Patient Assistance Program Xubex offers assistance to qualified individuals for generic medications through its innovative program. A licensed pharmacist in the United States fills all prescriptions with the same medications available from your local pharmacy. There is no cost to join and no monthly fees. All medications are shipped discreetly to your home, office or trusted family member. Our focus on providing exceptional service to our clients has been the hallmark of our business. The focus is to provide families and qualified individuals of all ages with access to prescription medications. Our service ensures lowcost, predictable pharmaceutical services. Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price ACEBUTOLOL 200MG BETA-ADRENERGIC BLOCKING 180 $30.00 ACYCLOVIR 200 MG, 400 MG, 800 MG NUCLEOSIDES AND NUCLEOTIDES 90 $30.00 AFEDITAB CR 30MG, 60MG DIHYDROPYRIDINES 60 $40.00 AFEDITAB CR 30MG, 60MG DIHYDROPYRIDINES 60 $60.00 ALBUTEROL INH 0.83MG/ML BETA-ADRENERGIC AGONISTS 180/60 $20.00 ALBUTEROL INH 5 MG/ML BETA-ADRENERGIC AGONISTS 40 $20.00 ALENDRONATE 5MG, 10MG BONE RESORPTION INHIBITORS 90 $20.00 ALENDRONATE 70MG BONE RESORPTION INHIBITORS 12 $20.00 ALFUZOSIN HCL ORAL TAB ER 10 MG ER ALPHA-ADRENERGIC BLOCKING AGENT(SYM 90 $45.00 ALLOPURINOL 100MG, 300MG ANTIGOUT 180 $20.00 ALPRAZOLAM 0.25MG, 0.5MG, 1MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV ALPRAZOLAM 2 MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV 270 $30.00 100 $20.00 AMILORIDE/HCT 5MG-50MG POTASSIUM-SPARING DIURETICS 90 $30.00 AMIODARONE 200MG ANTIARRHYTHMIC 180 $30.00 AMITRIPT 100 MG ANTIDEPRESSANTS 180 $20.00 AMITRIPT 10MG, 25MG, 50MG, 75MG ANTIDEPRESSANTS 360 $20.00 AMITRIPT 150 MG ANTIDEPRESSANTS 90 $20.00 AMLODIP/BENAZ 10/ 40MG DIHYDROPYRIDINES 50 $60.00 AMLODIP/BENAZ 2.5/10MG, 10/ 20MG DIHYDROPYRIDINES 60 $50.00 AMLODIP/BENAZ 2.5/10MG, 10/ 20MG DIHYDROPYRIDINES 60 $60.00 AMLODIP/BENAZ 5/ 10MG, 5/ 20MG, 5/ 40MG DIHYDROPYRIDINES 90 $50.00 AMLODIPINE 2.5MG, 5MG, 10MG DIHYDROPYRIDINES 180 $20.00 ANASTROZOLE 1 MG ANTINEOPLASTIC 90 $45.00 As of 7/10/2014 9:21:27 AM 1 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price ATENOLOL 25 MG, 50MG BETA-ADRENERGIC BLOCKING ATENOLOL ORAL TABLET 100 100 MG BETA-ADRENERGIC BLOCKING ATENOLOL/CHLO 50-25MG, 100-25MG BETA-ADRENERGIC BLOCKING 270 $20.00 270 $20.00 90 $20.00 ATORVASTATIN 20 MG, 40 MG HMG-COA REDUCTASE INHIBITORS 90 $30.00 ATORVASTATIN CALCIUM ORAL 10 MG, 80 MG HMG-COA REDUCTASE INHIBITORS 90 $30.00 AZATHIOPRINE 50MG IMMUNOSUPPRESSIVE 90 $30.00 BACLOFEN 10MG GABA-DERIVATIVE SKELETAL MUSCLE REL BACLOFEN 20 MG GABA-DERIVATIVE SKELETAL MUSCLE REL BENAZEPRIL 5MG, 10MG, 20MG, 40MG ANGIOTENSIN-CONVERTING ENZYME INHIB 360 $40.00 270 $40.00 180 $20.00 BENZTROPINE 0.5MG, 1MG, 2MG ANTICHOLINERGIC (CNS) 180 $40.00 BICALUTAMIDE 50 MG ANTINEOPLASTIC 90 $65.00 BISOPROL/HCTZ 5-6.25MG BETA-ADRENERGIC BLOCKING BISOPROLOL FUMARATE ORAL BISOPROLOL FUMARATE/HCTZ 10 MG BETA-ADRENERGIC BLOCKING 2.5/6.25MG BETA-ADRENERGIC BLOCKING BRIMONID TART 0.2% ALPHA-ADRENERGIC AGONISTS (EENT) 180 $20.00 180 $20.00 180 $20.00 15 $20.00 BUPROPION 75 MG, 100 MG ANTIDEPRESSANTS 90 $65.00 BUPROPION XL 150MG, 300 MG ANTIDEPRESSANTS 90 $65.00 BUSPIRONE 5MG, 10 MG, 15MG ANXIOLYTICS, SEDATIVES & HYPNOTICS, 270 $30.00 CALCIUM ACE 667 MG PHOSPHATE-REMOVING 90 $45.00 CALPHRON PHOSPHATE-REMOVING 200 $30.00 CARBIDOPA/LEV 10-100MG, 25-100MG, 25-250MG DOPAMINE PRECURSORS 180 $45.00 CARBIDOPA/LEV 25-100MG DOPAMINE PRECURSORS 90 $60.00 CARISOPRODOL 350 MG CENTRALLY ACTING SKELETAL MUSCLE RE CARVEDILOL 3.125MG, 6.25MG, 12.5MG, 25MG BETA-ADRENERGIC BLOCKING CETIRIZINE 5 MG, 10MG SECOND GENERATION ANTIHISTAMINES CHLORDIAZ 5MG, 10MG, 25MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV 270 $30.00 180 $20.00 90 $20.00 360 $30.00 CHLORPROP 100MG SULFONYLUREAS 90 $50.00 As of 7/10/2014 9:21:27 AM 2 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price CHLORZOXAZONE ORAL TABLET 500 MG CENTRALLY ACTING SKELETAL MUSCLE RE 120 $40.00 CILOSTAZOL 100MG PLATELET-AGGREGATION INHIBITORS 180 $40.00 CILOSTAZOL ORAL TABLET 50 50 MG PLATELET-AGGREGATION INHIBITORS 180 $40.00 CIMETIDINE 300 MG HISTAMINE H2-ANTAGONISTS 90 $30.00 CIMETIDINE ORAL TABLET 40 CIMETIDINE ORAL TABLET 80 400 MG HISTAMINE H2-ANTAGONISTS 90 $30.00 800 MG HISTAMINE H2-ANTAGONISTS 90 $60.00 CITALOPRAM 10 MG, 20 MG, 40 MG ANTIDEPRESSANTS 180 $20.00 CLONAZEPAM 0.5 MG, 1MG, 2MG BENZODIAZEPINES (ANTICONVULSANTS) 270 $30.00 CLONIDINE 0.1MG CENTRAL ALPHA-AGONISTS 270 $20.00 CLONIDINE 0.2MG, 0.3MG CENTRAL ALPHA-AGONISTS 180 $30.00 CLOPIDOGREL 75 MG PLATELET-AGGREGATION INHIBITORS 90 $20.00 CROMOLYN 4% MAST-CELL STABLILIZERS 30 $30.00 CYCLOBENZ 5MG, 10MG CENTRALLY ACTING SKELETAL MUSCLE RE 360 $30.00 CYCLOSPOR MIC 25MG IMMUNOSUPPRESSIVE 60 $55.00 DEPO TESTOST 200 MG ANDROGENS 3 $45.00 DEXAMETH 0.5MG, 0.75MG, 1.5MG, 4MG ADRENALS 180 $30.00 DEXAMETH 1MG ADRENALS 120 $40.00 DEXAMETH PHOS 0.1% CORTICOSTEROIDS (EENT) 10 $30.00 DIAZEPAM 2 MG, 5 MG, 10 MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV DICLOFEN POT 50 MG NONSTEROIDAL ANTI-INFLAMMATORY AGEN 360 $30.00 90 $80.00 DICYCLOMINE 10MG ANTIMUSCARINICS/ANTISPASMODICS 360 $20.00 DICYCLOMINE 20MG ANTIMUSCARINICS/ANTISPASMODICS 180 $30.00 DIGOXIN 0.125MG, 0.25MG CARDIOTONIC 90 $20.00 DILTIAZEM 30MG, 60MG CALCIUM-CHANNEL BLOCKING, MI DILTIAZEM 30MG, 60MG CALCIUM-CHANNEL BLOCKING, MI DILTIAZEM 90MG, 120MG CALCIUM-CHANNEL BLOCKING, MI DILTIAZEM CD 120MG CALCIUM-CHANNEL BLOCKING, MI DILTIAZEM XR 180MG, 240MG CALCIUM-CHANNEL BLOCKING, MI 360 $20.00 360 $30.00 180 $30.00 90 $40.00 90 $40.00 As of 7/10/2014 9:21:27 AM 3 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price DILTIAZEM XR 180MG, 240MG CALCIUM-CHANNEL BLOCKING, MI 90 $60.00 DIPHENOXYL/AT 2.5-0.025MG ANTIDIARRHEA 270 $40.00 DIVALPROEX DR 125 MG, 250 MG ANTICONVULSANTS, MISCELLANEOUS 180 $30.00 DIVALPROEX DR 500 MG ANTICONVULSANTS, MISCELLANEOUS 120 $30.00 DONEPEZIL 5MG, 10MG PARASYMPATHOMIMETIC (CHOLINERGIC AG DOXAZOSIN 1MG, 2MG, 4MG, 8MG ALPHA-ADRENERGIC BLOCKING DOXAZOSIN 1MG, 2MG, 4MG, 8MG ALPHA-ADRENERGIC BLOCKING 90 $20.00 90 $60.00 90 $70.00 DOXEPIN 10MG, 25MG ANTIDEPRESSANTS 180 $30.00 DOXEPIN 50 MG ANTIDEPRESSANTS 120 $40.00 DUTOPROL 25-12.5 MG, 50-12.5 MG, 100-12.5MG BETA-ADRENERGIC BLOCKING ENALAPRIL MAL 2.5 MG, 5 MG, 10 MG, 20 MG ANGIOTENSIN-CONVERTING ENZYME INHIB ENALAPRIL/HCT 5-12.5MG, 10-25MG ANGIOTENSIN-CONVERTING ENZYME INHIB 90 $50.00 180 $40.00 90 $20.00 ESCITALOPRAM 5 MG, 10 MG, 20 MG ANTIDEPRESSANTS 90 $30.00 ESTRADIOL 0.5MG, 1MG, 2MG ESTROGENS 90 $20.00 ESTROPIPATE 0.75MG, 1.5MG ESTROGENS 90 $30.00 FAMOTIDINE 20MG, 40MG HISTAMINE H2-ANTAGONISTS 180 $20.00 FEXOFENADINE 180MG SECOND GENERATION ANTIHISTAMINES 90 $30.00 FINASTERIDE 5 MG 5-ALPHA-REDUCTASE INHIBITORS 90 $30.00 FLUOXETINE 10 MG, 20MG ANTIDEPRESSANTS 270 $20.00 FLUOXETINE HC 40MG ANTIDEPRESSANTS 90 $30.00 FLUPHENAZ 1MG ANTIPSYCHOTIC 180 $30.00 FLUPHENAZ 2.5MG, 5MG, 10MG ANTIPSYCHOTIC 90 $30.00 FLURAZEPAM 15MG, 30MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV 90 $30.00 FOLIC ACID 1MG VITAMIN B COMPLEX 270 $20.00 FOSINOPRIL 10MG, 20MG, 40MG ANGIOTENSIN-CONVERTING ENZYME INHIB 90 $20.00 FUROSEMIDE 20MG, 40MG LOOP DIURETICS 270 $20.00 FUROSEMIDE 80 MG LOOP DIURETICS 360 $20.00 GABAPENTIN 100MG, 300MG, 400MG ANTICONVULSANTS, MISCELLANEOUS 270 $30.00 GEMFIBROZIL 600MG FIBRIC ACID DERIVATIVES 180 $30.00 As of 7/10/2014 9:21:27 AM 4 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price GLIMEPIRIDE 1MG, 2MG, 4MG SULFONYLUREAS 180 $20.00 GLIPIZIDE 5MG, 10MG SULFONYLUREAS 360 $20.00 GLIPIZIDE XL 2.5MG, 5MG, 10MG SULFONYLUREAS 90 $20.00 GLIPIZIDE XL 2.5MG, 5MG, 10MG SULFONYLUREAS 90 $30.00 GLYBUR/METFOR 2.5-500MG SULFONYLUREAS 180 $30.00 GLYBUR/METFOR 5-500MG SULFONYLUREAS 90 $30.00 GLYBURIDE MCR 1.5 MG SULFONYLUREAS 180 $30.00 GLYBURIDE MCR 3MG, 6 MG SULFONYLUREAS 90 $30.00 GLYBURIDE MCR 3MG, 6 MG SULFONYLUREAS 90 $40.00 GLYBURIDE/METFORMIN HCL O 1.25/250MG SULFONYLUREAS 180 $30.00 GUANFACINE 1MG CENTRAL ALPHA-AGONISTS 90 $30.00 GUANFACINE 2 MG CENTRAL ALPHA-AGONISTS 180 $30.00 HALOPERIDOL 0.5MG, 1MG, 2MG ANTIPSYCHOTIC 180 $30.00 HALOPERIDOL 5MG ANTIPSYCHOTIC 90 $30.00 HYDRALAZINE 10MG, 25MG, 50MG DIRECT VASODILATORS 100 $20.00 HYDROCHLOR0 12.5MG THIAZIDE DIURETICS 180 $20.00 HYDROCHLORO 25MG, 50MG THIAZIDE DIURETICS 180 $20.00 HYDROXYCHLORQ 200 MG 180 $30.00 HYDROXYUREA 500MG ANTINEOPLASTIC 120 $50.00 HYDROXYZ PAM 50 MG ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. HYDROXYZINE 25 MG ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. IBUPROFEN 400MG, 600MG, 800MG NONSTEROIDAL ANTI-INFLAMMATORY AGEN 180 $30.00 180 $30.00 360 $20.00 INDAPAMIDE 1.25MG, 2.5MG THIAZIDE-LIKE DIURETICS 180 $30.00 IPRAT/ALBUTER 0.5-3MG/3 BETA-ADRENERGIC AGONISTS 180ML or 60 Vials IPRATROP BROM 0.2 MG/ML ANTIMUSCARINICS/ANTISPASMODICS 180ML or 60 Vials ISONIAZID 300MG ANTITUBERCULOSIS 180 $40.00 ISOSORB MN 20MG, 30MG, 60MG NITRATES AND NITRITES 90 $30.00 ISOSORB MN 20MG, 30MG, 60MG NITRATES AND NITRITES 90 $40.00 JANTOVEN 1MG, 2MG, 2.5MG, 3MG, 4MG, 5MG, 6MG, 7.5MG, 10MG $30.00 $20.00 ANTICOAGULANTS 90 $20.00 LAMOTRIGINE 25MG, 100MG, 150MG, 200MG ANTICONVULSANTS, MISCELLANEOUS 180 $30.00 As of 7/10/2014 9:21:27 AM 5 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price LATANOPROST 0.005% PROSTAGLANDIN ANALOGS 7.50 $30.00 LEFLUNOMIDE 10MG, 20MG DISEASE-MODIFYING ANTIRHEUMATIC AGE 90 $65.00 LETROZOLE 2.5MG ANTINEOPLASTIC 90 $30.00 LEVETIRACETAM 250MG, 500MG, 750MG ANTICONVULSANTS, MISCELLANEOUS 180 $60.00 LEVOBUNOL O/S 0.5 % BETA-ADRENERGIC BLOCKING (EENT) LEVOBUNOLOL HCL OPHTHALMI 0.5 % BETA-ADRENERGIC BLOCKING (EE LEVOCETIRIZIN 5MG SECOND GENERATION ANTIHISTAMINES $41.78 10 $20.00 90 $45.00 LEVOFLOXACIN 250 MG, 500MG, 750MG QUINOLONES 30 $30.00 LEVOTHYROXINE 25MCG, 50MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 300MCG LEVOTHYROXINE 25MCG, 50MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 300MCG LEVOTHYROXINE 25MCG, 50MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 300MCG LEVOTHYROXINE 25MCG, 50MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 300MCG LEVOTHYROXINE 25MCG, 50MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 300MCG THYROID 90 $35.00 THYROID 90 $45.00 THYROID 90 $55.00 THYROID 90 $65.00 THYROID 90 $89.00 LISINOP/HCTZ 10-12.5MG, 20-12.5MG ANGIOTENSIN-CONVERTING ENZYME INHIB LISINOP/HCTZ 20-25MG ANGIOTENSIN-CONVERTING ENZYME INHIB LISINOPRIL 2.5 MG, 5MG, 10 MG, 20MG, 30 MG, 40MG ANGIOTENSIN-CONVERTING ENZYME INHIB LISINOPRIL 2.5 MG, 5MG, 10 MG, 20MG, 30 MG, 40MG ANGIOTENSIN-CONVERTING ENZYME INHIBITORS 270 $20.00 180 $20.00 180 $20.00 180 $20.00 LITHIUM CARB 150MG, 300MG ANTIMANIC 360 $30.00 LORATADINE 10MG SECOND GENERATION ANTIHISTAMINES LORAZEPAM 0.5MG, 1MG, 2MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV LOSARTAN 25 MG, 50 MG, 100 MG ANGIOTENSIN II RECEPTOR ANTAGONISTS LOSARTAN/HCTZ 50-12.5 MG, 100-12.5MG, 100-25MG ANGIOTENSIN II RECEPTOR ANTAGONISTS 100 $20.00 270 $30.00 90 $20.00 90 $20.00 LOVASTATIN 10 MG, 20MG, 40 MG HMG-COA REDUCTASE INHIBITORS 90 $30.00 MECLIZINE 12.5MG ANTIHISTAMINES (GI DRUGS) 270 $20.00 MECLIZINE HCL 25 MG ANTIHISTAMINES (GI DRUGS) 270 $20.00 As of 7/10/2014 9:21:27 AM 6 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price MEDROXYPROG 2.5MG, 5MG, 10MG PROGESTINS 180 $20.00 MEGESTROL ACE 20 MG, 40 MG ANTINEOPLASTIC 180 $40.00 MELOXICAM 7.5 MG, 15 MG NONSTEROIDAL ANTI-INFLAMMATORY AGEN 180 $20.00 MERCAPTOPURIN 50 MG ANTINEOPLASTIC 60 $75.00 METFORMIN 500 MG, 850 MG, 1000 MG BIGUANIDES 360 $30.00 METFORMIN 500MG BIGUANIDES 180 $30.00 METFORMIN 750MG BIGUANIDES 90 $20.00 METHOCARBAM 500 MG, 750MG CENTRALLY ACTING SKELETAL MUSCLE RE 270 $30.00 METHYLDOPA 250MG CENTRAL ALPHA-AGONISTS 180 $30.00 METOCLOPRAM 5MG, 10MG PROKINETIC 360 $30.00 METOPROLOL 25MG, 50MG, 100 MG BETA-ADRENERGIC BLOCKING 270 $20.00 METRONIDAZOLE 500MG ANTIPROTOZOALS, MISCELLANEOUS 90 $50.00 MINOCYCLINE 50 MG, 100 MG 90 $30.00 MIRTAZAPINE 15 MG, 30 MG, 45MG ANTIDEPRESSANTS 90 $30.00 MONTELUKAST 4MG, 5MG, 10MG LEUKOTRIENE MODIFIERS 90 $45.00 MYCOPHENOLATE 250MG IMMUNOSUPPRESSIVE 120 $60.00 MYCOPHENOLATE 500MG IMMUNOSUPPRESSIVE 90 $60.00 NABUMETONE 500MG, 750MG NONSTEROIDAL ANTI-INFLAMMATORY AGEN NAPROXEN 250 MG, 375MG, 500 MG NONSTEROIDAL ANTI-INFLAMMATORY AGEN NAPROXEN SOD 275MG, 550MG NONSTEROIDAL ANTI-INFLAMMATORY AGEN 90 $40.00 180 $20.00 120 $30.00 NEVIRAPINE 200 MG 180 $45.00 NIACIN ORAL TABLET 500 MG 500 MG ANTILIPEMIC, MISCELLANEOUS 360 $20.00 NITROGLY TRAN 0.2MG/HR, 0.4MG/HR NITRATES AND NITRITES 90 $65.00 NORTRIPTYLINE 10MG, 25MG, 50MG, 75MG ANTIDEPRESSANTS 180 $30.00 OLANZAPINE 2.5MG, 5MG, 7.5MG, 10 MG, 15MG, 20MG ANTIPSYCHOTIC 90 $30.00 OLANZAPINE 2.5MG, 5MG, 7.5MG, 10 MG, 15MG, 20MG ANTIPSYCHOTIC 90 $40.00 OLANZAPINE 2.5MG, 5MG, 7.5MG, 10 MG, 15MG, 20MG ANTIPSYCHOTIC 90 $65.00 OMEPRAZOLE DR 10MG, 20MG, 40MG PROTON-PUMP INHIBITORS 90 $30.00 ONDANSETRON 4 MG, 4MG, 8 MG, 8MG 5-HT3 RECEPTOR ANTAGONISTS 30 $30.00 As of 7/10/2014 9:21:27 AM 7 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price OXYBUTYNIN 5 MG GENITOURINARY SMOOTH MUSCLE RELAXAN 90 $50.00 PANTOPRAZOLE 20 MG, 40 MG PROTON-PUMP INHIBITORS 90 $20.00 PAROXETINE 10MG, 20 MG, 30 MG, 40MG ANTIDEPRESSANTS 90 $30.00 PENTOXIFYLLIN 400MG HEMORRHEOLOGIC 270 $45.00 PERINDOPRIL 2MG, 8MG ANGIOTENSIN-CONVERTING ENZYME INHIB PERINDOPRIL 4MG ANGIOTENSIN-CONVERTING ENZYME INHIB 90 $60.00 60 $60.00 PHENYTOIN 100MG ER HYDANTOINS 180 $30.00 PIOGLITAZONE 15 MG, 30 MG, 45 MG THIAZOLIDINEDIONES 90 $30.00 PRAMIPEXOLE 0.25MG, 0.5MG, 1MG, 1.5MG DOPAMINE RECEPTOR AGONISTS 180 $30.00 PRAMIPEXOLE DI-HCL ORAL T.125 MG DOPAMINE RECEPTOR AGONISTS 180 $30.00 PRAVACHOL 80MG HMG-COA REDUCTASE INHIBITORS 90 $55.00 PRAVASTATIN 10MG, 20MG, 40MG HMG-COA REDUCTASE INHIBITORS 90 $45.00 PRAVASTATIN 10MG, 20MG, 40MG HMG-COA REDUCTASE INHIBITORS 90 $55.00 PRAZOSIN 1MG, 2MG, 5 MG ALPHA-ADRENERGIC BLOCKING PRAZOSIN 1MG, 2MG, 5 MG ALPHA-ADRENERGIC BLOCKING 90 $30.00 90 $45.00 PREDNISONE 20MG ADRENALS 180 $20.00 PREDNISONE 5MG, 10 MG ADRENALS 360 $20.00 PRIMIDONE 50MG, 250MG BARBITURATES (ANTICONVULSANTS) 180 $30.00 PROCHLORPERAZ 5MG, 10MG ANTIHISTAMINES (GI DRUGS) 270 $30.00 PROPAFENONE 150 MG ANTIARRHYTHMIC 120 $40.00 PROPRANOLOL 10MG, 20MG, 40MG, 80MG BETA-ADRENERGIC BLOCKING 360 $20.00 QUETIAPINE 25 MG ANTIPSYCHOTIC 180 $40.00 QUETIAPINE 400 MG ANTIPSYCHOTIC $0.64 QUETIAPINE 50 MG, 100 MG, 200 MG, 300 MG ANTIPSYCHOTIC 90 $40.00 QUINAPRIL 5MG, 10MG, 20MG, 40MG ANGIOTENSIN-CONVERTING ENZYME INHIB 90 $30.00 RABEPRAZOLE 20 MG DR 90 $90.00 RAMIPRIL 1.25 MG, 2.5MG, 5MG, 10MG ANGIOTENSIN-CONVERTING ENZYME INHIB 90 $20.00 RANITIDINE 150MG, 300 MG HISTAMINE H2-ANTAGONISTS 180 $20.00 RESCRIPTOR 200MG ANTIRETROVIRALS $1.90 As of 7/10/2014 9:21:27 AM 8 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price REYATAZ 150MG, 200MG, 300MG ANTIRETROVIRALS $16.32 REYATAZ 150MG, 200MG, 300MG ANTIRETROVIRALS $32.34 RISPERIDONE 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG ANTIPSYCHOTIC 180 $60.00 RIZATRIPTAN 5 MG, 10 MG SELECTIVE SEROTONIN AGONISTS 18 $40.00 ROPINIROLE 0.25MG, 0.5MG, 1MG, 2MG, 3 MG, 4MG, 5 MG DOPAMINE RECEPTOR AGONISTS 90 $40.00 SERTRALINE 25 MG, 50MG, 100 MG ANTIDEPRESSANTS 180 $30.00 SILDENAFIL 20 MG PHOSPHODIESTERASE INHIBITORS 30 $30.00 SIMVASTATIN 5 MG, 10MG, 20 MG, 40MG, 80 MG HMG-COA REDUCTASE INHIBITORS 90 $20.00 SOTALOL AF 120 MG, 160MG BETA-ADRENERGIC BLOCKING SOTALOL AF 80MG BETA-ADRENERGIC BLOCKING SOTALOL HCL 80MG, 120MG, 160 MG BETA-ADRENERGIC BLOCKING SPIRONOLACT 25MG MINERALOCORTICOID (ALDOSTERONE) ANT SPIRONOLACT 50MG MINERALOCORTICOID (ALDOSTERONE) ANT 90 $30.00 180 $40.00 180 $40.00 90 $30.00 60 $40.00 STAVUDINE 1 MG/ML 200 $90.00 STAVUDINE 15 MG, 20 MG, 30 MG, 40 MG 60 $90.00 SUCRALFATE 1 GM PROTECTANTS 180 $55.00 SULFAMETH/TMP 400-80MG, 800-160MG SULFONAMIDES (SYSTEMIC) 180 $20.00 SULFAMETH/TMP 400-80MG, 800-160MG SULFONAMIDES (SYSTEMIC) 180 $30.00 SULFASALAZINE 500MG SULFONAMIDES (SYSTEMIC) 180 $45.00 SULFAZINE EC 500MG SULFONAMIDES (SYSTEMIC) 90 $40.00 SULINDAC 150 MG, 200MG NONSTEROIDAL ANTI-INFLAMMATORY AGEN 180 $30.00 SUMATRIPTAN 25MG, 50MG, 100MG SELECTIVE SEROTONIN AGONISTS 18 $35.00 SUSTIVA 200 MG, 200MG, 600MG ANTIRETROVIRALS $6.54 SUSTIVA 200 MG, 200MG, 600MG ANTIRETROVIRALS $19.61 TAMOXIFEN CIT 10 MG, 20MG ANTINEOPLASTIC 90 $45.00 TAMSULOSIN 0.4MG ALPHA-ADRENERGIC BLOCKING AGENT(SYM TEMAZEPAM 15MG, 30MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV TERAZOSIN 1MG, 2MG, 5MG, 10MG ALPHA-ADRENERGIC BLOCKING 90 $30.00 90 $30.00 180 $20.00 TERBINAFINE 250 MG ALLYLAMINES 90 $30.00 As of 7/10/2014 9:21:27 AM 9 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price THEOPHY ANHYD 100MG, 200MG RESPIRATORY SMOOTH MUSCLE RELAXANTS THEOPHY ANHYD 300MG RESPIRATORY SMOOTH MUSCLE RELAXANTS 180 $40.00 120 $40.00 THYROID 15MG, 30MG, 60MG, 90MG THYROID 90 $30.00 TIMOLOL O/S 0.25%, 0.5% BETA-ADRENERGIC BLOCKING (EE TIZANIDINE 2 MG CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 30 $20.00 90 $65.00 TOPIRAMATE 25MG, 50MG, 100MG, 200MG ANTICONVULSANTS, MISCELLANEOUS 180 $30.00 TORSEMIDE 5 MG, 10MG, 20MG LOOP DIURETICS 180 $30.00 TRAMADOL 50MG OPIATE AGONISTS 360 $30.00 TRAMADOL ACET 37.5-325MG OPIATE AGONISTS $0.31 TRANDOLAPRIL 1MG, 2MG, 4MG ANGIOTENSIN-CONVERTING ENZYME INHIB 90 $30.00 TRAZODONE 50MG, 100MG ANTIDEPRESSANTS 360 $20.00 TRIAMTER/HCTZ 37.5-25 MG, 75-50MG POTASSIUM-SPARING DIURETICS 90 $20.00 TRIAZOLAM 0.125 MG, 0.25MG BENZODIAZEPINES (ANXIOLYTIC,SEDATIV 90 $65.00 TRIHEXYPHENID 2MG ANTICHOLINERGIC (CNS) 180 $20.00 VENLAFAXINE 37.5 MG, 75 MG, 150 MG ANTIDEPRESSANTS 90 $40.00 VENTOLIN HFA 90 MCG BETA-ADRENERGIC AGONISTS 8 $18.00 VERAPAMIL 120 MG, 180MG, 240MG CALCIUM-CHANNEL BLOCKING, MI VERAPAMIL 80MG, 120MG CALCIUM-CHANNEL BLOCKING, MI 90 $40.00 180 $30.00 VIDEX EC 125MG, 250MG, 400MG ANTIRETROVIRALS $4.25 VIDEX EC 125MG, 250MG, 400MG ANTIRETROVIRALS $9.05 VIDEX EC 125MG, 250MG, 400MG ANTIRETROVIRALS $13.48 VIDEX PED 10MG/ML ANTIRETROVIRALS $57.13 VIRAMUNE 50MG/5ML, 200MG ANTIRETROVIRALS $10.26 VIRAMUNE XR 400 MG ANTIRETROVIRALS $18.09 WARFARIN SOD 1MG, 2MG, 2.5MG, 4MG, 5MG, 6MG, 7.5MG, 10MG ZALEPLON ORAL CAPSULE 10 ZALEPLON ORAL CAPSULE 5 M 10 MG ANXIOLYTICS, SEDATIVES & HYPNOTICS, 5 MG ANXIOLYTICS, SEDATIVES & HYPNOTICS, ZOLPIDEM TART 5MG, 10MG ANXIOLYTICS, SEDATIVES & HYPNOTICS, ANTICOAGULANTS 180 $30.00 60 $40.00 90 $40.00 90 $30.00 ZONISAMIDE 25 MG, 50 MG, 100 MG ANTICONVULSANTS, MISCELLANEOUS 90 $30.00 As of 7/10/2014 9:21:27 AM 10 of 24
Patient Assistance Program Medication List TRADE NAME Strength treatment Max Qty price ZONISAMIDE 25 MG, 50 MG, 100 MG ANTICONVULSANTS, MISCELLANEOUS 90 $60.00 As of 7/10/2014 9:21:27 AM 11 of 24
Free Medication Program At Xubex, we are always looking for ways to help patients get the medications they need. Our innovative programs have helped tens-of-thousands of people across the country for the past 5 years. We are proud to introduce our new program. Patients can receive up to 30 day supply of select popular brand medications absolutely Free. It is easy for you, your physician's office or an advocate to apply on your behalf to get up to 30 day supply of medications free. Your free medication will be shipped within one to two weeks after your request is approved by your physician. Free Medication Program List TRADE NAME Strength Remarks ADVAIR DISKUS 100-50MCG, 250-50MCG, 500-50MCG Quantity 1 As Directed ADVAIR HFA 45-21MCG, 115-21MCG, 230-21MCG Quantity 1 As Directed ALMOTRIPTAN MALATE ORAL T 6.25 MG, 12.5 MG Quantity 2 As Directed ARICEPT 5MG, 10MG, 23MG Quantity #30 One Tab Daily AXIRON 30MG BAYER BRZ2 BAYER CONTOUR Quantity #1 As Directed Quantity #1 As Directed BELVIQ 10 MG #30 qd BRILINTA 90MG Quantity 60 As Directed COLCHICINE ORAL TABLET 0. 0.6 MG Quantity 7 As Directed COMBIPATCH 0 0.14-0.05MG/24HR, 0.25-0.05MG/24HR Quantity 8 As Directed CRESTOR 5MG, 10MG, 20 MG, 40MG Quantity 30 As Directed DULERA 100 /5MCG, 100/5 MCG, 200 /5MCG, 200/5 MCG #120 bid ENJUVIA 0.3MG, 0.45MG, 0.9MG, 1.25MG Quantity 30 As Directed EXELON 1.5MG, 3MG, 4.5MG, 4.6MG/24HR, 6MG, 9.5MG/24HR Quantity 30 As Directed FANAPT 1MG, 2 MG, 4MG, 6MG, 8MG, 10MG, 12MG Quantity #60 as directed FANAPT 1MG, 2 MG, 4MG, 6MG, 8MG, 10MG, 12MG Quantity #60 as directed FARXIGA 5 MG, 10 MG #30 qd FREESTYLE LIT INTERMEZZO 1.75 MG, 3.5 MG #30 HS INVEGA 1.5MG, 3MG, 6MG, 9MG Quantity 30 As Directed JANUMET 50-1000MG, 50-500MG Quantity 30 + BGM #1 As directed JANUVIA 25MG, 50MG, 100MG QTY 30 UD + BGM #1 UD As of 7/10/2014 9:21:27 AM 12 of 24
Free Medication Program List TRADE NAME Strength Remarks KOMBIGLYZE XR 2.5/1000MG, 5MG/1000MG, 5MG/500MG #90 qd LIPTRUZET 10-10MG, 10-20MG, 10-40MG, 10-80MG MICARDIS 20MG, 40MG, 80MG Quantity #30 As Directed MYFORTIC 360 MG, 360MG Quantity 120 As Directed ONFI 10 MG, 20 MG 14 DAY FREE RAPAMUNE 1MG, 1MG/ML, 2MG Quantity 90 As Directed SYMBICORT 120 80-4.5MCG, 160-4.5MCG Quantity #1 As Directed TOVIAZ 4MG, 8MG Quantity 30 QD VIAGRA 25MG, 50MG, 100MG VYTORIN 10-10MG, 10-20MG, 10-40MG, 10-80MG Quantity 30 As Directed ZETIA 10MG Quantity 30 As Directed ZORTRESS 0.75MG Qty 30 UD As of 7/10/2014 9:21:28 AM 13 of 24
Co-pay Assistance Program Xubex offer co-pay assistance program to eligible individuals. Our program covers all or part of the co-pay you may be responsible for. Our program can save you hundreds of dollars each month. Programs we offer are sponsored by major pharmaceutical manufacturer. The requirement is straight forward and simple to understand. To be eligible, you must have coverage under individual or employer sponsored prescription drug coverage and you must not have coverage under Medicaid, Medicare or similar state or federal program. Massachusetts residents are not eligible Co-pay Assistance Program Medication List TRADE NAME Strength remarks ABILIFY 2MG, 5MG, 9.75MG/1.3ML, 10MG, 15MG, 20MG, 30MG UP TO $50 OFF ABILIFY OS 1MG/ML UP TO $50 OFF ACANYA 1.2-2.5% UP TO $25 OFF ACIPHEX 20MG UP TO $55 OFF ACTOPLUS MET Up to $60 off ACTOS 15MG, 30 MG, 45MG UP TO $50 OFF ACTOS 15MG, 30 MG, 45MG UP TO $60 OFF ADVAIR DISKUS 100-50MCG, 250-50MCG, 500-50MCG UP TO $10 OFF ADVAIR HFA 45-21MCG, 115-21MCG, 230-21MCG UP TO $10 OFF AGGRENOX 200 200-25MG UP TO $20 OFF ALCORTIN A 2-1-1% UP TO $20 OFF ALMOTRIPTAN MALATE ORAL T 6.25 MG, 12.5 MG UP TO $25 OFF ALPHAGAN P 0.1%, 0.15% UP TO $20 OFF ALVESCO 80MCG UP TO $75 OFF ALVESCO 60 IH 160MCG UP TO $75 OFF AMITIZA 8MCG, 24MCG UP TO $35 OFF AMRIX 15MG, 30MG UP TO $30 OFF ANDROGEL 1% UP TO $10 OFF ANDROGEL PUMP 1%, 1.62% UP TO $10 OFF ANGELIQ 0.5-1MG UP TO $20 OFF ANTARA 43MG UP TO $100 OFF APIDRA 100U/ML Up to $100 off APRISO 0.375GM UP TO $75 OFF As of 7/10/2014 9:21:28 AM 14 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks ARTHROTEC 50-0.2MG, 75-0.2MG Up to $100 off ASACOL HD 800MG UP TO $20 OFF ASMANEX TWST 110MCG, 220MCG UP TO $10 OFF ASMANEX TWST 110MCG, 220MCG UP TO $15 OFF ASTEPRO.15% 0.15% UP TO $25 OFF ATACAND 4MG, 8MG, 16MG, 32MG UP TO $50 0FF ATRALIN 0.05% UP TO $25 OFF ATRIPLA 200-300-600MG UP TO $200 OFF AVINZA 30MG, 45MG, 60MG, 75MG, 90MG, 120MG UP TO $30 OFF AVODART 0.5MG UP TO $15 OFF AXONA UP TO $15 OFF AZOPT 1 % Up to $150 off AZOPT 1 % Up to $75 off AZOR 5-20MG, 5-40MG, 10-20MG, 10-40MG UP TO $25 OFF BARACLUDE 0.5 MG, 1 MG Up to $200 off BAYER BRZ2 BAYER CONTOUR UP TO $35 OFF UP TO $35 OFF BENICAR 5MG, 20MG, 40MG UP TO $25 OFF BENICAR HCT 20-12.5MG, 40-12.5MG, 40-25MG UP TO $25 OFF BETAMETHASONE VALERATE TO 0.1 %, 0.12 % UP TO $25 OFF BETASERON 0.3MG COPAY ASSISTANCE BEYAZ Up to $25 Off BISMUTH/METRONID/TETRACYC 10 DAY UP TO $45 OFF BRILINTA 90MG UP TO $25 OFF BROVANA 15MCG/2ML Up to $30 off BUTRANS 5MCG/HR, 10MCG/HR, 20MCG/HR Up to $40 off CADUET 2.5-10MG, 2.5-20MG, 2.5-40MG, 5-10MG, 5-20MG, 5-40MG, 5-80MG, 10-10MG, 10-20MG, 10-40MG, 10-80MG UP TO $100 OFF CAMBIA 50MG UP TO $90 OFF CANASA 1000MG UP TO $60 OFF CARDURA XL 4MG, 8MG UP TO $20 OFF CELEBREX 50MG, 100 MG, 200MG, 400MG UP TO $15 OFF As of 7/10/2014 9:21:28 AM 15 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks CELLCEPT 200MG/ML, 250 MG, 500MG Up to $100 off CHANTIX 0.5MG, 1MG $30 OFF CLARINEX 0.5MG/ML, 5MG UP TO $25 OFF CLARINEX-D 120-2.5MG UP TO $25 OFF CLOBEX 0.05% UP TO $25 OFF CLOBEX 0.05% UP TO $45 OFF COLCHICINE ORAL TABLET 0. 0.6 MG UP TO $50 OFF COMBIGAN 0.2-0.5% UP TO $100 OFF COMBIGAN 0.2-0.5% UP TO $25 OFF COMBIVIR 150-300MG UP TO $100 OFF COMPLERA 200-25-300 Up to $200 off COPAXONE 20MG/ML Up to $250 off COREG CR 10MG, 20MG, 40MG, 80MG UP TO $10 OFF CRESTOR 5MG, 10MG, 20 MG, 40MG UP TO $50 OFF DARUNAVIR ETHANOLATE ORAL 800 MG Up to $100 off Co-pay DAYTRANA 10MG, 15MG/9HR, 20MG, 30MG UP TO $60 OFF DEPAKOTE 125MG UP TO $75 OFF DEPAKOTE DR 125MG, 250MG, 500MG UP TO $75 OFF DEPAKOTE ER 250MG, 500MG UP TO $75 OFF DETROL LA 2MG, 4MG UP TO $20 OFF DEXILANT 30MG, 60MG UP TO $55 OFF DIASTAT ACUD 10MG, 20MG UP TO $60 OFF DIASTAT-PEDTR 2.5MG UP TO $60 OFF DILANTIN 30MG, 100MG UP TO $50 OFF DIOVAN 40MG, 320MG UP TO $25 OFF DIOVAN HCT 80-12.5MG UP TO $35 OFF DORYX 150MG, 150 MG UP TO $50 OFF CO-PAY DUETACT 30-2MG, 30-4MG UP TO $60 OFF DUEXIS 800-26.6MG UP TO $50 0FF DULERA 100 /5MCG, 100/5 MCG, 200 /5MCG, 200/5 MCG DURAGESIC 12MCG/HR, 25MCG/HR, 50MCG/HR, 75MCG/HR, 100MCG/HR Up to $20 off UP TO $50 OFF As of 7/10/2014 9:21:28 AM 16 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks DYSPORT DS 500 UNIT Up to $50 off EDARBI 40MG, 80MG Up to $50 off EDARBYCLOR 40 MG-25MG, 40-12.5 MG Up to $50 off EDLUAR 10 MG UP TO $100 OFF EDURANT 25 MG Up to $100 off EFFEXOR XR 37.5MG, 75MG, 150MG UP TO $75 OFF ELMIRON 100MG UP TO $50 OFF ENBREL 25MG, 25MG/0.5ML, 50MG/ML UP TO $750 OFF ENBREL SURCLK 50MG/ML UP TO $750 OFF EPIDUO GEL 0.1-2.5% UP TO $10 OFF EPIVIR 10MG/ML, 10 MG/ML, 150MG, 300MG UP TO $100 OFF EPZICOM 600-300MG UP TO $100 OFF ESTROGEL 0.06% UP TO $20 OFF ESTROGENS, CONJUGATED VAG.625 MG UP TO $50 OFF EVAMIST 1.53MG UP TO $10 OFF EXALGO ER 8MG, 12MG, 16MG UP TO $60 OFF EXFORGE 5-160MG, 5-320MG, 10-160MG, 10-320MG UP TO $25 OFF EXFORGE HCT 5-160-25MG, 10-160-25MG, 10-320-25MG UP TO $25 OFF EXFORGE HCT 5 5-160-12.5MG UP TO $25 OFF EXFORGE HCT10 10-160-12.5MG UP TO $25 OFF FARXIGA 5 MG, 10 MG FEMARA 2.5MG UP TO $100.00 OFF COPAY FENOFIBRATE ORAL TABLET 1 120 MG UP TO $50 OFF FENOGLIDE 40MG UP TO $50 OFF FINACEA 15% UP TO $10 OFF FLECTOR 1.3% UP TO $30 OFF FOCALIN XR 5 MG, 10MG, 15MG, 20MG, 25MG, 30MG, 35MG, 40MG UP TO $60 OFF FORADIL INHLR 12 MCG $20 OFF COPAY FORFIVO XL 450 MG Up to $50 off FORTAMET 1000MG UP TO $30 OFF FORTAMET ER 500MG UP TO $30 OFF As of 7/10/2014 9:21:28 AM 17 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks FORTESTA 10MG PAY NO MORE THAN $25 FOSAMPRENAVIR CALCIUM ORA 700 MG UP TO $100 OFF FROVA BP 2.5MG UP TO $35 OFF GEODON 20MG, 40MG, 60MG, 80MG UP TO $75 OFF GLEEVEC 100MG, 400MG UP TO $25 OFF HECTOROL 0.5MCG, 1MCG, 2.5MCG UP TO $250 OFF HUMIRA 20MG/0.4ML, 40MG/0.8ML UP TO $100 OFF HUMIRA PEN 40MG/0.8ML UP TO $100 OFF HUMIRA PEN PS 40MG/0.8ML UP TO $100 OFF HUMIRA STRT C 40MG/0.8ML UP TO $100 OFF HYZAAR 100-12.5MG UP TO $10 OFF HYZAAR UOU 50-12.5MG, 100-25MG UP TO $10 OFF INTELENCE 100MG, 200 MG Up to $100 off INTELENCE 100MG, 200 MG UP TO $100 OFF CO-PAY INTERMEZZO 1.75 MG, 3.5 MG Upto $45 off INTUNIV 1MG, 2MG, 3MG, 4MG $25 OFF ISENTRESS 400MG UP TO $400 OFF JALYN 0.5-0.4MG UP TO $35.00 OFF JANUMET 50-1000MG, 50-500MG UP TO $100 0FF JANUVIA 25MG, 50MG, 100MG UP TO $10 OFF KALETRA 100-25MG, 200-50MG, 400-100MG/5ML UP TO $50 OFF CO-PAY KEPPRA XR 500MG, 750MG UP TO $25 OFF KOMBIGLYZE XR 2.5/1000MG, 5MG/1000MG, 5MG/500MG Up to $100 off LACRISERT 5MG UP TO $20 OFF LANTUS SOLO 100U/ML UP TO $25 OFF LEVAQUIN 250MG, 500 MG, 750MG UP TO $15 OFF LIALDA 1.2 GM 1200MG Up to $100 off LIMBREL 500 MG Up to $50 off LIMBREL250 250-50MG Up to $50 off LIMBREL500 500-50MG Up to $50 off LIPITOR 10MG, 20MG, 40MG, 80MG UP TO $10 OFF As of 7/10/2014 9:21:28 AM 18 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks LIPOFEN 50MG, 150MG UP TO $25 OFF LIPTRUZET 10-10MG, 10-20MG, 10-40MG, 10-80MG LIVALO 1 MG, 2 MG, 4 MG Up to $75 off LOCOID 0.1% UP TO $30 OFF LOCOID LIPCRM 0.1% UP TO $30 OFF LOCOID LIPCRM 0.1% UP TO $35 OFF LOVAZA 1GM UP TO $20 OFF LUNESTA 1MG, 2MG, 3MG SAVE UP TO $50 LUPRON 3 MO 11.25MG, 11.25MG, 22.5MG PAY MAX $10 LUPRON DEPOT 3.75MG, 7.5MG, 11.25MG, 15MG, 30MG, 45MG PAY MAX $10 LUVOX CR 100MG, 150MG UP TO $50 OFF MAXALT 5MG, 10MG UP TO $20 OFF MAXALT-MLT 5MG, 10MG UP TO $20 OFF METROGEL 1% UP TO $20 OFF MINOCIN 50MG, 100MG UP TO $40 OFF MIRAPEX 0.125MG, 0.25MG, 0.5MG, 1MG, 1.5MG UP TO $20 OFF MIRAPEX ER 0.375MG, 0.75MG, 1.5MG, 3MG, 4.5MG UP TO $40 OFF MONTELUKAST SODIUM ORAL T 10 MG UP TO $20 OFF MULTAQ 400MG UP TO $35 OFF NAPRELAN 375MG, 500MG, 750MG UP TO $30 OFF NASONEX 50MCG UP TO $15 OFF NEXIUM 10MG, 20MG, 40MG UP TO $50 OFF NIASPAN 500MG, 750MG, 1000MG NITROLINGUAL 0.4MG/DOSE UP TO $50 OFF NITROMIST 0.4MG UP TO $50 OFF NOVOLOG 100U/ML UP TO $25 OFF NOVOLOG MIX 70-30U/ML, 100U/ML UP TO $25 OFF NUCYNTA ER 50 MG, 100 MG, 150 MG, 200 MG, 250 MG UP TO $100 OFF NUEDEXTA 20-10MG PAY NO MORE THAN $30 NUVIGIL 50MG, 150MG, 250MG UP TO $5.00 OFF OLEPTRO TM 150MG, 300MG UP TO $30 OFF As of 7/10/2014 9:21:28 AM 19 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks OLUX 0.05% UP TO $25 OFF OLUX-E 0.05% UP TO $25 OFF OMNARIS NASAL 50MCG UP TO $40 OFF ONFI 10 MG, 20 MG UP TO $50 OFF ONGLYZA 2.5MG, 5MG UP TO $100 OFF ORACEA 40MG UP TO $25 OFF ORENCIA 125 MG/ML, 250MG ORENCIA 125 MG/ML, 250MG UP TO $100 OFF CO-PAY OXCARBAZEPINE 150MG, 300MG, 600MG UP TO $10 OFF PENNSAID 1.5% UP TO $60 OFF PEXEVA 10MG, 20MG, 30MG, 40MG UP TO $50 OFF PLAVIX 75MG Up to $100 off PRADAXA 75MG, 150MG UP TO $100 OFF PRASUGREL HCL ORAL TABLET 5 MG, 10 MG UP TO $25 OFF PREMARIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG $25 OFF PREZISTA 600 MG Up to $100 off Co-pay PREZISTA DS 150 MG Up to $100 off Co-pay PREZISTA DS 75 MG Up to $100 off Co-pay PRISTIQ 50MG $15 OFF PROGRAF 0.5MG, 1MG, 5MG, 5MG/ML UP TO $200 OFF PROLIA 60MG/ML UP TO $75 OFF PROVENTIL HFA 90 MCG UP TO $15 OFF PULMOZYME 1MG/ML COPAY ASSISTANCE QUETIAPINE 400 MG Up to $35 off RANEXA 500MG, 1000MG UP TO $60 OFF RAPAFLO 4MG, 8MG UP TO $50 OFF RAPAMUNE 1MG, 1MG/ML, 2MG UP TO $100 OFF RELPAX 20MG, 40MG UP TO $100 OFF REMICADE 100 MG Up to $550 off RENVELA NOT AVAILABLE, 800MG UP TO $155 OFF RESCRIPTOR 200MG UP TO $100 OFF As of 7/10/2014 9:21:28 AM 20 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks RETROVIR 100MG UP TO $100 OFF REYATAZ 150MG, 200MG, 300MG UP TO $200 OFF RISPERIDONE 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG UP TO $10 OFF CO-PAY RISPERIDONE 0.5MG, 1MG, 1MG/ML, 2MG, 3MG, 4MG Up to $10 off co-pay SAFYRAL 3-0.03-0.451MG UP TO $25 OFF SAIZEN 5MG, 8.8MG UP TO $50 OFF CO-PAY SAPHRIS BLK 5MG, 10MG UP TO $100 OFF SEASONIQUE UP TO $25 OFF SELZENTRY 150MG, 300MG UP TO $100 OFF SENSIPAR 30MG, 60MG, 90MG UP TO $300 OFF SEROQUEL 25 MG, 50 MG, 100 MG, 200 MG SEROQUEL XR 50MG, 150MG, 200MG, 300MG, 400MG Up to $75 off SILENOR 3MG, 6MG UP TO $25 OFF SIMBRINZA Up to $75 off SIMPONI 50MG UP TO $200 OFF SIMPONI SJ 50MG UP TO $200 OFF SINGULAIR 4MG, 10 MG UP TO $20 OFF SOLODYN ER 65MG, 115MG UP TO $50 OFF STALEVO 31.25-125-200MG, 50-200-200MG UP TO $100 OFF STALEVO 100 25-100-200MG UP TO $100 OFF STALEVO-150 37.5-150-200MG UP TO $100 OFF STALEVO-50 12.5-50-200MG UP TO $100 OFF STAVZOR 250MG, 500MG UP TO $50 OFF STELARA 45MG, 90MG UP TO $3000.00 OFF SUBOXONE 2-0.5MG, 8-2MG BOX OF 30 SUMATRIPTAN SUCC/NAPROXEN 85/ 500MG UP TO $50 OFF SUMAVEL DOSE 6MG/0.5ML UP TO $200 OFF SUSTIVA 200 MG, 200MG, 600MG UP TO $200 OFF SYMBICORT 120 80-4.5MCG, 160-4.5MCG UP TO $20 OFF SYMLIN 120 1000MCG/ML UP TO $30 OFF SYMLIN 60 1000MCG/ML UP TO $30 OFF As of 7/10/2014 9:21:28 AM 21 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks TACLONEX 0.005-0.064% UP TO $100 0FF TAFLUPROST/PF OPHTHALMIC Up to $70 off TARKA 2-180MG, 2-240MG, 4-240MG $10 OFF TEKTURNA 150MG, 300MG UP TO $25 OFF TEKTURNA HCT 150-12.5MG, 150-25MG, 300-12.5MG, 300-25MG UP TO $25 OFF TESTIM 1% 1% CO-PAY COVERAGE TOVIAZ 4MG, 8MG UP TO $25 OFF TRADJENTA 5MG UP TO $150 OFF TRAVATAN Z.004 % Up to $150 off TRAVATAN Z.004 % Up to $75 off TRETINOIN/EMOL CMB9/SKIN 0.1 % UP TO $100 OFF TRIBENZOR 5-20-12.5MG, 5-40-12.5MG, 5-40-25MG, 10-40- 12.5MG, 10-40-25MG UP TO $50 OFF TRILIPIX 45MG, 135MG UP TO $15 OFF TRIZIVIR 300-150-300MG UP TO $100 OFF TRUSOPT PLUS 2% UP TO $10 OFF TRUVADA 200-300MG UP TO $50 OFF TUSSIONEX 10-8MG/5ML ULORIC 40MG, 80MG UP TO $20 OFF ULTRAM ER 200MG, 300MG UP TO $35 OFF URIBEL 118-36-0.12-40.8-10 UP TO $40 OFF UROCIT-K, 5MEQ, 10MEQ UP TO $40 OFF VAGIFEM 10MCG UP TO $10 0FF VALSARTAN ORAL TABLET 160 160 MG UP TO $25 OFF VALSARTAN ORAL TABLET 80 80 MG UP TO $25 OFF VALSARTAN/HYDROCHLOROTHIA 160/12.5MG, 320/12.5MG, 320/25MG UP TO $25 OFF VANIQA 13.9% UP TO $25 OFF VANOS 0.1% UP TO $50 OFF VAPRISOL 20MG/100ML UP TO $50 OFF VARENICLINE TARTRATE ORAL 0.5 MG $30 OFF VECTICAL UP TO $25 OFF VELTIN 1.2-0.025% UP TO $50 OFF As of 7/10/2014 9:21:28 AM 22 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks VERAMYST 27.5MCG UP TO $25 OFF VERDESO 0.05 %, 0.05% UP TO $20 OFF VESICARE 5MG, 10MG UP TO $25 OFF VIAGRA 25MG, 50MG, 100MG VICTOZA PEN 6MG/ML UP TO $25 OFF VICTRELIS 200MG UP TO $200 OFF VIMOVO 375/20MG, 500/20MG VIMPAT 50MG, 100MG, 150MG, 200MG Up to $60 off VIRACEPT 250MG, 625MG UP TO $100 OFF VIREAD 300MG UP TO $50 OFF VIVITROL 380MG UP TO $500 OFF VOLTAREN 1 % VYTORIN 10-10MG, 10-20MG, 10-40MG, 10-80MG UP TO $20 OFF WELCHOL, 625MG UP TO $25 OFF WELLBUTRIN XL 150MG, 300MG UP TO $50 OFF XALATAN 0.005% UP TO $50 OFF XELODA 150MG, 500MG UP TO $400 OFF XOLEGEL 2% UP TO $25 OFF XOPENEX 0.31MG/3ML, 0.63MG/3ML, 1.25MG/0.5ML, 1.25MG/3ML UP TO $50 OFF XOPENEX HFA 45MCG UP TO $15 OFF XYZAL 5MG UP TO $20 OFF YASMIN 3-0.03MG UP TO $25 OFF ZANAFLEX 2MG, 4MG, 6MG UP TO $25 OFF ZEGERID 20-1100MG, 40-1100MG UP TO $30 OFF ZEGERID ORAL 20-1680MG, 40-1680MG UP TO $30 OFF ZELAPAR 1.25MG UP TO $40 OFF ZEMPLAR 1MCG, 2MCG, 2MCG/ML, 4MCG, 5MCG/ML UP TO $100 OFF ZENPEP 3000U, 5000U, 10000U, 15000U, 20000U, 25000U UP TO $50 OFF ZETIA 10MG UP TO $20 OFF ZIAGEN 20MG/ML, 300 MG ZIAGEN 20MG/ML, 300 MG UP TO $100 OFF As of 7/10/2014 9:21:28 AM 23 of 24
Co-pay Assistance Program Medication List TRADE NAME Strength remarks ZIANA 1.2-0.025% UP TO $50 OFF ZIOPTAN 0.0015 % Up to $70 off ZOLOFT 25 MG, 50MG, 100MG UP TO $50 OFF ZORVOLEX 18 MG, 35 MG ZUBSOLV 1.4-0.36MG, 5.7-1.4MG ZYFLO CR 600MG, 600 MG UP TO $40 OFF As of 7/10/2014 9:21:28 AM 24 of 24