Prescription Drug Plan

Effective 11/2/2015

Antibiotics DRUG NAME AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE) AMOXICILLIN 200 MG/5 ML (100 ML BOTTLE) AMOXICILLIN 200 MG/5 ML (75 ML BOTTLE) AMOXICILLIN 200 MG/5 ML (50 ML BOTTLE) AMOXICILLIN 250 MG CAPSULES AMOXICILLIN 250 MG/5 ML (150 ML BOTTLE) AMOXICILLIN 250 MG/5 ML (100 ML BOTTLE) AMOXICILLIN 250 MG/5 ML (80 ML BOTTLE) AMOXICILLIN 400 MG/5 ML (100 ML BOTTLE) AMOXICILLIN 400 MG/5 ML (75 ML BOTTLE) AMOXICILLIN 400 MG/5 ML (50 ML BOTTLE) AMOXICILLIN 500 MG CAPSULES AMOXICILLIN 875 MG TABLETS AMPICILLIN 250 MG CAPSULES AMPICILLIN 500 MG CAPSULES CEPHALEXIN 250 MG CAPSULES CEPHALEXIN 500 MG CAPSULES CIPROFLOXACIN 250 MG TABLETS CIPROFLOXACIN 500 MG TABLETS CIPROFLOXACIN 750 MG TABLETS CLINDAMYCIN 150 MG CASULES PENICILLIN V Pot 125/5 100 ML (100 ML BOTTLE) PENICILLIN V Pot 125/5 200 ML (200 ML BOTTLE) PENICILLIN VK 250 MG TABLETS PENICILLIN VK 250/5 ML (100 ML BOTTLE) PENICILLIN VK 250/5 ML (200 ML BOTTLE) PENICILLIN VK 500 MG TABLETS SULFAMETH/TRIMETH 400/80 MG TABLETS SULFAMETH/TRIMETH 800/160 MG TABLETS SULFASALAZINE 500 MG TABLETS

Qty $0.00 Copay 150 100 80 100 75 50 30 150 100 80 100 75 50 30 20 28 28

$

$

90 Day Qty 10.00

30 30 20 20 14 30

90

100 200 28 100 200 28 28 20

$ AMOX/K CLAV 500 MG TABLETS AMOX/K CLAV 875 MG TABLETS ISONIAZID 300 MG TABLETS METRONIDAZOLE 250 MG TABLETS METRONIDAZOLE 500 MG TABLETS $ AZITHROMYCIN 250 MG PAK (6 TABLETS) Antifungal DRUG NAME

$

DRUG NAME

$

FLUCONAZOLE 150 MG TABLETS NYSTATIN 100 MU/ML ORAL SUSP DROP NYSTATIN 100 MU/ML ORAL SUSP TERBINAFINE 250 MG TABLETS Antiviral AMANTADINE 50 MG/5 ML SYRUP ACYCLOVIR 200 MG CAPSULES ACYCLOVIR 400 MG TABLETS ACYCLOVIR 800 MG TABLETS

30 Day Qty 4.00

30 30 Day Qty 8.00 20 20 30 28 14 30 Day Qty 15.00 6 30 Day Qty 4.00 1 60 60 30 30 Day Qty 4.00 120 30 30 30

90 90 Day Qty $ 24.00

90 84 42 90 Day Qty N/A 90 Day Qty 10.00 3 180 180 90 90 Day Qty $ 10.00 360 90 90 90 $

Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be priced higher or may be added or deleted without notice. Can not be used in conjuction with other insurance.

Prescription Drug Plan

Effective 11/2/2015

Arthritis/ Pain DRUG NAME

$

ALLOPURINOL 100 MG TABLETS IBUPROFEN 400 MG TABLETS IBUPROFEN 600 MG TABLETS IBUPROFEN 800 MG TABLETS INDOMETHACIN 25 MG CAPSULES INDOMETHACIN 50 MG CAPSULES MELOXICAM 15 MG TABLETS MELOXICAM 7.5 MG TABLETS NAPROXEN 250 MG TABLETS NAPROXEN 375 MG TABLETS NAPROXEN 500 MG TABLETS $ BACLOFEN 10 MG TABLETS DICLOFENAC POT 50 MG TABLETS DICLOFENAC SOD DR 50 MG TABLETS DICLOFENAC SOD DR 75 MG TABLETS Asthma/Resp/Allergies DRUG NAME

$

ALBUTEROL 2 MG/5 ML SYRUP ALBUTEROL SULFATE 0.083 % NEB SOLN CETIRIZINE 10 MG TABLETS IPRATROPIUM BROMIDE 0.02% AMPULE LORATADINE 10 MG TABLETS HYDROXYZINE HCL 10MG/5ML SYRUP $ IPRATROPIUM BROM/ALBUTEROL SUL 0.5-2.5 $ FLUTICASONE 50 MCG NASAL SPRAY MONTELUKAST 5 MG TABLETS MONTELUKAST 10 MG TABLETS Cholesterol DRUG NAME

$

LOVASTATIN 10 MG TABLETS LOVASTATIN 20 MG TABLETS LOVASTATIN 40 MG TABLETS SIMVASTATIN 20 MG TABLETS SIMVASTATIN 40 MG TABLETS SIMVASTATIN 10 MG TABLETS SIMVASTATIN 5 MG TABLETS SIMVASTATIN 80 MG TABLETS $ GEMFIBROZIL 600 MG TABLETS $ PRAVASTATIN 10 MG TABLETS PRAVASTATIN 20 MG TABLETS PRAVASTATIN 40 MG TABLETS PRAVASTATIN 80 MG TABLETS

30 Day Qty 4.00 30 90 60 30 60 30 30 30 60 60 60 30 Day Qty 8.00 30 30 60 60 30 Day Qty 4.00 120 75 30 75 30 150 30 Day Qty 15.00 90 30 Day Qty 15.00 16 30 30 30 Day Qty 4.00 30 30 30 30 30 30 30 30 30 Day Qty 10.00 60 30 Day Qty 15.00 30 30 30 30

90 Day Qty 10.00 90 270 180 90 180 90 90 90 180 180 180 90 Day Qty $ 24.00 90 90 180 180 90 Day Qty $ 10.00 473 225 90 225 90 473 90 Day Qty

$

90 Day Qty 45.00 48 90 90 90 Day Qty $ 10.00 90 90 90 90 90 90 90 90 90 Day Qty $ 30.00 180 90 Day Qty $ 45.00 90 90 90 90 $

Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be priced higher or may be added or deleted without notice. Can not be used in conjuction with other insurance.

Prescription Drug Plan

Effective 11/2/2015

CNS DRUG NAME BENZTROPINE 0.5 MG TABLETS BENZTROPINE 1 MG TABLETS DIVALPROEX SODIUM DR 125 MG TABLETS DIVALPROEX SODIUM DR 250 MG TABLETS DIVALPROEX SODIUM DR 500 MG TABLETS GABAPENTIN 100 MG CAPSULES GABAPENTIN 300 MG CAPSULES GABAPENTIN 400 MG CAPSULES HYDROXYZINE HCL 10 MG TABLETS HYDROXYZINE HCL 25 MG TABLETS HYDROXYZINE HCL 50 MG TABLETS HYDROXYZINE PAM 25 MG CAPSULES LAMOTRIGINE 100 MG TABLETS LAMOTRIGINE 150 MG TABLETS LAMOTRIGINE 200 MG TABLETS LAMOTRIGINE 25 MG TABLETS LAMOTRIGINE 25 MG CHEW TABS MIRTAZAPINE 15 MG TABLETS MIRTAZAPINE 30 MG TABLETS PRIMIDONE 50 MG TABLETS PRIMIDONE 250 MG TABLETS ROPINIROLE 0.25 MG TABLETS ROPINIROLE 0.5 MG TABLETS ROPINIROLE 1 MG TABLETS ROPINIROLE 2 MG TABLETS ROPINIROLE 3 MG TABLETS ROPINIROLE 4 MG TABLETS ROPINIROLE 5 MG TABLETS TOPIRAMATE 25 MG TABLETS TOPIRAMATE 50 MG TABLETS TOPIRAMATE 100 MG TABLETS TOPIRAMATE 200 MG TABLETS ZONISAMIDE 25 MG CAPSULES ZONISAMIDE 50 MG CAPSULES ZONISAMIDE 100 MG CAPSULES

BENZTROPINE 2 MG TABLETS CARBAMAZEPINE 200 MG TABLETS- NEW ADDITION HYDROXYZINE PAM 50 MG CAPSULES MIRTAZAPINE 45 MG TABLETS OXCARBAZEPINE 150 MG TABLETS OXCARBAZEPINE 300 MG TABLETS OXCARBAZEPINE 600 MG TABLETS

SUMATRIPTAN 25 MG TABLETS SUMATRIPTAN 50 MG TABLETS SUMATRIPTAN 100 MG TABLETS Cough DRUG NAME BENZONATATE 100 MG CAPSULES PROMETHAZINE/DM 15-6.25 MG/5 ML SYRUP PROMETHAZINE 6.25/5 ML SYRUP*

30 Day Qty 4.00 30 30 60 60 30 60 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 Day Qty $ 8.00 30 60 30 30 60 60 30 30 Day Qty $ 24.00 9 9 9 30 Day Qty $ 4.00 14 120 120 $

90 Day Qty 10.00 90 90 180 180 90 180 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 Day Qty $ 22.00 90 180 90 90 180 $

90 90 Day Qty N/A

$

90 Day Qty 10.00 42 360 360

Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be priced higher or may be added or deleted without notice. Can not be used in conjuction with other insurance.

Prescription Drug Plan

Effective 11/2/2015

Diabetes DRUG NAME BLOOD GLUCOSE KIT BY TOPCARE BLOOD GLUCOSE TEST STRIPS 25 CT BY TOPCARE BLOOD GLUCOSE LANCETS BY TOPCARE GLIMEPIRIDE 1 MG TABLETS GLIMEPIRIDE 2 MG TABLETS GLIMEPIRIDE 4 MG TABLETS GLIPIZIDE 10 MG TABLETS GLIPIZIDE 5 MG TABLETS (DIABETA) GLYBURIDE 1.25 MG TABLETS GLYBURIDE 2.5 MG TABLETS GLYBURIDE 5 MG TABLETS GLYBURIDE/METFORMIN 1.25/250 MG TABLETS GLYBURIDE/METFORMIN 2.5/500 MG TABLETS GLYBURIDE/METFORMIN 5/500 MG TABLETS METFORMIN 1000 MG TABLETS METFORMIN 500 MG TABLETS METFORMIN 850 MG TABLETS METFORMIN ER 500 MG TABLETS METFORMIN ER 750 MG TABLETS

Qty $0.00 Copay

$

$

Ear/Eye $

$ TIMOLOL MAL 0.5% OPTHALMIC SOL (10 ML) Gastrointestinal DRUG NAME

$

FAMOTIDINE 20 MG TABLETS FAMOTIDINE 40 MG TABLETS METOCLOPRAMIDE 10 MG TABLETS METOCLOPRAMIDE 5 MG METOCLOPRAMIDE 5 MG/5 ML SYRUP OMEPRAZOLE 20 MG CAPSULES ONDANSETRON 4 MG TABLETS ONDANSETRON 8 MG TABLETS ONDANSETRON ODT 4 MG TABLETS ONDANSETRON ODT 8 MG TABLETS PROMETHAZINE 25 MG TABLETS RANITIDINE 150 MG TABLETS RANITIDINE 300 MG TABLETS RANITIDINE 15MG/ML SYRUP $ LACTULOSE 10 MG/15 ML SOLUTION $ DICYCLOMINE 10 MG CAPSULES DICYCLOMINE 20 MG TABLETS OMEPRAZOLE 40 MG CAPSULES

$

90 Day Qty 10.00 N/A N/A N/A 90 90 90 180 180 90 90 90 180 90 90

90 90 90

BLOOD GLUCOSE TEST STRIPS 50 CT BY TOPCARE GLYBURIDE 5 MG TABLETS (MICRONASE) GLYBURIDE MCR 3 MG TABLETS GLYBURIDE MCR 6 MG TABLETS DRUG NAME ANTIPYRINE/BENZO OTIC SOL CIPROFLOXACIN 0.3% OPTHALMIC SOL GENTAMICIN SUL 0.3% OPTHALMIC SOL TIMOLOL MAL 0.25% OPTHALMIC SOL (5 ML) TIMOLOL MAL 0.5% OPTHALMIC SOL (5 ML or 15 ML) TOBRAMYCIN 0.3% OPHTHALMIC SOLUTION TRIMETHOPRIM-POLY B OPTHALMIC SOL

30 Day Qty 4.00 1 25 100 30 30 30 60 60 30 30 30 60 30 30

60 60 30 Day Qty 8.00 50 30 30 30 30 Day Qty 4.00 10 5 5 5 5 5 10 30 Day Qty 8.00 10 30 Day Qty 4.00 60 60 60 60 240 30 20 20 14 7 12 60 30 150 30 Day Qty 4.00 240 30 Day Qty 8.00 90 60 30

180 180 90 Day Qty $ 20.00 N/A 90 90 90 90 Day Qty $ 10.00 30 15 15 N/A 15 15 30 90 Day Qty $ 24.00 N/A 90 Day Qty $ 10.00 180 180 180 180 90 60 60 42 21 36 180 90 473 90 Day Qty $ 12.00 960 90 Day Qty $ 24.00 270 180 90

Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be priced higher or may be added or deleted without notice. Can not be used in conjuction with other insurance.

Prescription Drug Plan

Effective 11/2/2015

Heart and Blood Pressure DRUG NAME AMLODIPINE BES 10 MG TABLETS AMLODIPINE BES 2.5 MG TABLETS AMLODIPINE BES 5 MG TABLETS AMLODIPINE/BENZ 2.5/10 MG CAPSULES AMLODIPINE/BENZ 5/10 MG CAPSULES AMLODIPINE/BENZ 5/20 MG CAPSULES AMLODIPINE/BENZ 10/20 MG CAPSULES ATENOLOL 100 MG TABLETS ATENOLOL 25 MG TABLETS ATENOLOL 50 MG TABLETS BENAZEPRIL 10 MG TABLETS BENAZEPRIL 20 MG TABLETS BENAZEPRIL 40 MG TABLETS BENAZEPRIL 5 MG TABLETS BISOPROLOL 5 MG TABLETS BISOPROLOL 10 MG TABLETS BISOPROLOL/HCTZ 10/6.25 TABLETS BISOPROLOL/HCTZ 5/6.25 TABLETS BISOPROLOL/HCTZ 2.5/6.25 TABLETS CARVEDILOL 12.5 MG TABLETS CARVEDILOL 25 MG TABLETS CARVEDILOL 3.125 MG TABLETS CARVEDILOL 6.25 MG TABLETS CLONIDINE 0.1 MG TABLETS CLONIDINE 0.2 MG TABLETS CLONIDINE 0.3 MG TABLETS ENALAPRIL/HCTZ 5/12.5 MG ENALAPRIL/HCTZ 10-25 MG FUROSEMIDE 10 MG/ ML SOLUTION FUROSEMIDE 20 MG TABLETS FUROSEMIDE 40 MG TABLETS FUROSEMIDE 80 MG TABLETS GUANFACINE 1 MG TABLETS GUANFACINE 2 MG TABLETS HYDRALAZINE 10 MG TABLETS HYDRALAZINE 25 MG TABLETS HYDRALAZINE 50 MG TABLETS HYDRALAZINE 100 MG TABLETS HYDROCHLOROTHIAZIDE 12.5 MG CAPSULES HYDROCHLOROTHIAZIDE 12.5 MG TABLETS HYDROCHLOROTHIAZIDE 25 MG TABLETS HYDROCHLOROTHIAZIDE 50 MG TABLETS ISOSORBIDE MONONITRATE 20 MG TABLETS LISINOPRIL 10 MG TABLETS LISINOPRIL 2.5 MG TABLETS LISINOPRIL 20 MG TABLETS LISINOPRIL 30 MG TABLETS LISINOPRIL 40 MG TABLETS LISINOPRIL 5 MG TABLETS LISINOPRIL-HCTZ 10-12.5 MG TABLETS LISINOPRIL-HCTZ 20-12.5 MG TABLETS LISINOPRIL-HCTZ 20-25 MG TABLETS METHYLDOPA 250 MG TABLETS METHYLDOPA 500 MG TABLETS METOPROLOL 100 MG TABLETS METOPROLOL 25 MG TABLETS METOPROLOL 50 MG TABLETS PENTOXIFLYLINE 400 MG TABLETS SOTALOL HCL 80 MG TABLETS SOTALOL HCL 120 MG TABLETS SOTALOL HCL 160 MG TABLETS SPIRONOLACTONE 25 MG TABLETS SPIRONOLACTONE 50 MG TABLETS SPIRONOLACTONE 100 MG TABLETS TERAZOSIN 10 MG CAPSULES TERAZOSIN 1 MG CAPSULES TERAZOSIN 2 MG CAPSULES TERAZOSIN 5 MG CAPSULES TRIAMTERENE/HCTZ 37.5-25 TABLETS

Qty $0.00 Copay

$

30 Day Qty 4.00 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 60 60 60 60 60 60 60 30 30 60 30 30 30 30 30 60 60 60 60 30 30 30 30 30

$

90 Day Qty 10.00 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 180 180 180 180 180 180 180 90 90 90 90 90 90 90 180 180 180 180 90 90 90 90 90

60 60 60 60 60 60 30 30 30 60 30 60 60 60 30 30 30 30 30 30 30 30 30 30 30 30

90 90 90 180 90 180 180 180 90 90 90 90 90 90 90 90 90 90 90 90

Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be priced higher or may be added or deleted without notice. Can not be used in conjuction with other insurance.

Prescription Drug Plan

Effective 11/2/2015

Heart and Blood Pressure DRUG NAME VERAPAMIL 120 MG TABLETS VERAPAMIL 80 MG TABLETS WARFARIN 10 MG TABLETS WARFARIN 1 MG TABLETS WARFARIN 2.5 MG TABLETS WARFARIN 2 MG TABLETS WARFARIN 3 MG TABLETS WARFARIN 4 MG TABLETS WARFARIN 5 MG TABLETS WARFARIN 6 MG TABLETS WARFARIN 7.5 MG TABLETS

AMIODARONE 200 MG TABLETS AMILORIDE/HCTZ 5 MG/50 MG TABLETS AMLODIPINE/BENZ 5/40 MG CAPSULES AMLODIPINE/BENZ 10/40 MG CAPSULES CILOSTAZOL 50 MG TABLETS CILOSTAZOL 100 MG TABLETS FOSINOPRIL 10 MG TABLETS FOSINOPRIL 20 MG TABLETS FOSINOPRIL 40 MG TABLETS FOSINOPRIL/HCTZ 10-12.5 MG TABLETS FOSINOPRIL/HCTZ 20-12.5 MG TABLETS ISOSORBIDE MONONITRATE ER 30 MG TABLETS ISOSORBIDE MONONITRATE ER 60 MG TABLETS LABETALOL HCL 100 MG TABLETS LABETALOL HCL 200 MG TABLETS LABETALOL HCL 300 MG TABLETS TRIAMTERENE/HCTZ37.5-25 CAPSULES TRIAMTERENE/HCTZ 75-50 MG TABLETS

CLOPIDOGREL 75 MG TABLETS INDAPAMIDE 1.25 MG TABLETS INDAPAMIDE 2.5 MG TABLETS DRUG NAME ATENOLOL/CHLOR 50/25 MG TABLETS ATENOLOL/CHLOR 100/25 MG TABLETS CHLOROTHIAZIDE 250 MG TABLETS DILTIAZEM 30 MG TABLETS DILTIAZEM 60 MG TABLETS DILTIAZEM 90 MG TABLETS DILTIAZEM 120 MG TABLETS DILTIAZEM CD 120 MG CAPSULES DILTIAZEM CD 180 MG CAPSULES DILTIAZEM CD 240 MG CAPSULES LOSARTAN POT 25 MG LOSARTAN POT 50 MG LOSARTAN POT 100 MG LOSARTAN-HCTZ 50/12.5 MG TABLETS LOSARTAN-HCTZ 100/12.5 MG TABLETS LOSARTAN-HCTZ 100/25 MG TABLETS RAMIPRIL 1.25 MG CAPSULES RAMIPRIL 10 MG CAPSULES RAMIPRIL 2.5 MG CAPSULES RAMIPRIL 5 MG CAPSULES

Qty $0.00 Copay

30 Day Qty 4.00 30 30 30 30 30 30 30 30 30 30 30 30 Day Qty $ 8.00 30 30 30 30 60 60 30 30 30 30 30 30 30 30 30 30 30 30 30 Day Qty $ 10.00 30 30 30 30 Day Qty $ 12.00 30 30 60 60 60 60 30 30 30 30 30 30 30 30 30 30 30 30 30 30 $

90 Day Qty 10.00 90 90 90 90 90 90 90 90 90 90 90 90 Day Qty $ 22.00 90 90 90 90 180 180 90 90 90 90 90 90 90 90 90 90 90 90 90 Day Qty $ 30.00 90 90 90 90 Day Qty $ 36.00 90 90 180 180 180 180 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $

Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be priced higher or may be added or deleted without notice. Can not be used in conjuction with other insurance.

Prescription Drug Plan

Effective 11/2/2015

Mental Health DRUG NAME

$

DRUG NAME

$

BUSPIRONE 5 MG TABLETS BUSPIRONE 10 MG TABLETS CITALOPRAM 10 MG TABLETS CITALOPRAM 20 MG TABLETS CITALOPRAM 40 MG TABLETS FLUOXETINE 10 MG CAPSULES FLUOXETINE 20 MG CAPSULES FLUOXETINE 40 MG CAPSULES FLUPHENAZINE 1 MG TABLETS FLUPHENAZINE 5 MG TABLETS FLUPHENAZINE 10 MG TABLETS LITHIUM CARBONATE 300 MG CAPSULES NORTRIPTYLINE 10 MG CAPSULES NORTRIPTYLINE 25 MG CAPSULES PAROXETINE 10 MG TABLETS PAROXETINE 20 MG TABLETS PAROXETINE 30 MG TABLETS PAROXETINE 40 MG TABLETS PROCHLORPERAZINE 10 MG TABLETS PROCHLORPERAZINE 5 MG TABLETS RISPERIDONE 0.25 MG TABLETS RISPERIDONE 0.5 MG TABLETS RISPERIDONE 1 MG TABLETS RISPERIDONE 2 MG TABLETS RISPERIDONE 3 MG TABLETS SERTRALINE 25 MG TABLETS SERTRALINE 50 MG TABLETS SERTRALINE 100 MG TABLETS TRAZODONE 100 MG TABLETS TRAZODONE 150 MG TABLETS TRAZODONE 50 MG TABLETS

AMITRIPTYLINE 10 MG TABLETS AMITRIPTYLINE 25 MG TABLETS BUSPIRONE 15 MG TABLETS NORTRIPTYLINE 50 MG CAPSULES NORTRIPTYLINE 75 MG CAPSULES RISPERIDONE 4 MG TABLETS THIOTHIXENE 1 MG THIORIDAZINE 10 MG TABLETS THIORIDAZINE 25 MG TABLETS $ AMITRIPTYLINE 50 MG TABLETS THIORIDAZINE 50 MG TABLETS $ VENLAFAXINE 25 MG TABLETS VENLAFAXINE 37.5 MG TABLETS VENLAFAXINE 50 MG TABLETS VENLAFAXINE 75 MG TABLETS VENLAFAXINE 100 MG TABLETS $ AMITRIPTYLINE 75 MG TABLETS AMITRIPTYLINE 100 MG TABLETS Muscle Relaxants DRUG NAME CYCLOBENZAPRINE 10 MG TABLETS CYCLOBENZAPRINE 5 MG TABLETS METHOCARBAMOL 500 MG TABLETS METHOCARBAMOL 750 MG TABLETS

$

30 Day Qty 4.00 60 60 30 30 30 30 30 30 30 30 30 90 30 30 30 30 30 30 30 30 60 60 60 60 60 30 30 30 30 30 30 30 Day Qty 8.00 30 30 60 30 30 60 30 30 30 30 Day Qty 12.00 30 30 30 Day Qty 18.00 60 60 60 60 60 30 Day Qty 24.00 30 30 30 Day Qty 4.00 30 30 30 30

90 Day Qty 10.00 180 180 90 90 90 90 90 90 90 90 90 270 90 90 90 90 90 90 90 90 180 180 180 180 180 90 90 90 90 90 90 90 Day Qty $ 22.00 90 90 180 90 90 180 90 90 90 90 Day Qty $ 36.00 90 90 90 Day Qty $ 50.00 180 180 180 180 180 90 Day Qty $ 65.00 90 90 90 Day Qty $ 10.00 90 90 90 90 $

Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be priced higher or may be added or deleted without notice. Can not be used in conjuction with other insurance.

Prescription Drug Plan

Effective 11/2/2015

Other DRUG NAME

$

CHLORHEXADINE GLUCOSE 0.12% SOLN DEXAMETHASONE .5 MG TABLETS DEXAMETHASONE 0.75 MG TABLETS DEXAMETHASONE 4 MG TABLETS LIDOCAINE 2% VISCOUS SOLUTION OXYBUTYNIN 5 MG/5 ML SYRUP PREDNISONE 1 MG TABLETS PREDNISONE 2.5 MG TABLETS PREDNISONE 20 MG TABLETS PREDNISONE 5 MG TABLETS PREDNISONE 10 MG TABLETS VITAMIN D 50,000 UNIT CAPSULES Skin DRUG NAME HYDROCORTISONE 1% CREAM 30 GM HYDROCORTISONE 2.5% CREAM 30 GM MICONAZOLE 2% (OTC) 28 GM CREAM SILVER SULFADIAZINE 1% (25 GM) CREAM TRIAMCINOLONE 0.025% 15 GM (tube) CREAM TRIAMCINOLONE 0.1% 15 GM (tube) CREAM

$

$ SILVER SULFADIAZINE 1% (50 GM) CREAM TRIAMCINOLONE 0.025% 15 GM (tube) OINTMENT TRIAMCINOLONE 0.025% 80 GM (tube) CREAM TRIAMCINOLONE 0.025% 80 GM (tube) OINTMENT TRIAMCINOLONE 0.1% 15 GM (tube) OINTMENT TRIAMCINOLONE 0.1% 80 GM (tube) CREAM TRIAMCINOLONE 0.1% 80 GM (tube) OINTMENT TRIAMCINOLONE 0.5% 15 GM (tube) CREAM TRIAMCINOLONE 0.5% 15 GM (tube) OINTMENT $ MUPIROCIN 2% OINTMENT Thyroid DRUG NAME

$

METHIMAZOLE 5 MG TABLETS METHIMAZOLE 10 MG TABLETS $ LEVOTHYROXINE 25 MCG TABLETS LEVOTHYROXINE 50 MCG TABLETS LEVOTHYROXINE 75 MCG TABLETS LEVOTHYROXINE 88 MCG TABLETS LEVOTHYROXINE 100 MCG TABLETS LEVOTHYROXINE 112 MCG TABLETS LEVOTHYROXINE 125 MCG TABLETS LEVOTHYROXINE 137 MCG TABLETS LEVOTHYROXINE 150 MCG TABLETS LEVOTHYROXINE 175 MCG TABLETS LEVOTHYROXINE 200 MCG TABLETS

30 Day Qty 4.00 480 12 12 6 100 150 90 30 30 30 30 8 30 Day Qty 4.00 30 30 28 25 15 15 30 Day Qty 8.00 50 15 80 80 15 80 80 15 15 30 Day Qty 24.00 22 30 Day Qty 4.00 30 30 30 Day Qty 8.00 30 30 30 30 30 30 30 30 30 30 30

$

90 Day Qty 10.00

36 36 18 300 N/A 270 90 90 90 90 24 90 Day Qty $ 10.00 90 90 84 75 45 45 90 Day Qty $ 18.00 45 240 240 45 240 240 45 45 90 Day Qty

90 Day Qty 10.00 90 90 90 Day Qty $ 24.00 90 90 90 90 90 90 90 90 90 90 90 $

Vaccines DRUG NAME ADACEL DECAVAC ENERGIX-B GARDASIL HAVRIX MENACTRA MMR PNEUMOVAX PREVNAR-13 SEASONAL INFLUENZA HIGH DOSE SEASONAL INFLUENZA QUADRAVALENT -NEW PRICE SEASONAL INFLUENZA TRIVALENT TWINRIX TYPHIM VARIVAX VIVOTIF ZOSTAVAX

Price 56.00 56.00 59.00 164.00 79.00 125.00 63.00 92.00 179.00 44.00 24.00 24.00 114.00 65.00 121.00 51.00 209.00

Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be priced higher or may be added or deleted without notice. Can not be used in conjuction with other insurance.

Prescription Drug Plan

Effective 11/2/2015

Vitamins/ Nutritional DRUG NAME

$

DRUG NAME

$

DRUG NAME ESTRADIOL 0.5 MG TABLETS ESTRADIOL 1 MG TABLETS ESTRADIOL 2 MG TABLETS MEDROXYPROGESTERONE AC 10 MG TABLETS MEDROXYPROGESTERONE AC 2.5 MG TABLETS MEDROXYPROGESTERONE AC 5 MG TABLETS

$

FOLIC ACID 1 MG TABLETS LUDENT CHEW FL 0.5 MG TABLETS LUDENT CHEW FL 1 MG TABLETS MAG 64 MG TABLETS MAG-OXIDE 400 MG TABLETS Mens Health FINASTERIDE 5 MG TABLETS Womens Health

$ ALENDRONATE SOD 35 MG TABLETS ALENDRONATE SOD 70 MG TABLETS CLOMIPHENE 50 MG TABLETS $ ALTAVERA 0.15-30 MG-MCG TABLETS CAMILA 0.35 MG TABLETS CYCLAFEM 1/35 MG-MCG TABLETS CYCLAFEM 7/7/7 TABLETS EMOQUETTE 0.15-30 MG-MCG TABLETS ERRIN 0.35 MG TABLETS ORSYTHIA 0.1-20 MG-MCG TABLETS PREVIFEM 28 TABLETS TRI-PREVIFEM TABLETS Baby Club Benefits DRUG NAME MULTI-VIT/FLUORIDE 0.25 MG/ML DROPS (POLY-VI-FLOR) MULTI-VIT/FLUORIDE 0.5 MG CHEW (POLY-VI-FLOR) MULTI-VIT/FLUORIDE 0.5 MG/ML DROPS (POLY-VI-FLOR) MULTI-VIT/IRON/FLUORIDE 0.25 MG/ML DROPS (POLY-VI-FLOR/FE) MULTIVITAMIN/FLUORIDE 0.25 MG CHEW (POLY-VI-FLOR) MVC-FLUORIDE 0.25 MG CHEW (POLY-VI-FLOR) MVC CHEW W FL 0.25 MG TABLETS MVC CHEW W FL 0.5 MG TABLETS PNV FOLIC ACID PLUS MULTI 27-1 MG TAB (PRENATAL PLUS) PRENATABS FA 29-1 MG TAB (NATATAB FA) PRENATABS RX 29-1 MG TAB (PRENATAL PLUS IRON) PRENATAL 19, 29-1 MG CHEW PRENATAL 19, 29-1 MG TAB PRENATAL PLUS 27-1 MG TAB PRENATAL- U 106.5-1 MG CAP TRINATE 28-1 MG TAB (STUARTNATAL PLUS) TRI-VIT/FLUORIDE 0.25 MG/ML DROPS (TRI-VI-FLOR) TRI-VIT/FLUORIDE/IRON 0.25 MG/ML DROPS (TRI-VIT-FLOR/FE)

30 Day Qty 4.00 30 120 120 30 60 30 Day Qty 9.00 30 30 Day Qty 4.00 30 30 30 30 30 30 30 Day Qty 9.00 4 4 5 28- Day 9.00 28 28 28 28 28 28 28 28 28 Qty $0.00 Copay 50 30 50 50 30 30 30 30 30 30 30 30 30 30 30 30 50 50

90 Day Qty 10.00 90 360 360 90 180 90 Day Qty $ 27.00 90 90 Day Qty $ 10.00 90 90 90 90 90 90 90 Day Qty $ 24.00 12 12 15 84- Day $ 27.00 84 84 84 84 84 84 84 84 84 $

Southeastern Grocers Rx Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of covered drugs. Some may be priced higher or may be added or deleted without notice. Can not be used in conjuction with other insurance.