Empire Plan Prescription Drug Program
2008 Preferred Drug List
|
Preferred
Brand Name Drug Proventil HFA (albuterol sulfate) Xopenex HFA (levabuterol tartrate) |
Non-Preferred Brand Name Drug ProAir HFA (albuterol sulfate) Ventolin HFA (albuterol sulfate) |
||
| Up to a 30-day supply from a retail network pharmacy or through Medco By Mail | $15 | Up to a 30-day supply from a retail network pharmacy or through Medco By Mail | $30 |
| 31 to 90 day supply from a retail network pharmacy | $30 | 31 to 90 day supply from a retail network pharmacy | $60 |
| 31 to 90 day supply from Medco By Mail | $20 | 31 to 90 day supply from Medco By Mail | $55 |