2018 pharmacy saver drug ist - unitedhealthcare® … pharmacy saver drug ist important notice: the...

2018 Pharmacy Saver Drug List

Important Notice: The 2018 Pharmacy Saver drug list is effective January 1, 20182018 participating pharmacies include: Walgreens, Kroger, HEB, Duane Reade, Bakers, City Market, Copps, Dillons, Fred Meyer, Frys, Gerbes, Harris Teeter, JayC, King Soopers, Metro Market, Payless, Pick N Save, QFC, Ralphs, Scotts and SmithsThe Pharmacy Saver program is available to UnitedHealthcare® MedicareRx for Groups (PDP) plan members and UnitedHealthcare® Group Medicare Advantage (HMO and PPO) plan members when their plan includes prescription drug coverage. To determine if your drug or pharmacy is included, please review this list of Pharmacy Saver drugs and participating pharmacies for 2018. If you have any questions, please call the number on the back of your member ID card.

Drug Name Qty

Pharmacy Saver Price

Walgreens, Duane Reade

Kroger, Bakers, City Market, Copps, Dillons, Fred Meyer, Frys, Gerbes, Harris Teeter, JayC, King Soopers,

Metro Market, Payless, Pick N Save, QFC, Ralphs, Scotts, Smiths

HEB

Acyclovir capsule 200mg 30 $5.00 $2.00 N/A60 $10.00 $4.00 N/A90 $15.00 $6.00 N/A

Albuterol syrup 2mg/5ml 120 $5.00 $2.00 N/A240 $10.00 $4.00 N/A360 $15.00 $6.00 N/A

Albuterol tablet 2mg 90 N/A $2.00 N/A180 N/A $4.00 N/A270 N/A $6.00 N/A

Albuterol tablet 4mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Alendronate tablet 5mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Alendronate tablet 10mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Alendronate tablet 35mg 4 N/A $2.00 $4.008 N/A $4.00 $8.00

12 N/A $6.00 $12.00


Drug Name Qty





HEB

Alendronate tablet 70mg 4 N/A $2.00 $4.008 N/A $4.00 $8.00

12 N/A $6.00 $12.00Allopurinol tablet 100mg 30 $5.00 $2.00 $4.00

60 $10.00 $4.00 $8.0090 $15.00 $6.00 $12.00

Allopurinol tablet 300mg 30 $5.00 $2.00 $4.0060 $10.00 $4.00 $8.0090 $15.00 $6.00 $12.00

Amiloride/HCTZ tablet 5-50

30 $2.00 $2.00 N/A60 $4.00 $4.00 N/A90 $6.00 $6.00 N/A

Amlodipine tablet 2.5mg 30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00

Amlodipine tablet 5mg 30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00

Amlodipine tablet 10mg 30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00

Amoxicillin capsule 250mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

150 N/A $2.00 N/A300 N/A $4.00 N/A450 N/A $6.00 N/A

Amoxicillin capsule 500mg 30 $2.00 $2.00 N/A60 $4.00 $4.00 N/A90 $6.00 $6.00 N/A


Drug Name Qty





HEB

Amoxicillin Suspension 125/5ml

150 $2.00 $2.00 N/A300 $4.00 $4.00 N/A450 $6.00 $6.00 N/A


100 $2.00 $2.00 N/A200 $4.00 $4.00 N/A300 $6.00 $6.00 N/A


80 N/A $2.00 N/A150 $2.00 N/A N/A160 N/A $4.00 N/A240 N/A $6.00 N/A300 $4.00 N/A N/A450 $6.00 N/A N/A


100 $5.00 $2.00 N/A200 $10.00 $4.00 N/A300 $15.00 $6.00 N/A

Anastrozole tablet 1mg 30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00

Atenolol/Chlorthalidone tablet 50-25mg

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Atenolol/Chlorthalidone tablet 100-25mg

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Atenolol tablet 25mg 30 N/A $2.00 $2.0060 N/A $4.00 $4.0090 N/A $6.00 $6.00



Drug Name Qty





HEB


Baclofen tablet 10mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Benazepril tablet 5mg 30 N/A $1.50 N/A60 N/A $3.00 N/A90 N/A $4.50 N/A

Benazepril tablet 10mg 30 N/A $1.50 $1.0060 N/A $3.00 $2.0090 N/A $4.50 $3.00

Benazepril tablet 20mg 30 N/A $1.50 $1.0060 N/A $3.00 $2.0090 N/A $4.50 $3.00

Benazepril tablet 40mg 30 $2.00 $1.50 $2.0060 $4.00 $3.00 $4.0090 $6.00 $4.50 $6.00

Bisoprolol/HCTZ tablet 2.5-6.25mg

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Bisoprolol/HCTZ tablet 5-6.25mg

30 N/A $2.00 $2.0060 N/A $4.00 $4.0090 N/A $6.00 $6.00

Bisoprolol/HCTZ tablet 10-6.25mg

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Bumetanide tablet 0.5mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


Drug Name Qty





HEB

Bumetanide tablet 1mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Buspirone tablet 5mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Buspirone tablet 10mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Captopril tablet 12.5mg 90 N/A $2.00 N/A180 N/A $4.00 N/A270 N/A $6.00 N/A

Captopril tablet 25mg 90 N/A $2.00 N/A180 N/A $4.00 N/A270 N/A $6.00 N/A

Captopril tablet 50mg 90 N/A $2.00 N/A180 N/A $4.00 N/A270 N/A $6.00 N/A

Captopril tablet 100mg 60 $5.00 N/A N/A120 $10.00 N/A N/A180 $15.00 N/A N/A90 N/A $2.00 N/A

180 N/A $4.00 N/A270 N/A $6.00 N/A

Carbamazepine tablet 200mg

100 N/A $2.00 N/A200 N/A $4.00 N/A300 N/A $6.00 N/A

Carvedilol tablet 3.125mg 30 N/A N/A $4.0060 N/A N/A $8.0090 N/A N/A $12.00


Drug Name Qty





HEB

Carvedilol tablet 3.125mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Carvedilol tablet 6.25mg 30 N/A N/A $4.0060 N/A N/A $8.0090 N/A N/A $12.0060 N/A $2.00 N/A

120 N/A $4.00 N/A180 N/A $6.00 N/A

Carvedilol tablet 12.5mg 30 N/A N/A $4.0060 N/A N/A $8.0090 N/A N/A $12.0060 N/A $2.00 N/A

120 N/A $4.00 N/A180 N/A $6.00 N/A

Carvedilol tablet 25mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Cephalexin capsule 250mg 40 N/A $2.00 N/A80 N/A $4.00 N/A

120 N/A $6.00 N/ACephalexin capsule 500mg 40 N/A $2.00 N/A

80 N/A $4.00 N/A120 N/A $6.00 N/A

Cimetidine tablet 200mg 60 $5.00 N/A N/A120 $10.00 N/A N/A180 $15.00 N/A N/A

Cimetidine tablet 300mg 60 $5.00 N/A N/A120 $10.00 N/A N/A180 $15.00 N/A N/A


Drug Name Qty





HEB

Cimetidine tablet 800mg 30 $2.00 $2.00 N/A60 $4.00 $4.00 N/A90 $6.00 $6.00 N/A

Ciprofloxacin tablet 250mg 20 N/A $2.00 N/A40 N/A $4.00 N/A60 N/A $6.00 N/A

Ciprofloxacin tablet 500mg 20 N/A $2.00 N/A40 N/A $4.00 N/A60 N/A $6.00 N/A

Citalopram tablet 20mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Citalopram tablet 40mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Clonidine tablet 0.1mg 30 $2.00 $2.00 N/A60 $4.00 $4.00 N/A90 $6.00 $6.00 N/A60 N/A N/A $2.00

120 N/A N/A $4.00180 N/A N/A $6.00

Clonidine tablet 0.2mg 30 $2.00 $2.00 N/A60 $4.00 $4.00 N/A90 $6.00 $6.00 N/A60 N/A N/A $2.00

120 N/A N/A $4.00180 N/A N/A $6.00

Clonidine tablet 0.3mg 60 N/A N/A $3.00120 N/A N/A $6.00180 N/A N/A $9.00


Drug Name Qty





HEB

Dexamethasone tablet 0.5mg

30 $5.00 $2.00 N/A60 $10.00 $4.00 N/A90 $15.00 $6.00 N/A


12 $5.00 N/A N/A18 N/A $2.00 N/A24 $10.00 N/A N/A36 $15.00 $4.00 N/A54 N/A $6.00 N/A


45 $5.00 N/A N/A90 $10.00 N/A N/A

135 $15.00 N/A N/ADexamethasone tablet 4mg

6 $2.00 N/A N/A12 $4.00 N/A N/A18 $6.00 N/A N/A12 N/A $2.00 N/A24 N/A $4.00 N/A36 N/A $6.00 N/A

Diclofenac Potassium tablet 50mg

30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Diclofenac tablet 75mg DR 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Diltiazem tablet 30mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A60 $5.00 N/A N/A90 $10.00 N/A N/A

180 $15.00 N/A N/A


Drug Name Qty





HEB

Diltiazem tablet 60mg 60 $5.00 $2.00 N/A120 $10.00 $4.00 N/A180 $15.00 $6.00 N/A



Diltiazem capsule 120mg ER

30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Divalproex tablet 125mg DR

60 $5.00 N/A N/A120 $10.00 N/A N/A180 $15.00 N/A N/A

Doxazosin tablet 1mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A




Enalapril/HCTZ tablet 5-12.5mg

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


Drug Name Qty





HEB

Enalapril tablet 2.5mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00

Enalapril tablet 5mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00

Enalapril tablet 10mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00

Enalapril tablet 20mg 30 $2.00 $2.00 $4.0060 $4.00 $4.00 $8.0090 $6.00 $6.00 $12.00

Erythromycin ointment OP 3.5 N/A $2.00 N/A7 N/A $4.00 N/A

10.5 N/A $6.00 N/A4 $2.00 N/A N/A8 $4.00 N/A N/A

12 $6.00 N/A N/AFamotidine tablet 20mg 30 N/A $2.00 N/A

60 N/A $4.00 $2.0090 N/A $6.00 N/A

120 N/A N/A $4.00180 N/A N/A $6.00

Famotidine tablet 40mg 30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00

Fluconazole tablet 150mg 1 N/A $2.00 N/A2 N/A $4.00 N/A3 N/A $6.00 N/A


Drug Name Qty





HEB

Fluocinonide cream-e 0.05%

15 N/A $2.00 N/A30 N/A $4.00 N/A45 N/A $6.00 N/A

Fluoxetine capsule 10mg 30 N/A $2.00 $2.0060 N/A $4.00 $4.0090 N/A $6.00 $6.00



Fluphenazine tablet 1mg 30 $2.00 N/A N/A60 $4.00 $2.00 N/A90 $6.00 N/A N/A

120 N/A $4.00 N/A180 N/A $6.00 N/A

Fosinopril tablet 10mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A



Furosemide tablet 20mg 30 $2.00 $2.00 $2.0060 $4.00 $4.00 $4.0090 $6.00 $6.00 $6.00


Drug Name Qty





HEB

Furosemide tablet 40mg 30 $2.00 $2.00 $2.0060 $4.00 $4.00 $4.0090 $6.00 $6.00 $6.00

Furosemide tablet 80mg 30 $2.00 $2.00 N/A60 $4.00 $4.00 N/A90 $6.00 $6.00 N/A60 N/A N/A $2.00

120 N/A N/A $4.00180 N/A N/A $6.00

Gentamicin cream 0.1% 15 N/A $2.00 N/A30 N/A $4.00 N/A45 N/A $6.00 N/A30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Gentamicin ointment 0.1% 15 $5.00 N/A N/A30 $10.00 N/A N/A45 $15.00 N/A N/A

Gentamicin solution 0.3% OP

5 $5.00 $2.00 N/A10 $10.00 $4.00 N/A15 $15.00 $6.00 N/A

Glimepiride tablet 1mg 30 $2.00 $2.00 $1.7560 $4.00 $4.00 $3.5090 $6.00 $6.00 $5.25

Glimepiride tablet 2mg 30 $2.00 $2.00 $2.0060 $4.00 $4.00 $4.0090 $6.00 $6.00 $6.00


Drug Name Qty





HEB

Glimepiride tablet 4mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00

Glipizide tablet 5mg 30 $2.00 $2.00 $1.7560 $4.00 $4.00 $3.5090 $6.00 $6.00 $5.25

Glipizide tablet 10mg 60 $2.00 $2.00 $1.75120 $4.00 $4.00 $3.50180 $6.00 $6.00 $5.25

Glipizide ER tablet 2.5mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Glipizide ER tablet 5mg 60 $5.00 N/A N/A120 $10.00 N/A N/A180 $15.00 N/A N/A

Glipizide ER tablet 10mg 60 $5.00 N/A N/A120 $10.00 N/A N/A180 $15.00 N/A N/A

Haloperidol tablet 0.5mg 30 $2.00 N/A N/A60 $4.00 $2.00 N/A90 $6.00 N/A N/A

120 N/A $4.00 N/A180 N/A $6.00 N/A

Haloperidol tablet 1mg 30 $2.00 N/A N/A60 $4.00 N/A N/A90 $6.00 N/A N/A60 N/A $2.00 N/A

120 N/A $4.00 N/A180 N/A $6.00 N/A


Drug Name Qty





HEB


120 N/A $4.00 N/A180 N/A $6.00 N/A


120 N/A $4.00 N/A180 N/A $6.00 N/A

Hydralazine tablet 10mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Hydralazine tablet 25mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Hydrochlorothiazide capsule 12.5mg

30 N/A $2.00 $2.0060 N/A $4.00 $4.0090 N/A $6.00 $6.00

Hydrochlorothiazide tablet 25mg

30 $2.00 $2.00 $2.0060 $4.00 $4.00 $4.0090 $6.00 $6.00 $6.00

Hydrochlorothiazide tablet 50mg

30 N/A $2.00 $2.0060 N/A $4.00 $4.0090 N/A $6.00 $6.00


Drug Name Qty





HEB

Hydrocortisone cream 1% 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

28.35 $2.00 N/A N/A56.7 $4.00 N/A N/A

85.05 $6.00 N/A N/AHydrocortisone cream 2.5% 30 $5.00 $2.00 N/A

60 $10.00 $4.00 N/A90 $15.00 $6.00 N/A

Hydrocortisone ointment 1%

28.35 $2.00 N/A N/A56.7 $4.00 N/A N/A

85.05 $6.00 N/A N/AHydrocortisone ointment 2.5%

28.35 $5.00 N/A N/A56.7 $10.00 N/A N/A

85.05 $15.00 N/A N/AIbuprofen Suspension 100/5ml

120 $2.00 N/A N/A240 $4.00 N/A N/A360 $6.00 N/A N/A

Ibuprofen tablet 400mg 90 N/A $2.00 N/A180 N/A $4.00 N/A270 N/A $6.00 N/A

Ibuprofen tablet 600mg 60 $5.00 $2.00 N/A120 $10.00 $4.00 N/A180 $15.00 $6.00 N/A

Ibuprofen tablet 800mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Indapamide tablet 1.25mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


Drug Name Qty





HEB

Indapamide tablet 2.5mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00

Isoniazid tablet 100mg 30 $2.00 N/A N/A60 $4.00 N/A N/A90 $6.00 N/A N/A

Isoniazid tablet 300mg 30 $2.00 $2.00 N/A60 $4.00 $4.00 N/A90 $6.00 $6.00 N/A

Isosorbide Mononitrate tablet 30mg ER

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Isosorbide Mononitrate tablet 60mg ER

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Lactulose solution 10gm/15

237 $2.00 N/A N/A474 $4.00 N/A N/A711 $6.00 N/A N/A

Lamotrigine tablet 25mg 60 N/A N/A $2.00120 N/A N/A $4.00180 N/A N/A $6.00

Lamotrigine tablet 100mg 60 N/A N/A $2.00120 N/A N/A $4.00180 N/A N/A $6.00

Levobunolol solution 0.5% OP

5 N/A $2.00 N/A10 N/A $4.00 N/A15 N/A $6.00 N/A

Levothyroxine tablet 25mcg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


Drug Name Qty





HEB




Levothyroxine tablet 100mcg

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


Drug Name Qty





HEB

Lidocaine solution 2% visc 100 $5.00 $2.00 N/A200 $10.00 $4.00 N/A300 $15.00 $6.00 N/A

Lisinopril/HCTZ tablet 10-12.5

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Lisinopril/HCTZ tablet 20-12.5

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Lisinopril/HCTZ tablet 20-25mg

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Lisinopril tablet 2.5mg 30 N/A $2.00 $1.7560 N/A $4.00 $3.5090 N/A $6.00 $5.25

Lisinopril tablet 5mg 30 N/A $2.00 $1.7560 N/A $4.00 $3.5090 N/A $6.00 $5.25



Lisinopril tablet 30mg 30 N/A N/A $1.7560 N/A N/A $3.5090 N/A N/A $5.25

Lisinopril tablet 40mg 30 N/A N/A $1.7560 N/A N/A $3.5090 N/A N/A $5.25


Drug Name Qty





HEB

Lithium Carbonate capsule 150mg

60 $5.00 N/A N/A120 $10.00 N/A N/A180 $15.00 N/A N/A


90 $5.00 $2.00 N/A180 $10.00 $4.00 N/A270 $15.00 $6.00 N/A


60 $5.00 N/A N/A120 $10.00 N/A N/A180 $15.00 N/A N/A

Lithium Carbonate tablet 300mg

60 $5.00 N/A N/A120 $10.00 N/A N/A180 $15.00 N/A N/A

Losartan Potassium tablet 25mg

60 N/A N/A $1.75120 N/A N/A $3.50180 N/A N/A $5.25

Losartan Potassium tablet 50mg

60 N/A N/A $1.75120 N/A N/A $3.50180 N/A N/A $5.25

Lovastatin tablet 10mg 30 N/A $1.50 $1.7560 N/A $3.00 $3.5090 N/A $4.50 $5.25

Lovastatin tablet 20mg 30 N/A $1.50 $1.7560 N/A $3.00 $3.5090 N/A $4.50 $5.25

Lovastatin tablet 40mg 30 N/A N/A $1.7560 N/A N/A $3.5090 N/A N/A $5.25

Medroxyprogesterone Acetate tablet 2.5mg

30 $5.00 $2.00 N/A60 $10.00 $4.00 N/A90 $15.00 $6.00 N/A


Drug Name Qty





HEB

Medroxyprogesterone Acetate tablet 5mg

30 $5.00 $2.00 N/A60 $10.00 $4.00 N/A90 $15.00 $6.00 N/A

Medroxyprogesterone Acetate tablet 10mg

30 $5.00 $2.00 N/A60 $10.00 $4.00 N/A90 $15.00 $6.00 N/A

Meloxicam tablet 7.5mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00

Meloxicam tablet 15mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00

Metformin tablet 500mg 60 N/A $1.75 $1.00120 N/A $3.50 $2.00180 N/A $5.25 $3.00

Metformin tablet 500mg ER 60 N/A $1.75 N/A120 N/A $3.50 N/A180 N/A $5.25 N/A

Metformin tablet 750mg ER 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A



Methylprednisolone tablet 4mg

21 N/A $2.00 N/A42 N/A $4.00 N/A63 N/A $6.00 N/A


Drug Name Qty





HEB

Methylprednisolone tablet 4mg (dose pack)

21 N/A $2.00 N/A42 N/A $4.00 N/A63 N/A $6.00 N/A

Metoclopramide solution 5mg/5ml

60 $5.00 N/A N/A120 $10.00 $2.00 N/A180 $15.00 N/A N/A240 N/A $4.00 N/A360 N/A $6.00 N/A

Metoclopramide tablet 10mg

60 $2.00 $2.00 N/A120 $4.00 $4.00 N/A180 $6.00 $6.00 N/A

Metoprolol Tartrate tablet 25mg

60 N/A $2.00 $2.00120 N/A $4.00 $4.00180 N/A $6.00 $6.00


60 N/A $2.00 $2.00120 N/A $4.00 $4.00180 N/A $6.00 $6.00


60 N/A $2.00 $2.00120 N/A $4.00 $4.00180 N/A $6.00 $6.00

Nadolol tablet 20mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Nadolol tablet 40mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Naproxen tablet 375mg 60 N/A $2.00 $2.00120 N/A $4.00 $4.00180 N/A $6.00 $6.00


Drug Name Qty





HEB

Naproxen tablet 500mg 60 N/A $2.00 $4.00120 N/A $4.00 $8.00180 N/A $6.00 $12.00

Naproxen sodium tablet 275mg

30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Neomycin/Polymyxin/Dexamethasone ointment 0.1% OP

3.5 N/A $2.00 N/A7 N/A $4.00 N/A

10.5 N/A $6.00 N/A5 $5.00 N/A N/A

10 $10.00 N/A N/A15 $15.00 N/A N/A

Neomycin/Polymyxin/ Dexamethasone Suspension 0.1% OP

4 $5.00 N/A N/A8 $10.00 N/A N/A

12 $15.00 N/A N/A5 N/A $2.00 N/A

10 N/A $4.00 N/A15 N/A $6.00 N/A

Nortriptyline capsule 10mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Nortriptyline capsule 25mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Nortriptyline capsule 75mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Nystatin/Triamcinolone cream

30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


Drug Name Qty





HEB

Nystatin/Triamcinolone ointment

15 $5.00 $2.00 N/A30 $10.00 $4.00 N/A45 $15.00 $6.00 N/A

Nystatin cream 100000 15 N/A $2.00 N/A30 N/A $4.00 N/A45 N/A $6.00 N/A30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Oxybutynin tablet 5mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Paroxetine tablet 10mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Paroxetine tablet 20mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Paroxetine tablet 40mg 30 N/A N/A $4.0060 N/A N/A $8.0090 N/A N/A $12.00

Penicilln VK solution 125/5ml

200 N/A $2.00 N/A400 N/A $4.00 N/A600 N/A $6.00 N/A

Penicilln VK solution 250/5ml

100 $2.00 $2.00 N/A200 $4.00 $4.00 N/A300 $6.00 $6.00 N/A


Drug Name Qty





HEB

Penicilln VK tablet 250mg 40 N/A $2.00 N/A80 N/A $4.00 N/A

120 N/A $6.00 N/A28 $2.00 N/A N/A56 $4.00 N/A N/A84 $6.00 N/A N/A

Pilocarpine solution 1% OP 15 $5.00 N/A N/A30 $10.00 N/A N/A45 $15.00 N/A N/A

Pilocarpine solution 2% OP 15 $5.00 N/A N/A30 $10.00 N/A N/A45 $15.00 N/A N/A

Polymyxin B/Trimethoprim solution

10 $2.00 $2.00 N/A20 $4.00 $4.00 N/A30 $6.00 $6.00 N/A

Pramipexole tablet 0.125mg

30 N/A N/A $4.0060 N/A N/A $8.0090 N/A N/A $12.00

Pramipexole tablet 0.25mg 30 N/A N/A $4.0060 N/A N/A $8.0090 N/A N/A $12.00



Pramipexole tablet 1mg 30 N/A N/A $4.0060 N/A N/A $8.0090 N/A N/A $12.00


Drug Name Qty





HEB


Pravastatin tablet 10mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A



Prazosin HCL capsule 1mg 30 $5.00 $2.00 N/A60 $10.00 $4.00 N/A90 $15.00 $6.00 N/A

Prazosin HCL capsule 2mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Prazosin HCL capsule 5mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Prednisone con 5mg/ml 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Prednisone pak 5mg 48 N/A $2.00 N/A96 N/A $4.00 N/A

144 N/A $6.00 N/APrednisone pak 10mg 48 N/A $2.00 N/A

96 N/A $4.00 N/A144 N/A $6.00 N/A


Drug Name Qty





HEB

Prednisone tablet 2.5mg 30 $5.00 $2.00 N/A60 $10.00 $4.00 N/A90 $15.00 $6.00 N/A

Prednisone tablet 5mg 30 $2.00 N/A N/A60 $4.00 N/A N/A90 $6.00 N/A N/A

Prednisone tablet 10mg 30 $2.00 $2.00 N/A60 $4.00 $4.00 N/A90 $6.00 $6.00 N/A

Prednisone tablet 20mg 30 $2.00 $2.00 N/A60 $4.00 $4.00 N/A90 $6.00 $6.00 N/A

Prochlorperazine tablet 10mg

30 N/A $2.00 $2.0060 N/A $4.00 $4.0090 N/A $6.00 $6.00

Propranolol tablet 10mg 60 $2.00 $2.00 N/A120 $4.00 $4.00 N/A180 $6.00 $6.00 N/A




Quinapril tablet 5mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A


Drug Name Qty





HEB

Quinapril tablet 10mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Quinapril tablet 20mg 30 $5.00 N/A $2.0060 $10.00 N/A $4.0090 $15.00 N/A $6.00

Quinapril tablet 40mg 30 $5.00 N/A $3.0060 $10.00 N/A $6.0090 $15.00 N/A $9.00

Ramipril capsule 2.5mg 30 N/A N/A $1.7560 N/A N/A $3.5090 N/A N/A $5.25

Ramipril capsule 5mg 30 N/A N/A $1.7560 N/A N/A $3.5090 N/A N/A $5.25

Ramipril capsule 10mg 30 N/A N/A $1.7560 N/A N/A $3.5090 N/A N/A $5.25

Ranitidine tablet 150mg 60 N/A $2.00 $4.00120 N/A $4.00 $8.00180 N/A $6.00 $12.00

Ranitidine tablet 300mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00

Risperidone tablet 0.25mg 30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00

Ropinirole tablet 0.25mg 30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00


Drug Name Qty





HEB

Ropinirole tablet 0.5mg 30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00

Ropinirole tablet 1mg 30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00



Silver Sulfadiazine cream 1%

50 $5.00 $2.00 N/A100 $10.00 $4.00 N/A150 $15.00 $6.00 N/A

Simvastatin tablet 5mg 30 N/A N/A $4.0060 N/A N/A $8.0090 N/A N/A $12.00






Drug Name Qty





HEB

Sulfamethoxazole/Trimethoprim Suspension 200-40/5

120 $5.00 $2.00 N/A240 $10.00 $4.00 N/A360 $15.00 $6.00 N/A

Sulfamethoxazole/Trimethoprim tablet 400-80mg

20 N/A $2.00 N/A28 $2.00 N/A N/A40 N/A $4.00 N/A56 $4.00 N/A N/A60 N/A $6.00 N/A84 $6.00 N/A N/A

Sodium Sulfacetamide solution 10% OP

15 $5.00 $2.00 N/A30 $10.00 $4.00 N/A45 $15.00 $6.00 N/A

Sotalol HCL tablet 80mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Spironolactone tablet 25mg 30 $5.00 $2.00 N/A60 $10.00 $4.00 N/A90 $15.00 $6.00 N/A

Sprintec 28 tablet 28 day 28 N/A $2.00 N/A56 N/A $4.00 N/A84 N/A $6.00 N/A

Tamoxifen tablet 10mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Tamoxifen tablet 20mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Terazosin capsule 1mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A


Drug Name Qty





HEB




Terbinafine tablet 250mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Tetracycline capsule 250mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Tetracycline capsule 500mg 60 $2.00 $2.00 N/A120 $4.00 $4.00 N/A180 $6.00 $6.00 N/A

Thiothixene capsule 2mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A

Timolol Maleate solution 0.25% OP

5 N/A $2.00 N/A10 N/A $4.00 N/A15 N/A $6.00 N/A

Timolol Maleate solution 0.5% OP

5 N/A $2.00 N/A10 N/A $4.00 N/A15 N/A $6.00 N/A

Tobramycin solution 0.3% OP

5 $2.00 $2.00 N/A10 $4.00 $4.00 N/A15 $6.00 $6.00 N/A


Drug Name Qty





HEB

Tramadol HCL tablet 50mg 60 N/A $2.00 N/A120 N/A $4.00 N/A180 N/A $6.00 N/A

Trazodone tablet 50mg 30 N/A $2.00 $2.0060 N/A $4.00 $4.0090 N/A $6.00 $6.00



Triamcinolone cream 0.025%

15 $5.00 $2.00 N/A30 $10.00 $4.00 N/A45 $15.00 $6.00 N/A

Triamcinolone cream 0.1% 80 N/A $2.00 N/A160 N/A $4.00 N/A240 N/A $6.00 N/A

Triamcinolone cream 0.5% 15 $2.00 $2.00 N/A30 $4.00 $4.00 N/A45 $6.00 $6.00 N/A

Triamcinolone ointment 0.1%

15 N/A $2.00 N/A30 N/A $4.00 N/A45 N/A $6.00 N/A80 $2.00 N/A N/A

160 $4.00 N/A N/A240 $6.00 N/A N/A

Triamterene/HCTZ capsule 37.5-25

30 $2.00 $2.00 $2.0060 $4.00 $4.00 $4.0090 $6.00 $6.00 $6.00


Drug Name Qty





HEB

Triamterene/HCTZ tablet 37.5-25

30 N/A N/A $2.0060 N/A N/A $4.0090 N/A N/A $6.00

Triamterene/HCTZ tablet 75-50mg

30 N/A $2.00 $2.0060 N/A $4.00 $4.0090 N/A $6.00 $6.00

Tri-sprintec tablet 28 N/A $2.00 N/A56 N/A $4.00 N/A84 N/A $6.00 N/A

Verapamil tablet 80mg 30 $5.00 N/A N/A60 $10.00 $2.00 N/A90 $15.00 N/A N/A

120 N/A $4.00 N/A180 N/A $6.00 N/A

Verapamil tablet 120mg 30 $5.00 N/A N/A60 $10.00 N/A N/A90 $15.00 N/A N/A60 N/A $2.00 N/A

120 N/A $4.00 N/A180 N/A $6.00 N/A

Warfarin tablet 1mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00


Warfarin tablet 2.5mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00


Drug Name Qty





HEB





Warfarin tablet 7.5mg 30 N/A $2.00 $4.0060 N/A $4.00 $8.0090 N/A $6.00 $12.00

Warfarin tablet 10mg 30 N/A $2.00 N/A60 N/A $4.00 N/A90 N/A $6.00 N/A

Drugs and prices may vary between pharmacies and are subject to change during the plan year. Prices are based on quantity filled at the pharmacy. Quantities may be limited by pharmacy based on their dispensing policy or by the plan based on Quantity Limit requirements; if prescription is in excess of a limit, copay amounts may be higher.Other pharmacies are available in our network. Members may use any pharmacy in the network, but may not receive Pharmacy Saver pricing. Pharmacies participating in the Pharmacy Saver program may not be available in all areas. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change each year.Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies. For Medicare Advantage and Prescription Drug Plans: A Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in these plans depends on the plan’s contract renewal with Medicare.The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.Y0066_171010_153201 SPRJ36360

2018 pharmacy saver drug ist - unitedhealthcare® … pharmacy saver drug ist important notice: the...

Documents