$4 Generic List
$4 Generic List Only applies to IU Health and Kroger retail pharmacies Therapy Acyclovir 200mg Albuterol sulfate syrup Alendronate 70mg Amitriptyline 10mg Amitriptyline 75mg Amlodipine 2.5mg Amoxicillin 125mg/5ml susp Amoxicillin 400mg/5ml susp Atenolol 25mg Atenolol-chlorthalidone 100/25mg Benazepril 20mg Benztropine 0.5mg Bisoprolol-hydrochlorothiazide 2.5/6.25mg Bumetanide 0.5mg Buspirone 10mg Carvedilol 6.25mg Cephalexin 250mg Ciprofloxacin 250mg Citalopram 20mg Clonidine 0.2mg Cyclobenzaprine 10mg Dexamethasone 0.75mg Dicyclomine 20mg Enalapril maleate 10mg Enalapril-hctz 10/25mg Estradiol 1mg Famotidine 20mg Fluoxetine 20mg Furosemide 20mg Gabapentin 100mg Gentamicin 0.1% cream Glimepiride 2mg Glipizide 10mg Guanfacine 1mg Haloperidol 1mg Hydralazine 10mg Hydrochlorothiazide 25mg Therapy Albuterol sulfate 2mg Albuterol 0.85% neb Allopurinol 100mg Amitriptyline 25mg Amitriptyline 100mg Amlodipine 5mg Amoxicillin 200mg/ 5ml susp Amoxicillin 250mg Atenolol 50mg Benazepril 5mg Benazepril 40mg Benztropine 1mg Bisoprolol-hydrochlorothiazide 5/6.25mg Bumetanide 1mg Carbamazepine 200mg Carvedilol 12.5mg Cephalexin 500mg Ciprofloxacin 500mg Citalopram 40mg Clonidine 0.3mg Cytra-2 oral soln Diclofenac eye drops 0.1% Enalapril maleate 2.5mg Enalapril maleate 20mg Erythromycin eye 5mg/gm ointment Estradiol 2mg Fluconazole 150mg Fluoxetine 40mg Furosemide 40mg Gentak eye drops 0.3% Gentamicin 0.1% ointment Glimepiride 4mg Glyburide micronized 3mg Guanfacine 2mg Haloperidol 2mg Hydralazine 25mg Hydrochlorothiazide 50mg 1 Therapy Albuterol sulfate 4mg Alendronate 35mg Allopurinol 300mg Amitriptyline 50mg Amitriptyline 150mg Amlodipine 10mg Amoxicillin 250mg/5ml susp Antipyrine-benzocaine ear drops Atenolol 100mg Benazepril 10mg Benzonatate 100mg Benztropine 2mg Bisoprolol-hydrochlorothiazide 10/6.25mg Buspirone 5mg Carvedilol 3.125mg Carvedilol 25mg Chlorhexidine gluconate mouthwash Citalopram 10mg Clonidine 0.1mg Cyclobenzaprine 5mg Dexamethasone 0.5mg Dicyclomine 10mg Enalapril maleate 5mg Enalapril-hctz 5/12.5mg Estradiol 0.5mg Famotidine 10mg Fluoxetine 10mg Folic acid 1mg Furosemide 80mg Gentamicin eye drops 0.3% Glimepiride 1mg Glipizide 5mg Glyburide micronized 6mg Haloperidol 0.5mg Haloperidol 5mg Hydrochlorothiazide 12.5mg Hydrocortisone 1% cream iuhealthplans.org Only applies to IU Health and Kroger retail pharmacies Therapy Hydrocortisone 2.5% Ibuprofen 600mg Indapamide 2.5mg Isoniazid 300mg Levothyroxine 75mcg Levothyroxine 112mcg Levothyroxine 150mcg Lidocaine viscous mucosal 2% soln Lisinopril 10mg Lisinopril 40mg Lisinopril-hydrochlorothiazide 20/25mg Lovastatin 10mg Medroxyprogesterone 2.5mg Meloxicam 7.5mg Metformin 500mg Methyldopa 250mg Metoclopramide 10mg Metoprolol tartrate 100mg Naproxen 500mg Nortriptyline 50mg Paroxetine 20mg Penicillin v potassium 250mg Polymyxin b sulfate solution 500,000 Prednisone 10mg Prochlorperazine 10mg Promethazine-dm syrup Propranolol 40mg tablet Ranitidine 300mg Sertraline 100mg Simvastatin 20mg Sodium fluoride chewable 0.25mg Sulfamethoxazole-trimethoprim 400/80mg Terazosin 2mg Terbinafine 250mg Therapy Ibuprofen 100mg/5ml susp Ibuprofen 800mg Indomethacin 25mg Levothyroxine 25mcg Levothyroxine 88mcg Levothyroxine 125mcg Levothyroxine 175mcg Lisinopril 2.5mg Lisinopril 20mg Lisinopril-hydrochlorothiazide 10/12.5mg Lithium carbonate 300mg Therapy Ibuprofen 400mg Indapamide 1.25mg Ipratropium bromide neb Levothyroxine 50mcg Levothyroxine 100mcg Levothyroxine 137mcg Levothyroxine 200mcg Lisinopril 5mg Lisinopril 30mg Lisinopril-hydrochlorothiazide 20/12.5mg Loratadine 10mg Lovastatin 20mg Medroxyprogesterone 5mg Meloxicam 15mg Metformin 850mg Metoclopramide soln Metoprolol tartrate 25mg Naproxen 125mg/5ml Nortriptyline 10mg Nystatin 100,000u/gm cream Penicillin v potassium 250mg/5ml soln Phenazopyridine 100mg Prednisone 2.5mg Prednisone 20mg Promethazine syrup Propranolol 10mg tablet Propranolol 80mg tablet Sertraline 25mg Silver sulfadiazine topical cream Simvastatin 40mg Sotalol 80mg Sulfamethoxazole-trimethoprim 800/160mg Terazosin 5mg Tobramycin eye drops 0.3% Lovastatin 40mg Medroxyprogesterone 10mg Metformin er 500mg Metformin 1,000mg Metoclopramide 5mg Metoprolol tartrate 50mg Naproxen 375mg Nortriptyline 25mg Paroxetine 10mg Penicillin v potassium 125mg/5ml soln Phenazopyridine 200mg Prednisone 5mg Prochlorperazine 5mg Promethazine 25mg Propranolol 20mg tablet Ranitidine 150mg Sertraline 50mg Simvastatin 10mg Simvastatin 80mg Spironolactone 25mg Terazosin 1mg 2 Terazosin 10mg Trazodone 50mg iuhealthplans.org Only applies to IU Health and Kroger retail pharmacies Therapy Trazodone 100mg Therapy Trazodone 150mg Triamcinolone acetonide 0.1% cream Triamcinolone acetonide 0.5% cream Triamterene-hydrochlorothiazide 37.5/25mg Verapamil 80mg Warfarin 2mg Warfarin 4mg Warfarin 7.5mg Triamterene-hydrochlorothiazide 75/50mg Verapamil 120mg Warfarin 2.5mg Warfarin 5mg Warfarin 10mg Therapy Triamcinolone acetonide 0.025% cream Triamcinolone acetonide 0.1% ointment Trihexyphenidyl 2mg Warfarin 1mg Warfarin 3mg Warfarin 6mg For questions, please contact our pharmacy staff at 317.963.0515 or toll-free at 800.467.7979 for further assistance. IU Health Plans Pharmacy Benefits Management 950 N Meridian Street Suite 600 Indianapolis, IN 46204 3 T 866.822.6504 F 855.398.8762 iuhealthplans.org
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