Fax: (909) 285-1119        

NCPDP: 5647574                           

Updated: 8/7/2019

ACNE TOPICALS

Manufac

Covered

Not Cov

Cash

Aczone 7.5%

Almirall

$35

$75

-

Altreno 0.05% Lot

Ortho

Copay

$125

$125

Clindagel

Ortho

$40

$100

$100

Duac (Clinda 1.2%/BPO 5%)

Copay

$45

$45

Epiduo Forte

Galder

$0

$75

$75

Fabior 1% Foam

Mayne

$0

$45

$95

Onexton

Ortho

$0

-

-

Retin A Micro 0.6%/0.8%

Ortho

$0

$100

$100

Tazorac 0.05%/0.1%

Almirall

$0

$75

-

Veltin Gel

Almirall

Copay

$50

$50

ORAL ANTIBIOTICS

Manufac

Covered

Not Cov

Cash

Oracea 40mg

Galder

$35

$45

$45

Oracea Generic 40mg

Galder

$0

-

-

Doxy Hyc IR 75mg/IR 150mg

Mayne

$0

-

-

Doxy MPC 120mg tabs

Mayne

$0

$65

$95

Doxy Hyc DR 50mg/DR 200mg

Mayne

$0

$25

$45

Doxy Hyc DR 100mg

Mayne

$0

$45

$45

Minolira

Epi

$0

$50

$50

Seysara 60mg, 100mg, 150mb

Almirall

$0

$50

-

Targadox 50mg (AG)

Journey

-

-

-

Ximino 45mg, 90mg, 135mg

Journey

$25

$50

-

ROSACEA

Manufac

Covered

Not Cov

Cash

Finacea Foam

Leo

Copay

$260

$260

Mirvaso

Galder

$35

$75

$75

Rhofade

Aclaris

$0

$50

-

Soolantra Cream 1%

Galder

$0

$75

$75

SS/Sulfur Cleanser 5/10

Copay

$45

$45

SS/Sulfur Cleanser 9/4.5

Copay

$50

$50

DERMATITIS/ECZEMA

Manufac

Covered

Not Cov

Cash

Elidel

Ortho

$40

$100

$100

Eucrisa

Pfizer

$0

$70.

$70

Nutraseb Facial Cream

Isdin

$30

$45

-

Promiseb Cream

Encore

$20

$65

-

Sorilux Foam

Mayne

$0

$45

$95

BARRIER CREAM

Manufac

Covered

Not Cov

Cash

Ceracade Emulsion

Journey

$20

$50

-

Ceramax Cream

Intra

$30

$70

$70

Lux-MD Med Repair Emulsion

$35

$35

$35

ANTIVIRALS

Manufac

Covered

Not Cov

Cash

Xerese

Ortho

$40

$100

$100

Sitavig #2

Epi

$0

$35

$35

TOPICAL STEROIDS

Manufac

Covered

Not Cov

Cash

Ala-Scalp

Crown

$35

$35

$35

Apexicon E Cream

Pharma

$25

$25

$75

Bryhali Lotion

Ortho

$0

$25

$25

Capex Shampoo

Galde

$35

$125

$125

Clobetasol Cream 0.05%

Copay

$45

$45

Clobetasol Foam 0.05%

Mylan

Copay

$55

$55

Clobetasol Emulsion Foam

Mylan

Copay

Varies

-

Cloderm Cream 0.1%

Epi

$0

$35

Varies

Cordran Tape

Almirall

$35

$75

-

Derma-Smoothe Body Oil

Copay

$45

$45

Duobrii

Ortho

$0

$25

$25

Enstilar 60g

Leo

$0

$75

$75

Halog Cream/Oint

Sun

$0

50

$50

Impoyz 0.025%

Encore

$25

$50

$75

Lexette Foam (Halobet 0.05%)

Mayne

$0

$45

$95

Sernivo Spray 0.05%

Encore

$0

$75

 -

Ultravate Lotion

Sun

$25

$75

-

Verdeso

Almirall

$0

$50

-

ANTIFUNGALS

Manufac

Covered

Not Cov

Cash

Exelderm 1% Sol/Crm

Journey

$0

$0

-

Jublia

Ortho

$25

$125

-

Kerydin

Pharma

$25

$75

-

Ketoconazole Shampoo

Copay

$25

$25

Luzu

Ortho

$25

$100

$100

Naftin 2% Gel

Sebela

Nuvail

Epi

$35

$35

-

Oxistat 1%

Pharma

$25

$25

$75

Xolegel

Almirall

$50

$50

-

ANTINEOPLASTICS

Manufac

Covered

Not Cov

Cash

Fluorouracil Cream %5

Mayne

Copay

$50

$50

Fluoroplex 1%

Almirall

$0

$50

$50

Imiquimod 5%

Copay

$20/$35

$20/$35

Picato 0.015% or 0.05%

Leo

$20

$125

-

Tolak 4% Cream

Pierre

$0-$75

$75

$75

ADDITIONAL

Manufac

Covered

Not Cov

Cash

Alevicyn

Itra

$0

$35

$35

Absorica 10,20,30,35,40

Sun

Copay

Varies

-

Bensal HP

Epi

$0

$35

$35

Isotretinoin 10,20,40

Copay

$95

$95

Isotretinoin 30mg

Copay

$150

$150

Hydroquinone Cream 4%

$35

$35

$35

Qbrexza

Dermira

$35

-

-

TriLuma Cream

Galder

$35

$125

$125

Xepi

Cutanea

$25

$25

-

Generic Pricing

Generic Medication

Size

Covered

Cash

Acyclovir ointment 5%

30gm

copay

$40

Adapalene gel 0.3%

45gm

copay

$50

Adapalene/BP 0.1/2.5%

45gm

copay

$55

Alclometasone cream 0.05%

45gm

copay

$40

Alclometasone ointment 0.05%

60gm

copay

$40

Ammonium Lactate 12% cream

226g

copay

$10

Azelaic acid gel 15%

50gm

copay

$70

Bacitracin ointment

28.4g

copay

$15

Benzoyl Peroxide 10% gel

60g

copay

$20

Benzoyl Peroxide 10% wash

142g

copay

$15

Benzoyl Peroxide 5% gel

60g

copay

$20

Benzoyl Peroxide 5% wash

148g

copay

$15

Betamethasone Aug cream0.05%

60gm

copay

$30

Betamethasone Aug lotion 0.05%

60ml

copay

-

Betamethasone dip lotion 0.05%

60ml

copay

$30

Calcipotriene cream 0.005%

120gm

copay

$160

Calcipotriene cream 0.005%

60gm

copay

$90

Calcipotriene ointment 0.005%

120gm

copay

$160

Calcipotriene ointment 0.005%

60gm

copay

$120

Calcipotriene solution 0.005%

60ml

copay

$65

Calmoseptine ointment

71g

copay

$10

Ciclopirox gel 0.77%

45gm

copay

$40

Ciclopirox olami susp 0.77% lotion

60ml

copay

$50

Ciclopirox olamine cream 0.77%

90gm

copay

$20

Ciclopirox shampoo 1%

120ml

copay

$40

Ciclopirox solution 8% nail

6.6ml

copay

$18

Clindamycin solution 1%

60ml

copay

$45

Clindamycin gel 1%

60gm

copay

$45

Clindamycin Pledgets

#60

copay

-

Clindamycin/BP 1%/5%

50gm

copay

$80

Clindamycin/BP 1.2%/5%

45gm

copay

$40

Clobetasol cream 0.05%

60gm

copay

$40

Clobetasol foam 0.05%

100gm

copay

$65

Clobetasol foam 0.05%

50gm

copay

$50

Clobetasol ointment 0.05%

60gm

copay

$25

Clobetasol shampoo 0.05%

118ml

copay

$70

Clobetasol solution 0.05%

50ml

copay

$50

Clobetasol SPRAY 0.05%

125ML

copay

$65

Clotrimazole cream

30g

copay

$10

Clotrimazole/beta cream 1%/0.05%

45g

copay

$15

Clotrimazole/beta lotion 1%/0.05%

30ml

copay

$70

Desonide cream 0.05%

60gm

copay

$35

Desonide lotion 0.05%

59ml

copay

$70

Desoximetasone cream 0.025%

60gm

copay

$40

Diclofenac 1% gel

100gm

copay

$25

Diclofenac 1.5% solution

50ml

copay

$35

Diflorasone cream 0.05%

60gm

copay

$350

Drysol 20%

60ml

copay

$20

Econazole cream 1%

85gm

copay

$28

Erythromycin/BP gel 3%/5%

46.6gm

copay

$60

Estradiol Vaginal cream 0.01%

42.5g

copay

$60

Fluocinolone cream 0.025%

60gm

copay

$60

Fluocinolone oil 0.01% body

118ml

copay

$40

Fluocinolone oil 0.01% scalp

118ml

copay

$40

Fluocinolone ointment 0.025%

60gm

copay

$60

Fluocinolone solution 0.01%

60ml

copay

$48

Fluocinonide cream 0.05%

60gm

copay

$40

Fluocinonide ointment 0.05%

60gm

copay

$40

Fluocinonide solution 0.05%

60ml

copay

$32

Fluorouracil cream 5%

40gm

copay

$50

Gentamicin cream 0.1%

30gm

copay

$50

Gentamicin ointment 0.1%

30gm

copay

$40

Halobetasol Cream 0.05%

50g

copay

$50

Halobetasol ointment 0.05%

50gm

copay

$55

Hydrocortisone susppo 25mg

24ct

copay

$80

Hydrocortisone Val cream 0.2%

45gm

copay

$50

Hydrocortisone cream 2.5%

30gm

copay

$8

Hydroquinone cream 4%

28.35gm

copay

$30

Imiquimod cream 5%

24ct

copay

$30

Isotretinoin 20mg

#30

copay

$90

Isotretinoin 30mg

#30

copay

$120

Isotretinoin 40mg

#30

copay

$90

Ketoconazole cream 2%

60gm

copay

$40

Ketoconazole shampoo 2%

120ml

copay

$18

Lidocaine oral solution 2%

100ml

copay

$10

Lidocaine/priloca 2.5/2.5% cream

30gm

copay

$18

Metronidazole cream 0.75%

45gm

copay

$50

Metronidazole cream 1%

55gm

copay

$75

Metronidazole gel 0.75%

45gm

copay

$35

Mometasone cream 0.1%

45gm

copay

$18

Mometasone ointment 0.1%

45gm

copay

$13

Mometasone solution 0.1%

60gm

copay

$20

Mupirocin Cream 2%

30gm

copay

$220

Mupirocin ointment 2%

22g

copay

$10

Nystatin cream 100.000 USP

30g

copay

$10

Nystatin ointment 100,000 USP

30g

copay

$10

Nystatin powder 100,000

15gm

copay

$15

Nystatin/trimaci cream

60gm

copay

$30

Nystatin/trimaci ointment

60gm

copay

$35

Permethrin cream 5%

60gm

copay

$35

Pimecrolimus cream 1%

60gm

copay

$320

Podofilox solution 0.5%

3.5ml

copay

-

Proctozone-HC cream 2.5%

30gm

copay

$25

Selenium suspen 2.5% lotion

120ml

copay

$30

Sulfacetamide sodium wash 10%

355ml

copay

$80

Tacrolimus ointment 0.03%

60gm

copay

$150

Tacrolimus ointment 0.1%

60gm

copay

$150

Tretinoin cream 0.025%

45gm

copay

$50

Tretinoin cream 0.05%

20gm

copay

$40

Tretinoin cream 0.05%

45gm

copay

$85

Tretinoin cream 0.1%

20gm

copay

$45

Tretinoin cream 0.1%

45gm

copay

$90

Triamcinolone cream 0.025%

80g

copay

$12

Triamcinolone cream 0.1%

454g

copay

$30

Triamcinolone cream 0.1%

80g

copay

$12

Triamcinolone ointment 0.025%

80g

copay

$13

Triamcinolone ointment 0.1%

454g

copay

$30

Triamcinolone ointment 0.1%

80g

copay

$18