Rx Outreach Medication List Rx Outreach Medication Available Strengths 90-Day Supply 180-Day Supply

Transcription

1 Rx Outreach Medication List Rx Outreach Medication Available Strengths 90-Day Supply 180-Day Supply Allergies/Asthma Albuterol Inhalation Solution 0.083%/3mL $15 for up to 75 vials Azelastine nasal spray 137mcg $30 per nasal spray Budesonide Inhalation Solution 0.25mg/2mL $32 for up to 10 vials Budesonide Inhalation Solution 0.5mg/2mL $37 for up to 10 vials Budesonide nasal spray 8.6g/32mcg $62 per nasal spray Cetirizine HCl tablet - OTC (no prescription required) $10 per bottle of 100 tablets (minimum 2 bottles) Epinephrine Auto Injector 0.15mg/0.15mL, 0.3mg/0.3mL $250 for a 2 unit pack Fexofenadine OTC tablet 60mg, 180mg (no prescription required) $40 for 100 tablets Fluticasone nasal spray 50mcg $15 per nasal spray Hydrocortisone tablet 5mg $15 for up to 90 tablets Hydrocortisone tablet Hydroxyzine HCL tablet 25mg, 50mg $25 Hydroxyzine pamoate capsule 25mg, 50mg $25 Ipratropium/Albuterol Inhalation Solution 0.5mg/3.0mg vial $25 for up to 90 vials Ketotifen Fumerate OTC Solution 0.025%/5mL (no prescription required) $9 per dropper Loratadine OTC tablet (no prescription required) $10 per bottle of 100 tablets (minimum 2 bottles) Levocetirizine tablet 5mg $35 $65 Montelukast Sodium tablet, 5mg chewable ProAir RespiClick Powder Inhaler 0.65g (200 inhalations) $35 per inhaler canister Zafirlukast tablet, $30 for 60 tablets Anti-Anxiety Alprazolam tablet (CS) 0.25mg, 0.5mg, 1mg, 2mg $9 for up to 90 tablets Buspirone tablet 5mg,, 15mg $20 Buspirone tablet 30mg $35 Chlordiazepoxide capsule (CS) 5mg,, 25mg $15 for up to 180 capsules Clonazepam tablet (CS) 0.5mg $9 for up to 90 tablets Clonazepam tablet (CS) 1mg, 2mg $10 for up to 90 tablets Diazepam tablet (CS) 2mg, 5mg, $8 for up to 90 tablets Lorazepam tablet (CS) 0.5mg $25 Lorazepam tablet (CS) 1mg, 2mg $30 Antimicrobial/Antiviral/Antifungal Acyclovir capsule 200mg $20 Acyclovir tablet 400mg, 800mg $20 Clindamycin HCL capsule 150mg $45 $85 Clotrimazole/Betamethasone Cream 15gm (1%/0.05%) Fluconazole tablet 100mg, 200mg $35 for up to 30 tablets Isoniazid tablet 300mg $20 Minocycline capsule 50mg, 75mg, 100mg $45 $85 Nyamyc Topical Powder 100,000U/g (60g bottle) $25 per bottle Nystatin tablet units Sulfamethoxazole/Trimethoprim DS 800mg/160mg $20 Valacyclovir HCl tablet $50 for up to 90 tablets Valacyclovir HCl tablet 1gm $75 for up to 90 tablets Zidovudine tablet 300mg $30 for up to 60 tablets Arthritis/Pain Aspirin EC tablet (OTC) 325mg (no prescription required) $7 for a bottle of 100 Azathioprine tablet 50mg Capsaicin Cream, 0.025% (OTC) 60gm (no prescription required) $12 per tube Celecoxib capsule 50mg, 100mg $15 for up to 30 capsules Celecoxib capsule 200mg, 400mg $35 for up to 30 capsules Diclofenac EC tablet 50mg, 75mg $25 Diclofenac ER tablet 100mg $40 Etodolac capsule 200mg, 300mg $40 for up to 90 caps Etodolac tablet 400mg, Hydroxychloroquine tablet 200mg $22 for up to 30 tablets Ibuprofen tablet 400mg, 600mg, 800mg $20 Lidocaine 5% patch 5% of lidocaine per patch $99 for a box of 30 patches Meloxicam tablet 7.5mg, 15mg $20 Methotrexate tablet 2.5mg $20 per 12 tablets Nabumetone tablet, 750mg $40 Naproxen Sodium tablet 550mg $25 Naproxen tablet 250mg, 375mg, $20 Sulfasalazine DR tablet Tramadol tablet (CS) 50mg $7 for up to 90 tablets Tramadol HCl ER tablet (CS) 100mg, 200mg $40 for up to 30 tablets Tramadol HCl ER tablet (CS) 300mg $60 for up to 30 tablets Tramadol/Acetaminophen tablet (CS) 37.5mg/325mg $30 for up to 120 tablets

2 Cancer Anastrozole tablet 1mg Hexalen capsule 50mg $40 for a 30-day supply Hydroxyurea capsule $25 for up to 90 caps Letrozole tablet 2.5mg $30 $55 Nilandron tablet 150mg $0* Panretin gel 0.1% 60gm $40 per tube Tamoxifen Citrate tablet Tamoxifen Citrate tablet Cholesterol/Triglycerides Atorvastatin tablet, 40mg, 80mg $25 $45 Colestipol Micronized tablet 1gm $60 for up to 60 tablets Fenofibrate tablet 48mg, 54mg, 160mg $55 $95 Fenofibrate tablet 145mg $55 for up to 30 tablets Fenofibrate, micronized capsule 134mg $70 Fenofibric acid DR capsule 135mg $60 for up to 30 capsules Gemfibrozil tablet 600mg $30 $55 Lovastatin tablet,, 40mg $9 $18 Niacin ER tablet $45 for up to 30 tablets Niacin ER tablet 1000mg $50 for up to 30 tablets Niacin SA capsule (OTC) 250mg (no prescription required) $9 for a bottle of 100 Niacor tablet $25 for up to 180 tablets Omega-3-acid ethyl esters capsule 1gm $80 for up to 120 capsules Pravastatin tablet,, 40mg, 80mg Prevalite Powder 4g/5.5g dose packet $25 for a carton of 42 packets Prevalite Powder 4g/5.5g dose packet $25 for a carton of 60 packets Prevalite Powder 4g/5.5g powder can (231g) $25 per can Rosuvastatin Calcium tablet 5mg,,, 40mg, 80mg Simvastatin tablet 5mg,,, 40mg, 80mg $20 $35 Dermatology Alclometasone Dipropionate Cream 15gm Betamethasone Dipropionate Cream, Aug 15gm $25 per tube Halobetasol Prop ointment, 0.05% 15gm $35 per tube Mometasone Furoate Cream 15gm Mometasone Furoate Ointment 15gm Triamcinolone cream, 0.1% 454gm (0.1%) $18 per jar Triamcinolone ointment, 0.1% 454gm (0.1%) $20 per jar Diabetes Blood Glucose Monitor (Prodigy N/A (No prescription required) One free monitor annually Blood Glucose Monitor Control Sol., Low 4ml. Vial (No prescription required) $5 per vial Blood Glucose Strips, No Coding Box of 50 (No prescription required) $15 per box Blood Glucose Twist Top Lancets 28G Box of 100; min order - 2 boxes (No prescription required) $5 per box; min order $10 Glimepiride tablet 1mg, 2mg, 4mg $20 Glipizide ER tablet 2.5mg, 5mg, $35 $65 Glipizide tablet 5mg, $20 Glyburide tablet 1.25mg, 2.5mg, 5mg $20 Glyburide, micronized tablet 1.5mg, 3mg, 6mg $20 Glyburide/Metformin tablet 1.25/250mg, 2.5/, 5/ $30 $55 Insulin Syringes (Prodigy ) 28G 12.7mm-1cc, 31G 8mm-1/2cc, 31G 8mm-1/3cc $13 for a box of 100 Metformin HCL ER tablet, 750mg $20 Metformin HCL tablet, 850mg, 1000mg $20 Pioglitazone HCL tablet 15mg, 30mg, 45mg $25 Rapaglinide tablet 0.5mg, 1mg, 2mg Gastrointestinal AcipHex tablet Balsalazide Disodium capsule 750mg Dicyclomine capsule $20 Dicyclomine tablet $20 Diphenoxylate/Atropine tablet (CS) 2.5/0.025mg $35 Donnatal elixir (CS) (mint or grape) 16.2/0.1037/0.0194/0.0065mg $0* Donnatal tablet (CS) 16.2/0.1037/0.0194/0.0065mg $0* Esomeprazole DR capsule, 40mg $40 for up to 30 capsules Famotidine tablet, 40mg $20 Lactulose Oral Solution 10gm/15mL $10 per bottle Lansoprazole DR capsule 30mg $20 for up to 30 capsules Loperamide capsule 2mg $9 for up to 30 capsules Meclizine HCL tablet 12.5mg, 25mg $30 $55 Metoclopramide HCL tablet 5mg, (limit 1 fill; no refills) $20 Omeprazole capsule,, 40mg $35 $65 Ondansetron / Ondansetron ODT tablet 4mg $50 for up to 135 tabs Ondansetron / Ondansetron ODT tablet 8mg $50 for up to 90 tabs Pantoprazole tablet, 40mg $20

3 Gastrointestinal (cont'd) Prochlorperazine tablet 5mg, $20 Ranitidine tablet 150mg, 300mg $20 Sucralfate tablet 1gm $30 for up to 120 tablets Sulfasalazine tablet $50 $95 Heart/Circulation Aspirin EC tablet (OTC) 81mg (no prescription required) $9 for a bottle of 120 Cilostazol tablet 50mg, 100mg $30 $55 Clopidogrel tablet 75mg Digoxin tablet 0.125mg, 0.25mg Flecainide Acetate tablet 50mg, 100mg, 150mg Folic Acid tablet 1mg $20 Isosorbide Mononitrate ER tablet 30mg, 60mg $15 for up to 90 tablets Isosorbide Mononitrate ER tablet 1 Isosorbide Mononitrate tablet, $20 Jantoven (Warfarin) tablet mg: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 $25 Lanoxin tablet.0625mg,.1875mg $0* Nitroglycerin SA capsule 2.5mg, 6.5mg, 9mg $45 $85 Pacerone tablet 100mg, 200mg, 400mg $25 $45 Pentoxifylline ER tablet 400mg $30 $55 Potassium Chloride ER tablet 8mEQ, 10mEQ, 20mEQ Potassium Citrate tablet 5mEQ, 10mEQ $15 for up to 90 tablets Propafenone HCL tablet 150mg, 225mg, 300mg $40 $75 Sorine tablet 80mg, 1, 160mg, 240mg $20 Hormones Androxy tablet (CS) $25 Estradiol tablet 0.5mg, 1mg, 2 mg $20 Estropipate tablet 0.625(0.75mg) Estropipate tablet 1.25 (1.5mg) $33 for up to 90 tablets Medroxyprogesterone tablet 2.5mg, 5mg, $15 Norethindrone Acetate tablet 5mg $75 for up to 50 tablets Prednisone tablet 1mg, 2.5mg, 5mg,,, 50mg $20 Progesterone capsule 100mg, 200mg $30 for up to 36 capsules Testosterone Cypionate Solution (CS) 200mg/ml - 1ml vial $20 per vial Testosterone Cypionate Solution (CS) 200mg/ml - 10ml vial $75 per vial Testosterone Gel packet (CS) 50mg (5g of gel per packet) $25 for a carton of 30 packets Testosterone Gel pump (CS) 75g pump - 2 pumps per carton (12.5mg per pump actuation) $25 for a carton of 2 pumps Testosterone Gel tube (CS) 50mg (5g of gel per tube) $25 for a carton of 30 tubes Hypertension/Hypotension Amlodipine tablet 2.5mg, 5mg, $20 $40 Amlodipine/Benazepril capsule 5/, 5/, 10/ $50 for up to 90 capsules Amlodipine/Benazepril capsule 10/40mg $12 for up to 30 capsules Amlodipine/Valsartan tablet 5/160mg, 5/3, 10/160mg, 10/3 $25 for up to 30 tablets Amlodipine/Valsartan/HCTZ tablet 5/160/12.5mg, 5/160/25mg, 10/160/12.5mg, 10/160/25mg, 10/320/25mg $60 for up to 30 tablets Atenolol tablet 25mg, 50mg, 100mg $9 $18 Atenolol/Chlorthalidone tablet 50/25mg, 100/25mg $20 Benazepril tablet 5mg,,, 40mg $20 Benazepril/HCTZ tablet 5/6.25mg, 10/12.5mg, 20/12.5mg, 20/25mg $25 $45 Bisoprolol/HCTZ tablet 2.5/6.25mg, 5/6.25mg, 10/6.25mg $20 Candesartan Cilexetil tablet 4mg, 8mg $30 for up to 30 tablets Candesartan Cilexetil tablet 16mg, 32mg $40 for up to 30 tablets Candesartan Cilexetil-HCTZ tablet 16/12.5mg Candesartan Cilexetil-HCTZ tablet 32/12.5mg, 32/25mg $45 for up to 90 tablets Captopril tablet 12.5mg, 25mg, 50mg, 100mg Carvedilol tablet 3.125mg, 6.25mg, 12.5mg, 25mg $20 Chlorthalidone tablet 25mg, 50mg $30 $55 Clonidine HCL tablet 0.1mg, 0.2mg, 0.3mg $20 Clonidine patch 0.3mg/day $80 per pack of 4 Dibenzyline capsule $0* Diltiazem ER capsule (24hr) (Dilt-XR) 1, 180mg, 240mg Diltiazem ER capsule (Dilt-CD) 1, 180mg, 240mg, 300mg Doxazosin Mesylate tablet 1mg, 2mg, 4mg, 8mg Dutoprol tablet 25/12.5mg, 50/12.5mg, 100/12.5mg $0* Dyrenium capsule 50mg, 100mg $0 Enalapril Maleate tablet 2.5mg, 5mg,, $20 Enalapril/HCTZ tablet 5/12.5mg, 10/25mg $20 Eplerenone tablet 25mg, 50mg $25 for a 30-day supply Felodipine ER tablet 2.5mg, 5mg Felodipine ER tablet $70 for up to 90 tablets Furosemide tablet, 40mg, 80mg $9 $18 Hydralazine tablet, 25mg, 50mg, 100mg $25 $45 Hydrochlorothiazide capsule 12.5mg $20 Hydrochlorothiazide tablet 25mg, 50mg $20 Indapamide tablet 1.25mg, 2.5mg $20 Irbesartan tablet 75mg, 150mg, 300mg $30 $55

4 Hypertension/Hypotension (cont'd) Irbesartan/HCTZ tablet 150mg/12.5mg, 300mg/12.5mg $30 $55 Labetalol HCL tablet 100mg, 200mg, 300mg Lisinopril tablet 2.5mg, 5mg,,, 30mg, 40mg $9 $18 Lisinopril/HCTZ tablet 10/12.5mg, 20/12.5mg, 20/25mg $9 $18 Losartan Potassium tablet 25mg, 50mg, 100mg $20 $40 Losartan/HCTZ tablet 50/12.5mg, 100/12.5mg, 100/25mg $25 $45 Metolazone tablet 2.5mg, 5mg $35 $65 Metoprolol Succinate ER tablet 25mg, 50mg, 100mg $35 $65 Metoprolol Succinate ER tablet 200mg $45 $85 Metoprolol Tartrate tablet 25mg, 50mg, 100mg $20 Midodrine HCl tablet 2.5mg, 5mg, Nifedipine capsule Nifedipine capsule $55 for up to 30 capsules Nifedipine ER tablet 30mg, 60mg $50 $95 Prazosin capsule 1mg, 2mg $20 for up to 90 capsules Prazosin capsule 5mg 40mg 80mg $55 for up to 90 tablets Propranolol HCL ER capsule 60mg, 80mg, 1, 160mg $45 for up to 30 capsules Quinapril tablet 5mg,,, 40mg $30 $55 Quinapril/HCTZ tablet 10/12.5mg, 20/12.5mg, 20/25mg Ramipril capsule 1.25mg, 2.5mg, 5mg, $25 $45 Sildenafil Citrate tablet $20 for up to 30 tablets Spironolactone tablet 25mg $20 Spironolactone/HCTZ tablet 25mg/25mg Telmisartan tablet, 40mg, 80mg $35 $65 Terazosin capsule 1mg, 2mg, 5mg, $20 Trandolapril tablet 1mg, 2mg, 4mg $30 $55 Triamterene/HCTZ capsule 37.5/25mg $20 Triamterene/HCTZ tablet 37.5/25mg, 75/50mg $20 Valsartan tablet 40mg, 80mg $30 for 90 tablets Valsartan tablet 160mg, 3 $40 for 90 tablets Valsartan/HCTZ tablet 80/12.5mg, 160/12.5mg, 160/25mg, 320/12.5mg, 320/25mg $35 $65 Verapamil SR tablet 1, 180mg, 240mg $25 $40 Verapamil tablet 40mg, 80mg, 1 $20 Immunosuppressant Mycophenolate Mofetil capsule 250mg $65 for up to 180 capsules Mycophenolate Mofetil tablets $65 for up to 180 tablets Tacrolimus capsule 0.5mg $60 for up to 90 capsules Tacrolimus capsule 1mg $75 for up to 90 capsules Insomnia Eszopiclone tablet (CS) 1mg, 2mg, 3mg Temazepam capsule (CS) 15mg, 30mg $16 for up to 90 capsules Zaleplon capsule (CS) 5mg, $35 for up to 90 capsules Zolpidem Tartrate tablet (CS) 5mg, $30 Zolpidem Tartrate ER tablet (CS) 6.25mg, 12.5mg $45 for up to 30 tablets Mental Health Amitriptyline tablet $15 for up to 90 tablets Amitriptyline tablet 25mg, 50mg Amitriptyline tablet 75mg, 100mg Amitriptyline tablet 150mg $60 for up to 90 tablets Amoxapine tablet 100mg $32 for up to 30 tablets Aripiprazole tablet 2mg, 5mg,, 15mg $35 for up to 30 tablets Aripiprazole tablet, 30mg $40 for up to 30 tablets Bupropion HCL tablet 75mg $40 Bupropion HCL tablet 100mg Bupropion HCL SR tablet 100mg, 150mg, 200mg $65 Bupropion HCL XL tablet 150mg, 300mg $65 Chlorpromazine HCL tablet, 25mg, 50mg, 100m, 200mg $35 Citalopram tablet,, 40mg $20 Doxepin capsule, 25mg, 50mg $20 for up to 90 capsules Doxepin capsule 75mg, 100mg $35 for up to 90 capsules Duloxetine HCL DR capsule, 30mg, 60mg $45 Escitalopram tablet 5mg,, $15 Fluoxetine capsule,, 40mg $15 Fluvoxamine Maleate tablet 100mg $12 for up to 30 tablets Haloperidol tablet 0.5mg, 1mg, 2mg, 5mg $25 Lithium Carbonate capsule 150mg, 300mg $10 for up to 270 capsules Lithium Carbonate ER tablet 300mg, 450mg $35 Loxapine capsule 5mg, $20 for up to 60 capsules Loxapine capsule 25mg, 50mg $45 for up to 60 capsules Mirtazapine tablet 15mg, 30mg, 45mg $30 Nortriptyline HCL capsule, 25mg, 50mg, 75mg $20 Olanzapine tablet 2.5mg, 5mg, 7.5mg,

5 Mental Health (cont'd) Olanzapine tablet 15mg, $50 for up to 90 tablets Parnate tablet $0* Paroxetine HCL tablet,, 30mg, 40mg $20 Phenelzine sulfate tablet 15mg $60 for up to 120 tablets Perphenazine tablet 2mg, 4mg $20 for up to 30 tablets Perphenazine tablet 8mg, 16mg $35 for up to 30 tablets Quetiapine Fumarate tablet 25mg, 50mg, 100mg Quetiapine Fumarate tablet 200mg, 300mg Quetiapine Fumarate tablet 400mg $50 for up to 90 tablets Risperidone tablet 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg $45 Sertraline tablet 25mg, 50mg, 100mg $25 Trazodone tablet 50mg, 100mg, 150mg $10 Trifluoperazine HCl tablet 1mg, 2mg, 5mg, $25 Venlafaxine tablet 25mg, 37.5mg, 50mg, 75mg, 100mg $45 Venlafaxine ER capsule 37.5mg, 75mg, 150mg $45 Ziprasidone capsule, 40mg, 60mg, 80mg $65 for up to 90 capsules Muscle Relaxers Baclofen tablet, $15 Chlorzoxazone tablet Cyclobenzaprine tablet 5mg, $25 Methocarbamol tablet, 750mg $15 for up to 90 tablets Tizanidine HCL tablet 2mg, 4mg $55 Neurology Amantadine tablet 100mg $30 Benztropine tablet 0.5mg, 1mg, 2mg $20 Bromocriptine tablet 2.5mg $65 for up to 30 tablets Carbamazepine tablet Carbamazepine ER tablet Carbidopa/Levodopa/Entacapone tablet 200mg 200mg, 400mg 12.5/50/200mg, 18.75/75/200mg, 25/100/200mg, 31.25/125/200mg, 37.5/150/200mg, 50/200/200mg $45 for up to 60 tablets Carbidopa / Levodopa SR tablet 25/100mg, 50/200mg $45 $85 Carbidopa / Levodopa tablet 10/100mg, 25/100mg, 25/250mg $45 $85 Dexmethylphenidate HCl tablet (CS) 2.5mg $17 for up to 30 tablets (30- Dexmethylphenidate HCl tablet (CS) 5mg $22 for up to 30 tablets (30- Dexmethylphenidate HCl tablet (CS) $25 for up to 30 tablets (30- Dextroamphetamine-Amphetamine tablet $20 for up to 30 tablets (30-5mg, 7.5mg,, 12.5mg, 15mg,, 30mg (CS) Dextroamphetamine-Amphetamine ER $70 for up to 30 capsules 5mg,, 15mg, capsule (CS) Dextroamphetamine-Amphetamine ER $80 for up to 30 capsules 25mg, 30mg capsule (CS) Dextroamphetamine sulfate ER capsule $50 for up to 30 capsules 5mg, (CS) Dextroamphetamine sulfate ER capsule $60 for up to 30 capsules 15mg (CS) Divalproex NA DR tablet 125mg, 250mg, $35 $65 Divalproex SOD ER tablet 250mg $65 for up to 90 tablets Divalproex SOD ER tablet $95 for up to 90 tablets Donepezil tablet 5mg, $15 Gabapentin capsule 100mg, 300mg, 400mg $25 for up to 270 capsules Gabapentin tablet 600mg, 800mg $45 for up to 270 tablets Guanfacine ER tablet 1mg, 2mg, 3mg, 4mg $50 for up to 60 tablets Lamotrigine tablet 25mg, 100mg, 150mg, 200mg $30 $55 Levetiracetam tablet 250mg,, 750mg $50 $95 Levetiracetam tablet 1000mg Levetiracetam ER tablet, 750mg $80 for up to 180 tablets Memantine HCL tablet 5mg, $25 for up to 60 tablets Methylphenidate tablet (CS) 5mg, $15 for up to 30 tablets (30- Methylphenidate tablet (CS) $25 for up to 30 tablets (30- Methylphenidate CD capsule (CS) $65 for up to 30 capsules Methylphenidate CD capsule (CS), 30mg $75 for up to 30 capsules

6 Neurology (cont'd) Methylphenidate CD capsule (CS) 40mg, 50mg, 60mg $95 for up to 30 capsules Methylphenidate LA capsule (CS), 30mg, 40mg $115 for up to 30 capsules Modafinil tablet (CS) 100mg, 200mg $80 Oxcarbazepine tablet 150mg, 300mg, 600mg $30 Phenytoin Sodium capsule 100mg $20 for up to 180 capsules Pramipexole tablet 0.125mg, 0.25mg, 0.5mg, 1mg, 1.5mg $25 for up to 180 tablets Primidone tablet 50mg $10 for up to 60 tablets Primidone tablet 250mg $16 for up to 60 tablets Qudexy XR capsule 25mg, 50mg, 100mg, 150mg, 200mg $25 $45 Rasagiline Mesylate tablet 0.5mg, 1mg $80 for up to 30 tablets Rivastigmine tartrate capsule 1.5mg, 3mg, 4.5mg, 6mg $50 for up to 60 capsules Ropinirole HCL tablet 0.25mg, 0.5mg, 1mg, 2mg $45 $85 Sumatriptan Succ tablet 25mg $35 for up to 72 tablets Sumatriptan Succ tablet 50mg $35 for up to 54 tablets Sumatriptan Succ tablet 100mg $35 for up to 27 tablets Topiramate tablet 25mg, 50mg, 100mg, 200mg $35 $65 Trospium Chloride tablet $50 for up to 60 tablets Valproic acid capsule 250mg $35 $65 Zonegran capsule 25mg $30 Zonegran capsule 100mg New patients: Letter of necessity from provider is required $20 for up to 90 capsules Zonisamide capsule 50mg, 100mg $18 for up to 90 capsules Nutritional/Metabolic Ferrous Sulfate EC tablet 325mg (no prescription required) $6 per bottle of 100 tablets (minimum 2 bottles) Folgard tablet (OTC) 2000IU D3/800mcg folic acid/12mg B6/120mcg B12 (no prescription required) $25 for 60 tablets Folgard OS tablet $22 for 60 tablets Folgard RX tablet Folic Acid 2.2 tablet Magnesium Oxide tablet (OTC) PNV Prenatal Multivitamin Plus Iron & Folic Acid tablet calcium/1.1mg folic acid/300iu D3/12.5mg B6/250mcg B12/100mg magnesium/1.5mg boron 2.2mg folic acid/25mg B6/1mg B12 2.2mg folic acid/25mg B6/500mcg B12 400mg (no prescription required) 27mg/1mg 60mg/60mg/5mg (no prescription required) 50mg (no prescription required) 100mg (no prescription required) 50,000IU (no prescription required) $25 for 90 tablets $9 for 90 tablets $8 for a bottle of 120 $9 for up to 30 tablets $16 for a bottle of 100 $11 for a bottle of 100 $7 for a bottle of 100 $15 for 12 capsules Vitamin B Complex capsule (OTC) Vitamin B-6 tablet (OTC) Vitamin B-6 tablet (OTC) Vitamin D3 capsule (OTC) Ophthalmic Artificial Tears 1.4% drops (OTC) 15ml bottle (no prescription required) $9 per bottle Brimonidine Tartrate 0.2% Solution 0.2%/10ml dropper $15 per dropper Dorzolamide HCl 2% Solution 10ml dropper $15 per dropper Dorzolamide/Timolol Solution 2%/0.5% 10ml dropper $15 per dropper Latanoprost 0.005% Solution 2.5ml dropper $45 (limit 3) Oral Contraceptives Norethindrone tablet 28's (0.35mg) $35 $65 Norethindrone/Ethinyl Estradiol tablet 28's (0.4mg/0.035mg) $35 $65 Sprintec tablet 28's $35 (limit 3) $65 (limit 6) Tri-Sprintec tablet 28's $35 (limit 3) $65 (limit 6) Prostate Bicalutamide tablet 50mg $35 $65 Dutasteride capsule 0.5mg $40 for up to 30 capsules Finasteride tablet 5mg $25 $45 Tamsulosin capsule 0.4mg $30 $55 Uroxatral tablet $0* Thyroid Levothyroxine tablet mcg: 25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300 $20 Liothyronine Sodium tablet 5mcg, 25mcg $15 for up to 30 tablets Liothyronine Sodium tablet 50mcg $20 for up to 30 tablets Methimazole tablet 5mg, $9 for up to 30 tablets Propylthiouracil tablet 50mg $45 for up to 90 tablets SSKI oral solution 1g/ml dropper $20 per dropper SSKI oral solution 8 fl. oz. bottle (237ml) $25 per bottle Miscellaneous Alendronate tablet 70mg (Once a week dosage) $20 (limit 12) $40 (limit 24) Allopurinol tablet 100mg, 300mg $20 Benzonatate capsule 100mg $12 for up to 30 capsules Benzonatate capsule 200mg $15 for up to 30 capsules Bethanechol tablet 5mg,, 25mg, 50mg $25 Calcitriol capsule 0.25mcg $17 for up to 30 capsules Calcitriol capsule 0.5mcg $20 for up to 30 capsules Calcium acetate capsule 667mg $25 for up to 90 capsules Cevimeline HCl capsule 30mg $80 for up to 90 capsules

7 Miscellaneous (cont'd) Fortical Nasal Spray 2200 IU/ml (3.7mL bottle) $25 per bottle Levalbuterol Solution 1.25mg/3mL $55 for up to 24 vials Lidocaine 2% viscous solution 100ml $7 per bottle Oxandrolone tablet (CS) 2.5mg, (Requires statement of diagnosis by provider) $25 for up to 30 tablets Oxybutynin tablet 5mg $20 Oxybutynin Chloride ER tablet 5mg,, 15mg $45 $85 Pyridostigmine BR tablet 60mg $37 for up to 90 tablets Raloxifene tablet 60mg $45 for up to 30 tablets Risedronate Sodium tablet 35mg (once a week dosage) $50 per pack of 4 tablets Risedronate Sodium tablet 35mg (once a week dosage) $75 per pack of 12 tablets Risedronate Sodium tablet 150mg (once a month dosage) $80 per dosage Tolterodine Tartrate tablet 1mg, 2mg $30 for up to 30 tablets Vitamin D3 tablet (OTC) (cholecalciferol) 400IU (no prescription required) $11 for a bottle of 100 Important Reminders: If you want to order a new prescription for a 6-month supply, please ask your doctor to write it for a 180-day supply. You need to tell us if you want a 180-day supply. Rx Outreach is a fully licensed pharmacy. Rx Outreach reserves the right to add or delete medicines available, change fees, or discontinue the program at any time. Rx Outreach does not accept returns of unused medicine dispenses pursuant to a valid prescription or refund fees for any such prescription. You are responsible for the package upon delivery. All prescriptions are evaluated by a pharmacist before being filled. The quantity may be limited based on dose restrictions set by therapeutic guidelines and state regulations. We cannot ship controlled substances to a P.O. Box or doctor's office. Your shipping address for these must be a deliverable U.S. Postal Service street address Rx Outreach. All Rights Reserved Rx Outreach / P. O. Box / St. Louis, MO RXO DLRXO117