Prescription Drug Plan
Effective
2/10/2017
*Quantity and other restrictions apply.
Antibiotics
DRUG NAME
AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE)
AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE)
AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE)
AMOXICILLIN 200 MG/5 ML (100 ML BOTTLE)
AMOXICILLIN 200 MG/5 ML (75 ML BOTTLE)
AMOXICILLIN 200 MG/5 ML (50 ML BOTTLE)
AMOXICILLIN 250 MG CAPSULES
AMOXICILLIN 250 MG/5 ML (150 ML BOTTLE)
AMOXICILLIN 250 MG/5 ML (100 ML BOTTLE)
AMOXICILLIN 250 MG/5 ML (80 ML BOTTLE)
AMOXICILLIN 400 MG/5 ML (100 ML BOTTLE)
AMOXICILLIN 400 MG/5 ML (75 ML BOTTLE)
AMOXICILLIN 400 MG/5 ML (50 ML BOTTLE)
AMOXICILLIN 500 MG CAPSULES
AMOXICILLIN 875 MG TABLETS
AMPICILLIN 250 MG CAPSULES
AMPICILLIN 500 MG CAPSULES
CEPHALEXIN 250 MG CAPSULES
CEPHALEXIN 500 MG CAPSULES
CIPROFLOXACIN 250 MG TABLETS
CIPROFLOXACIN 500 MG TABLETS
CIPROFLOXACIN 750 MG TABLETS
CLINDAMYCIN 150 MG CASULES
PENICILLIN V Pot 125/5 100 ML (100 ML BOTTLE)
PENICILLIN V Pot 125/5 200 ML (200 ML BOTTLE)
PENICILLIN VK 250 MG TABLETS
PENICILLIN VK 250/5 ML (100 ML BOTTLE)
PENICILLIN VK 250/5 ML (200 ML BOTTLE)
PENICILLIN VK 500 MG TABLETS
SULFAMETH/TRIMETH 400/80 MG TABLETS
SULFAMETH/TRIMETH 800/160 MG TABLETS
SULFASALAZINE 500 MG TABLETS
Qty*
$0.00 Copay
$
30
$
DRUG NAME
FLUCONAZOLE 150 MG TABLETS
NYSTATIN 100 MU/ML ORAL SUSP DROP
NYSTATIN 100 MU/ML ORAL SUSP
TERBINAFINE 250 MG TABLETS
Antiviral
DRUG NAME
AMANTADINE 50 MG/5 ML SYRUP
ACYCLOVIR 200 MG CAPSULES
ACYCLOVIR 400 MG TABLETS
ACYCLOVIR 800 MG TABLETS
30 Day Qty*
8.00
20
20
N/A
30
28
14
30 Day Qty*
15.00
6
30 Day Qty*
$
4.00
1
60
60
30
30 Day Qty*
$
4.00
120
30
30
30
$
AZITHROMYCIN 250 MG PAK (6 TABLETS)
90 Day Qty*
$
10.00
90
100
200
28
100
200
28
28
20
AMOX/K CLAV 500 MG TABLETS
AMOX/K CLAV 875 MG TABLETS
CLINDAMYCIN 300 MG CAPSULES
ISONIAZID 300 MG TABLETS
METRONIDAZOLE 250 MG TABLETS
METRONIDAZOLE 500 MG TABLETS
Antifungal
30 Day Qty*
4.00
150
100
80
100
75
50
30
150
100
80
100
75
50
30
20
28
28
30
30
20
20
14
30
90
90 Day Qty*
$
24.00
30
90
84
42
90 Day Qty*
N/A
90 Day Qty*
$
10.00
3
180
180
90
90 Day Qty*
$
10.00
360
90
90
90
Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be higher or may be added/deleted without notice. Can not be used in conjuction with other
insurance.
Prescription Drug Plan
Effective
2/10/2017
*Quantity and other restrictions apply.
Arthritis/ Pain
DRUG NAME
30 Day Qty*
4.00
30
90
60
30
60
30
30
30
60
60
60
90 Day Qty*
$
10.00
90
270
180
90
180
90
90
90
180
180
180
30 Day Qty*
8.00
30
60
60
30 Day Qty*
$
4.00
120
75
30
75
30
90 Day Qty*
$
24.00
90
180
180
90 Day Qty*
$
10.00
473
225
90
225
90
$
ALLOPURINOL 100 MG TABLETS
IBUPROFEN 400 MG TABLETS
IBUPROFEN 600 MG TABLETS
IBUPROFEN 800 MG TABLETS
INDOMETHACIN 25 MG CAPSULES
INDOMETHACIN 50 MG CAPSULES
MELOXICAM 15 MG TABLETS
MELOXICAM 7.5 MG TABLETS
NAPROXEN 250 MG TABLETS
NAPROXEN 375 MG TABLETS
NAPROXEN 500 MG TABLETS
$
BACLOFEN 10 MG TABLETS
DICLOFENAC SOD DR 50 MG TABLETS
DICLOFENAC SOD DR 75 MG TABLETS
Asthma/Resp/Allergies
DRUG NAME
ALBUTEROL 2 MG/5 ML SYRUP
ALBUTEROL SULFATE 0.083 % NEB SOLN
CETIRIZINE 10 MG TABLETS
IPRATROPIUM BROMIDE 0.02% AMPULE
LORATADINE 10 MG TABLETS
$
IPRATROPIUM BROM/ALBUTEROL SUL 0.5-2.5
30 Day Qty*
15.00
90
30 Day Qty*
15.00
16
30
30
30 Day Qty*
$
4.00
30
30
30
30
30
30
30
30
90 Day Qty*
$
45.00
48
90
90
90 Day Qty*
$
10.00
90
90
90
90
90
90
90
90
30 Day Qty*
10.00
60
30 Day Qty*
$
15.00
30
30
30
30
90 Day Qty*
$
30.00
180
90 Day Qty*
$
45.00
90
90
90
90
$
FLUTICASONE 50 MCG NASAL SPRAY
MONTELUKAST 5 MG TABLETS
MONTELUKAST 10 MG TABLETS
Cholesterol
DRUG NAME
LOVASTATIN 10 MG TABLETS
LOVASTATIN 20 MG TABLETS
LOVASTATIN 40 MG TABLETS
SIMVASTATIN 20 MG TABLETS
SIMVASTATIN 40 MG TABLETS
SIMVASTATIN 10 MG TABLETS
SIMVASTATIN 5 MG TABLETS
SIMVASTATIN 80 MG TABLETS
$
GEMFIBROZIL 600 MG TABLETS
ATORVASTATIN 10 MG TABLETS
ATORVASTATIN 20 MG TABLETS
ATORVASTATIN 40 MG TABLETS
ATORVASTATIN 80 MG TABLETS
90 Day Qty*
Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be higher or may be added/deleted without notice. Can not be used in conjuction with other
insurance.
Prescription Drug Plan
Effective
2/10/2017
*Quantity and other restrictions apply.
CNS
DRUG NAME
30 Day Qty*
4.00
30
30
60
60
30
60
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
90 Day Qty*
$
10.00
90
90
180
180
90
180
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
30 Day Qty*
8.00
30
60
60
30
30 Day Qty*
$
4.00
15
120
120
30 Day Qty*
$
4.00
30
30
30
60
60
30
30
30
60
30
30
90 Day Qty*
$
22.00
90
180
60
60
180
180
$
BENZTROPINE 0.5 MG TABLETS
BENZTROPINE 1 MG TABLETS
DIVALPROEX SODIUM DR 125 MG TABLETS
DIVALPROEX SODIUM DR 250 MG TABLETS
DIVALPROEX SODIUM DR 500 MG TABLETS
GABAPENTIN 100 MG CAPSULES
GABAPENTIN 300 MG CAPSULES
GABAPENTIN 400 MG CAPSULES
LAMOTRIGINE 100 MG TABLETS
LAMOTRIGINE 150 MG TABLETS
LAMOTRIGINE 200 MG TABLETS
LAMOTRIGINE 25 MG TABLETS
LAMOTRIGINE 25 MG CHEW TABS
PRIMIDONE 50 MG TABLETS
PRIMIDONE 250 MG TABLETS
ROPINIROLE 0.25 MG TABLETS
ROPINIROLE 0.5 MG TABLETS
ROPINIROLE 1 MG TABLETS
ROPINIROLE 2 MG TABLETS
ROPINIROLE 3 MG TABLETS
ROPINIROLE 4 MG TABLETS
ROPINIROLE 5 MG TABLETS
TOPIRAMATE 25 MG TABLETS
TOPIRAMATE 50 MG TABLETS
TOPIRAMATE 100 MG TABLETS
TOPIRAMATE 200 MG TABLETS
ZONISAMIDE 25 MG CAPSULES
ZONISAMIDE 50 MG CAPSULES
ZONISAMIDE 100 MG CAPSULES
$
BENZTROPINE 2 MG TABLETS
OXCARBAZEPINE 150 MG TABLETS
OXCARBAZEPINE 300 MG TABLETS
OXCARBAZEPINE 600 MG TABLETS
Cough
DRUG NAME
BENZONATATE 100 MG CAPSULES- UPDATED QUANTITY
PROMETHAZINE/DM 15-6.25 MG/5 ML SYRUP
PROMETHAZINE 6.25/5 ML SYRUP*
Diabetes
DRUG NAME
GLIMEPIRIDE 1 MG TABLETS
GLIMEPIRIDE 2 MG TABLETS
GLIMEPIRIDE 4 MG TABLETS
GLIPIZIDE 10 MG TABLETS
GLIPIZIDE 5 MG TABLETS (DIABETA)
GLYBURIDE 1.25 MG TABLETS
GLYBURIDE 2.5 MG TABLETS
GLYBURIDE 5 MG TABLETS
GLYBURIDE/METFORMIN 1.25/250 MG TABLETS
GLYBURIDE/METFORMIN 2.5/500 MG TABLETS
GLYBURIDE/METFORMIN 5/500 MG TABLETS
METFORMIN 1000 MG TABLETS
METFORMIN 500 MG TABLETS
METFORMIN 850 MG TABLETS
METFORMIN ER 500 MG TABLETS
METFORMIN ER 750 MG TABLETS
Qty*
$0.00 Copay
90
90 Day Qty*
$
10.00
45
360
360
90 Day Qty*
$
10.00
90
90
90
180
180
90
90
90
180
90
90
225
360
270
Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be higher or may be added/deleted without notice. Can not be used in conjuction with other
insurance.
Prescription Drug Plan
Effective
2/10/2017
*Quantity and other restrictions apply.
Diabetes
30 Day Qty*
5.00
25
100
30 Day Qty*
$
8.00
30
30
30
30 Day Qty*
$
10.00
50
30 Day Qty*
$
20.00
100
90 Day Qty*
$
20.00
90
90
90
90 Day Qty*
N/A
$
4.00
$
8.00
10
30 Day Qty*
$
4.00
60
60
60
60
240
30
20
20
14
7
12
150
30 Day Qty*
$
4.00
240
$
$
BLOOD GLUCOSE PREM TEST STRIPS 25 CT BY TOPCARE
BLOOD GLUCOSE LANCETS BY TOPCARE
GLYBURIDE 5 MG TABLETS (MICRONASE)
GLYBURIDE MCR 3 MG TABLETS
GLYBURIDE MCR 6 MG TABLETS
BLOOD GLUCOSE PREM TEST STRIPS 50 CT BY TOPCARE
BLOOD GLUCOSE PREM TEST STRIPS 100 CT BY TOPCARE
90 Day Qty*
N/A
90 Day Qty*
N/A
Ear/Eye
DRUG NAME
CIPROFLOXACIN 0.3% OPTHALMIC SOL
GENTAMICIN SUL 0.3% OPTHALMIC SOL
LATANOPROST 0.005% OPTHALMIC SOL (3 ML BOTTLE)
TIMOLOL MAL 0.25% OPTHALMIC SOL (5 ML)
TIMOLOL MAL 0.5% OPTHALMIC SOL (5 ML or 15 ML)
TOBRAMYCIN 0.3% OPHTHALMIC SOLUTION
TRIMETHOPRIM-POLY B OPTHALMIC SOL
5
5
N/A
5
5
5
10
$
TIMOLOL MAL 0.5% OPTHALMIC SOL (10 ML)
Gastrointestinal
DRUG NAME
FAMOTIDINE 20 MG TABLETS
FAMOTIDINE 40 MG TABLETS
METOCLOPRAMIDE 10 MG TABLETS
METOCLOPRAMIDE 5 MG
METOCLOPRAMIDE 5 MG/5 ML SYRUP
OMEPRAZOLE 20 MG CAPSULES
ONDANSETRON 4 MG TABLETS
ONDANSETRON 8 MG TABLETS
ONDANSETRON ODT 4 MG TABLETS
ONDANSETRON ODT 8 MG TABLETS
PROMETHAZINE 25 MG TABLETS
RANITIDINE 15MG/ML SYRUP
LACTULOSE 10 MG/15 ML SOLUTION
$
DICYCLOMINE 10 MG CAPSULES
DICYCLOMINE 20 MG TABLETS
OMEPRAZOLE 40 MG CAPSULES
PANTOPRAZOLE 20 MG TABLETS
PANTOPRAZOLE 20 MG TABLETS
RANITIDINE 150 MG TABLETS- NEW PRICE
RANITIDINE 300 MG TABLETS- NEW PRICE
30 Day Qty*
8.00
90
60
30
30
30
60
30
10.00
15
15
3
N/A
15
15
30
24.00
N/A
90 Day Qty*
$
10.00
180
180
180
180
90
60
60
42
21
36
473
90 Day Qty*
$
12.00
960
90 Day Qty*
$
24.00
270
180
90
90
90
180
90
Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be higher or may be added/deleted without notice. Can not be used in conjuction with other
insurance.
Prescription Drug Plan
Effective
2/10/2017
*Quantity and other restrictions apply.
Heart and Blood Pressure
DRUG NAME
AMLODIPINE 2.5 MG TABLETS
AMLODIPINE 5 MG TABLETS
AMLODIPINE 10 MG TABLETS
AMLODIPINE/BENZ 2.5/10 MG CAPSULES
AMLODIPINE/BENZ 5/10 MG CAPSULES
AMLODIPINE/BENZ 5/20 MG CAPSULES
AMLODIPINE/BENZ 10/20 MG CAPSULES
ATENOLOL 100 MG TABLETS
ATENOLOL 25 MG TABLETS
ATENOLOL 50 MG TABLETS
BENAZEPRIL 10 MG TABLETS
BENAZEPRIL 20 MG TABLETS
BENAZEPRIL 40 MG TABLETS
BENAZEPRIL 5 MG TABLETS
BISOPROLOL 5 MG TABLETS
BISOPROLOL 10 MG TABLETS
BISOPROLOL/HCTZ 10/6.25 TABLETS
BISOPROLOL/HCTZ 5/6.25 TABLETS
BISOPROLOL/HCTZ 2.5/6.25 TABLETS
CARVEDILOL 12.5 MG TABLETS
CARVEDILOL 25 MG TABLETS
CARVEDILOL 3.125 MG TABLETS
CARVEDILOL 6.25 MG TABLETS
CLONIDINE 0.1 MG TABLETS
CLONIDINE 0.2 MG TABLETS
CLONIDINE 0.3 MG TABLETS
ENALAPRIL/HCTZ 5/12.5 MG
ENALAPRIL/HCTZ 10-25 MG
FUROSEMIDE 20 MG TABLETS
FUROSEMIDE 40 MG TABLETS
FUROSEMIDE 80 MG TABLETS
GUANFACINE 1 MG TABLETS
GUANFACINE 2 MG TABLETS
HYDRALAZINE 10 MG TABLETS
HYDRALAZINE 25 MG TABLETS
HYDRALAZINE 50 MG TABLETS
HYDRALAZINE 100 MG TABLETS
HYDROCHLOROTHIAZIDE 12.5 MG CAPSULES
HYDROCHLOROTHIAZIDE 12.5 MG TABLETS
HYDROCHLOROTHIAZIDE 25 MG TABLETS
HYDROCHLOROTHIAZIDE 50 MG TABLETS
ISOSORBIDE MONONITRATE 20 MG TABLETS
LISINOPRIL 10 MG TABLETS
LISINOPRIL 2.5 MG TABLETS
LISINOPRIL 20 MG TABLETS
LISINOPRIL 30 MG TABLETS
LISINOPRIL 40 MG TABLETS
LISINOPRIL 5 MG TABLETS
LISINOPRIL-HCTZ 10-12.5 MG TABLETS
LISINOPRIL-HCTZ 20-12.5 MG TABLETS
LISINOPRIL-HCTZ 20-25 MG TABLETS
METHYLDOPA 250 MG TABLETS
METHYLDOPA 500 MG TABLETS
METOPROLOL 100 MG TABLETS
METOPROLOL 25 MG TABLETS
METOPROLOL 50 MG TABLETS
PENTOXIFLYLINE 400 MG TABLETS
SOTALOL HCL 80 MG TABLETS
SOTALOL HCL 120 MG TABLETS
SOTALOL HCL 160 MG TABLETS
SPIRONOLACTONE 25 MG TABLETS
SPIRONOLACTONE 50 MG TABLETS
SPIRONOLACTONE 100 MG TABLETS
TERAZOSIN 10 MG CAPSULES
TERAZOSIN 1 MG CAPSULES
TERAZOSIN 2 MG CAPSULES
TERAZOSIN 5 MG CAPSULES
TRIAMTERENE/HCTZ 37.5-25 TABLETS
Qty*
$0.00 Copay
$
30 Day Qty*
4.00
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
60
60
60
60
60
60
60
30
30
30
30
30
30
30
60
60
60
60
30
30
30
30
30
90 Day Qty*
$
10.00
N/A
N/A
N/A
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
180
180
180
180
180
180
180
90
90
90
90
90
90
90
180
180
180
180
90
90
90
90
90
180
180
180
180
180
180
30
30
30
60
30
60
60
60
30
30
30
30
30
30
30
30
30
30
30
30
90
90
90
180
90
180
180
180
90
90
90
90
90
90
90
90
90
90
90
90
Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be higher or may be added/deleted without notice. Can not be used in conjuction with other
insurance.
Prescription Drug Plan
Effective
2/10/2017
*Quantity and other restrictions apply.
Heart and Blood Pressure
DRUG NAME
Qty*
$0.00 Copay
$
VERAPAMIL 120 MG TABLETS
VERAPAMIL 80 MG TABLETS
WARFARIN 10 MG TABLETS
WARFARIN 1 MG TABLETS
WARFARIN 2.5 MG TABLETS
WARFARIN 2 MG TABLETS
WARFARIN 3 MG TABLETS
WARFARIN 4 MG TABLETS
WARFARIN 5 MG TABLETS
WARFARIN 6 MG TABLETS
WARFARIN 7.5 MG TABLETS
$
AMIODARONE 200 MG TABLETS
AMILORIDE/HCTZ 5 MG/50 MG TABLETS
AMLODIPINE/BENZ 5/40 MG CAPSULES
AMLODIPINE/BENZ 10/40 MG CAPSULES
CILOSTAZOL 50 MG TABLETS
CILOSTAZOL 100 MG TABLETS
FOSINOPRIL 10 MG TABLETS
FOSINOPRIL 20 MG TABLETS
FOSINOPRIL 40 MG TABLETS
FOSINOPRIL/HCTZ 10-12.5 MG TABLETS
FOSINOPRIL/HCTZ 20-12.5 MG TABLETS
ISOSORBIDE MONONITRATE ER 30 MG TABLETS
ISOSORBIDE MONONITRATE ER 60 MG TABLETS
LOSARTAN POT 25 MG TABLETS
LOSARTAN POT 50 MG TABLETS
LOSARTAN POT 100 MG TABLETS
LOSARTAN/HCTZ 50-12.5 MG TABLETS
LOSARTAN/HCTZ 100-12.5 MG TABLETS
LOSARTAN/HCTZ 100-25 MG TABLETS
TRIAMTERENE/HCTZ37.5-25 CAPSULES
TRIAMTERENE/HCTZ 75-50 MG TABLETS
$
CLOPIDOGREL 75 MG TABLETS
INDAPAMIDE 1.25 MG TABLETS
INDAPAMIDE 2.5 MG TABLETS
DRUG NAME
ATENOLOL/CHLOR 50/25 MG TABLETS
ATENOLOL/CHLOR 100/25 MG TABLETS
CHLOROTHIAZIDE 250 MG TABLETS
DILTIAZEM 30 MG TABLETS
DILTIAZEM 60 MG TABLETS
DILTIAZEM 90 MG TABLETS
DILTIAZEM 120 MG TABLETS
DILTIAZEM CD 120 MG CAPSULES
DILTIAZEM CD 180 MG CAPSULES
DILTIAZEM CD 240 MG CAPSULES
$
30 Day Qty*
4.00
30
30
30
30
30
30
30
30
30
30
30
90 Day Qty*
$
10.00
90
90
90
90
90
90
90
90
90
90
90
30 Day Qty*
8.00
30
30
30
30
60
60
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
90 Day Qty*
$
22.00
90
90
90
90
180
180
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
30 Day Qty*
10.00
30
30
30
90 Day Qty*
$
30.00
90
90
90
30 Day Qty*
12.00
30
30
60
60
60
60
30
30
30
30
90 Day Qty*
$
36.00
90
90
180
180
180
180
90
90
90
90
Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be higher or may be added/deleted without notice. Can not be used in conjuction with other
insurance.
Prescription Drug Plan
Effective
2/10/2017
*Quantity and other restrictions apply.
Mental Health
DRUG NAME
30 Day Qty*
4.00
60
60
30
30
30
30
30
30
30
30
90
30
30
30
30
30
30
30
30
60
60
60
60
60
30
30
30
30
30
30
90 Day Qty*
$
10.00
180
180
90
90
90
90
90
90
90
90
270
90
90
90
90
90
90
90
90
180
180
180
180
180
90
90
90
90
90
90
30 Day Qty*
8.00
30
30
60
30
30
30
30
30
60
30
30 Day Qty*
$
12.00
30
30
30
30 Day Qty*
$
24.00
30
30
30 Day Qty*
$
4.00
30
30
30
30
90 Day Qty*
$
22.00
90
90
180
90
90
90
90
90
180
90
90 Day Qty*
$
36.00
90
90
90
90 Day Qty*
$
65.00
90
90
90 Day Qty*
$
10.00
90
90
90
90
$
BUSPIRONE 5 MG TABLETS
BUSPIRONE 10 MG TABLETS
CITALOPRAM 10 MG TABLETS
CITALOPRAM 20 MG TABLETS
CITALOPRAM 40 MG TABLETS
FLUOXETINE 10 MG CAPSULES
FLUOXETINE 20 MG CAPSULES
FLUOXETINE 40 MG CAPSULES
FLUPHENAZINE 5 MG TABLETS
FLUPHENAZINE 10 MG TABLETS
LITHIUM CARBONATE 300 MG CAPSULES
NORTRIPTYLINE 10 MG CAPSULES
NORTRIPTYLINE 25 MG CAPSULES
PAROXETINE 10 MG TABLETS
PAROXETINE 20 MG TABLETS
PAROXETINE 30 MG TABLETS
PAROXETINE 40 MG TABLETS
PROCHLORPERAZINE 10 MG TABLETS
PROCHLORPERAZINE 5 MG TABLETS
RISPERIDONE 0.25 MG TABLETS
RISPERIDONE 0.5 MG TABLETS
RISPERIDONE 1 MG TABLETS
RISPERIDONE 2 MG TABLETS
RISPERIDONE 3 MG TABLETS
SERTRALINE 25 MG TABLETS
SERTRALINE 50 MG TABLETS
SERTRALINE 100 MG TABLETS
TRAZODONE 100 MG TABLETS
TRAZODONE 150 MG TABLETS
TRAZODONE 50 MG TABLETS
DRUG NAME
AMITRIPTYLINE 10 MG TABLETS
AMITRIPTYLINE 25 MG TABLETS
BUSPIRONE 15 MG TABLETS
ESCITALOPRAM 5 MG TABLETS
ESCITALOPRAM 10 MG TABLETS
ESCITALOPRAM 20 MG TABLETS
NORTRIPTYLINE 50 MG CAPSULES
NORTRIPTYLINE 75 MG CAPSULES
RISPERIDONE 4 MG TABLETS
THIOTHIXENE 1 MG
AMITRIPTYLINE 50 MG TABLETS
DONEPEZIL 5 MG TABLETS
DONEPEZIL 10 MG TABLETS
AMITRIPTYLINE 75 MG TABLETS
AMITRIPTYLINE 100 MG TABLETS
Muscle Relaxants
DRUG NAME
CYCLOBENZAPRINE 10 MG TABLETS
CYCLOBENZAPRINE 5 MG TABLETS
METHOCARBAMOL 500 MG TABLETS
METHOCARBAMOL 750 MG TABLETS
$
Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be higher or may be added/deleted without notice. Can not be used in conjuction with other
insurance.
Prescription Drug Plan
Effective
2/10/2017
*Quantity and other restrictions apply.
Other
DRUG NAME
CHLORHEXADINE GLUCOSE 0.12% SOLN
DEXAMETHASONE .5 MG TABLETS
DEXAMETHASONE 0.75 MG TABLETS
DEXAMETHASONE 4 MG TABLETS
OXYBUTYNIN 5 MG/5 ML SYRUP
PREDNISONE 1 MG TABLETS
PREDNISONE 2.5 MG TABLETS
PREDNISONE 20 MG TABLETS
PREDNISONE 5 MG TABLETS
PREDNISONE 10 MG TABLETS
VITAMIN D 50,000 UNIT CAPSULES
Skin
DRUG NAME
HYDROCORTISONE 1% CREAM 30 GM
HYDROCORTISONE 2.5% CREAM 30 GM
SILVER SULFADIAZINE 1% (25 GM) CREAM
TRIAMCINOLONE 0.025% 15 GM (tube) CREAM
TRIAMCINOLONE 0.1% 15 GM (tube) CREAM
30 Day Qty*
4.00
480
12
12
6
150
90
30
30
30
30
8
30 Day Qty*
$
4.00
30
30
25
15
15
90 Day Qty*
$
10.00
30 Day Qty*
8.00
50
15
80
80
15
80
80
15
15
90 Day Qty*
$
18.00
$
$
SILVER SULFADIAZINE 1% (50 GM) CREAM
TRIAMCINOLONE 0.025% 15 GM (tube) OINTMENT
TRIAMCINOLONE 0.025% 80 GM (tube) CREAM
TRIAMCINOLONE 0.025% 80 GM (tube) OINTMENT
TRIAMCINOLONE 0.1% 15 GM (tube) OINTMENT
TRIAMCINOLONE 0.1% 80 GM (tube) CREAM
TRIAMCINOLONE 0.1% 80 GM (tube) OINTMENT
TRIAMCINOLONE 0.5% 15 GM (tube) CREAM
TRIAMCINOLONE 0.5% 15 GM (tube) OINTMENT
30 Day Qty*
24.00
22
30 Day Qty*
$
4.00
30
30
30 Day Qty*
$
12.00
30
30
30
30
30
30
30
30
30
30
30
36
36
18
N/A
270
90
90
90
90
24
90 Day Qty*
$
10.00
90
90
75
45
45
45
240
240
45
240
240
45
45
90 Day Qty*
$
MUPIROCIN 2% OINTMENT
Thyroid
DRUG NAME
METHIMAZOLE 5 MG TABLETS
METHIMAZOLE 10 MG TABLETS
LEVOTHYROXINE 25 MCG TABLETS
LEVOTHYROXINE 50 MCG TABLETS
LEVOTHYROXINE 75 MCG TABLETS
LEVOTHYROXINE 88 MCG TABLETS
LEVOTHYROXINE 100 MCG TABLETS
LEVOTHYROXINE 112 MCG TABLETS
LEVOTHYROXINE 125 MCG TABLETS
LEVOTHYROXINE 137 MCG TABLETS
LEVOTHYROXINE 150 MCG TABLETS
LEVOTHYROXINE 175 MCG TABLETS
LEVOTHYROXINE 200 MCG TABLETS
90 Day Qty*
$
10.00
90
90
90 Day Qty*
$
36.00
90
90
90
90
90
90
90
90
90
90
90
Vaccines
DRUG NAME
ADACEL
DECAVAC
ENERGIX-B
GARDASIL
HAVRIX
MENACTRA
MMR
PNEUMOVAX
PREVNAR-13
SEASONAL INFLUENZA HIGH DOSE
SEASONAL INFLUENZA QUADRAVALENT
SEASONAL INFLUENZA TRIVALENT
TWINRIX
TYPHIM
VARIVAX
VIVOTIF
ZOSTAVAX
Price
56.00
56.00
59.00
164.00
79.00
125.00
87.00
100.00
179.00
49.00
24.00
24.00
114.00
99.00
121.00
73.00
209.00
Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be higher or may be added/deleted without notice. Can not be used in conjuction with other
insurance.
Prescription Drug Plan
Effective
2/10/2017
*Quantity and other restrictions apply.
Vitamins/ Nutritional
DRUG NAME
FOLIC ACID 1 MG TABLETS
LUDENT CHEW FL 0.5 MG TABLETS
LUDENT CHEW FL 1 MG TABLETS
MAG-OXIDE 400 MG TABLETS
Mens Health
DRUG NAME
FINASTERIDE 5 MG TABLETS
Womens Health
DRUG NAME
ESTRADIOL 0.5 MG TABLETS
ESTRADIOL 1 MG TABLETS
ESTRADIOL 2 MG TABLETS
MEDROXYPROGESTERONE AC 10 MG TABLETS
MEDROXYPROGESTERONE AC 2.5 MG TABLETS
MEDROXYPROGESTERONE AC 5 MG TABLETS
30 Day Qty*
4.00
30
120
120
60
30 Day Qty*
$
9.00
30
30 Day Qty*
$
4.00
30
30
30
30
30
30
90 Day Qty*
$
10.00
90
360
360
180
90 Day Qty*
$
27.00
90
90 Day Qty*
$
10.00
90
90
90
90
90
90
30 Day Qty*
9.00
4
4
5
90 Day Qty*
$
24.00
12
12
15
$
$
ALENDRONATE SOD 35 MG TABLETS
ALENDRONATE SOD 70 MG TABLETS
CLOMIPHENE 50 MG TABLETS
28- Day*
$
APRI 0.15-30 MG-MCG TABLETS
CYCLAFEM 1/35 MG-MCG TABLETS
CYCLAFEM 7/7/7 TABLETS
LEVONOR/ETH ESTRADIOL 0.15-30 MG-MCG TABLETS
LEVONOR/ETH ESTRADIOL 0.1-20 MG-MCG TABLETS (A1 & A2)
NORETHINDRONE 0.35 MG (A1)
NORETHINDRONE 0.35 MG (A2)
PREVIFEM 28 TABLETS
TRI-PREVIFEM TABLETS
Baby Club Benefits
DRUG NAME
MULTI-VIT/FLUORIDE 0.25 MG/ML DROPS (POLY-VI-FLOR)
MULTI-VIT/FLUORIDE 0.5 MG CHEW (POLY-VI-FLOR)
MULTI-VIT/FLUORIDE 0.5 MG/ML DROPS (POLY-VI-FLOR)
MULTI-VIT/IRON/FLUORIDE 0.25 MG/ML DROPS (POLY-VI-FLOR/FE)
MULTIVITAMIN/FLUORIDE 0.25 MG CHEW (POLY-VI-FLOR)
MVC-FLUORIDE 0.25 MG CHEW (POLY-VI-FLOR)
MVC CHEW W FL 0.25 MG TABLETS
MVC CHEW W FL 0.5 MG TABLETS
PNV FOLIC ACID PLUS MULTI 27-1 MG TAB (PRENATAL PLUS)
PRENATABS FA 29-1 MG TAB (NATATAB FA)
PRENATABS RX 29-1 MG TAB (PRENATAL PLUS IRON)
PRENATAL 19, 29-1 MG CHEW
PRENATAL 19, 29-1 MG TAB
PRENATAL PLUS 27-1 MG TAB
PRENATAL- U 106.5-1 MG CAP
TRI-VIT/FLUORIDE 0.25 MG/ML DROPS (TRI-VI-FLOR)
TRI-VIT/FLUORIDE/IRON 0.25 MG/ML DROPS (TRI-VIT-FLOR/FE)
9.00
28
28
28
28
28
28
28
28
28
Qty*
$0.00 Copay
50
30
50
50
30
30
30
30
30
30
30
30
30
30
30
50
50
$
84- Day*
27.00
84
84
84
84
84
84
84
84
84
Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be higher or may be added/deleted without notice. Can not be used in conjuction with other
insurance.