostar Pen) $20

Levemir (Vial/Flexpen) $20

Levoxyl (Exception to Brand Alternative) $20

Narcan $20

Novolin 70/30 $20

Novolin N $20

Novolin R $20

NovoLog Mix 70/30 (Vial/Flexpen) $20

NovoLog (Vial/Flexpen) $20

Pred-G (Ophthalmic) $20

Premarin $20

Prempro $20

Prezista $20

Proctofoam HC $20

Pulmicort (Flexhaler) $20

Spiriva $20

Symbicort (Inhaler) $20

Synthroid (Exception to Brand alternative) $20

Tecfidera $20

Tivicay $20

Toujeo $20

Triumeq $20

Truvada $20

Vemlidy $20

Victoza $20

Vyvanse $20

Xarelto $20

OTC Copay

Aspirin (Men age 45-79 years old & Women age 55-79) $0

Folic Acid (0.4mg- 0.8mg) $0

Iron Supplementation (Infants 6-12 months old) $0

Birth Control & Emergency Contraception Copay

Coverage is for Dependents with CampusCare Coverage for Students are under Student Health Service Fee

Generic for Alesse (Tablets) $0

Generic for Ortho-Cyclen (Tablets) $0

Generic for Ortho-tri-cyclen (Tablets) $0

Generic for Ortho Novum7/7/7 (Tablets) $0

Generic for Ortho Novum 1/35 (Tablets) $0

Generic for Micronor (Progesterone Only-Tablets) $0

Generic for Loestrin Fe 1/20 (Tablets) $0

Generic for Depo-Provera (Injection) $0

Generic for Ortho Evra (Patch) $0

Brand for Ortho Tri Cyclen Lo (Tablets) $0

Emergency Contraception (Ella/Plan B/My Way) $0

Nuvaring $0

GENERIC FORMULARY Copay

ACE Inhibitors

Benazepril $10

Captopril $10

Enalapril $10

Lisinopril $10

Quinapril $10Ramipril $10

Acne Agents

Benzoyl Peroxide/Clindamycin $10

Benzoyl Peroxide/Eythromycin $10

Claravis (Branded Generic For Accutane) $10

Clindamycin (Topical Gel/Lotion/Solution) $10

Myorisan (Branded Generic For Accutane) $10Sotret (Branded Generic For Accutane) $10

Actinic Keratosis

Imiquimod 5% (Cream Only) $10

ADHD Agents

Amphetamine salts $10

Atomoxetine $10

Clonidine (Tablets Only) $10

Dextroamphetamine $10Methylphenidate-Hydrochloride IR/SR/ER (Oral Only) $10

Alzheimer's Agents

DRUGS LISTED BY CLASS

Galantamine (Tablet) $10Rivastigmine (Capsules) $10

Anaphylaxis Treatment Agents

Epinepherine (0.3g/0.15mg) (Jr) (Injection) $10

Androgens

Testosterone (Topical/Injection) $10

Anesthetics

Lidocaine (Topical/Oral) $10

Angiotensin Blockers

Amlodipine/Benzapril $10

Candesartan $10

Hydrochlorothiazide/Losartan Potassium $10

Losartan $10Valsartan $10

Antibiotics

Amoxicillin $10

Amoxicillin/Clavulanate $10

Ampicillin $10

Azithromycin (Tablet/Powder Suspension) $10

Cefadroxil $10

Cefpodoxime $10

Cephalexin $10


Clindamycin (Oral/Vag Cream) $10

Dicloxacillin $10

Doxycycline $10

Erythromycin (Oral/Topical) $10

Erythromycin Ethylsuccinate $10

Levofloxacin $10

Metronidazole (Oral/Cream/Lotion/Gel/Vaginal) $10

Minocycline $10

Mupirocin (Ointment/Cream) $10

Nitrofurantoin $10

Ofloxacin $10

Penicillin V Potassium $10


Sulfadiazine (Tablet) $10Trimethoprim/Sulfamethoxazole $10

Anticoagulants

Enoxaparin (Injection) $10Warfarin $10

Anticonvulsants

Carbamazepine IR/ER $10

Clonazepam $10

Diazepam $10

Divalproex $10

Gabapentin $10

Lamotrigine $10

Levetiracetam $10

Oxcarbazepine $10

Phenobarbital $10

Phenytoin $10

Primidone $10

Topiramate $10Valproic Acid (Capsules/Syrup) $10

Antidepressants

Amitriptyline $10

Bupropion IR/SR/XL $10

Citalopram $10

Desvenlafaxine $10

Duloxetine $10

Escitalopram $10

Fluoxetine $10

Fluvoxamine $10

Imipramine $10

Mirtazapine $10

Nefazodone $10

Nortriptyline $10

Paroxetine IR/CR $10

Sertraline $10

Trazodone $10Venlafaxine IR/XR $10

Antiemetic/Antivertigo Agents

Metoclopramide $10

Ondansetron (Tabs/Orally Disinegrating ODT) $10

Prochlorperazine $10Promethazine $10

Antifungals

Clotrimazole/Betamethasone $10

Econazole (Cream) $10

Fluconazole (Tablets/Oral Suspension) $10

Griseofulvin (Suspension) $10

Griseofulvin (Tabets/Oral Suspension) $10

Ketoconazole (Cream/Shampoo) $10

Ketoconazole (Oral) $10

Nystatin (Suspension/Ointment/Cream) $10

Nystatin/Triaminolone (Cream) $10

Selenium Sulfifide 2.25% and 2.5% (Shampoo/Lotion) $10

Terbinafine $10Terconazole $10

Antimyasthenic Agents

Pyridostigmine $10

Antimycobacterials

Isoniazid $10

Isoniazid/Rifampin $10

Pyrazinamide $10Rifampin $10

Antineoplastics

Methotrexate $10Tamoxifen $10

Antiparasitic Agents

Hydroxychloroquine $10

Mebendazole $10Quinine Sulfate $10

Antiparkinson Agents

Bromocriptine $10

Carbidopa/Levodopa $10

Levodopa/Carbidopa $10

Pramipexole $10Ropinirole $10

Antipsoriatics

Calcipotriene (Cream/Ointment/Solution) $10

Antipsychotics

Aripiprazole $10

Haloperidol $10

Loxapine $10

Olanzapine $10

Quetiapine $10

Risperidone $10Ziprasidone $10

Antiretrovirals

Abacavir $10

Abacavir/Lamivudine $10

Atazanavir $10

Efavirenz $10

Fosamprenavir $10

Lamivudine $10

Tenofovir Disoproxil Fumarate $10Ritonavir $10

Antispasticity Agents

Baclofen $10

Antivirals

Acyclovir (Tablets/Capsules/Ointment/Cream) $10

Famciclovir $10

Itraconazole $10

Oseltamivir $10Valacyclovir $10

Anxiolytics

Alprazolam IR/ER $10

Buspirone $10

Clonazepam $10

Hydroxyzine $10Lorazepam $10

Beta-Adrenergic Agents

Albuterol (Metered Dose Inhalers/Tablets/Syrup/Nebules) $10


Levalbuterol $10Terbutaline Sulfate $10

Beta-Adrenergic Receptor Blocking Agents

Atenolol $10

Labetalol $10

Metoprolol IR/XL $10

Pindolol $10

Propranolol (Tabs/Capsules) $10Sotalol $10

Bone Resorption Suppression & Related Agents

Alendronate Sodium $10

Benign Prostatic Hyperplasia Agents

Alfuzosin $10

Doxazosin $10

Finasteride (5mg Only) (1mg is Excluded From Coverage) $10

Tamsulosin $10Terazosin $10

Bipolar Agents

Lithium Carbonate/Lithium Citrate $10

Calcium Channel Blockers

Amlodipine $10

Diltiazem $10

Felodipine $10

Nifedipine $10

Prazosin $10Verapamil $10

Cardiovascular Agents

Amiodarone $10

Digoxin $10

Hydralazine $10

Isosorbide Dinitrate $10

Isosorbide Mononitrate $10

Methyldopa $10

Minoxidil (Oral Only) $10

Pentoxifylline $10Procainamide $10

Corticosteroids

Betamethasone dipropionate $10

Betamethasone Valerate (Lot/Cream/Ointment/Foam) $10

Diflorasone (Cream) $10

Fluocinolone $10

Hydrocortisone (Topical/Rectal) $10Triamcinolone (Topical) $10

Cough

Benzonatate $10

Diabetes

Glipizide $10

Glyburide $10

Glyburide/Metformin $10

Metformin IR/ER $10Pioglitazone $10

Diuretics

Furosemide $10

Hydrochlorothiazide $10

Metolazone $10

Sorbitol $10

Spironolactone $10

Spironolactone/HCTZ $10

Triamterene/Hydrochlorothiazide $10

Dysuria

Phenazopyridine $10

Electrolytes, Minerals, & Vitamins

Potassium Chloride (Tablet) $10

Prenatal Vitamins with Folic Acid $10Vitamin D (Ergocalciferol D2) $10

Gastrointestinal Agents

Dicyclomine $10

Diphenoxylate/Atropine $10

Glycopyrrolate $10

Hyoscyamine $10

Lansoprazole/Amoxicillin/Clarithromycin $10

Misoprostol $10

Polyethylene Glycol-Electrolyte (Solution/Powder) $10

Sucralfate $10Ursodiol $10

Genital warts

Podofilox (Solution) $10

Glucocorticoids

Methylprednisolone $10

Prednisolone (Oral) $10Prednisone $10

Gout

Allopurinol $10

Colchicine $10Probenecid $10

Hepatitis B

Adefovir (Tablet) $10Lamivudine $10

Hormonal Agents, Suppressant

Cabergoline $10

Medoxyprogesterone Acetate $10

Methimazole $10Propylthiouracil $10

Hormones-estrogens

Delestrogen (Injection) $10Estradiol (Oral Tablets/Injection/Topical Patches) $10

Immunosuppressive Agents

Azathioprine $10

Methotrexate $10

Mycophenolate $10

Pimecroliumus $10

Siroliumus $10Tacrolimus (Capsules/Topical) $10

Inhaled Anticholinergics


Insomnia agents

Ramelteon $10Zolpidem $10

Laxatives

Lactulose $10

Leukotriene Anatagonists

Montelukast $10

Lice Treatment

Permethrin (Cream) $10

Lipotropics

Atorvastatin $10

Cholestyramine $10

Ezetimibe $10

Ezetimibe/Simvastatin $10

Fenofibrate $10

Gemfibrozil $10

Niacin ER (Tablet) $10Simvastatin $10

Migraine

Eletriptan $10

Rizatriptan $10Sumatriptan $10

Miscellaneous

Neostigmine Bromide $10

Musculoskeletal Therapy Agents

Chlorzoxazone $10Cyclobenzaprine $10

Nasal Steroids

Budesonide (Respules/Nasal Spray) $10Mometasone (Cream/Ointment/Nasal Spray) $10

Nitrates

Nitroglycerin $10

NSAIDs-Nonsteroidal anti-inflammatory drugs

Diclofenac DR/ER (Not Topical) $10

Etodolac $10

Ibuprofen $10

Indomethacin $10

Naproxen (375mg/500mg Only) $10

Salsalate $10Sulindac $10

Opioids

Acetaminophen/Codeine $10

Butalbital/Acetaminophen/Caffeine 50/325/40 $10

Hydrocodone/Acetaminophen $10

Hydrocodone Bitartate/Ibuprofen $10

Oxycodone/Acetaminophen $10Tramadol $10

Ophthalmics

Brimonidine $10


Dexamethasone $10

Dex/Neo/Poly 0.1% (Ophthalmic Suspension/Ointment) $10

Dorzolamide/Timolol $10

Epinastine $10

Gentamycin (Ophthalmic) $10

Ketorolac (Ophthalmic) $10

Latanoprost $10

Ofloxacin $10

Pilocarpine $10

Prednisolone (Ophthalmic) $10


Sulfacetamide/Prednisolone $10

Timolol Maleate 5% GFS (Ophthalmic Solution) $10

Tobramycin 0.3%/Dexamethasone 0.1% $10

Trifluridine 1% (Ophthalmic Solution) $10Trimethoprim/Polymyxin $10

Otic

Neomycin/Polmyxin/Hydrocortisone 1% Otic $10

Neomycin/Polymyxn B/Gramicidin (Ophthalmic) $10

Ofloxacin $10

Platelet Aggregation Inhibitors

Clopidogel $10

Progesterone/Hydroxyprogesterone

Progesterone (Micronized Oral Cap) $10

Proton Pump Inhibitors

Lansoprazole (30mg Only) $10

Omeprazole (40mg Only) $10Pantoprazole $10

Respiratory Agents

Cromolyn Nebules $10Theophylline $10

Retinoids

Tretinoin $10

Thyroid Supplements

Levothyroxine $10

Ulcerative Colitis

Mesalamine (Tablets) $10Sulfasalazine $10

Urinary Incontinence

Oxybutynin $10

Tolterodine $10

BRAND FORMULARY Copay

ADHD Agents/Stimulants

Vyvanse $20

Androgens

Depo Testosterone $20

Anticoagulants

Coumadin (Exception to Brand Alternative) $20Xarelto $20

Antiretrovirals

Descovy $20

Emtriva $20

Genvoya $20

Isentress $20

Prezista $20

Tivicay $20

Triumeq $20

Truvada $20Vemlidy $20

Diabetes

Glucagon (1mg Kit) $20

Victoza $20

Hemorrhoids Treatment

Proctofoam HC $20

Hormone Replacement Therapy

Premarin $20Prempro $20

Inhaled Anticholinergics

Atrovent (HFA) $20Spiriva $20

Inhaled Long-Acting Muscarinic Antagonist

Incruse Ellipta $20

Inhaled Steroids

Arnuity Ellipta (Inhaler) $20

Asmanex (Twisthaler) $20

Flovent (HFA) $20

Pulmicort (Flexhaler) $20Symbicort (Inhaler) $20

Insulins

Apidra (Vial/Solostar pen) $20

Basaglar $20

Humalog (Vial/Kwikpen) $20



Humulin 70/30 (Vial/Pen) $20

Humulin N (Vial/Pen) $20

Humulin R $20

Insulins (ALL) $20

Lantus (Vial/Solostar Pen) $20

Levemir (Vial/Flexpen) $20

Novolin 70/30 $20

Novolin N $20

Novolin R $20

NovoLog Mix 70/30 (Vial/Flexpen) $20

NovoLog (Vial/Flexpen) $20Toujeo $20

Multiple Sclerosis Agents

Tecfidera $20

Opioid Overdose Emergency Agent

Narcan $20

Ophthalmics

Pred-G (Ophthalmic) $20

Otic

Ciprodex Otic $20Cipro HC Otic $20

Thyroid Supplements

Levoxyl (Exception to Brand Alternative) $20

Synthroid (Exception to Brand Alternative) $20

Birth Control & Emergency Contraception Copay

Coverage is for Dependents with CampusCare Coverage for Students are under Student Health Service Fee

Generic for Alesse (Tablets) $0

Generic for Ortho-Cyclen (Tablets) $0

Generic for Ortho-tri-cyclen (Tablets) $0

Generic for Ortho Novum7/7/7 (Tablets) $0

Generic for Ortho Novum 1/35 (Tablets) $0

Generic for Micronor (Progesterone Only-Tablets) $0

Generic for Loestrin Fe 1/20 (Tablets) $0

Generic for Depo-Provera (Injection) $0

Generic for Ortho Evra (Patch) $0

Brand for Ortho Tri Cyclen Lo (Tablets) $0

Emergency Contraception (Ella/Plan B/My Way) $0

Nuvaring $0

OTC Copay

Aspirin (Men age 45-79 years old & Women age 55-79) $0

Folic Acid (0.4mg- 0.8mg) $0

Iron Supplementation (Infants 6-12 months old) $0

generic formulary copay - campuscare...methylphenidate-hydrochloride ir/sr/er (oral only) $10...

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