Download Generic List for PowerCare Rx D

Rx D Drug List
Note: The Rx D Drug List copay applies only to the generics listed in this Rx D Drug List. Please note the specific form and
strength combinations that qualify a Generic drug to be listed. Generic drugs with form and strength combinations other than those
listed In this Rx D Drug List, as well as most other Generic drugs not listed in this Rx D Drug List, are discounted approximately 25%
to 60%.
Name
ACETAMINOPHEN
ACETIC ACID/ALUMINUM ACETATE
ALBUTEROL
ALBUTEROL SULFATE
ALBUTEROL SULFATE
ALLOPURINOL
ALLOPURINOL
ALPRAZOLAM
ALPRAZOLAM
ALPRAZOLAM
AMANTADINE HCL
AMINOPHYLLINE
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL
AMITRIPTYLINE HCL/PERPHENAZINE
AMITRIPTYLINE HCL/PERPHENAZINE
AMOXICILLIN TRIHYDRATE
AMOXICILLIN TRIHYDRATE
AMOXICILLIN TRIHYDRATE
AMOXICILLIN TRIHYDRATE
AMOXICILLIN TRIHYDRATE
AMOXICILLIN TRIHYDRATE
AMOXICILLIN TRIHYDRATE
AMPICILLIN TRIHYDRATE
AMPICILLIN TRIHYDRATE
AMPICILLIN TRIHYDRATE
ASPIRIN
ASPIRIN
ASPIRIN
ATENOLOL
ATENOLOL
ATENOLOL
BELLADONNA ALKALOIDS/PHENOBARB
BELLADONNA ALKALOIDS/PHENOBARB
BENZTROPINE MESYLATE
BENZTROPINE MESYLATE
BETAMETHASONE DIPROPIONATE
BETAMETHASONE VALERATE
BETAMETHASONE VALERATE
BETAMETHASONE VALERATE
**Formulary is subject to change without notice**
Strength
325mg
2%
90mcg
2mg
2mg/5ml
100mg
300mg
0.25mg
0.5mg
1mg
50mg/5ml
200mg
100mg
10mg
150mg
25mg
50mg
75mg
10-2mg
25-2mg
125mg
125mg5ml
250mg
250mg/5ml
200mg/5ml
400mg/5ml
500mg
125mg/5ml
250mg
250mg/5ml
325mg
800mg
975mg
25 mg
50 mg
100 mg
16.2mg
16.2mg/5ml
0.5mg
1mg
0.05%
0.1%
0.1%
0.1%
Form
Tablet
Drops Otic
Inhaler
Tablet
Syrup
Tablet
Tablet
Tablet
Tablet
Tablet
Syrup
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet Chew
Suspension
Capsule
Suspension
Suspension
Suspension
Capsule
Suspension
Capsule
Suspension
Tablet EC
Tablet SA
Tablet EC
Tablet
Tablet
Tablet
Tablet
Elixir
Tablet
Tablet
Lotion
Cream
Ointment
Lotion
091201
BUMETANIDE
CAPTOPRIL
CAPTOPRIL
CAPTOPRIL
CARISOPRODOL
CEFACLOR
CEFACLOR
CEFACLOR
CEPHALEXIN MONOHYDRATE
CEPHALEXIN MONOHYDRATE
CHLORAL HYDRATE
CHLORDIAZEPOXIDE HCL
CHLORDIAZEPOXIDE HCL
CHLORDIAZEPOXIDE HCL
CHLORHEXIDINE GLUCONATE
CHLORPHENIRAMINE MALEATE
CHLORPHENIRAMINE MALEATE
CHLORTHALIDONE
CHLORTHALIDONE
CHLORTHALIDONE/ATENOLOL
CHLORTHALIDONE/ATENOLOL
CHLORZOXAZONE
CHLORZOXAZONE
CHOLESTYRAMINE/SUCROSE
CIMETIDINE
CIMETIDINE
CIMETIDINE
CIMETIDINE
CLEMASTINE FUMARATE
CLIDINIUM/CHLORDIAZEPOXIDE
CLINDAMYCIN PHOSPHATE
CLIOQUINOL/HYDROCORTISONE
CLONAZEPAM
CLONAZEPAM
CLONAZEPAM
CLONIDINE HCL
CLONIDINE HCL
CODEINE PHOSPHATE/APAP
CODEINE/PROMETHAZINE HCL
COLCHICINE
CYPROHEPTADINE HYDROCHLORIDE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE
DEXCHLORPHENIRAMINE MALEATE
DIAZEPAM
DIAZEPAM
DIAZEPAM
DICYCLOMINE HYDROCHLORIDE
DICYCLOMINE HYDROCHLORIDE
DILTIAZEM HCL
DILTIAZEM HCL
DIMENHYDRINATE
DIPHENHYDRAMINE HCL
**Formulary is subject to change without notice**
0.5mg
12.5 mg
25 mg
50 mg
350mg
125mg/5ml
187mg/5ml
250mg/5ml
125mg/5ml
250mg/5ml
500mg/5ml
10 mg
25 mg
5 mg
1.2mg/ml
12 mg
12 mg
25 mg
50 mg
50/25
100/25
250mg
500mg
4G
200mg
300mg
300mg/5ml
400mg
0.67mg/5ml
2.5/5
1%
3-1%
0.5mg
1mg
2mg
0.1mg
0.2mg
12-120mg/5
10-6.25/5
0.6mg
2mg/5ml
0.25mg
0.5mg
0.75mg
1.5mg
2mg/5ml
10mg
2mg
5mg
10mg
20mg
30mg
60mg
50mg
12.5mg/5ml
Tablet
Tablet
Tablet
Tablet
Tablet
Suspension
Suspension
Suspension
Suspension
Suspension
Syrup
Capsule
Capsule
Capsule
Liquid
Tablet SA
Capsule SA
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Powder
Tablet
Tablet
Liquid
Tablet
Syrup
Capsule
Solution
Cream
Tablet
Tablet
Tablet
Tablet
Tablet
Elixir
Syrup
Tablet
Syrup
Tablet
Tablet
Tablet
Tablet
Syrup
Tablet
Tablet
Tablet
Capsule
Tablet
Tablet
Tablet
Tablet
Elixir
091201
DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE HCL
DIPHENOXYLATE HCL/ATROP SULF
DIPYRIDAMOLE
DM HB/P-EPHED HCL/CARBINOX
D-METHORPHAN HB/P-EPD HC/BPM
D-METHORPHAN HB/P-EPHED/BPM
D-METHORPHAN HB/PROMETHAZINE
DOCUSATE SODIUM
DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE
DOXEPIN HYDROCHLORIDE
DOXEPIN HYDROCHLORIDE
DOXEPIN HYDROCHLORIDE
DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ENALAPRIL MALEATE
ERYTHROMYCIN BASE
ERYTHROMYCIN BASE/ETHANOL
ERYTHROMYCIN ESTOLATE
ERYTHROMYCIN ETHYLSUCCINATE
ERYTHROMYCIN ETHYLSUCCINATE
ERYTHROMYCIN STEARATE
ERYTHROMYCIN/SULFISOXAZOLE
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTROPIPATE
FERROUS SULFATE
FERROUS SULFATE
FERROUS SULFATE
FLUOCINOLONE ACETONIDE
FLUOCINOLONE ACETONIDE
FLUOCINONIDE
FLUORIDE ION/IRON/VIT A,C&D
FLUORIDE ION/MULTIVITS W-FE
FLUORIDE ION/MULTIVITS W-FE
FLUORIDE ION/VIT A,C&D
FLUORIDE ION/VIT A,C&D
FLUPHENAZINE HYDROCHLORIDE
FLURAZEPAM HYDROCHLORIDE
FLURAZEPAM HYDROCHLORIDE
FOLIC ACID
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
FUROSEMIDE
GLIPIZIDE
GLIPIZIDE
GLYBURIDE MICRONIZED
**Formulary is subject to change without notice**
25mg
50mg
2.5-.025mg
25mg
15-60-4/5
15-60-4/5
10-30-2/5
15-6.25/5
100mg
1mg
2mg
4mg
8mg
100mg/ml
10mg
25mg
100mg
100mg
50mg
10mg
2.5mg
5mg
2%
2%
125mg/5ml
200mg/5ml
400mg/5ml
250mg
200-600/5
0.5mg
1mg
2mg
0.75mg
220mg/5ml
325mg
325mg
0.01%
0.01%
0.05%
0.25mg/ml
0.25mg/ml
1mg
.25mg/ml
1mg
1mg
15mg
30mg
1mg
10mg/ml
20mg
40mg
80mg
10mg
5mg
1.5mg
Capsule
Capsule
Tablet
Tablet
Syrup
Syrup
Syrup
Syrup
Capsule
Tablet
Tablet
Tablet
Tablet
Oral Conc
Capsule
Capsule
Tablet
Capsule
Capsule
Tablet
Tablet
Tablet
Solution
Solution
Oral Suspension
Oral Suspension
Oral Suspension
Tablet
Suspension
Tablet
Tablet
Tablet
Tablet
Elixir
Tablet
Tablet EC
Solution
Cream
Cream
Drops
Drops
Tablet Chew
Drops
Tablet Chew
Tablet
Capsule
Capsule
Tablet
Solution
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
091201
GLYBURIDE MICRONIZED
GUAIFENESIN
GUAIFENESIN
GUAIFENESIN
GUAIFENESIN/CODEINE PHOSPHATE
GUAIFENESIN/D-METHORPHAN HB
GUAIFENESIN/D-METHORPHAN HB
GUAIFENESIN/D-METHORPHAN HB
GUAIFENESIN/DYPHYLLINE
GUAIFENESIN/HYDROCODONE
GUAIFENESIN/P-EPHED HCL/HCOD
GUAIFENESIN/P-EPHED HCL/HCOD
GUAIFENESIN/P-EPHEDRINE
GUAIFENESIN/P-EPHEDRINE HCL/HCOD
GUAIFENESIN/P-EPHEDRINE/COD
GUAIFENESIN/P-EPHEDRINE/COD
GUAIFENESIN/PSEUDOEPHEDRINE
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL
HALOPERIDOL LACTATE
HCTZ/TRIAMTERENE
HYDRALAZINE HYDROCHLORIDE
HYDRALAZINE HYDROCHLORIDE
HYDRALAZINE HYDROCHLORIDE
HYDRALAZINE HYDROCHLORIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE/AMILORIDE
HYDROCODONE BIT/HOMATROPINE
HYDROCODONE BITARTRATE/APAP
HYDROCODONE BITARTRATE/APAP
HYDROCODONE BITARTRATE/APAP
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROCORTISONE
HYDROXYZINE HYDROCHLORIDE
HYDROXYZINE PAMOATE
HYDROXYZINE PAMOATE
HYOSCYAMINE SULFATE
HYOSCYAMINE SULFATE
HYOSCYAMINE SULFATE
HYOSCYAMINE SULFATE
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
IBUPROFEN
INDAPAMIDE
INDAPAMIDE
INDOMETHACIN
INDOMETHACIN
ISONIAZID
**Formulary is subject to change without notice**
3mg
100mg/5ml
200mg
600mg
10/100mg
100-10/5ml
200-20/5ml
600-30mg
100-100/15
100-30-2.5mg
100-30-2.5mg
600-60mg
200-60-5mg
10/100/30mg
200mg
600/120
0.5mg
1mg
2mg
5mg
2mg/ml
50-75mg
100mg
10mg
25mg
50mg
25mg
50mg
50/5
5-1-.5MG/5
2.5-167/5
5/500
7.5-650mg
1%
1%
1%
1%
10mg/5ml
25mg
50mg
0.125mg
0.125mg
0.375mg
125mcg/5ml
100mg/5ml
200mg
400mg
600mg
800mg
1.25mg
2.5mg
25mg
50mg
100mg
Tablet
Syrup
Tablet
Tablet SA
Liquid
Liquid
Elixir
Tablet SR
Elixir
Syrup
Elixir
Solution
Tablet SR
Expectorant
Syrup
Syrup
Tablet SA
Tablet
Tablet
Tablet
Tablet
Oral Conc
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Syrup
Elixir
Tablet
Tablet
Lotion
Cream
Ointment
Solution
Syrup
Capsule
Capsule
Tablet
Tablet Subl
Tablet SR
Elixir
Oral Suspension
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Capsule
Capsule
Tablet
091201
ISONIAZID
ISOSORBIDE DINITRATE
ISOSORBIDE DINITRATE
ISOSORBIDE DINITRATE
ISOSORBIDE DINITRATE
ISOSORBIDE DINITRATE
ISOSORBIDE MONONITRATE
ISOSORBIDE MONONITRATE
ISOXSUPRINE HCL
ISOXSUPRINE HCL
LACTULOSE
LACTULOSE
LIDOCAINE HCL
LISINOPRIL
LISINOPRIL
LITHIUM CITRATE
LOPERAMIDE HCL
LORAZEPAM
LORAZEPAM
MAG HYDROX/AL HYDROX/SIMETH
MECLIZINE HYDROCHLORIDE
MECLIZINE HYDROCHLORIDE
MEDROXYPROGESTERONE ACET
MEDROXYPROGESTERONE ACET
MEDROXYPROGESTERONE ACET
METAPROTERENOL SULFATE
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL
METOPROLOL TARTRATE
METRONIDAZOLE
MICONAZOLE NITRATE
MULTIVITAMINS W-FLUORIDE
MULTIVITAMINS W-FLUORIDE
MULTIVITAMINS W-FLUORIDE
MULTIVITAMINS W-FLUORIDE
NADOLOL
NAPROXEN
NAPROXEN
NEOMYCIN/BACITRA/POLYMYXIN
NICARDIPINE HCL
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NITROGLYCERIN
NORTRIPTYLINE HYDROCHLORIDE
NORTRIPTYLINE HYDROCHLORIDE
NORTRIPTYLINE HYDROCHLORIDE
NORTRIPTYLINE HYDROCHLORIDE
NYSTATIN
NYSTATIN
NYSTATIN/TRIAMCIN
NYSTATIN/TRIAMCIN
OXYBUTYNIN CHLORIDE
OXYBUTYNIN CHLORIDE
**Formulary is subject to change without notice**
300mg
10mg
2.5mg
20mg
5mg
5mg
30mg
60mg
10mg
20mg
10gm/15ml
10gm/15ml
2%
2.5mg
5mg
8mEQ/5ml
2mg
0.5mg
1mg
200-200-20
12.5mg
25mg
10mg
2.5mg
5mg
10mg/5ml
10mg
5mg
5mg/5ml
50mg
250mg
2%
0.25mg/ml
0.5mg
0.5mg/ml
1mg
20mg
125mg/5ml
250mg
20mg
0.3mg
0.6mg/hr
2.5mg
6.5mg
10mg
10mg/5m
25mg
50mg
100MU/G
100MU/G
100000-0.1
100000-0.1
5mg
5mg/5ml
Tablet
Tablet
Tablet Subl
Tablet
Tablet
Tablet Subl
Tablet SR
Tablet SR
Tablet
Tablet
Syrup
Syrup
Solution
Tablet
Tablet
Syrup
Capsule
Tablet
Tablet
Liquid
Tablet
Tablet
Tablet
Tablet
Tablet
Syrup
Tablet
Tablet
Syrup
Tablet
Tablet
Cream
Drops
Tablet
Drops
Tablet
Tablet
Oral Suspension
Tablet
Ointment (gm)
Capsule
Tablet Subl
Tablet Subl
Capsule SA
Capsule SA
Capsule
Solution
Capsule
Capsule
Ointment (gm)
Cream
Cream
Ointment (gm)
Tablet
Syrup
091201
OXYCODONE HCL/ACETAMINOPHEN
PAPAVERINE HYDROCHLORIDE
PENICILLIN V POTASSIUM
PENICILLIN V POTASSIUM
PHENAZOPYRIDINE HCL
PHENAZOPYRIDINE HCL
PHENOBARBITAL
PHENOBARBITAL
PHENOBARBITAL
PHENOBARBITAL
PHENOBARBITAL
PHENYLEPHRINE/CHLOR-MAL/SCOP
PHENYLEPHRINE/HYDROCOD BIT/CP
PHENYLEPHRINE/HYDROCODONE/CPM
PHENYLEPHRINE/HYDROCODONE/CPM
PINDOLOL
PIROXICAM
PIROXICAM
POT GUAIACO/HYDROCOD BIT
POT GUAIACO/HYDROCODONE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
PREDNISOLONE
PREDNISONE
PREDNISONE
PREDNISONE
PREDNISONE
PRENATAL VITAMINS/IRON/FA
PROCHLORPERAZINE MALEATE
PROMETHAZINE HCL
PROPOXYPHENE NAPSYLATE/APAP
PROPRANOLOL HCL/HCTZ
PROPRANOLOL HCL/HCTZ
PROPRANOLOL HYDROCHLORIDE
PROPRANOLOL HYDROCHLORIDE
PROPRANOLOL HYDROCHLORIDE
PROPRANOLOL HYDROCHLORIDE
PROPRANOLOL HYDROCHLORIDE
PSEUDOEPHEDRINE HCL
PSEUDOEPHEDRINE HCL/BR-PHENIR MAL
PSEUDOEPHEDRINE HCL/BR-PHENIR MAL
PSEUDOEPHEDRINE HCL/CARBINOX MAL
PSEUDOEPHEDRINE HCL/CHLOR-MAL
PSEUDOEPHEDRINE HCL/COD/CHLORPHENIR
PSEUDOEPHEDRINE HCL/HYDROCOD BIT
PSEUDOEPHEDRINE HCL/HYDROCOD BIT/CP
PSEUDOEPHEDRINE HCL/HYDROCOD BIT/CP
PSEUDOEPHEDRINE HCL/HYDROCODONE
RANITIDINE HCL
SALSALATE
SALSALATE
SELENIUM SULFIDE
SODIUM CL IRRIG SOLN
SODIUM FLUORIDE
**Formulary is subject to change without notice**
5/325
150mg
125mg/5ml
250mg/5ml
100mg
200mg
100mg
15mg
20mg/5ml
30mg
60mg
10-2-1.25mg
5-2-2mg/5ml
5-1.67-2mg
5-2.5-2mg
5mg
10mg
20mg
300-5MG/5
300-5mg
20MEQ/15ML
40MEQ/15ML
8mEq
5mg
10mg
2.5mg
20mg
5mg
27-0.5mg
5mg
6.25mg/5ml
100-650
40-25mg
80-25mg
10mg
20mg
40mg
60mg
80mg
30mg
60-4MG/5ML
60-6mg
60-4mg/5ml
120-8mg
30-10-2/5
60-5mg/5ml
30-2.5-2/5
30-2.5-2/5
60-5mg/5ml
150mg
500mg
750mg
2.50%
0.5mg
Tablet
Capsule SA
Oral Suspension
Oral Suspension
Tablet
Tablet
Tablet
Tablet
Elixir
Tablet
Tablet
Syrup
Syrup
Syrup
Syrup
Tablet
Capsule
Capsule
Syrup
Solution
Liquid
Liquid
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Syrup
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Syrup
Capsule SA
Syrup
Capsule SA
Liquid
Liquid
Liquid
Syrup
Solution
Tablet
Tablet
Tablet
Shampoo
Irrig Solution
Tablet Chew
091201
SODIUM FLUORIDE
SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFAMETHOXAZOLE/TRIMETHOPRIM
TEMAZEPAM
TEMAZEPAM
TERAZOSIN HCL
TERAZOSIN HCL
TERAZOSIN HCL
TETRACYCLINE HYDROCHLORIDE
TETRACYCLINE HYDROCHLORIDE
THEOPHYLLINE ANHYDROUS
THEOPHYLLINE ANHYDROUS
THIOTHIXENE
TRAZODONE HCL
TRAZODONE HCL
TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE ACETONIDE
VALPROATE SODIUM
VERAPAMIL HCL
VERAPAMIL HCL
VITAMIN B-COMPLEX W/C
WATER FOR IRRIG. STERILE
YOHIMBINE HCL
ZINC SULFATE
**Formulary is subject to change without notice**
1mg
400-80mg
15mg
30mg
1mg
2mg
5mg
250mg
500mg
100mg
80mg15ml
1mg
100mg
50mg
0.025%
0.025%
0.1%
0.1%
0.50%
250mg/5ml
120mg
80mg
5.4mg
220mg
Tablet Chew
Tablet
Oral Suspension
Capsule
Capsule
Capsule
Capsule
Capsule
Capsule
Capsule
Tablet CR
Elixir
Capsule
Tablet
Tablet
Cream
Ointment
Cream
Ointment
Cream
Syrup
Tablet
Tablet
Tablet
Irrig Solution
Tablet
Capsule
091201