Max saver plan drug list 08-21-13.xls

MAX Saver Plan Drug List
08/21/13
GENERIC NAME
AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML ATENOLOL & CHLORTHALIDONE TAB 100-25 MG ATENOLOL & CHLORTHALIDONE TAB 50-25 MG GENERIC NAME
CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV) CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV) CITALOPRAM HYDROBROMIDE TAB 10 MG (BASE EQUIV) CITALOPRAM HYDROBROMIDE TAB 20 MG (BASE EQUIV) CITALOPRAM HYDROBROMIDE TAB 40 MG (BASE EQUIV) GENERIC NAME
IPRATROPIUM 0.02% NEBULIZER SOLUTION (25x2.5ml Vials) LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG GENERIC NAME
MAGNESIUM CHLORIDE TAB CR 535 MG (64 MG ELEMENTAL MG) PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML PHENYLEPHRINE-CHLORPHEN-DM LIQUID 3.5-1-3 MG/ML PHENYLEPHRINE-CHLORPHEN-DM SYRUP 12.5-4-15 MG/5ML PHENYLEPHRINE-CHLORPHEN-DM SYRUP 6-2-15 MG/5ML PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG GENERIC NAME
SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF) SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF) SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG 1. Niemann Foods’s Prescription Max Saver Plan (the “Max Saver Plan”) is available at all Niemann Foods, County Market, Cub Foods Pharmacies in Illinois and Missouri 2. The Max Saver Plan applies only to certain generic drugs at commonly prescribed dosages. Higher dosages cost more. You may obtain a list of generic drugs and dosages covered under the Max Saver Plan at Niemann Foods Retail Pharmacies The drug list may change and also may vary by state. Not all formulations of a drug (for example, enteric-coated, extended or timed release formulations) are covered under the Max Saver Plan. Max Saver Plan pricing not available when a covered drug is dispensed as part of a compound. 3. Under the Max Saver Plan at Niemann Foods Retail Pharmacies, $4 is the price for up to a 30-day supply of certain covered generic drugs at commonly prescribed Prices for quantities between a 30-day supply and a 90-day supply of drugs covered by both the Max Saver Plan are prorated based on the Max Saver Plan price. Prorated pricing is not available under the Max Saver Plan for prepackaged drugs. For pricing policies relating to prepackaged drugs (such as tubes, vials or bottles), see Section 4.
4. Prepackaged drugs are covered under the Max Saver Plan only in the unit sizes specified on the drug list. Prepackaged drugs are dispensed based on the quantities prescribed and unit sizes in stock at the dispensing pharmacy. Unit sizes not specified on the drug list are not covered under the Max Saver Plan. Multi-unit purchases are charged at a per unit price, based on the price per unit size dispensed, unless otherwise specified. Prepackaged drugs dispensed in unit sizes not specified on the drug list may be priced higher, even if equivalent quantities of the drug are available in specified unit sizes. Prorated pricing is not available under the Max Saver Plan for prepackaged drugs.
5. Max Saver Plan pricing may be limited to select manufacturers of a covered drug and is available as long as supplies from such manufacturers are in stock at the dispensing pharmacy.
6. You may pay less or more than the Max Saver Plan price, depending on the terms of your health plan. Prescriber permission may be required to change a 30-day prescription to a 90-day prescription. Certain plans, including government-funded programs may not cover a 90-day supply. 7. For purchases made at Niemann Foods Retail Pharmacies, prescriptions must initially be filled in person, and refills must be picked up in store. There are no substitutions.

Source: http://mycountymarket.com/files/1113/7953/2619/Alphabetized_MAX_Saver_Plan_Drug_List.pdf