Prescription Drug Program
Low-Cost Generic List
You may be familiar with your local retail pharmacy’s advertising generic medications for only $4 a month. Express
Scripts, Ohio State’s pharmacy benefit manager, offers a low-cost generic list1 of medications delivered to your door, for
those that utilize Home Delivery.
What does this mean for you?
• If your generic maintenance medication is on the Express Scripts low-cost generic list found at go.osu.edu/rx1, you
will receive a 90-day supply for only $10.
• This is a savings from the standard generic copay.
What if my specific medication is not on the list?
• You may be taking a medication that has an alternative on the list — check with your doctor.
What does approved quantity mean on the low-cost generic list?
• The low cost generic copayment applies for a quantity based on standard dosing of the listed medication. For example, if I have a
prescription for Lisinopril 10 mg tablet, the lower copayment will only apply for up to 90 tablets as noted on the list below. If your
doctor writes for more or less than the approved quantity, then your copayment will be more or less than $10. In the case of higher
quantities you will pay more than $10, but no more than your regular generic copay.
Will the low-cost generic list change?
• Yes, the low-cost generic medication list is subject to change.
What if I am not using home delivery but want to start now?
• Let Express Scripts do the work for you! Call 1-866-727-5867 and ask to start the process.
• Express Scripts will call your doctor to get a new prescription for home delivery. When you call, please have these
items nearby:
1. Your ID number (found on the front of your member ID card)
2. Your doctor’s name and phone number
3. Your current medications or medicine containers
• Prefer to do it yourself?
1. Visit StartHomeDelivery.com.
2. Mail your prescriptions. Complete the home delivery form found online at go.osu.edu/rxdeliver. Include a new
prescription and copayment and mail it to Express Scripts. Be sure to ask your doctor for a 90-day prescription
(with up to one year of refills, if appropriate).
Please have a 30-day supply of your medication(s) on hand when you first order your prescriptions through home delivery
from the Express Scripts pharmacy.
If you have questions about this enhancement to your home delivery benefit, contact Express Scripts at 1-866-727-5867.
1
List subject to change
The Ohio State University Office of Human Resources
Prescription Drug Program – Low-Cost Generic List
Page 1 of 4
Revised 01/10/13
Prescription Drug Program
Low-Cost Generic List
Strength
Form
Approved
Quantity
Allopurinol
100MG
Tablet
90
Allopurinol
300MG
Tablet
90
Amiloride/Hydrochlorothiazide
5MG-50MG Tablet
90
Amitriptyline HCL
10MG
Tablet
90
Generic Drug
Amitriptyline HCL
100MG
Tablet
90
Amitriptyline HCL
25MG
Tablet
Amitriptyline HCL
50MG
Amitriptyline HCL
75MG
Amoxicillin Trihydrate
Amoxicillin Trihydrate
Generic Drug
1
Carvedilol
3.125MG
Tablet
180
Carvedilol
6.25MG
Tablet
180
Cephalexin Monohydrate
250MG
Capsule
84
Strength
Form
Cephalexin Monohydrate
500MG
Capsule
90
Chlorhexidine Gluconate
0.12%
Mouthwash per 3 pints
Tablet
90
Chlorpropamide
100MG
Tablet
90
Tablet
90
Cimetidine
800MG
Tablet
90
250MG
Capsule
90
Ciprofloxacin HCL
250MG
Tablet
42
500MG
Capsule
90
Ciprofloxacin HCL
500MG
Tablet
60
0.1MG
Tablet
90
1
Approved
Quantity
90
Atenolol
100MG
Tablet
90
Clonidine HCL
Atenolol
50MG
Tablet
90
Clonidine HCL
0.2MG
Tablet
90
Atenolol
25MG
Tablet
90
Dexamethasone
0.5MG
Tablet
90
Atenolol/Chlorthalidone
50MG-25MG
Tablet
90
Dexamethasone
0.75MG
Tablet
36
Atenolol/Chlorthalidone
100-25MG
Tablet
90
Dexamethasone
4MG
Tablet
18
Baclofen
10MG
Tablet
90
Digoxin
125MCG
Tablet
90
Benazepril HCL
5MG
Tablet
90
Digoxin
250MCG
Tablet
90
Benazepril HCL
10MG
Tablet
90
D-Methorphan Hb/Prometh HCL
15-6.25/5
Syrup
per 12ozbottle
Benazepril HCL
20MG
Tablet
90
Doxazosin Mesylate
1MG
Tablet
90
Benazepril HCL
40MG
Tablet
90
Doxazosin Mesylate
2MG
Tablet
90
4MG
Tablet
90
Benazepril/Hctz
5MG/6.25MG Tablet
90
Doxazosin Mesylate
Benazepril/Hctz
10-12.5MG Tablet
90
Doxazosin Mesylate
8MG
Tablet
90
Benazepril/Hctz
20-12.5MG Tablet
90
Enalapril Maleate
5MG
Tablet
90
10MG
Tablet
90
Benazepril/Hctz
20-25MG
Tablet
90
Enalapril Maleate
Benzonatate
100MG
Capsule
42
Enalapril Maleate
20MG
Tablet
90
Benztropine Mesylate
2MG
Tablet
90
Enalapril Maleate
2.5MG
Tablet
90
Bisoprol/Hydrochlorothiazide
2.5-6.25MG Tablet
90
Enalapril/Hydrochlorothiazide
5-12.5MG
Tablet
90
Bisoprol/Hydrochlorothiazide
5-6.25MG
Tablet
90
Estradiol
1MG
Tablet
90
Bisoprol/Hydrochlorothiazide
10-6.25MG Tablet
90
Estradiol
2MG
Tablet
90
Captopril
100MG
180
Estradiol
0.5MG
Tablet
90
20MG
Tablet
180
3
Tablet
Captopril
25MG
Tablet
180
Famotidine
Captopril
50MG
Tablet
180
Fluconazole
150MG
Tablet
Captopril
12.5MG
Tablet
180
Fluocinolone Acetonide
0.01%
Solution
per 6oz bottle
Carbamazepine
200MG
Tablet
180
Fluoxetine HCL
10MG
Capsule
90
Carvedilol
25MG
Tablet
180
Fluoxetine HCL
20MG
Capsule
90
Carvedilol
12.5MG
Tablet
180
Fluoxetine HCL
40MG
Capsule
90
1
List subject to change
The Ohio State University Office of Human Resources
Prescription Drug Program – Low-Cost Generic List
Page 2 of 4
Revised 01/10/13
Prescription Drug Program
Low-Cost Generic List
Fluoxetine HCL
10MG
Tablet
90
Furosemide
20MG
Tablet
90
Fluoxetine HCL
20MG
Tablet
90
Furosemide
40MG
Tablet
90
Fluphenazine HCL
1MG
Tablet
90
Furosemide
80MG
Tablet
90
Folic Acid
1MG
Tablet
90
150MCG
Tablet
90
Form
Approved
Quantity
Levothyroxine Sodium
Strength
Levothyroxine Sodium
175MCG
Tablet
90
Glimepiride
1MG
Tablet
90
Levothyroxine Sodium
88MCG
Tablet
90
Glimepiride
2MG
Tablet
90
Levothyroxine Sodium
137MCG
Tablet
90
Glimepiride
4MG
Tablet
90
Lidocaine HCL
20MG/ML
Solution
3 bottles (300 ml
Glipizide
5MG
Tablet
90
Glipizide
10MG
Tablet
180
Glyburide,Micronized
3MG
Tablet
90
Generic Drug
Strength
Form
Approved
Quantity
Glyburide,Micronized
6MG
Tablet
90
Lisinopril
5MG
Tablet
90
10MG
Tablet
90
90
Generic Drug
1
1
Guanfacine HCL
1MG
Tablet
90
Lisinopril
Haloperidol
0.5MG
Tablet
90
Lisinopril
20MG
Tablet
Haloperidol
1MG
Tablet
90
Lisinopril
2.5MG
Tablet
90
300MG
Capsule
270
Haloperidol
2MG
Tablet
90
Lithium Carbonate
Haloperidol
5MG
Tablet
90
Loratadine
10MG
Tablet
90
Hydralazine HCL
10MG
Tablet
90
Medroxyprogesterone Acet
10MG
Tablet
30
Hydralazine HCL
25MG
Tablet
90
Medroxyprogesterone Acet
2.5MG
Tablet
90
Medroxyprogesterone Acet
5MG
Tablet
90
Megestrol Acetate
20MG
Tablet
90
Meloxicam
7.5MG
Tablet
90
Meloxicam
15MG
Tablet
90
Metformin HCL
500MG
Tablet
180
Metformin HCL
850MG
Tablet
180
Metformin HCL
1000MG
Tablet
180
Metformin HCL
500MG
Tab.Sr 24h
180
Methyldopa
250MG
Tablet
180
Methyldopa
500MG
Tablet
90
Methylprednisolone
4MG
Tablet
63
Metoclopramide HCL
10MG
Tablet
180
Metoprolol Tartrate
25MG
Tablet
180
Metoprolol Tartrate
100MG
Tablet
180
Metoprolol Tartrate
50MG
Tablet
180
Metronidazole
250MG
Tablet
84
Metronidazole
500MG
Tablet
42
Oxybutynin Chloride
5MG
Tablet
180
Paroxetine HCL
10MG
Tablet
90
Paroxetine HCL
20MG
Tablet
90
Hydrochlorothiazide
12.5MG
Capsule
90
Hydrochlorothiazide
25MG
Tablet
90
Hydrochlorothiazide
50MG
Tablet
90
Hydrocortisone
1%
Cream(Gm) per 90gm tube
Hydrocortisone
2.5%
Cream(Gm) per 90gm tube
Hydrocortisone Acetate
25MG
Supp.Rect
36
Indomethacin
25MG
Capsule
180
Ipratropium Bromide
0.2MG/ML
Solution
90 vials
Isoniazid
300MG
Tablet
90
Isosorbide Mononitrate
60MG
Tab.Sr 24h
90
Isosorbide Mononitrate
30MG
Tab.Sr 24h
90
Lactulose
10G/15ML
Solution
Levothyroxine Sodium
112MCG
Tablet
90
Levothyroxine Sodium
25MCG
Tablet
90
Levothyroxine Sodium
50MCG
Tablet
90
Levothyroxine Sodium
100MCG
Tablet
90
Levothyroxine Sodium
75MCG
Tablet
90
Levothyroxine Sodium
200MCG
Tablet
90
Levothyroxine Sodium
125MCG
Tablet
90
per 1½ pint
1
List subject to change
The Ohio State University Office of Human Resources
Prescription Drug Program – Low-Cost Generic List
Page 3 of 4
Revised 01/10/13
Prescription Drug Program
Low-Cost Generic List
Penicillin V Potassium
250MG
Tablet
84
Pravastatin Sodium
20MG
Tablet
90
Phenazopyridine HCL
100MG
Tablet
18
Pravastatin Sodium
40MG
Tablet
90
Phenazopyridine HCL
200MG
Tablet
90
Prazosin HCL
1MG
Capsule
90
Pilocarpine HCL
2%
Drops
3-15 ml bottles
Prazosin HCL
2MG
Capsule
90
Potassium Chloride
20MEQ/15ML Liquid
per 3 pints
Prazosin HCL
5MG
Capsule
90
Pravastatin Sodium
10MG
Tablet
90
Strength
Form
Approved
Quantity
Generic Drug
Strength
Form
Prednisone
10MG
Tablet
90
Terbinafine HCL
250MG
Tablet
90
Prednisone
2.5MG
Tablet
90
Tetracycline HCL
250MG
Capsule
180
Prednisone
20MG
Tablet
90
Tetracycline HCL
500MG
Capsule
180
Prednisone
5MG
Tablet
90
Thioridazine HCL
25MG
Tablet
90
Prenatal Vit/Fe Fumarate/Fa
27-1MG
Tablet
90
Thioridazine HCL
50MG
Tablet
90
Prochlorperazine Maleate
10MG
Tablet
90
Promethazine HCL
6.25MG/5ML Syrup
Promethazine HCL
25MG
Propranolol HCL
Generic Drug
1
1
Approved
Quantity
Thiothixene
2MG
Capsule
90
18 ounces
Trazodone HCL
50MG
Tablet
90
Tablet
36
Trazodone HCL
100MG
Tablet
90
10MG
Tablet
180
Trazodone HCL
150MG
Tablet
90
Propranolol HCL
20MG
Tablet
180
Triamterene/Hydrochlorothiazid 75-50MG
Tablet
90
Propranolol HCL
40MG
Tablet
180
Triamterene/Hydrochlorothiazid 37.5-25MG Tablet
90
Propranolol HCL
80MG
Tablet
180
Trihexyphenidyl HCL
2MG
Tablet
180
Ranitidine HCL
150MG
Tablet
180
Verapamil HCL
120MG
Tablet
90
Ranitidine HCL
300MG
Tablet
90
Verapamil HCL
80MG
Tablet
90
Sotalol HCL
80MG
Tablet
90
Warfarin Sodium
10MG
Tablet
90
Spironolactone
25MG
Tablet
90
Warfarin Sodium
2MG
Tablet
90
Sulfamethoxazole/Trimethoprim
400-80MG
Tablet
84
Warfarin Sodium
1MG
Tablet
90
Sulfamethoxazole/Trimethoprim
800-160MG Tablet
60
Warfarin Sodium
5MG
Tablet
90
Terazosin HCL
1MG
Capsule
90
Warfarin Sodium
2.5MG
Tablet
90
Terazosin HCL
2MG
Capsule
90
Warfarin Sodium
7.5MG
Tablet
90
Terazosin HCL
5MG
Capsule
90
Warfarin Sodium
3MG
Tablet
90
Terazosin HCL
10MG
Capsule
90
Warfarin Sodium
4MG
Tablet
90
Warfarin Sodium
6MG
Tablet
90
1
List subject to change
The Ohio State University Office of Human Resources
Prescription Drug Program – Low-Cost Generic List
Page 4 of 4
Revised 01/10/13