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*† AMOXICILLIN 400MG/5ML AMOXIL® 75 SUSPENSION *† AMOXICILLIN CHEW 125MG AMOXIL® *† AMOXICILLIN CHEW 250MG AMOXIL® AMOXICILLIN PEDIATRIC 50MG/ML AMOXIL® *†ANTIPYRINE/BENZOCAINE AURALGAN® 10 OTIC CHLORTHALIDONE 50-25MG TENORETIC® 30 TABLET ATENOLOL / CHLORTHALIDONE 100-25MG TENORETIC® 30 TABLET BBACLOFEN 10MG
BELLADONNA ALK/PB 16.2MG DONNATAL® 60 TABLET † BENAZEPRIL/HCTZ 10-12.5MG LOTENSIN HCT® 30 TABLET † BENAZEPRIL/HCTZ 20-12.5MG LOTENSIN HCT® 30 TABLET *† BENAZEPRIL/HCTZ 20-25MG LOTENSIN HCT® 30 TABLET BISOPROLOL/HCTZ 2.5-6.25MG ZIAC® cCAPTOPRIL 12.5MG
Generic nAme
BrAnd nAme Qty Form
†CARBAMAZEPINE CHEWABLE 100MG TEGRETOL® *† ALBUTEROL NEBULIZER 0.50% PROVENTIL® 20 CHLORHEXIDINE GLUCONATE 0.12% PERIDEX® *† CHLORPROPAMIDE 100MG DIABINESE® 30 TABLET *† CHLORTHALIDONE 25MG HYGROTON® 30 TABLET *† CHLORTHALIDONE 50MG HYGROTON® 30 TABLET *† AMOXICILLIN 200MG/5ML AMOXIL® 75 SUSPENSION CYANOCOBALAMIN 1000MCG/ML VITIAMIN B12 INJ® 10 *† DEC-CHLORPHEN DM 3.5-1-3MG/ML RONDEC DM® 30 *† HEMORRHOIDAL-HC 25MG ANUSOL-HC® 12 SUPPOSITORY † HYDROCHLOROTHIAZIDE 12.5MG MICROZIDE® 30 HYDROCHLOROTHIAZIDE 25MG HYDRODIURIL® 30 HYDROCHLOROTHIAZIDE 50MG HYDRODIURIL® 30 DIPHENHYDRAMINE HCL 50MG BENADRYL® 30 CAPSULE *† HYDROXYZINE HCL 10MG/5ML ATARAX® HYDROXYZINE PAMOATE 25MG VISTARIL® HYDROXYZINE PAMOATE 50MG VISTARIL® iIBUPROFEN 100MG/5ML MOTRIN® 120 SUSPENSION
IOPHEN DM LIQUID 100-10/5ML TUSSI-ORGANIDIN DM® 120 SYRUP ENALAPRIL MALEATE/HCTZ 10-25MG VASERETIC® ISOSORBIDE DINITRATE ORAL 5MG ISORDIL® ISOSORBIDE DINITRATE ORAL 10MG ISORDIL® ISOSORBIDE DINITRATE ORAL 20MG ISORDIL® *†ISOSORBIDE MONO ER 30MG IMDUR® *†ISOSORBIDE MONO ER 60MG IMDUR® † LEUCOVORIN CALCIUM 5MG LEUCOVOR® 4 TABLET *†FLUOCINOLONE ACETONIDE 0.01% SYNALAR® LISINOPRIL/HCTZ 10-12.5MG PRINZIDE®/ 30 TABLET LISINOPRIL/HCTZ 20-12.5MG PRINZIDE®/ 30 TABLET LITHIUM CARBONATE 300MG ESKALITH® 90 CAPSULE GLYBURIDE/METFORMIN 2.5/500MG GLUCOVANCE® 60 GLYBURIDE/METFORMIN 5/500MG GLUCOVANCE® 60 MAGNESIUM OXIDE 400MG MAG-OX® 30 TABLET POTASSIUM CHLORIDE 10% KAY-CIEL® 480 LIQUID MEDROXYPROGESTERONE 2.5MG PROVERA® MEDROXYPROGESTERONE 5MG PROVERA® MEDROXYPROGESTERONE 10MG PROVERA® *† PREDNISOLONE 15MG/5ML ORAPRED® 50 SOLUTION PREDNISONE DOSEPACK 5MG STERAPRED® 21 TABLET METHYLPREDNISOLONE 4MG MEDROL® 21 TABLET *† PREDNISONE DOSEPACK 5MG STERAPRED® 48 METHYLPREDNISOLONE DOSEPAK 4MG MEDROL® *† PREDNISONE DOSEPACK 10MG STERAPRED DS® 21 TABLET METOCLOPRAMIDE 5MG/5ML REGLAN® 60 SYRUP *† PREDNISONE DOSEPACK 10MG STERAPRED DS® 48 TABLET METOPROLOL TARTRATE 25MG LOPRESSOR® 60 TABLET METOPROLOL TARTRATE 50MG LOPRESSOR® 60 TABLET METOPROLOL TARTRATE 100MG LOPRESSOR® 60 TABLET *† SELENIUM SULFIDE 2.50% SELSUN® *† SILVER SULFADIAZINE 1% SILVADENE® 50 CREAM *†SMZ/TMP PEDIATRIC 200-40MG/5ML BACTRIM PED® 120 SUSPENSION *† SODIUM FLUORIDE 0.5MG/ML LURIDE DROP® 50 SODIUM FLUORIDE CHEWABLE 0.25MG LURIDE® SODIUM FLUORIDE CHEWABLE 0.5MG LURIDE® SODIUM FLUORIDE CHEWABLE 1MG LURIDE® SODIUM FLUORIDE DENTAL 5000 PREVIDENT *† SULFACETAMIDE SODIUM 10% SODIUM SULAMYD® 15 PHENAZOPYRIDINE 100MG PYRIDIUM® 6 TABLET *† PHENAZOPYRIDINE 200MG PYRIDIUM® 30 TABLET *† TIMOLOL MALEATE 0.50% TIMOPTIC® 5 OPHTHALMIC TRIAMTERENE/HCTZ 37.5-25MG MAXZIDE® 30 TABLET TRIAMTERENE/HCTZ 37.5-25MG DYAZIDE® TRIAMTERENE/HCTZ 75-50MG MAXZIDE® 30 TABLET *† TRI-VENT DPC 6-2-15MG/5ML ATUSS DR® *Due to state laws, these drugs are not covered under the 30-day program in MN and WI; however, they have been competitively priced. †Due to state laws, these drugs are not covered under the 90-day program in MN and WI; however, they have been competitively priced. Please ask your pharmacist for specific pricing in these states. $4 prescriptions are for up to a 30-day supply at commonly prescribed dosages. Drug list subject to change. This list was created on 4-15-11. Please visit our website at www.hy-vee.com for a current list of affected drugs and

Source: http://catretirees.com/HY-VEE%20400list_alpha90.pdf