Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml 2160ml Hydroxyzine HCl Tab 10 MG 30 90 Hydroxyzine HCl Tab 25 MG 30 90 Hydroxyzine HCl Tab 50 MG 30 90 Loratadine 10mg tab 30 90 Montelukast Sodium Tab 10 MG 30 90 Promethazine DM syrup 120ml 360ml Promethazine HCl Syrup 6.25 MG/5ML 180ml 540ml Amoxicillin 125mg/5ml susp (80ml bottle) 80ml 240ml Amoxicillin 125mg/5ml susp (100ml bottle) 100ml 300ml Amoxicillin 125mg/5ml susp (150ml bottle) 150ml 450ml Amoxicillin 200mg/5ml susp (50ml bottle) 50ml 150ml Amoxicillin 200mg/5ml susp (75ml bottle) 75ml 225ml Amoxicillin 200mg/5ml susp (100ml bottle) 100ml 300ml Amoxicillin 250mg cap 30 90 Amoxicillin 250mg/5ml susp (80ml bottle) 80ml 240ml Amoxicillin 250mg/5ml susp (100ml bottle) 100ml 300ml $9/30 $24/90 Amoxicillin 250mg/5ml susp (150ml bottle) 150ml 450ml Amoxicillin 400mg/5ml susp (50ml bottle) 50ml 150ml Amoxicillin 400mg/5ml susp (75ml bottle) 75ml 225ml Amoxicillin 400mg/5ml susp (100ml bottle) 100ml 300ml Amoxicillin 500mg cap 30 90 Amoxicillin 500mg tab 12 36 Ceftriaxone Sodium For Inj 1 GM 1 3 Ceftriaxone Sodium For Inj 250 MG 1 3 Ceftriaxone Sodium For Inj 500 MG 1 3 Cephalexin 250mg cap 28 84 Cephalexin 500mg cap 30 90 Ciprofloxacin 250mg tab 14 42 Ciprofloxacin 500mg tab 20 60 Clindamycin Phosophate Inj 300 MG/2 ML 1 3 Penicillin VK 125mg/5ml susp (100ml bottle) 100ml 300ml Penicillin VK 250mg tab 28 84 SMZ-TMP 400mg-80mg tab 28 84 SMZ-TMP DS 800mg-160mg tab 20 60 Allopurinol 100mg tab 30 90 Allopurinol 300mg tab 30 90 Baclofen 10mg tab 30 90 Cyclobenzaprine 5mg tab 30 90 Feel free to speak to your Pharmacist Page 1 of 8
Arthritis & Pain Asthma Cholesterol Diabetes Cyclobenzaprine 10mg tab 30 90 Dexamethasone 0.5mg tab 30 90 Dexamethasone 0.75mg tab 12 36 Dexamethasone 4mg tab 6 18 Diclofenac DR 75mg tab 60 180 Ibuprofen 100mg/5ml susp 120ml 360ml Ibuprofen 400mg tab 90 270 Ibuprofen 600mg tab 60 180 Ibuprofen 800mg tab 30 90 Indomethacin 25mg cap 60 180 Meloxicam 7.5mg tab 30 90 Meloxicam 15mg tab 30 90 Naproxen 250mg tab 60 180 Naproxen 375mg tab 60 180 Naproxen 500mg tab 60 180 Albuterol 2mg tab 90 270 Albuterol 4mg tab 60 180 Albuterol 2mg/5ml syrup 120ml 360ml Ipratropium 0.02% nebulizer soln (25x2.5ml vials) 1 3 Atorvastatin Calcium Tab 10 MG (Base Equivalent) 30 90 Lovastatin Tab 10 MG 30 90 Lovastatin Tab 20 MG 30 90 Lovastatin Tab 40 MG 30 90 Simvastatin Tab 5 MG 30 90 Simvastatin Tab 10 MG 30 90 Simvastatin Tab 20 MG 30 90 Simvastatin Tab 40 MG 30 90 Simvastatin Tab 80 MG 30 90 Glimepiride 1mg tab 30 90 Glimepiride 2mg tab 30 90 Glimepiride 4mg tab 30 90 Glipizide 5mg tab 30 90 Glipizide 10mg tab 60 180 Glyburide 2.5mg tab 30 90 Glyburide 5mg tab 30 90 Glyburide, micronized 3mg tab 30 90 Glyburide, micronized 6mg tab 30 90 Metformin 500mg tab 60 180 Metformin 850mg tab 60 180 Metformin 1000mg tab 60 180 Metformin 500mg ER tab 60 180 Pioglitazone HCl Tab 15 MG (Base Equiv) 30 90 Feel free to speak to your Pharmacist Page 2 of 8
Fungal Infections Gastrointestinal Health Glaucoma & Eye Care Heart Health & Blood Pressure Clotrimazole Cream 1% 30 90 Fluconazole 150mg tab 1 3 Nystatin cream (15gm tube) 1 3 Nystatin cream (30gm tube) 1 3 Terbinafine 250mg tab 30 90 Dicyclomine 10mg cap 90 270 Dicyclomine 20mg tab 60 180 Famotidine 20mg tab 60 180 Famotidine 40mg tab 30 90 Lactulose syrup 236ml 708ml Metoclopramide 10mg tab 60 180 Metoclopramide syrup 60ml 180ml Omeprazole Cap DR 20 MG 30 90 Omeprazole Cap DR 40 MG 30 90 Pantoprazole Sodium EC Tab 40 MG 30 90 Promethazine HCl Tab 12.5 MG 12 36 Promethazine 25mg tab 12 36 Promethazine plain syrup 180ml 540ml Ranitidine 150mg tab 60 180 Ranitidine 300mg tab 30 90 Ranitidine HCl Syrup 15mg/ml (75 mg/5ml) 60 180 Erythromycin op. ointment (3.5gm tube) 3.5gm 10.5gm Gentak 0.3% op. soln 5 15 Gentamicin 0.3% op. soln (5ml bottle) 5ml 15ml Levobunolol 0.5% op. soln (5ml bottle) 5ml 15ml $9/30 $24/90 Neomycin/Polymyxin/Dexamethasone 0.1% op. ointment (3.5gm tube) 3.5 g Neomycin/Polymyxin/Dexamethasone 0.1% op. susp (5ml bottle) 5ml 15ml Pilocarpine 1% op. soln (15ml bottle) 15ml 45ml Pilocarpine 2% op. soln (15ml bottle) 15ml 45ml Polymyxin Sulfate/TMP op. soln (10ml bottle) 10ml 30ml Timolol Maleate 0.25% op. soln (5ml bottle) 5ml 15ml Timolol Maleate 0.5% op soln (5ml bottle) 5ml 15ml Tobramycin 0.3% op. soln (5ml bottle) 5ml 15ml Amlodipine Besylate Tab 2.5 MG 30 90 Amlodipine Besylate Tab 5 MG 30 90 Amlodipine Besylate Tab 10 MG 30 90 Atenolol 25mg tab 30 90 Atenolol 50mg tab 30 90 Atenolol 100mg tab 30 90 Benazepril 5mg tab 30 90 10.5 g Feel free to speak to your Pharmacist Page 3 of 8
Heart Health & Blood Pressure Benazepril 10mg tab 30 90 Benazepril 20mg tab 30 90 Benazepril 40mg tab 30 90 Bisoprolol-HCTZ 2.5mg-6.25mg tab 30 90 Bisoprolol-HCTZ 5mg-6.25mg tab 30 90 Bisoprolol-HCTZ 10mg-6.25mg tab 30 90 Carvedilol 3.125mg tab 60 180 Carvedilol 6.25mg tab 60 180 Carvedilol 12.5mg tab 60 180 Carvedilol 25mg tab 60 180 Clonidine 0.1mg tab 30 90 Clonidine 0.2mg tab 30 90 Clonidine HCl Tab 0.3 MG 30 90 Clopidogrel Bisulfate Tab 75 MG 30 90 Dopamine HCl Inj 40 MG/ML 5 15 Enalapril-HCTZ 5mg-12.5mg tab 30 90 Furosemide 20mg tab 30 90 Furosemide 40mg tab 30 90 Furosemide 80mg tab 30 90 Guanfacine 1mg tab 30 90 Hydralazine 10mg tab 30 90 Hydralazine 25mg tab 30 90 Hydrochlorothiazide (HCTZ) 12.5mg tab 30 90 Hydrochlorothiazide (HCTZ) 12.5mg cap 30 90 Hydrochlorothiazide (HCTZ) 25mg tab 30 90 Hydrochlorothiazide (HCTZ) 50mg tab 30 90 Indapamide 1.25mg tab 30 90 Indapamide 2.5mg tab 30 90 Isosorbide Mononitrate 30mg ER tab 30 90 Isosorbide Mononitrate 60mg ER tab 30 90 Lisinopril-HCTZ 10mg-12.5mg tab 30 90 Lisinopril-HCTZ 20mg-12.5mg tab 30 90 Lisinopril-HCTZ 20mg-25mg tab 30 90 Lisinopril 2.5mg tab 30 90 Lisinopril 5mg tab 30 90 Lisinopril 10mg tab 30 90 Lisinopril 20mg tab 30 90 Lisinopril Tab 30 MG 30 90 Lisinopril Tab 40 MG 30 90 Losartan Potassium & Hydrochlorothiazide Tab 100-25 MG 30 90 Losartan Potassium & Hydrochlorothiazide Tab 50-12.5 MG 30 90 Losartan Potassium & Hydrochlorothiazide Tab 100-12.5 MG 30 90 Losartan Potassium Tab 25 MG 30 90 Feel free to speak to your Pharmacist Page 4 of 8
Heart Health & Blood Pressure Men's Health Mental Health Losartan Potassium Tab 50 MG 30 90 Losartan Potassium Tab 100 MG 30 90 Methyldopa 250mg tab 60 180 Metoprolol Tartrate 25mg tab 60 180 Metoprolol Tartrate 50mg tab 60 180 Metoprolol Tartrate 100mg tab 60 180 Ramipril Cap 2.5 MG 30 90 Ramipril Cap 5 MG 30 90 Ramipril Cap 10 MG 30 90 Sotalol HCL 80mg tab 30 90 Spironolactone 25mg tab 30 90 Terazosin 1mg cap 30 90 Terazosin 2mg cap 30 90 Terazosin 5mg cap 30 90 Terazosin 10mg cap 30 90 Torsemide Tab 10 MG 30 90 Triamterene-HCTZ 75mg-50mg tab 30 90 Triamterene-HCTZ 37.5mg-25mg tab 30 90 Valsartan Tab 80 MG 30 90 Verapamil 80mg tab 30 90 Verapamil 120mg tab 30 90 Warfarin 1mg tab 30 90 Warfarin 2mg tab 30 90 Warfarin 2.5mg tab 30 90 Warfarin 3mg tab 30 90 Warfarin 4mg tab 30 90 Warfarin 5mg tab 30 90 Warfarin 6mg tab 30 90 Warfarin 7.5mg tab 30 90 Warfarin 10mg tab 30 90 $9/30 Finasteride 5mg tab 30 Amitriptyline 10mg tab 30 90 Amitriptyline 25mg tab 30 90 Amitriptyline 50mg tab 30 90 Amitriptyline 75mg tab 30 90 Amitriptyline 100mg tab 30 90 Benztropine 2mg tab 30 90 Buspirone 5mg tab 60 180 Buspirone 10mg tab 60 180 Citalopram 10mg tab 30 90 Citalopram 20mg tab 30 90 Citalopram 40mg tab 30 90 Feel free to speak to your Pharmacist Page 5 of 8
Mental Health Donepezil Hydrochloride Tab 5 MG 30 90 Donepezil Hydrochloride Tab 10 MG 30 90 Doxepin HCl Conc 10 MG/ML 30 90 Escitalopram Oxalate Tab 20 MG (Base Equiv) 30 90 Fluoxetine HCl Solution 20 MG/5ML 75 225 Fluoxetine 10mg cap 30 90 Fluoxetine 10mg tab 30 90 Fluoxetine 20mg cap 30 90 Fluoxetine 40mg cap 30 90 Haloperidol 0.5mg tab 30 90 Haloperidol 1mg tab 30 90 Haloperidol 2mg tab 30 90 Haloperidol 5mg tab 30 90 Haloperidol Lactate Inj 5 MG/ML 1 3 Hydroxyzine Pamoate Cap 50 MG 30 90 Imipramine HCl Tab 10 MG 30 90 Imipramine HCl Tab 25 MG 30 90 Lamotrigine Tab 100 MG 30 90 Lamotrigine Tab 200 MG 30 90 Lithium Carbonate 150mg cap 30 90 Lithium Carbonate 300mg cap 90 270 Mirtazapine Tab 15mg 30 90 Nortriptyline 10mg cap 30 90 Nortriptyline 25mg cap 30 90 Paroxetine 10mg tab 30 90 Paroxetine 20mg tab 30 90 Paroxetine 30mg tab 30 90 Prochlorperazine 10mg tab 30 90 Quetiapine Fumarate Tab 25 MG 30 90 Quetiapine Fumarate Tab 50 MG 30 90 Quetiapine Fumarate Tab 100 MG 30 90 Risperidone Tab 0.25 MG 30 90 Risperidone Tab 0.5 MG 30 90 Risperidone Tab 1 MG 30 90 Risperidone Tab 2 MG 30 90 Risperidone Tab 3 MG 30 90 Sertraline HCl Tab 25 MG 30 90 Sertraline HCl Tab 50 MG 30 90 Sertraline HCl Tab 100 MG 30 90 Topiramate Tab 25 MG 60 180 Trazodone 50mg tab 30 90 Trazodone 100mg tab 30 90 Feel free to speak to your Pharmacist Page 6 of 8
Mental Health Parkinson's Disease Skin Conditions Thyroid Conditions Trazodone 150mg tab 30 90 Trihexyphenidyl 2mg tab 60 180 Pramipexole Dihydrochloride Tab 0.125 MG 30 90 Pramipexole Dihydrochloride Tab 0.25 MG 30 90 Pramipexole Dihydrochloride Tab 0.5 MG 30 90 Pramipexole Dihydrochloride Tab 1 MG 30 90 Hydrocortisone Oint 1% 28.35g 85.05g Hydrocortisone 1% cream (28.35-30g tube) 28.35g 85.05g Hydrocortisone 2.5% cream (30gm tube) 30g 90g Hydrocortisone Oint 2.5% 28.35g 85.05g Lidocaine HCl Local Inj 1% 20 60 Lidocaine HCl Local Preservative Free (PF) Inj 1% 30 90 Lidocaine-Prilocaine Cream Kit 2.5-2.5% 1 3 Silver Sulfadiazine 1% cream* (50gm tube) 50 150 Triamcinolone 0.025% cream (15gm tube) 15 45 Triamcinolone 0.025% cream (80gm tube) 80 240 Triamcinolone 0.1% cream (15gm tube) 15 45 Triamcinolone 0.1% cream (80gm tube) 80 240 Triamcinolone 0.1% ointment (15gm tube) 15 45 Triamcinolone 0.1% ointment (80gm tube) 80 240 Triamcinolone 0.5% cream (15gm tube) 15 45 Levothyroxine 25mcg tab 30 90 Levothyroxine 50mcg tab 30 90 Levothyroxine 75mcg tab 30 90 Levothyroxine 88mcg tab 30 90 Levothyroxine 100mcg tab 30 90 Levothyroxine 112mcg tab 30 90 Levothyroxine 125mcg tab 30 90 Levothyroxine 137mcg tab 30 90 Levothyroxine 150mcg tab 30 90 Levothyroxine 175mcg tab 30 90 Levothyroxine 200mcg tab 30 90 Viruses Acyclovir 200mg cap 30 90 Vitamins & Ergocalciferol Cap 50000 IU 4 12 Nutritional Health Folic Acid 1mg tab 30 90 Mag 64 64mg tab 60 180 Magnesium Oxide 400mg tab 30 90 Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.5 MG 30 90 Pediatric Multiple Vitamins w/ Fluoride Chew Tab 1 MG 30 90 Prenatal Plus qty 30 30 90 Sodium Fluoride.25mg chewable (120ct bottle) 1 n/a Sodium Fluoride Chew Tab 0.5 MG (from 1.1 MG NaF) 30 90 Feel free to speak to your Pharmacist Page 7 of 8
Sodium Fluoride Chew Tab 0.55 MG 30 90 Drug Category Vitamins & Nutritional Health Sodium Fluoride Chew Tab 1 MG (from 2.2 MG NaF) 30 90 Sodium Fluoride Cream 1.1% 51 153 Women's Health $9/30 $24/90 Other Alendronate SOD 35mg tab 4 12 Alendronate SOD 70mg tab 4 12 Clomiphene 50mg tab 5 15 Estradiol 0.5mg tab 30 90 Estradiol 1mg tab 30 90 Estradiol 2mg tab 30 90 Medroxyprogesterone Acetate 2.5mg tab 30 90 Medroxyprogesterone Acetate 5mg tab 30 90 Medroxyprogesterone Acetate 10mg tab 10 30 Oral Contraceptives $9 Levonorgestrel/Ethinyl Estradiol 28 Kurvelo 28 Norethindrone USP 0.35mg 28 Enskyce 28 Jencycla 28 Pirmella 1/35 28 Pirmella 7/7/7 28 Sprintec 28 Tri-Sprintec 28 Chlorhexidine Gluconate 0.12% soln (473ml bottle) 473ml 1419ml Megestrol 20mg tab 30 90 Ondansetron HCl Inj 40 MG/20ML (2 MG/ML) 20 60 Ondansetron HCl Tab 4 MG 30 90 Prednisone 2.5mg tab 30 90 Prednisone 5mg tab 30 90 Primidone Tab 50 MG 30 90 Ropinirole Hydrochloride Tab 0.25 MG 30 90 Ropinirole Hydrochloride Tab 0.5 MG 30 90 Ropinirole Hydrochloride Tab 2 MG 30 90 Ropinirole Hydrochloride Tab 3 MG 30 90 Ropinirole Hydrochloride Tab 4 MG 30 90 Sodium Chloride Inj 0.9% 30 90 Sodium Chloride Inj 4 meq/ml (23.4%) 60 180 Disclaimer: / prescriptions include up to a 90-day supply of covered drugs at commonly prescribed doses. $9/$24 prescriptions include up to a 90-day supply of covered drugs at commonly prescribed dosages. Physician permission may be required to change a 30-day prescription to a 90-day prescription. This list is subject to change. Feel free to speak to your Pharmacist Page 8 of 8