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Program Name: 305



Overview:
This program provides generic medications – at a minimal $20/month cost - for patients
who cannot afford them, and who meet certain other guidelines.

Medications covered:
albuterol inhaler 5 mg/mL (Proventil HFA)
albuterol inhaler 5 mg/mL (Proventil UD)
albuterol inhaler 17 gm (Proventil)
albuterol tablets 2 mg (Proventil)
albuterol tablets 4 mg (Proventil)
allopurinol tablets 100 mg (Zyloprim)
allopurinol tablets 300 mg (Zyloprim)
alprazolam tablets 0.25 mg (Xanax)
alprazolam tablets 0.5 mg (Xanax)
alprazolam tablets 1 mg (Xanax)
alprazolam tablets 2 mg (Xanax)
amiloride with hydrochlorothiazide (Moduretic)
aminophylline tablets 100 mg (aminophylline)
aminophylline tablets 200 mg (aminophylline)
amiodarone tablets 200 mg (Cordarone)
amitriptyline tablets 10 mg (Elavil)
amitriptyline tablets 25 mg (Elavil)
amitriptyline tablets 50 mg (Elavil)
amitriptyline tablets 75 mg (Elavil)
amitriptyline tablets 100 mg (Elavil)
amitriptyline tablets 150 mg (Elavil)
atenolol tablets 25 mg (Tenormin)
atenolol tablets 50 mg (Tenormin)
atenolol tablets 100 mg (Tenormin)
atenolol/chlorthalidone tablets 50/100 mg (Tenoretic)
belladonna/ppb tablets (Donnatal)
benazepril tablets 5 mg (Lotensin)
benazepril tablets 10 mg (Lotensin)
benazepril tablets 20 mg (Lotensin)
benazepril tablets 40 mg (Lotensin)
benazepril HCTZ tablets 5/6.25 mg (Lotensin HCT)
benazepril HCTZ tablets 10/6.25 mg (Lotensin HCT)
benazepril HCTZ tablets 20/12.5 mg (Lotensin HCT)
benazepril HCTZ tablets 20/25 mg (Lotensin HCT)
benztropine mesylate tablets 0.5 mg (Cogentin)
benztropine mesylate tablets 1 mg (Cogentin)
benztropine mesylate tablets 2 mg (Cogentin)
bisoprolol/HCTZ tablets 2.5 mg (Ziac)
bisoprolol/HCTZ tablets 5 mg (Ziac)
bisoprolol/HCTZ tablets 10 mg (Ziac)
bumetanide tablets 0.5 mg (Bumex)
bumetanide tablets 1 mg (Bumex)
bumetanide tablets 2 mg (Bumex)
bupropion tablets 75 mg (Wellbutrin)
bupropion tablets 100 mg (Wellbutrin)
buspirone tablets 5 mg (BuSpar)
buspirone tablets 10 mg (BuSpar)
buspirone tablets 15 mg (BuSpar)
captopril tablets 12.5 mg (Capoten)
captopril tablets 25 mg (Capoten)
captopril tablets 50 mg (Capoten)
captopril tablets 100 mg (Capoten)
captopril/HCTZ tablets 25 mg (Capozide)
captopril/HCTZ tablets 25 mg (Capozide)
captopril/HCTZ tablets 50 mg (Capozide)
carbamazepine tablets 200 mg (Tegretol)
carisoprodol tablets 350 mg (Soma)
chlordiazepoxide tablets 5 mg (Librium)
chlordiazepoxide tablets 10 mg (Librium)
chlordiazepoxide tablets 25 mg (Librium)
chlordiazepoxide/clidinium tablets (Librax)
chlorpropamide tablets 250 mg (Diabinese)
chlorzoxazone tablets 500 mg (Paraflex)
cimetidine tablets 300 mg (Tagamet)
cimetidine tablets 400 mg (Tagamet)
cimetidine tablets 800 mg (Tagamet)
ciprofloxacin tablets 250 mg (Cipro)
ciprofloxacin tablets 500 mg (Cipro)
ciprofloxacin tablets 700 mg (Cipro)
clonazepam tablets 0.5 mg (Klonopin)
clonazepam tablets 1 mg (Klonopin)
clonazepam tablets 2 mg (Klonopin)
clonidine tablets 0.1 mg (Catapres)
clonidine tablets 0.2 mg (Catapres)
colchicine tablets 0.6 mg (colchicine)
desipramine tablets 10 mg (Norpramine)
desipramine tablets 25 mg (Norpramine)
diazepam tablets 2 mg (Valium)
diazepam tablets 5 mg (Valium)
diazepam tablets 10 mg (Valium)
diclofenac pot. tablets 50 mg (Cataflam)
diclofenac sod. tablets 50 mg (Voltaren)
diclofenac sod. tablets 75 mg (Cataflam)
diclofenac sod. tablets 75 mg (Voltaren)
dicyclomine tablets 10 mg (Bentyl)
dicyclomine tablets 20 mg (Bentyl)
diltiazem tablets 30 mg (Cardizem)
diltiazem tablets 60 mg (Cardizem)
diltiazem tablets 90 mg (Cardizem)
doxazosin tablets 1 mg (Cardura)
doxazosin tablets 2 mg (Cardura)
doxazosin tablets 4 mg (Cardura)
doxazosin tablets 8 mg (Cardura)
doxepin capsules 25 mg (Sinequan)
doxepin capsules 50 mg (Sinequan)
doxepin capsules 75 mg (Sinequan)
doxepin capsules 100 mg (Sinequan)
doxycycline capsules 100 mg (Vibramycin)
doxycycline tablets 100 mg (Vibramycin)
enalapril maleate tablets 2.5 mg (Vasotec)
enalapril maleate tablets 5 mg (Vasotec)
enalapril maleate tablets 10 mg (Vasotec)
enalapril maleate tablets 20 mg (Vasotec)
enalapril/HCTZ tablets 5/12.5 mg (Vaseretic)
enalapril/HCTZ tablets 10/25 mg (Vaseretic)
estradiol tablets 0.5 mg (Estrace)
estradiol tablets 1 mg (Estrace)
estradiol tablets 2 mg (Estrace)
estropipate tablets 0.75 mg (Ogen)
estropipate tablets 1.5 mg (Ogen)
famotidine tablets 20 mg (Pepcid)
famotidine tablets 40 mg (Pepcid)
fluconazole tablets 100 mg (Diflucan)
fluconazole tablets 150 mg (Diflucan)
fluconazole tablets 200 mg (Diflucan)
fluoxetine tablets 10 mg (Prozac)
fluoxetine tablets 20 mg (Prozac)
fluphenazine hydrochloride tablets 2.5 mg (Prolixin)
fluphenazine hydrochloride tablets 5 mg (Prolixin)
fluphenazine hydrochloride tablets 10 mg (Prolixin)
flurazepam tablets 15 mg (Dalmane)
flurazepam tablets 30 mg (Dalmane)
folic acid tablets 1 mg (folic acid)
fosinopril tablets 10 mg (Monopril)
fosinopril tablets 20 mg (Monopril)
fosinopril tablets 40 mg (Monopril)
furosemide tablets 20 mg (Lasix)
furosemide tablets 40 mg (Lasix)
furosemide tablets 80 mg (Lasix)
glipizide tablets 5 mg (Glucotrol)
glipizide tablets 10 mg (Glucotrol)
glyburide tablets 2.5 mg (DiaBeta Micronase)
glyburide tablets 5 mg (DiaBeta Micronase)
glyburide, micronized tablets 6 mg (Glynase PresTab)
hydralazine tablets 10 mg (Apresoline)
hydralazine tablets 25 mg (Apresoline)
hydralazine tablets 50 mg (Apresoline)
hydrochlorothiazide tablets 25 mg (Esidrix)
hydrochlorothiazide tablets 50 mg (Esidrix)
hydroxyzine pamoate capsules 25 mg (Vistaril)
hydroxyzine pamoate capsules 50 mg (Vistaril)
ibuprofen tablets 400 mg (Motrin)
ibuprofen tablets 600 mg (Motrin)
ibuprofen tablets 800 mg (Motrin)
indomethacin capsules 25 mg (Indocin)
indomethacin capsules 50 mg (Indocin)
ipratropium aerosol spray (Atrovent Inhalation)
isosorbide dinitrate tablets 5 mg (Isordil)
isosorbide dinitrate tablets 10 mg (Isordil)
isosorbide dinitrate tablets 20 mg (Isordil)
isosorbide mononitrate tablets 20 mg (Ismo)
isosorbide mononitrate tablets 30 mg (Imdur)
isosorbide mononitrate tablets 60 mg (Imdur)
levothyroxine injection 50 mcg (Synthroid)
levothyroxine tablets 25 mcg (Synthroid)
levothyroxine tablets 75 mcg (Synthroid)
levothyroxine tablets 100 mcg (Synthroid)
levothyroxine tablets 112 mcg (Synthroid)
levothyroxine tablets 125 mcg (Synthroid)
levothyroxine tablets 150 mcg (Synthroid)
levothyroxine tablets 175 mcg (Synthroid)
levothyroxine tablets 200 mcg (Synthroid)
lisinopril tablets 2.5 mg (Prinivil)
lisinopril tablets 5 mg (Prinivil)
lisinopril tablets 10 mg (Prinivil)
lisinopril tablets 20 mg (Prinivil)
lisinopril tablets 30 mg (Prinivil)
lisinopril tablets 40 mg (Prinivil)
lithium carbonate capsules 300 mg (Eskalith)
lorazepam tablets 0.5 mg (Ativan)
lorazepam tablets 1 mg (Ativan)
lorazepam tablets 2 mg (Ativan)
meclizine tablets 12.5 mg (Antivert)
meclizine tablets 25 mg (Antivert)
medroxyprogesterone tablets 2.5 mg (Provera)
medroxyprogesterone acetate tablets 5 mg (Provera)
medroxyprogesterone acetate tablets 10 mg (Provera)
metformin tablets 500 mg (Glucophage)
metformin tablets 850 mg (Glucophage)
metformin tablets 1000 mg (Glucophage)
metoprolol tablets 25 mg (Lopressor)
metoprolol tablets 50 mg (Lopressor)
metoprolol tablets 100 mg (Lopressor)
mirtazepine tablets 15 mg (Remeron)
mirtazepine tablets 30 mg (Remeron)
mirtazepine tablets 45 mg (Remeron)
nadolol tablets 20 mg (Corgard)
nadolol tablets 40 mg (Corgard)
nadolol tablets 80 mg (Corgard)
naproxen tablets 375 mg (Naprosyn)
naproxen tablets 500 mg (Naprosyn)
niacin tablets 500 mg (Niaspan)
nortriptyline HCl capsules 25 mg (Pamelor)
nortriptyline HCl capsules 50 mg (Pamelor)
nortriptyline HCl capsules 75 mg (Pamelor)
oxybutynin chloride tablets 5 mg (Ditropan)
phenobarbital tablets 15 mg (Solfoton)
phenobarbital tablets 30 mg (Solfoton)
phenobarbital tablets 60 mg (Solfoton)
potassium chloride tablets 10 mEq (Klor-Con)
potassium chloride tablets 20 mEq (Klor-Con)
prednisone tablets 5 mg (Deltasone)
prednisone tablets 10 mg (Deltasone)
propranolol tablets 10 mg (Inderal)
propranolol tablets 20 mg (Inderal)
propranolol tablets 40 mg (Inderal)
propranolol tablets 80 mg (Inderal)
ranitidine tablets 150 mg (Zantac)
ranitidine tablets 300 mg (Zantac)
sotalol HCl tablets 80 mg (Betapace)
spironolactone tablets 25 mg (Aldactone)
spironolactone tablets 120 mg (Aldactone)
spironolactone tablets 160 mg (Aldactone)
sulfasalazine tablets 25 mg (Azulfidine)
Sulindac tablets 150 mg (Clinoril)
Sulindac tablets 200 mg (Clinoril)
temazepam capsules 15 mg (Restoril)
temazepam capsules 30 mg (Restoril)
terazosin tablets 2 mg (Hytrin)
terazosin tablets 5 mg (Hytrin)
terazosin tablets 10 mg (Hytrin)
thyroid tablets 15 mg (Thyroid)
thyroid tablets 30 mg (Thyroid)
thyroid tablets 60 mg (Thyroid)
thyroid tablets 90 mg (Thyroid)
thyroid tablets 120 mg (Thyroid)
thyroid tablets 180 mg (Thyroid)
tramadol tablets 50 mg (Ultram)
trazodone tablets 50 mg (Desyrel)
trazodone tablets 100 mg (Desyrel)
trazodone tablets 150 mg (Desyrel)
triamterene/HCTZ tablets 37.5 mg/25 mg (Maxzide)
triamterene/HCTZ tablets 75 mg/50 mg (Maxzide)
trihexyphenidyl tablets 2 mg (Artane)
verapamil tablet 80 mg (Isoptin)
verapamil tablet 120 mg (Isoptin)
verapamil tablets 80 mg (Calan)
verapamil tablets 120 mg (Calan)
verapamil SR tablets 120 mg (Calan SR)
verapamil SR tablets 180 mg (Calan SR)
verapamil SR tablets 240 mg (Calan SR)
warfarin sod tablets 1 mg (Coumadin)
warfarin sod tablets 2 mg (Coumadin)
warfarin sod tablets 2.5 mg (Coumadin)
warfarin sod tablets 3 mg (Coumadin)
warfarin sod tablets 4 mg (Coumadin)
warfarin sod tablets 5 mg (Coumadin)
warfarin sod tablets 6 mg (Coumadin)
warfarin sod tablets 7.5 mg (Coumadin)
warfarin sod tablets 10 mg (Coumadin)


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