AMANTADINE 50 MG/5 ML SYRUP ACYCLOVIR 200 MG CAPSULES ACYCLOVIR 400 MG TABLETS ACYCLOVIR 800 MG TABLETS 30 90
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1 Antibiotics Qty* DRUG NAME $0.00 Copay $ 4.00 $ AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE) 150 AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE) 100 AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE) 80 AMOXICILLIN 200 MG/5 ML (100 ML BOTTLE) 100 AMOXICILLIN 200 MG/5 ML (75 ML BOTTLE) 75 AMOXICILLIN 200 MG/5 ML (50 ML BOTTLE) 50 AMOXICILLIN 250 MG CAPSULES 30 AMOXICILLIN 250 MG/5 ML (150 ML BOTTLE) 150 AMOXICILLIN 250 MG/5 ML (100 ML BOTTLE) 100 AMOXICILLIN 250 MG/5 ML (80 ML BOTTLE) 80 AMOXICILLIN 400 MG/5 ML (100 ML BOTTLE) 100 AMOXICILLIN 400 MG/5 ML (75 ML BOTTLE) 75 AMOXICILLIN 400 MG/5 ML (50 ML BOTTLE) 50 AMOXICILLIN 500 MG CAPSULES 30 AMOXICILLIN 875 MG TABLETS 20 AMPICILLIN 250 MG CAPSULES 28 AMPICILLIN 500 MG CAPSULES 28 CEPHALEXIN 250 MG CAPSULES 30 CEPHALEXIN 500 MG CAPSULES 30 CIPROFLOXACIN 250 MG TABLETS 20 CIPROFLOXACIN 500 MG TABLETS 20 CIPROFLOXACIN 750 MG TABLETS 14 CLINDAMYCIN 150 MG CASULES PENICILLIN V Pot 125/5 100 ML (100 ML BOTTLE) 100 PENICILLIN V Pot 125/5 200 ML (200 ML BOTTLE) 200 PENICILLIN VK 250 MG TABLETS 28 PENICILLIN VK 250/5 ML (100 ML BOTTLE) 100 PENICILLIN VK 250/5 ML (200 ML BOTTLE) 200 PENICILLIN VK 500 MG TABLETS 28 SULFAMETH/TRIMETH 400/80 MG TABLETS 28 SULFAMETH/TRIMETH 800/160 MG TABLETS 20 SULFASALAZINE 500 MG TABLETS $ 8.00 $ AMOX/K CLAV 500 MG TABLETS 20 AMOX/K CLAV 875 MG TABLETS 20 CLINDAMYCIN 300 MG CAPSULES N/A 30 ISONIAZID 300 MG TABLETS METRONIDAZOLE 250 MG TABLETS METRONIDAZOLE 500 MG TABLETS Antifungal Antiviral $ N/A AZITHROMYCIN 250 MG PAK (6 TABLETS) 6 FLUCONAZOLE 150 MG TABLETS 1 3 NYSTATIN 100 MU/ML ORAL SUSP DROP NYSTATIN 100 MU/ML ORAL SUSP TERBINAFINE 250 MG TABLETS AMANTADINE 50 MG/5 ML SYRUP ACYCLOVIR 200 MG CAPSULES ACYCLOVIR 400 MG TABLETS ACYCLOVIR 800 MG TABLETS 30 90
2 Arthritis/ Pain 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 $ 8.00 $ BACLOFEN 10 MG TABLETS DICLOFENAC SOD DR 50 MG TABLETS DICLOFENAC SOD DR 75 MG TABLETS Asthma/Resp/Allergies ALBUTEROL 2 MG/5 ML SYRUP ALBUTEROL SULFATE % NEB SOLN CETIRIZINE 10 MG TABLETS IPRATROPIUM BROMIDE 0.02% AMPULE LORATADINE 10 MG TABLETS $ IPRATROPIUM BROM/ALBUTEROL SUL Cholesterol $ $ FLUTICASONE 50 MCG NASAL SPRAY MONTELUKAST 5 MG TABLETS MONTELUKAST 10 MG TABLETS 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 $ $ ATORVASTATIN 10 MG TABLETS ATORVASTATIN 20 MG TABLETS ATORVASTATIN 40 MG TABLETS ATORVASTATIN 80 MG TABLETS 30 90
3 CNS Cough Diabetes 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 LAMOTRIGINE 100 MG TABLETS LAMOTRIGINE 150 MG TABLETS LAMOTRIGINE 200 MG TABLETS LAMOTRIGINE 25 MG TABLETS LAMOTRIGINE 25 MG CHEW TABS 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 $ 8.00 $ BENZTROPINE 2 MG TABLETS OXCARBAZEPINE 150 MG TABLETS OXCARBAZEPINE 300 MG TABLETS 60 OXCARBAZEPINE 600 MG TABLETS BENZONATATE 100 MG CAPSULES- UPDATED QUANTITY PROMETHAZINE/DM MG/5 ML SYRUP PROMETHAZINE 6.25/5 ML SYRUP* Qty* DRUG NAME $0.00 Copay $ 4.00 $ 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 225 METFORMIN 500 MG TABLETS 360 METFORMIN 850 MG TABLETS 270 METFORMIN ER 500 MG TABLETS METFORMIN ER 750 MG TABLETS
4 Diabetes Ear/Eye $ 5.00 N/A BLOOD GLUCOSE PREM TEST STRIPS 25 CT BY TOPCARE 25 BLOOD GLUCOSE LANCETS BY TOPCARE 100 $ 8.00 $ GLYBURIDE 5 MG TABLETS (MICRONASE) GLYBURIDE MCR 3 MG TABLETS GLYBURIDE MCR 6 MG TABLETS $ N/A BLOOD GLUCOSE PREM TEST STRIPS 50 CT BY TOPCARE 50 $ N/A BLOOD GLUCOSE PREM TEST STRIPS 100 CT BY TOPCARE 100 CIPROFLOXACIN 0.3% OPTHALMIC SOL 5 15 GENTAMICIN SUL 0.3% OPTHALMIC SOL 5 15 LATANOPROST 0.005% OPTHALMIC SOL (3 ML BOTTLE) N/A 3 TIMOLOL MAL 0.25% OPTHALMIC SOL (5 ML) 5 N/A TIMOLOL MAL 0.5% OPTHALMIC SOL (5 ML or 15 ML) 5 15 TOBRAMYCIN 0.3% OPHTHALMIC SOLUTION 5 15 TRIMETHOPRIM-POLY B OPTHALMIC SOL $ 8.00 $ TIMOLOL MAL 0.5% OPTHALMIC SOL (10 ML) 10 N/A Gastrointestinal FAMOTIDINE 20 MG TABLETS FAMOTIDINE 40 MG TABLETS METOCLOPRAMIDE 10 MG TABLETS METOCLOPRAMIDE 5 MG METOCLOPRAMIDE 5 MG/5 ML SYRUP 240 OMEPRAZOLE 20 MG CAPSULES ONDANSETRON 4 MG TABLETS ONDANSETRON 8 MG TABLETS ONDANSETRON ODT 4 MG TABLETS ONDANSETRON ODT 8 MG TABLETS 7 21 PROMETHAZINE 25 MG TABLETS RANITIDINE 15MG/ML SYRUP $ 4.00 $ LACTULOSE 10 MG/15 ML SOLUTION $ 8.00 $ DICYCLOMINE 10 MG CAPSULES DICYCLOMINE 20 MG TABLETS OMEPRAZOLE 40 MG CAPSULES PANTOPRAZOLE 20 MG TABLETS PANTOPRAZOLE 20 MG TABLETS RANITIDINE 150 MG TABLETS- NEW PRICE RANITIDINE 300 MG TABLETS- NEW PRICE 30 90
5 Heart and Blood Pressure Qty* DRUG NAME $0.00 Copay $ 4.00 $ AMLODIPINE 2.5 MG TABLETS 30 N/A AMLODIPINE 5 MG TABLETS 30 N/A AMLODIPINE 10 MG TABLETS 30 N/A 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 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 MG 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 180 LISINOPRIL 2.5 MG TABLETS 180 LISINOPRIL 20 MG TABLETS 180 LISINOPRIL 30 MG TABLETS 180 LISINOPRIL 40 MG TABLETS 180 LISINOPRIL 5 MG TABLETS 180 LISINOPRIL-HCTZ MG TABLETS LISINOPRIL-HCTZ MG TABLETS LISINOPRIL-HCTZ 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 TABLETS 30 90
6 Heart and Blood Pressure Qty* DRUG NAME $0.00 Copay $ 4.00 $ 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 $ 8.00 $ 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 MG TABLETS FOSINOPRIL/HCTZ MG TABLETS ISOSORBIDE MONONITRATE ER 30 MG TABLETS ISOSORBIDE MONONITRATE ER 60 MG TABLETS LOSARTAN POT 25 MG TABLETS LOSARTAN POT 50 MG TABLETS LOSARTAN POT 100 MG TABLETS LOSARTAN/HCTZ MG TABLETS LOSARTAN/HCTZ MG TABLETS LOSARTAN/HCTZ MG TABLETS TRIAMTERENE/HCTZ CAPSULES TRIAMTERENE/HCTZ 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 30 90
7 Mental Health 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 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 DRUG NAME $ 8.00 $ AMITRIPTYLINE 10 MG TABLETS AMITRIPTYLINE 25 MG TABLETS BUSPIRONE 15 MG TABLETS ESCITALOPRAM 5 MG TABLETS ESCITALOPRAM 10 MG TABLETS ESCITALOPRAM 20 MG TABLETS NORTRIPTYLINE 50 MG CAPSULES NORTRIPTYLINE 75 MG CAPSULES RISPERIDONE 4 MG TABLETS THIOTHIXENE 1 MG $ $ AMITRIPTYLINE 50 MG TABLETS DONEPEZIL 5 MG TABLETS DONEPEZIL 10 MG TABLETS $ $ AMITRIPTYLINE 75 MG TABLETS AMITRIPTYLINE 100 MG TABLETS Muscle Relaxants CYCLOBENZAPRINE 10 MG TABLETS CYCLOBENZAPRINE 5 MG TABLETS METHOCARBAMOL 500 MG TABLETS METHOCARBAMOL 750 MG TABLETS 30 90
8 Other Skin CHLORHEXADINE GLUCOSE 0.12% SOLN 480 DEXAMETHASONE.5 MG TABLETS DEXAMETHASONE 0.75 MG TABLETS DEXAMETHASONE 4 MG TABLETS 6 18 OXYBUTYNIN 5 MG/5 ML SYRUP 150 N/A 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 8 24 HYDROCORTISONE 1% CREAM 30 GM HYDROCORTISONE 2.5% CREAM 30 GM SILVER SULFADIAZINE 1% (25 GM) CREAM TRIAMCINOLONE 0.025% 15 GM (tube) CREAM TRIAMCINOLONE 0.1% 15 GM (tube) CREAM $ 8.00 $ SILVER SULFADIAZINE 1% (50 GM) CREAM 50 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 Thyroid Vaccines $ MUPIROCIN 2% OINTMENT 22 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 DRUG NAME Price ADACEL DECAVAC ENERGIX-B GARDASIL HAVRIX MENACTRA MMR PNEUMOVAX PREVNAR SEASONAL INFLUENZA HIGH DOSE SEASONAL INFLUENZA QUADRAVALENT SEASONAL INFLUENZA TRIVALENT TWINRIX TYPHIM VARIVAX VIVOTIF ZOSTAVAX
9 Vitamins/ Nutritional FOLIC ACID 1 MG TABLETS LUDENT CHEW FL 0.5 MG TABLETS LUDENT CHEW FL 1 MG TABLETS MAG-OXIDE 400 MG TABLETS Mens Health DRUG NAME $ 9.00 $ FINASTERIDE 5 MG TABLETS Womens Health 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 $ 9.00 $ ALENDRONATE SOD 35 MG TABLETS 4 12 ALENDRONATE SOD 70 MG TABLETS 4 12 CLOMIPHENE 50 MG TABLETS Day* 84- Day* $ 9.00 $ APRI MG-MCG TABLETS CYCLAFEM 1/35 MG-MCG TABLETS CYCLAFEM 7/7/7 TABLETS LEVONOR/ETH ESTRADIOL MG-MCG TABLETS LEVONOR/ETH ESTRADIOL MG-MCG TABLETS (A1 & A2) NORETHINDRONE 0.35 MG (A1) NORETHINDRONE 0.35 MG (A2) PREVIFEM 28 TABLETS TRI-PREVIFEM TABLETS Baby Club Benefits Qty* DRUG NAME $0.00 Copay MULTI-VIT/FLUORIDE 0.25 MG/ML DROPS (POLY-VI-FLOR) 50 MULTI-VIT/FLUORIDE 0.5 MG CHEW (POLY-VI-FLOR) 30 MULTI-VIT/FLUORIDE 0.5 MG/ML DROPS (POLY-VI-FLOR) 50 MULTI-VIT/IRON/FLUORIDE 0.25 MG/ML DROPS (POLY-VI-FLOR/FE) 50 MULTIVITAMIN/FLUORIDE 0.25 MG CHEW (POLY-VI-FLOR) 30 MVC-FLUORIDE 0.25 MG CHEW (POLY-VI-FLOR) 30 MVC CHEW W FL 0.25 MG TABLETS 30 MVC CHEW W FL 0.5 MG TABLETS 30 PNV FOLIC ACID PLUS MULTI 27-1 MG TAB (PRENATAL PLUS) 30 PRENATABS FA 29-1 MG TAB (NATATAB FA) 30 PRENATABS RX 29-1 MG TAB (PRENATAL PLUS IRON) 30 PRENATAL 19, 29-1 MG CHEW 30 PRENATAL 19, 29-1 MG TAB 30 PRENATAL PLUS 27-1 MG TAB 30 PRENATAL- U MG CAP 30 TRI-VIT/FLUORIDE 0.25 MG/ML DROPS (TRI-VI-FLOR) 50 TRI-VIT/FLUORIDE/IRON 0.25 MG/ML DROPS (TRI-VIT-FLOR/FE) 50
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