PRESCRIPTIONS STARTING AT JUST $5 WITH

Harvard Pilgrim’s 4-Tier Drug Program!

$5 Tier 1 drug name Drug form

1 If you’re enrolled in our Best Buy HSA PPO coverage, all covered drugs (including those purchasedthrough the mail service prescription drug program) apply toward your in-network medical deductible.

2 Savings vary based on specific benefit design. Mail order savings do not apply to members who areenrolled through a Maine-based employer group.

Acetaminophen-Codeine 120-12mg/5mL ElixirAcetaminophen-Codeine 300mg-15mg TabletAcetaminophen-Codeine 300mg-30mg TabletAk-Pentolate 1% DropsAlbuterol Sulfate 2mg TabletAlbuterol Sulfate 2mg/5mL SyrupAlbuterol Sulfate 4mg TabletAllopurinol 100mg TabletAllopurinol 300mg TabletAlprazolam 0.25mg TabletAlprazolam 0.5mg TabletAlprazolam 1mg TabletAlprazolam 2mg TabletAmiloride-Hydrochlorothiazide 5mg-50mg TabletAmitriptyline 10mg TabletAmitriptyline 25mg TabletAmitriptyline 50mg TabletAmitriptyline 75mg TabletAmitriptyline 100mg TabletAmitriptyline 150mg TabletAmoxicillin 125mg Chewable Tablet Amoxicillin 125mg/5mL Oral SuspensionAmoxicillin 250mg CapsuleAmoxicillin 250mg Chewable TabletAmoxicillin 250mg/5mL Oral Suspension

Amoxicillin 400mg/5mL Oral SuspensionAmoxicillin 500mg CapsuleAmoxicillin 875mg TabletAtenolol 25mg TabletAtenolol 50mg TabletAtenolol 100mg TabletAtenolol-Chlorthalidone 50mg-25mg TabletAtenolol-Chlorthalidone 100mg-25mg TabletAtropine Sulfate 1% DropsAtropine Sulfate 1% OintmentBelladonna-Phenobarbital 16.2mg TabletBetamethasone Valerate 0.1% CreamBetamethasone Valerate 0.1% OintmentBleph-10 DropsCaptopril 12.5mg TabletCaptopril 25mg TabletCaptopril 50mg TabletCheratussin AC 100-10mg/5mL LiquidChloral Hydrate 500mg/5mL SyrupChlordiazepoxide 5mg CapsuleChlordiazepoxide 10mg CapsuleChlordiazepoxide 25mg CapsuleChlorothiazide 250mg TabletChlorothiazide 500mg TabletChlorthalidone 25mg Tablet

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$5 Tier 1 drug name

You’ll pay a low, $5 copayment (for up to a 30-day supply) on many generic prescriptions to treat a variety of diseases and conditions.1 All generic drugs contain the same active ingredients as their brand-name counterparts.

If you take any of our Tier 1 drugs regularly, you may even save a full month’s copayment through the mail service prescription drug program when you order a 90-day supply.2

> Check out the wide range of Tier 1 medications available with our 4-Tier Prescription Drug Program

Chlorthalidone 50mg TabletChlorzoxazone 500mg TabletCiprofloxacin 250mg TabletCiprofloxacin 500mg TabletCiprofloxacin 750mg TabletClonazepam 0.5mg TabletClonazepam 1mg TabletClonazepam 2mg TabletClonidine 0.1mg TabletClonidine 0.2mg TabletClonidine 0.3mg TabletCyanocobalamin 1000 mcg/mL VialCyclopentolate 1% DropsDexamethasone 0.5mg TabletDexamethasone 0.75mg TabletDexamethasone 1mg TabletDexamethasone 1.5mg TabletDexamethasone 4mg TabletDiazepam 2mg TabletDiazepam 5mg TabletDiazepam 10mg TabletDigoxin 125mcg TabletDigoxin 250mcg TabletDiphenhydramine 25mg CapsuleDiphenhydramine 50mg CapsuleDoxazosin 4mg TabletDoxazosin 8mg TabletDoxepin 10mg CapsuleDoxepin 25mg CapsuleDoxepin 50mg CapsuleDoxepin 75mg CapsuleDoxepin 100mg CapsuleDoxycycline Hyclate 50mg CapsuleDoxycycline Hyclate 100mg TabletDoxycycline Hyclate 100mg CapsuleEnalapril 2.5mg TabletEnalapril 5mg TabletEnalapril 10mg TabletEnalapril 20mg TabletEndocet 5mg-325mg TabletEthedent 0.25 (0.55mg) Chewable TabletEthedent 0.5 (1.1mg) Chewable TabletEthedent 1 (2.2mg) Chewable TabletFamotidine 20mg TabletFluconazole 150mg TabletFluoxetine 10mg CapsuleFluoxetine 10mg TabletFluoxetine 20mg CapsuleFlurazepam 15mg CapsuleFlurazepam 30mg CapsuleFolic Acid 1mg TabletFurosemide 20mg TabletFurosemide 40mg TabletFurosemide 80mg TabletGani-Tuss NR 100-10mg/5mL LiquidGentak 0.3% DropsGentamicin Sulfate 0.1% CreamGentamicin Sulfate 0.1% OintmentGentamicin Sulfate 0.3% DropsGlimepiride 1mg TabletGlimepiride 2mg TabletGlimepiride 4mg TabletGlipizide 5mg Tablet

Glipizide 10mg TabletGlyburide 1.25mg TabletGlyburide, Micronized 1.5mg TabletGlyburide, Micronized 3mg TabletGlyburide, Micronized 6mg TabletGuaifenesin-Codeine 100-10mg/5mL LiquidHydrochlorothiazide 12.5mg CapsuleHydrochlorothiazide 25mg TabletHydrochlorothiazide 50mg TabletHydrocodone-Acetaminophen Tablet5mg-500mgHydrocodone-Acetaminophen Tablet7.5-650mgHydrocodone-Acetaminophen Tablet7.5-750mgHydrocortisone 1% CreamHydrocortisone 1% OintmentHydrocortisone 2.5% CreamHydrocortisone 2.5% OintmentIbuprofen 400mg TabletIbuprofen 600mg TabletIbuprofen 800mg TabletIndapamide 1.25mg TabletIndapamide 2.5mg TabletIophen-C NR 100-10mg/5mL LiquidIsoniazid 100mg TabletIsoniazid 300mg TabletIsosorbide Dinitrate 5mg TabletIsosorbide Dinitrate 10mg Sublingual TabletIsosorbide Dinitrate 10mg TabletLisinopril 2.5mg TabletLisinopril 5mg TabletLisinopril 10mg TabletLisinopril 20mg TabletLisinopril 30mg TabletLisinopril 40mg TabletMedroxyprogesterone Acetate 2.5mg TabletMedroxyprogesterone Acetate 5mg TabletMedroxyprogesterone Acetate 10mg TabletMetoprolol Tartrate 25mg TabletMetoprolol Tartrate 50mg TabletMetoprolol Tartrate 100mg TabletMetronidazole 250mg TabletMetronidazole 500mg TabletMytussin AC 100-10mg/5mL LiquidNatalcare Pic TabletNatalcare Plus TabletNatalcare Rx TabletNatalcare Three TabletNatatab FA TabletNeomycin-Bacitracin-Polymyxin Ointment3.5mg-400Neomycin-Polymyxin-Dexameth 0.1% DropsNeomycin-Polymyxin-Dexameth Ointment3.5-10K-1Nystatin 100,000units/gm CreamNystatin 100,000units/gm OintmentNystatin-Triamcinolone 100,000-0.1 CreamNystatin-Triamcinolone 100,000-0.1 OintmentOxycodone-Acetaminophen 5mg-325mg TabletPenicillin V Potassium 125mg/5mL Oral SuspensionPenicillin V Potassium 250mg TabletPenicillin V Potassium 250mg/5mL Oral SuspensionPenicillin V Potassium 500mg Tablet

Drug form Drug form$5 Tier 1 drug name $5 Tier 1 drug name

Phenazopyridine 100mg TabletPhenazopyridine 200mg TabletPhenobarbital 15mg TabletPhenobarbital 16.2mg TabletPhenobarbital 30mg TabletPhenobarbital 32.4mg TabletPhenobarbital 60mg TabletPhenobarbital 64.8mg TabletPhenobarbital 97.2mg TabletPhenobarbital 100mg TabletPhenylephrine 2.5% DropsPilocarpine 0.5% DropsPilocarpine 1% DropsPilocarpine 2% DropsPilocarpine 4% DropsPiroxicam 10mg CapsulePiroxicam 20mg CapsulePolyvitamin with Iron-Fluoride Drops0.25mg/mLPolyvitamin with Iron-Fluoride Drops0.5mg/mLPrednisolone 5mg TabletPrednisone 1mg TabletPrednisone 2.5mg TabletPrednisone 5mg Dose PackPrednisone 5mg TabletPrednisone 10mg Dose PackPrednisone 10mg TabletPrednisone 20mg Tablet Prednisone 50mg TabletPrenafirst TabletPrenaplus TabletPrenatabs FA TabletPrenatal 1 Plus 1 TabletPrenatal 19 Chewable TabletPrenatal Low Iron TabletPrenatal MTR TabletPrenatal Plus 27mg-1mg TabletPrenatal Rx 1 60mg-1mg TabletPrenatal Z 65mg-1mg TabletProchlorperazine Maleate 5mg TabletProchlorperazine Maleate 10mg TabletProcto-Pak 1% CreamProctosol-HC 2.5% CreamPromethazine-DM 15-6.25/5mL SyrupPropranolol 10mg TabletPropranolol 20mg TabletPropranolol 40mg Tablet

Propranolol 80mg TabletRenaf 0.5 (1.1mg) Chewable TabletRenaf 1 (2.2mg) Chewable TabletRenal Caps 1mg CapsuleReno Caps 1mg CapsuleRoxicet 5mg-325mg TabletSelfemra 10mg CapsuleSelfemra 20mg CapsuleSodium Fluoride 0.25 (0.55) Chewable TabletSodium Fluoride 0.5 (1.1mg) TabletSodium Fluoride 0.5 (1.1mg) Chewable TabletSodium Fluoride 0.5mg/mL DropsSodium Fluoride 1mg (2.2mg) Chewable TabletSulfacetamide Sodium 10% DropsSulfamide 10% DropsTemazepam 15mg CapsuleTemazepam 30mg CapsuleTetracycline 250mg CapsuleTetracycline 500mg CapsuleThyroid 32.5mg TabletThyroid 60mg TabletThyroid 65mg TabletThyroid 120mg TabletTobramycin Sulfate 0.3% DropsTrazodone 50mg TabletTrazodone 100mg TabletTriamcinolone Acetonide 0.025% CreamTriamcinolone Acetonide 0.025% OintmentTriamcinolone Acetonide 0.1% CreamTriamcinolone Acetonide 0.1% OintmentTriamcinolone Acetonide 0.5% CreamTriamcinolone Acetonide 0.5% OintmentTriamterene-Hydrochlorothiazide Capsule37.5-25mgTriamterene-Hydrochlorothiazide Tablet37.5-25mgTriamterene-Hydrochlorothiazide Tablet75-50mgTrimox 250mg CapsuleTrimox 250mg/5mL Oral SuspensionTrinate 28mg-1mg TabletTri-Vitamin with Iron-Fluoride 0.25mg/mL Drops Tri-Vitamin-Fluoride 0.25mg/mL DropsTri-Vitamins with Fluoride 0.5mg/mL DropsVinate One 60mg-1mg TabletVinate-M 27mg-1mg TabletVi-Q-Tuss 100-5mg/5 SyrupVitamin D 50,000 units Capsule

Drug form Drug form

Learn moreVisit www.harvardpilgrim.org/4tier. You’ll also find information about our mail serviceprescription drug program as well as links to reliable resources about specific medicationsand unbiased drug reports and recommendations.

If you don’t have Internet access, call our Member Services department at (888) 333-4742. For TTY service, call (800) 637-8257.

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$5 Tier 1 drug name $5 Tier 1 drug name

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Harvard Pilgrim Health Care93 Worcester Street, Wellesley, MA 02481

(800) 848-9995www.harvardpilgrim.orgHarvard Pilgrim Health Care includes

Harvard Pilgrim Health Care and its affiliates,Harvard Pilgrim Health Care of New Englandand HPHC Insurance Company