Value-Priced Medication list
In addition to the discounts on thousands of brand-name and all generic medications that Walgreens Prescription
Savings Club members enjoy, club members may now receive even deeper
discounts on these 700+ generics through a three-tier formulary.**
The price for a generic drug is based on its tier and whether it is a 30-day or 90-day supply:
• 30-day-supply drugs cost $5 (tier 1), $10 (tier 2) or $15 (tier 3)
• 90-day-supply drugs cost $10 (tier 1), $20 (tier 2) or $30 (tier 3)
arthritis or Pain (cont.)
Value Generics
antifungal
Drug Name
FLUCONAZOLE 50MG TAB
FLUCONAZOLE 150MG TAB
TERBINAFINE 250MG TAB
Drug Name
Tier
3
2
2
Quantity
30 90
TIZANIDINE 2MG TAB
TRAMADOL 50MG TAB
20
1
30
asthma
60
3
90
antimalaria
Drug Name
MEFLOQUINE HCL 250MG TAB
Tier
3
Quantity
30 90
5
15
antiviral
Drug Name
ACYCLOVIR 200MG CAP
ACYCLOVIR 400MG TAB
ACYCLOVIR 800MG TAB
Tier
Quantity
30 90
2
2
2
60 180
60 180
35 105
Tier
Quantity
30 90
arthritis or Pain
Drug Name
BACLOFEN 10MG TAB
BACLOFEN 20MG TAB
CARISOPRODOL 350MG TAB
CHLORZOXAZONE 500MG TAB
CYCLOBENZAPRINE 5MG TAB
CYCLOBENZAPRINE 10MG TAB
DICLOFENAC POTASSIUM 50MG TAB
DICLOFENAC SODIUM 25MG TAB
DICLOFENAC SODIUM 50MG TAB
DICLOFENAC SODIUM 75MG EC TAB
DICLOFENAC SODIUM 100MG ER TAB
ETODOLAC 300MG CAP
ETODOLAC ER 400 TAB
FLURBIPROFEN 50MG TAB
FLURBIPROFEN 100MG TAB
IBUPROFEN 100MG/5ML ORAL SUSP
IBUPROFEN 400MG TAB
IBUPROFEN 600MG TAB
IBUPROFEN 800MG TAB
INDOMETHACIN 25MG CAP
INDOMETHACIN 50MG CAP
KETOPROFEN 50MG CAP
KETOPROFEN 75MG CAP
KETOROLAC 10MG TAB
KETOROLAC 30MG/ML INJ, 2ML
LEFLUNOMIDE 10MG TAB
MELOXICAM 7.5MG TAB
MELOXICAM 15MG TAB
NABUMETONE 500MG TAB
NAPROXEN 250MG TAB
NAPROXEN 375MG TAB
NAPROXEN 500MG TAB
NAPROXEN 375MG DR TAB
NAPROXEN DR 500MG TAB
NAPROXEN SODIUM 275MG TAB
NAPROXEN SODIUM 550MG TAB
OXAPROZIN 600MG TAB
SULINDAC 150MG TAB
2
3
3
3
2
2
3
3
3
3
3
3
3
3
3
2
2
2
2
2
1
3
3
2
3
3
2
2
3
1
1
1
3
3
1
3
3
3
90
90
90
60
30
30
60
60
60
60
30
60
30
60
60
120
90
60
60
60
30
90
60
15
15
30
30
30
60
60
60
60
60
60
30
30
60
60
270
270
270
180
90
90
180
180
180
180
90
180
90
180
180
360
270
180
180
180
90
270
180
45
45
90
90
90
180
180
180
180
180
180
90
90
180
180
Drug Name
ALBUTEROL 0.083% INH SOLN 25X3ML
ALBUTEROL 0.5% INH SOL 20ML
ALBUTEROL SULFATE 2MG TAB
ALBUTEROL SULFATE 4MG TAB
ALBUTEROL SULF INH SOLN 1.25MG/3ML
ALBUTEROL SULFATE SYRUP (2MG/5ML)
AMINOPHYLLINE 100MG TAB
AMINOPHYLLINE 200MG TAB
DYPHYLLINE-GG 100-100 ELIXIR
DYPHYLLIN-GG TAB
IPRATROPIUM INHAL SOLN 60 X 2.5ML
TERBUTALINE 2.5MG TAB
TERBUTALINE 5MG TAB
THEOPHYLLINE 200MG CR TAB
THEOPHYLLINE 300MG CR TAB
THEOPHYLLINE 100MG ER TAB
THEOPHYLLINE 200MG ER TAB
Blood Pressure/Heart Health (cont.)
Tier
Quantity
30 90
3
3
60 180
120 360
Tier
Quantity
30 90
2
2
2
3
3
1
2
2
2
3
2
3
3
3
3
2
3
75
20
60
60
90
120
60
60
240
30
75
30
30
60
60
60
60
225
60
180
180
270
360
180
180
720
90
225
90
90
180
180
180
180
Blood Pressure/Heart Health
Drug Name
AMILORIDE 5MG / HCTZ 50MG TAB
AMIODARONE 200MG TAB
AMLODIPINE BESYLATE 2.5MG TAB
AMLODIPINE BESYLATE 5MG TAB
AMLODIPINE BESYLATE 10MG TAB
AMLODIPINE-BENAZ 2.5/10MG CAP
AMLODIPINE-BENAZ 5/10MG CAP
AMLODIPINE-BENAZ 5/20MG CAP
AMLODIPINE-BENAZ 10/20MG CAP
ATENOLOL 100MG TAB
ATENOLOL 100MG/CHLORTHAL 25MG TAB
ATENOLOL 25MG TAB
ATENOLOL 50MG TAB
ATENOLOL/CHLORTHALIDONE 50/25 TAB
BENAZEPRIL 5MG TAB
BENAZEPRIL 10MG TAB
BENAZEPRIL 20MG TAB
BENAZEPRIL 40MG TAB
BENAZEPRIL/HCTZ 5/6.25MG TAB
BENAZEPRIL/HCTZ 10/12.5MG TAB
BENAZEPRIL/HCTZ 20/12.5MG TAB
BENAZEPRIL/HCTZ 20/25MG TAB
BISOPROLOL FUMARATE 5MG TAB
BISOPROLOL/HCTZ 2.5MG/6.25MG TAB
BISOPROLOL/HCTZ 5MG/6.25MG TAB
BISOPROLOL/HCTZ 10MG/6.25MG TAB
BUMETANIDE 0.5MG TAB
BUMETANIDE 1MG TAB
BUMETANIDE 2MG TAB
CAPTOPRIL 12.5MG TAB
CAPTOPRIL 25MG TAB
CAPTOPRIL 50MG TAB
CAPTOPRIL 100MG TAB
Tier
2
1
2
2
2
3
3
3
3
1
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
3
2
2
2
2
Quantity
30 90
30
30
30
30
30
30
30
30
30
30
30
60
60
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
60
60
60
60
90
90
90
90
90
90
90
90
90
90
90
180
180
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
90
180
180
180
180
Drug Name
CAPTOPRIL/HCTZ 25/15 TAB
CAPTOPRIL/HCTZ 25/25 TAB
CAPTOPRIL/HCTZ 50/15 TAB
CAPTOPRIL/HCTZ 50/25 TAB
CARTIA 120MG XT CAP
CARVEDILOL 3.125MG TAB
CARVEDILOL 6.25MG TAB
CARVEDILOL 12.5MG TAB
CARVEDILOL 25MG TAB
CHLOROTHIAZIDE 250MG TAB
CHLOROTHIAZIDE 500MG TAB
CHLORTHALIDONE 25MG TAB
CHLORTHALIDONE 50MG TAB
CILOSTAZOL 50MG TAB
CILOSTAZOL 100MG TAB
CLONIDINE 0.1MG TAB
CLONIDINE 0.2MG TAB
CLONIDINE 0.3MG TAB
DIGOXIN 0.125MG TAB
DIGOXIN 0.25MG TAB
DILTIAZEM 30MG TAB
DILTIAZEM 60MG TAB
DILTIAZEM 90MG TAB
DILTIAZEM 120MG TAB
DILTIAZEM ER 120MG CAP (XR-24HR)
DIPYRIDAMOLE 25MG TAB
DIPYRIDAMOLE 50MG TAB
DIPYRIDAMOLE 75MG TAB
DOXAZOSIN 1MG TAB
DOXAZOSIN 2MG TAB
DOXAZOSIN 4MG TAB
DOXAZOSIN 8MG TAB
ENALAPRIL 2.5MG TAB
ENALAPRIL 5MG TAB
ENALAPRIL 10MG TAB
ENALAPRIL 20MG TAB
ENALAPRIL-HCTZ 5-12.5MG TAB
ENALAPRIL-HCTZ 10-25MG TAB
FOSINOPRIL 10MG TAB
FOSINOPRIL 20MG TAB
FOSINOPRIL 40MG TAB
FUROSEMIDE 8MG/ML SOLN
FUROSEMIDE 10MG/ML ORAL SOLN 60ML
FUROSEMIDE 20MG TAB
FUROSEMIDE 40MG TAB
FUROSEMIDE 80MG TAB
GUANFACINE 1MG TAB
GUANFACINE 2MG TAB
HYDRALAZINE 10MG TAB
HYDRALAZINE 25MG TAB
HYDRALAZINE 50MG TAB
HYDROCHLOROTHIAZIDE 12.5MG CAP
HYDROCHLOROTHIAZIDE 12.5MG TAB
HYDROCHLOROTHIAZIDE 25MG TAB
HYDROCHLOROTHIAZIDE 50MG TAB
INDAPAMIDE 1.25MG TAB
INDAPAMIDE 2.5MG TAB
ISOSORBIDE DINITRATE 5MG ORAL TAB
ISOSORBIDE DINITRATE 10MG ORAL TAB
ISOSORBIDE DINITRATE 20MG ORAL TAB
ISOSORBIDE DINITRATE 30MG ORAL TAB
Tier
2
2
3
3
3
2
2
2
2
2
3
3
3
3
3
2
2
2
1
1
2
2
2
2
3
3
3
3
2
2
2
2
1
1
1
1
1
1
2
2
2
3
3
1
1
1
2
2
1
2
3
2
3
1
1
2
2
1
2
2
3
Quantity
30 90
60
60
60
60
30
60
60
60
60
60
60
30
30
60
60
60
60
60
30
30
60
60
60
30
30
60
60
60
30
30
30
30
60
60
60
60
60
30
30
30
30
120
90
60
60
30
30
30
60
60
90
30
30
30
30
30
30
90
90
90
60
180
180
180
180
90
180
180
180
180
180
180
90
90
180
180
180
180
180
90
90
180
180
180
90
90
180
180
180
90
90
90
90
180
180
180
180
180
90
90
90
90
360
270
180
180
90
90
90
180
180
270
90
90
90
90
90
90
270
270
270
180
Value-Priced Medication List (cont.)
Blood Pressure/Heart Health (cont.)
Drug Name
Tier
ISOSORBIDE DINITRATE 2.5MG SL TAB
2
ISOSORBIDE DINITRATE 5MG SUBL TAB
3
ISOSORBIDE MONONITRATE 10MG TAB
3
ISOSORBIDE MONONITRATE 20MG TAB
3
ISOSORBIDE MONONITRATE 30MG ER TAB 2
ISOSORBIDE MONONITRATE 60MG ER TAB 2
ISOSORBIDE MONONITRATE 120MG ER TAB 3
LABETALOL 100MG TAB
2
LABETALOL 200MG TAB
2
LISINOPRIL 2.5MG TAB
2
LISINOPRIL 5MG TAB
2
LISINOPRIL 10MG TAB
1
LISINOPRIL 20MG TAB
1
LISINOPRIL 30MG TAB
2
LISINOPRIL 40MG TAB
2
LISINOPRIL-HCTZ 10/12.5MG TAB
2
LISINOPRIL-HCTZ 20/12.5MG TAB
2
LISINOPRIL-HCTZ 20/25MG TAB
2
LOSARTAN/HCTZ 100/12.5MG TAB
3
METHYLDOPA 250MG TAB
3
METHYLDOPA 500MG TAB
3
METOLAZONE 2.5MG TAB
3
METOLAZONE 5MG TAB
3
METOLAZONE 10MG TAB
3
METOPROLOL TARTRATE 25MG TAB
2
METOPROLOL TARTRATE 50MG TAB
2
METOPROLOL TARTRATE 100MG TAB
2
MOEXIPRIL 7.5MG TAB
3
MOEXIPRIL 15MG TAB
3
MOEXIPRIL/HCTZ 7.5-12.5MG TAB
3
MOEXIPRIL/HCTZ 15-12.5MG TAB
3
MOEXIPRIL/HCTZ 15-25MG TAB
3
NADOLOL 20MG TAB
2
NADOLOL 40MG TAB
2
NADOLOL 80MG TAB
3
NICARDIPINE 20MG CAP
3
NIFEDIAC CC 60MG ER TAB
3
NITROGLYCERIN 2.5MG SR CAP
1
NITROGLYCERIN 6.5MG SR 100
1
PENTOXIFYLLINE 400MG ER TAB
3
PERINDOPRIL 4MG TAB
3
PRAZOSIN 1MG CAP
1
PRAZOSIN 2MG CAP
2
PRAZOSIN HCL 5MG CAP
2
PROPAFENONE 150MG TAB
3
PROPRANOLOL 10MG TAB
2
PROPRANOLOL 20MG TAB
2
PROPRANOLOL 40MG TAB
2
PROPRANOLOL 60MG TAB
3
PROPRANOLOL 80MG TAB
2
PROPRANOLOL ER 60MG CAP
3
PROPRANOLOL ER 80MG CAP
3
PROPRANOLOL ER 120MG CAP
3
PROPRANOLOL ER 160MG CAP
3
QUINAPRIL 5MG TAB
2
QUINAPRIL 10MG TAB
2
QUINAPRIL 20MG TAB
2
QUINAPRIL 40MG TAB
2
QUINAPRIL/HCTZ 10-12.5MG TAB
3
QUINIDINE SULFATE 200MG (3GR) TAB
3
RAMIPRIL 1.25MG CAP
3
SOTALOL 120MG TAB
2
SOTALOL 160MG TAB
3
SPIRONOLACTONE 25MG TAB
2
SPIRONOLACTONE 50MG TAB
2
SPIRONOLACTONE 25MG W/HCTZ 25MG TAB2
TERAZOSIN 1MG CAP
2
TERAZOSIN 2MG CAP
2
TERAZOSIN 5MG CAP
2
TERAZOSIN 10MG CAP
2
TICLOPIDINE 250MG TAB
3
TORSEMIDE 5MG TAB
3
TORSEMIDE 10MG TAB
3
TORSEMIDE 20MG TAB
3
TORSEMIDE 100MG** TAB
3
2
Blood Pressure/Heart Health (cont.)
Quantity
30 90
30
120
60
60
30
30
30
60
60
30
30
30
30
30
30
30
30
30
30
60
60
30
30
30
60
60
60
30
30
30
30
30
30
30
30
60
30
30
30
60
30
30
60
60
90
60
60
60
60
60
30
30
30
30
30
30
30
30
30
90
30
60
60
30
30
30
30
30
30
30
60
30
30
30
30
90
360
180
180
90
90
90
180
180
90
90
90
90
90
90
90
90
90
90
180
180
90
90
90
180
180
180
90
90
90
90
90
90
90
90
180
90
90
90
180
90
90
180
180
270
180
180
180
180
180
90
90
90
90
90
90
90
90
90
270
90
180
180
90
90
90
90
90
90
90
180
90
90
90
90
Drug Name
TRANDOLAPRIL 1MG TAB
TRANDOLAPRIL 2MG TAB
TRANDOLAPRIL 4MG TAB
TRIAMTERENE 37.5MG/ HCTZ 25MG CAP
TRIAMTERENE 37.5MG/ HCTZ 25MG TAB
TRIAMTERENE 75MG/ HCTZ 50MG TAB
VERAPAMIL 40MG TAB
VERAPAMIL 80MG TAB
VERAPAMIL 120MG TAB
VERAPAMIL 120MG ER CAP
VERAPAMIL 180MG ER CAP
VERAPAMIL 240MG ER CAP
VERAPAMIL ER 100MG CAP (24 HR)
VERAPAMIL ER 120MG TAB
VERAPAMIL ER 180MG TAB
VERAPAMIL ER 240MG TAB
WARFARIN SOD 1MG TAB
WARFARIN SOD 2.5MG TAB
WARFARIN SOD 2MG TAB
WARFARIN SOD 3MG TAB
WARFARIN SOD 4MG TAB
WARFARIN SOD 5MG TAB
WARFARIN SOD 6MG TAB
WARFARIN SOD 7.5MG TAB
WARFARIN SOD 10MG** TAB
cough/cold/allergy (cont.)
Tier
Quantity
30 90
2
1
2
2
2
1
3
1
2
3
3
3
3
3
3
3
1
1
1
1
1
2
2
2
2
30 90
30 90
30 90
30 90
30 90
30 90
60 180
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
Tier
Quantity
30 90
3
3
1
1
1
1
1
1
3
2
2
2
3
3
30 90
60 180
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
Tier
Quantity
30 90
cholesterol
Drug Name
FENOFIBRATE 54MG TAB
GEMFIBROZIL 600MG TAB
LOVASTATIN 10MG TAB
LOVASTATIN 20MG TAB
LOVASTATIN 40MG TAB
PRAVASTATIN 10MG TAB
PRAVASTATIN 20MG TAB
PRAVASTATIN 40MG TAB
PRAVASTATIN 80MG TAB
SIMVASTATIN 5MG TAB
SIMVASTATIN 10MG TAB
SIMVASTATIN 20MG TAB
SIMVASTATIN 40MG TAB
SIMVASTATIN 80MG TAB
cough/cold/allergy
Drug Name
BENZONATATE 100MG CAP
BENZONATATE 200MG CAP
BROMDEX D SYRUP
CETIRIZINE 1MG/ML SYRUP
CETIRIZINE 10MG TAB
CLEMASTINE 2.68MG TAB
CLEMASTINE FUMARATE SYRUP
CYPROHEPTADINE 2MG/5ML SYRUP
CYPROHEPTADINE 4MG TAB
DE-CHLOR DM LIQUID
DE-CHLOR DR SYRUP
DEHISTINE SYRUP
DIPHENHYDRAMINE 50MG CAP
FLUTICASONE NASAL SP (120INH) 16GM
IPRATROPIUM 0.03% NASAL SPRAY 30ML
IPRATROPIUM 0.06% NASAL SPRAY 15ML
LORATADINE 10MG TAB
NOHIST TAB
ORGAN-I NR 200MG TAB
OR-LORATADINE-D 24HR TAB
PBM ALLERGY SYRUP
PHENYLTOLOXAMINE PE CPM SYRUP
PROMETHAZINE 12.5MG SUPP
PROMETHEGAN 25MG SUPP
PROMETHAZINE 6.25MG/5ML SYRUP
PROMETHAZINE 12.5MG TAB
PROMETHAZINE 25MG TAB
PROMETHAZINE 50MG TAB
PROMETHAZINE DM SYRUP
1
3
3
3
2
3
3
3
1
2
2
3
2
3
3
3
1
3
3
3
3
2
3
3
2
1
1
2
2
30
30
120
120
30
60
240
120
60
120
180
240
30
16
30
15
30
30
120
30
120
240
9
12
240
12
12
60
180
90
90
360
360
90
180
720
360
180
360
540
720
90
48
90
45
90
90
360
90
360
720
27
36
720
36
36
180
540
Drug Name
QUARTUSS DM DROPS 30ML
QV-ALLERGY SYRUP
REME TUSSIN DM SYRUP
SILDEC PE-DM SYRUP
SILDEC-PE SYRUP
SUPRESS-DX PED DROPS 30ML
TRIPOHIST LIQUID
Tier
3
3
3
1
1
3
3
Quantity
30 90
30
240
150
120
120
30
120
90
720
450
360
360
90
360
Diabetes
Drug Name
GLIMEPIRIDE 1MG TAB
GLIMEPIRIDE 2MG TAB
GLIMEPIRIDE 4MG TAB
GLIPIZIDE 5MG TAB
GLIPIZIDE 10MG TAB
GLIPIZIDE ER 10MG TAB
GLIPIZIDE XL 2.5MG TAB
GLIPIZIDE XL 5MG TAB
GLIPIZIDE-METFORMIN 2.5MG/500MG TAB
GLIPIZIDE-METFORMIN 5MG/500MG TAB
GLYBURIDE 1.25MG TAB
GLYBURIDE 2.5MG TAB
GLYBURIDE 5MG TAB
GLYBURIDE MICRO 1.5MG TAB
GLYBURIDE MICRO 3MG TAB
GLYBURIDE MICRO 6MG TAB
GLYBURIDE/METFORMIN 1.25/250MG TAB
GLYBURIDE/METFORMIN 2.5/500MG TAB
GLYBURIDE/METFORMIN 5/500MG TAB
METFORMIN 500MG TAB
METFORMIN 850MG TAB
METFORMIN 1000MG TAB
METFORMIN ER 500MG 24HR TAB
METFORMIN ER 750MG 24HR TAB
Tier
1
1
1
1
1
3
3
3
3
3
1
2
2
1
1
1
1
1
3
1
1
1
1
3
Quantity
30 90
30
30
30
30
60
30
60
30
90
90
30
30
30
30
30
30
60
60
90
90
90
90
60
60
90
90
90
90
180
90
180
90
270
270
90
90
90
90
90
90
180
180
270
270
270
270
180
180
ear care
Drug Name
ACETIC ACID 2% OTIC SOLN
ANTIPYRINE BENZOCAINE OTIC SOL 15ML
Tier
3
2
Quantity
30 90
15
15
45
45
erectile Dysfunction
Drug Name
PAPAVERINE 30MG/ML SOL
Tier
3
Quantity
30 90
15
45
eye care
Drug Name
Tier
BACITRACIN/POLYMYX OPHTHOINT 3.5GM 3
CARTEOLOL HCL 1% OPH SOL 5ML
3
CARTEOLOL HCL 1% OPH SOL 10ML
3
CARTEOLOL HCL 1% OPH SOL 15ML
3
CROMOLYN SODIUM 4% OPHTH SOLN 10ML 3
CYCLOPENTOL 1% OPTH SOLN 15ML
3
DEXAMETHASONE 0.1% OPHTH SOLN 5ML 3
DORZOLAMIDE 2% OPHTH SOLN 10ML
3
ERYTHROMYCIN OPHTH OINT 3.5GM
2
GENTAMICIN 0.3% OPHTH SOLN 5ML
2
KETOROLAC 0.4% OPTH SOLN 5ML
3
KETOROLAC 0.5% OPHTH SOLN 5ML
3
LEVOBUNOLOL 0.5% OPTH SOLN 5ML
2
NEO/POLY/DEX OPHTH SUSP 5ML
2
NEO/POLY/DEXAMETH OPHTH OINT. 3.5GM 2
PILOCARPINE 0.5% OPHTH SOLN
3
POLYMYXIN-B/TRIMETHOPRIMOPHTH SOLN 2
PREDNISOLONE AC 1% OPHTH SUSP 5ML 3
SULFACETAMIDE NA 10% OPH SOL 15ML 2
TIMOLOL MALEATE .25% OPHTH SOL 5ML 2
TIMOLOL MALEATE 0.5% OPHTH SOLN 5ML 2
TOBRAMYCIN 0.3% OPH SOL 5ML
2
TROPICAMIDE 1% OP SOLN
3
Quantity
30 90
3.5 10.5
5 15
10 30
15 45
10 30
15 45
5 15
10 30
3.5 10.5
5 15
5 15
5 15
5 15
5 15
3.5 10.5
15 45
10 30
5 15
15 45
5 15
5 15
5 15
15 45
Value-Priced Medication List (cont.)
Gastrointestinal Health
Drug Name
BELLADONNA ALKALOIDS W/PB TAB
CIMETIDINE 200MG TAB
CIMETIDINE 300MG TAB
CIMETIDINE 400MG TAB
CIMETIDINE 800MG TAB
CIMETIDINE ORAL LIQ 300MG/5ML
DICYCLOMINE 10MG CAP
DICYCLOMINE 10MG/5ML SOLN
DICYCLOMINE 20MG TAB
DOC-Q-LACE 100MG CAP
FAMOTIDINE 20MG TAB
FAMOTIDINE 40MG TAB
GENERLAC 10GM/15ML SOLN
GLYCOPYRROLATE 1MG TAB
GLYCOPYRROLATE 2MG TAB
HYOSCYAMINE 0.125MG ORAL DIS TAB
HYOSCYAMINE 0.125MG SUBLINGUAL TAB
HYOSCYAMINE SULFATE 0.125MG TAB
LACTULOSE 10GM/15ML SOLN
METOCLOPRAMIDE 5MG TAB
METOCLOPRAMIDE 10MG TAB
METOCLOPRAMIDE HCL 5MG/5ML SOLN
NIZATIDINE 150MG CAP
NIZATIDINE 300MG CAP
OMEPRAZOLE 20MG CAP
RANITIDINE 150MG TAB
RANITIDINE 300MG TAB
RANITIDINE 15MG/ML (75MG/5ML) SYRUP
RANITIDINE 300MG CAP
SUCRALFATE 1GM TAB
infections (cont.)
Tier
Quantity
30 90
1
2
2
2
3
3
2
3
1
2
2
3
2
3
3
3
3
3
3
2
2
1
3
3
3
2
2
3
3
3
60 180
60 180
60 180
60 180
60 180
240 720
90 270
118 354
60 180
60 180
60 180
30 90
237 711
90 270
60 180
60 180
90 270
90 270
473 1,419
60 180
60 180
60 180
60 180
30 90
30 90
60 180
30 90
120 360
30 90
90 270
Tier
Quantity
30 90
2
2
60 180
60 180
Tier
Quantity
30 90
Gout
Drug Name
ALLOPURINOL 100MG TAB
ALLOPURINOL 300MG TAB
infections
Drug Name
AMOX-CLAV 400MG CHEW TAB
AMOX-CLAV 200MG/5ML SUSP 100ML
AMOX-CLAV 400MG/5ML SUSP 100ML
AMOX-CLAV 500MG TAB
AMOX-CLAV ES 600MG/5ML SUSP 125ML
AMOXICILLIN 250MG CAP
AMOXICILLIN 500MG CAP
AMOXICILLIN 125MG CHEWABLE TAB
AMOXICILLIN 250MG CHEW TAB
AMOXICILLIN 125MG/5ML SUSP 150ML
AMOXICILLIN 200MG/5ML SUSP 100ML
AMOXICILLIN 250MG/5ML SUSP 150ML
AMOXICILLIN 400MG/5ML SUSP 75ML
AMOXICILLIN 500MG TAB
AMOXICILLIN 875MG TAB
AMPICILLIN 250MG CAP
AMPICILLIN 500MG CAP
CEFACLOR 250MG CAP
CEFADROXIL 500MG CAP
CEFDINIR 125MG/5ML SUSPENSION 60ML
CEFDINIR 250MG/5ML SUSPENSION 60ML
CEFUROXIME 250MG TAB
CEPHALEXIN 125MG/5ML SUSP 200ML
CEPHALEXIN 250MG/5ML SUSP 200ML
CEPHALEXIN 250MG CAP
CEPHALEXIN 500MG CAP
CIPROFLOXACIN 250MG TAB
CIPROFLOXACIN 500MG TAB
CIPROFLOXACIN 750MG TAB
CLINDAMYCIN 150MG CAP
CLINDAMYCIN 300MG CAP
DICLOXACILLIN 250MG CAP
DOXYCYCLINE HYCLATE 50MG CAP
DOXYCYCLINE HYCLATE 100MG CAP
DOXYCYCLINE HYCLATE 20MG TAB
DOXYCYCLINE HYCLATE 100MG TAB
3
3
3
3
3
3
1
1
2
3
2
1
1
1
3
3
2
3
3
3
3
3
3
3
1
1
1
1
1
3
3
3
3
1
1
3
3
20
100
100
20
125
30
30
30
40
150
100
150
75
30
20
40
60
30
20
60
60
20
200
100
28
30
14
20
20
30
28
40
30
20
60
30
60
300
300
60
375
90
90
90
120
450
300
450
225
90
60
120
180
90
60
180
180
60
600
300
84
90
42
60
60
90
84
120
90
60
180
90
Drug Name
DOXYCYCLINE MONOHYDRATE 50MG TAB
DOXYCYCLINE MONOHYDRATE 100MG TAB
ERYTHROMYCIN ES 200MG/5ML SUSP
METRONIDAZOLE 250MG TAB
METRONIDAZOLE 500MG TAB
MINOCYCLINE 50MG CAP
MINOCYCLINE 75MG CAP
MINOCYCLINE 100MG CAP
PENICILLIN VK 125MG/5ML SOLN 200ML
PENICILLIN VK 250MG/5ML SOLN 100ML
PENICILLIN VK 250MG TAB
PENICILLIN VK 500MG TAB
SMZ/TMP REGULAR STRENGTH TAB
SULFAMETH/TRIMETHOPRIM 800/160 TAB
SULFAMETH-TRIMETH SUSP
TETRACYCLINE 250MG CAP
TETRACYCLINE 500MG CAP
TRIMETHOPRIM 100MG TAB
Mental Health (cont.)
Tier
3
3
1
2
3
3
3
3
1
1
1
1
1
2
1
2
2
3
Quantity
30 90
30
30
120
28
14
60
60
30
200
100
30
20
28
28
150
60
60
30
90
90
360
84
42
180
180
90
600
300
90
60
84
84
450
180
180
90
Medical Devices
Drug Name
PROCHAMBER AERO SPACER
Tier
3
Quantity
30 90
1
3
Mental Health
Drug Name
AMANTADINE 50MG/5ML SYRUP
AMITRIPTYLINE 10MG TAB
AMITRIPTYLINE 25MG TAB
AMITRIPTYLINE 50MG TAB
AMITRIPTYLINE 75MG TAB
AMITRIPTYLINE 100MG** TAB
AMITRIPTYLINE 150MG TAB
BENZTROPINE 0.5MG TAB
BENZTROPINE 1MG TAB
BENZTROPINE 2MG TAB
BUSPIRONE 5MG TAB
BUSPIRONE 10MG TAB
BUSPIRONE 15MG TAB
CARBAMAZEPINE 100MG CHEWABLE TAB
CARBAMAZEPINE 200MG TAB
CHLORDIAZEPOXIDE 5MG CAP
CHLORDIAZEPOXIDE 10MG CAP
CHLORDIAZEPOXIDE 25MG CAP
CITALOPRAM 10MG TAB
CITALOPRAM 20MG TAB
CITALOPRAM 40MG TAB
CLOMIPRAMINE 25MG CAP
CLOMIPRAMINE 50MG CAP
DIVALPROEX DR 125MG TAB
DOXEPIN 10MG CAP
DOXEPIN 25MG CAP
DOXEPIN 50MG CAP
DOXEPIN 75MG CAP
DOXEPIN 100MG** CAP
DOXEPIN HCL 10MG/ML CONC 118ML
FLUOXETINE 10MG CAP
FLUOXETINE 20MG CAP
FLUOXETINE 40MG CAP
FLUOXETINE 10MG TAB
FLUOXETINE 20MG TAB
FLUOXETINE 20MG/5ML LIQUID
FLUPHENAZINE 1MG TAB
FLUPHENAZINE 2.5MG TAB
FLUPHENAZINE 5MG TAB
FLUVOXAMINE 25MG TAB
FLUVOXAMINE 100MG TAB
GABAPENTIN 100MG CAP
GABAPENTIN 300MG CAP
GABAPENTIN 400MG CAP
GABAPENTIN 250MG/5ML SOLN
HALOPERIDOL 0.5MG TAB
HALOPERIDOL 1MG TAB
HALOPERIDOL 2MG TAB
Tier
3
1
1
1
2
1
2
1
3
2
2
2
3
3
2
3
2
2
2
2
2
3
3
3
1
2
2
2
2
3
1
1
1
1
1
3
2
3
3
3
3
2
3
3
3
2
1
2
Quantity
30 90
360
30
30
30
30
30
30
30
60
30
60
60
60
120
100
60
60
60
30
30
30
60
60
90
30
30
30
30
30
90
30
30
30
30
30
150
60
30
30
30
60
90
90
90
236
60
30
30
1080
90
90
90
90
90
90
90
180
90
180
180
180
360
300
180
180
180
90
90
90
180
180
270
90
90
90
90
90
270
90
90
90
90
90
450
180
90
90
90
180
270
270
270
708
180
90
90
Drug Name
HALOPERIDOL 2MG/ML CONCENTRATE
HALOPERIDOL 5MG** TAB
HYDROXYZINE 10MG/5ML SYRUP
HYDROXYZINE HCL 10MG TAB
HYDROXYZINE PAMOATE 25MG CAP
IMIPRAMINE 10MG TAB
IMIPRAMINE 25MG TAB
IMIPRAMINE 50MG TAB
LAMOTRIGINE 5MG CHEWABLETAB
LAMOTRIGINE 25MG CHEWABLE TAB
LITHIUM CARBONATE 150MG CAP
LITHIUM CARBONATE 300MG CAP
LITHIUM CARBONATE 600MG CAP
LITHIUM CARBONATE 300MG TAB
LITHIUM CARBONATE ER 450MG TAB
METHYLPHENIDATE 5MG TAB
MIRTAZAPINE 15MG ORAL DSNTGRT TAB
MIRTAZAPINE 30MG ORAL DSNTGRT TAB
MIRTAZAPINE 7.5MG TAB
MIRTAZAPINE 15MG TAB
MIRTAZAPINE 30MG TAB
NORTRIPTYLINE 10MG CAP
NORTRIPTYLINE 25MG CAP
NORTRIPTYLINE 50MG CAP
NORTRIPTYLINE 75MG CAP
OXCARBAZEPINE 150MG TAB
PAROXETINE 10MG TAB
PAROXETINE 20MG TAB
PAROXETINE 30MG TAB
PHENOBARBITAL 15MG TAB
PHENOBARBITAL 30MG TAB
PHENOBARBITAL 64.8MG TAB
PHENOBARBITAL 97.2MG TAB
PRAMIPEXOLE 0.125MG TAB
PRAMIPEXOLE 0.25MG TAB
PRAMIPEXOLE 0.5MG TAB
PRAMIPEXOLE 1.5MG TAB
PRIMIDONE 50MG TAB
PROCHLORPERAZINE 5MG TAB
PROCHLORPERAZINE 10MG TAB
RISPERIDONE 0.25MG TAB
RISPERIDONE ODT 0.5MG TAB
RISPERIDONE ODT 1MG TAB
RISPERIDONE ODT 2MG TAB
ROPINIROLE 0.25MG TAB
SERTRALINE 25MG TAB
SERTRALINE 50MG TAB
SERTRALINE 100MG TAB
THIORIDAZINE 10MG TAB
THIORIDAZINE 25MG TAB
THIORIDAZINE 50MG TAB
THIORIDAZINE 100MG** TAB
THIOTHIXENE 1MG CAP
THIOTHIXENE 2MG CAP
THIOTHIXENE 5MG CAP
THIOTHIXENE 10MG** CAP
TRAZODONE 50MG TAB
TRAZODONE 100MG TAB
TRAZODONE 150MG TAB
TRIFLUOPERAZINE 1MG TAB
TRIFLUOPERAZINE 2MG TAB
TRIFLUOPERAZINE 5MG TAB
TRIFLUOPERAZINE 10MG TAB
TRIHEXYPHENIDYL 2MG TAB
TRIHEXYPHENIDYL 5MG TAB
VALPROIC ACID 250MG/5ML SYRUP
VENLAFAXINE 25MG TAB
VENLAFAXINE 37.5MG TAB
VENLAFAXINE 50MG TAB
VENLAFAXINE 75MG TAB
VENLAFAXINE 100MG TAB
ZONISAMIDE 25MG CAP
ZONISAMIDE 50MG CAP
Tier
3
2
3
3
3
3
3
3
3
3
3
2
3
3
3
2
3
3
3
1
3
2
2
3
3
3
2
2
3
2
2
2
2
3
3
3
3
3
2
2
3
3
3
3
3
2
3
3
2
2
2
3
2
2
3
3
2
1
2
3
3
3
3
2
3
3
3
3
3
3
3
3
3
Quantity
30 90
135
30
240
60
90
60
60
30
150
180
60
90
60
60
60
60
30
30
30
30
30
30
30
60
30
90
30
30
30
90
90
90
60
30
30
60
60
60
30
30
60
60
60
30
60
30
30
30
60
30
30
60
60
60
60
60
30
30
30
60
60
60
60
60
90
540
60
60
60
60
60
90
90
405
90
720
180
270
180
180
90
450
540
180
270
180
180
180
180
90
90
90
90
90
90
90
180
90
270
90
90
90
270
270
270
180
90
90
180
180
180
90
90
180
180
180
90
180
90
90
90
180
90
90
180
180
180
180
180
90
90
90
180
180
180
180
180
270
1620
180
180
180
180
180
270
270
Value-Priced Medication List (cont.)
Mouth/Throat/Dental
Drug Name
Thyroid conditions (cont.)
Tier
CHLORHEXIDINE ORAL RINSE 473ML
LIDOCAINE VISCOUS 2% ORAL SOL 100ML
PILOCARPINE 5MG TAB
SF 5000 PLUS 1.1% CREAM 51GM
STANNOUS FLUORIDE 0.63% RINSE
2
2
3
3
3
Quantity
30 90
473
100
90
60
300
1419
300
270
180
900
skin conditions
Drug Name
Tier
ALCLOMETASONE DIP 0.05% CREAM 60GM
AMMONIUM LACTATE 12%
CREAM 2X140GM
BENZOYL PEROXIDE 10% AQ GEL 60GM
BENZOYL PEROXIDE 10% WASH 227GM
BENZOYL PEROXIDE 10% WSH LIQ 148GM
BENZOYL PEROXIDE 2.5% AQ GEL 60GM
BENZOYL PEROXIDE 5% AQ GEL 60GM
BENZOYL PEROXIDE 5% WASH227GM
BETAMETHASONE VAL 0.1% CRM 15GM
CICLOPIROX 0.77% CREAM 15GM
CICLOPIROX 8% TOPICAL SOLN 6.6ML
CICLOPIROX TOPICAL SUSPENSION 30ML
CICLOPIROX TOPICAL SUSPENSION 60ML
CLINDAMYCIN 1% GEL 60GM
CLINDAMYCIN 1% TOPICAL SOLN 60ML
CLOTRIMAZOLE 1% CREAM 30GM
CLOTRIMAZOLE 1% SOLN 30ML
DESONIDE 0.05% OINT 15GM
ERYTHROMYCIN 2% GEL 30GM
ERYTHROMYCIN 2% TOPICAL SOLN 60ML
FLUOCINONIDE 0.05% GEL 15GM
FLUOCINONIDE 0.05% CREAM 30GM
FLUOCINONIDE -E 0.05% CREAM 15GM
FLUOCINONIDE -E 0.05% CREAM 30GM
FLUOCINONIDE -E 0.05% CREAM 60GM
GENTAMICIN 0.1% CREAM 15GM
GENTAMICIN 0.1% OINT (TOPICAL)
HALOBETASOL 0.05% OINT 50GM
HYDROCORTISONE 1% CREAM 28.35GM
HYDROCORTISONE 1% OINT 28.35GM
HYDROCORTISONE 2.5% CREAM 30GM
HYDROCORTISONE 2.5% OINT 28.35GM
HYDROCORTISONE BUT 0.1% OINT 15GM
HYDROQUINONE 4% CRM W/SUNSCREEN
HYPERCARE 20% SOL DAB-O-MATIC 60ML
MELQUIN 3% SOLN 30ML
MOMETASONE 0.1% OINT 15GM
MOMETASONE 0.1% OINT 45GM
MOMETASONE 0.1% TOPICAL SOLN 30ML
MOMETASONE 0.1% TOPICAL SOLN 60ML
NYSTATIN OINT 15GM
SALICYLIC AC 6% SHAMPOO 177ML
SELENIUM SULFIDE 2.5% SHAMPOO(LOTN)
TRIAMCINOLONE 0.025% CREAM 454GM
TRIAMCINOLONE 0.5% CREAM 15GM
TRIAMCINOLONE 0.1% CREAM 454GM
TRIAMCINOLONE 0.1% OINT 80GM
UREA 40% LOTION 236.6ML
UREA 50% NAIL GEL 18ML
3
Quantity
30 90
60 180
3 280 840
3
60 180
3 227 681
3 148 444
3
60 180
3
60 180
3 227 681
3
15 45
3
15 45
3
6.6 19.8
3
30 90
3
60 180
3
60 180
3
60 180
3
30 90
3
30 90
3
15 45
3
30 90
2
60 180
3
15 45
2
30 90
2
15 45
3
30 90
3
60 180
2
15 45
1
15 45
3
50 150
2 28.35 85.05
2 28.35 85.05
2
30 90
3
60 180
3
15 45
3
30 90
3
60 180
3
30 90
3
15 45
3
45 135
3
30 90
3
60 180
3
15 45
3 177 531
2 118 354
1
15 45
2
15 45
2
90 270
3
80 240
3 236.6 709.8
3
18 54
Thyroid conditions
Drug Name
LEVOTHROID 0.1MG TAB
LEVOTHYROXINE 0.025MG (25MCG) TAB
LEVOTHYROXINE 0.05MG (50MCG) TAB
LEVOTHYROXINE 0.075MG (75MCG) TAB
LEVOTHYROXINE 0.088MG (88MCG) TAB
LEVOTHYROXINE 0.112MG (112MCG) TAB
LEVOTHYROXINE 0.125MG (125MCG) TAB
LEVOTHYROXINE 0.137MG (137MCG) TAB
LEVOTHYROXINE 0.150MG (150MCG) TAB
LEVOTHYROXINE 0.175MG (175MCG)TAB
4
Tier
2
2
2
2
2
2
2
2
2
2
Quantity
30 90
30
30
30
30
30
30
30
30
30
30
90
90
90
90
90
90
90
90
90
90
Drug Name
Women’s Health
Tier
Quantity
30 90
2
2
2
3
2
2
30 90
30 90
30 90
30 90
60 180
60 180
Tier
Quantity
30 90
LEVOTHYROXINE 0.2MG(200MCG) TAB
LEVOTHYROXINE 0.3MG (300MCG) TAB
METHIMAZOLE 5MG TAB
METHIMAZOLE 10MG TAB
NATURE-THROID 0.5GR (32.5MG) TAB
PROPYLTHIOURACIL 50MG TAB
urinary Health
Drug Name
BETHANECHOL 5MG TAB
BETHANECHOL 10MG TAB
BETHANECHOL 25MG TAB
BETHANECHOL 50MG TAB
OXYBUTYNIN 5MG TAB
OXYBUTYNIN 5MG/5ML SYRUP
OXYBUTYNIN ER 5MG TAB
OXYBUTYNIN ER 10MG TAB
OXYBUTYNIN ER 15MG TAB
3
3
3
3
2
3
3
3
3
60
60
90
90
60
240
30
30
30
180
180
270
270
180
720
90
90
90
Vitamins and nutritional Health
Drug Name
Tier
CALCIUM-FA PLUS D CHEW WAFERS
CYANOCOBALAMIN 1000MCG/ML INJ, 1ML
FABB TAB
FE C PLUS TAB
FEROTRIN CAP
FERREX 150 FORTE CAP
FLUORIDE 0.25MG F CHEWABLE TAB
FLUORIDE 0.5MG F CHEWABLE TAB
FLUORIDE 1.0MG F CHEWABLE TAB
FOLBECAL TAB
FOLBEE PLUS TAB
FOLBEE TAB
FOLIC ACID 1MG TAB
HEMATINIC/ FA TAB
HEMATINIC PLUS TAB 10 X 10
KLOR-CON 10MEQ TAB
MULTIGEN FOLIC TAB
MULTIGEN TAB
MULTIVIT/F 0.25MG CHEWABLE TAB
MULTI-VIT/FL 0.25MG DROPS 50ML
MULTI-VITA-F 0.5MG CHEW TAB
MULTI-VIT/FLUORIDE 1MG CHEW TAB
MULTIVITAMIN W/FL .5MG/ML ORAL DROP
MULTIVITAMINS W/ FL 1.0MG CHEW TAB
MULTIVITS W/FL 1MG & IRON CHEW TAB
NATALCARE PLUS TAB(1MG FOLIC ACID)
OB-NATAL ONE CAP
PHOSPHA 250 NEUTRAL TAB
POLY-IRON 150 CAP
POLY-IRON 150 FORTE CAP
POT CHLOR 10% LIQ SF (20MEQ/15ML)
POTASSIUM CHLOR 20% LIQ(40MEQ/15ML)
POTASSIUM CL 10MEQ ER TAB
PRENAFIRST TAB
PRENATAB FA TAB
PRENATAL - U CAP
PRENATAL 19 CHEWABLE TAB
PRENATAL 19 TAB
PRENATAL PLUS TAB
RE DUALVIT F CAP
RE PRENATAL MULTIVIT W/IRON CHEW TB
RENA-VITE RX TAB
RENAL SOFTGEL CAP
SE-NATAL 19 TAB
THEROBEC PLUS TAB
TRI-VIT/FE FL .25MG DROPS 50ML
VINATE AZ TAB
VINATE C TAB
VINATE CARE CHEWABLE TAB
VINATE GT TAB
VITAMIN D 50,000IU CAP
3
1
3
3
3
2
2
1
2
3
3
3
2
2
3
3
3
3
2
3
1
2
3
3
1
1
3
3
2
3
2
2
3
3
2
3
3
2
2
3
3
1
2
2
3
3
3
3
3
2
1
Quantity
30 90
60
3
30
30
60
45
120
30
30
30
30
30
30
30
30
30
30
30
30
50
30
30
50
30
30
30
30
100
60
45
473
710
30
30
30
30
30
30
30
30
30
30
30
30
30
50
30
30
30
30
4
180
9
90
90
180
135
360
90
90
90
90
90
90
90
90
90
90
90
90
150
90
90
150
90
90
90
90
300
180
135
1419
2130
90
90
90
90
90
90
90
90
90
90
90
90
90
150
90
90
90
90
12
Drug Name
Tier
Quantity
30 90
3
3
3
3
3
3
2
3
3
1
1
1
2
3
2
1
1
2
3
3
30 90
30 90
4 12
4 12
30 90
45 135
5 15
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
10 30
30 90
60 180
30 90
Tier
Quantity
30 90
ALENDRONATE 5MG TAB
ALENDRONATE 10MG TAB
ALENDRONATE 35MG TAB
ALENDRONATE 70MG TAB
ANASTROZOLE 1MG TAB
CLINDAMYCIN 2% VAGINAL CREAM 40GM
CLOMIPHENE CITRATE 50MG TAB
EST ESTRGN METHTEST 0.625/1.25MG TB
EST ESTRGN METHTEST 1.25/2.5MG TAB
ESTRADIOL 0.5MG TAB
ESTRADIOL 1MG TAB
ESTRADIOL 2MG TAB
ESTROPIPATE 0.625MG (0.75MG) TAB
ESTROPIPATE 1.5MG (1.25MG) TAB
MEDROXYPROGESTERONE 2.5MG TAB
MEDROXYPROGESTERONE 5MGTAB
MEDROXYPROGESTERONE 10MGTAB
MEGESTROL ACETATE 20MG TAB
TAMOXIFEN 10MG TAB
TAMOXIFEN 20MG TAB
Other
Drug Name
ANAGRELIDE 0.5MG CAP
ANAGRELIDE 1MG CAP
ANUCORT-HC 25MG RECTAL SUPP 24’S
CYTRA-2 SOLN
CYTRA-K ORAL SOLN
DEXAMETHASONE 0.5MG TAB
DEXAMETHASONE 0.75MG TAB
DEXAMETHASONE 1MG TAB
DEXAMETHASONE 1.5MG TAB
DEXAMETHASONE 4MG TAB
FINASTERIDE 5MG TAB
PHENAZOPYRIDINE 100MG TAB
PHENAZOPYRIDINE 200MG TAB
PREDNISOLONE 15MG/5ML SOLN
PREDNISOLONE SOD PHOS 15MG/5ML SOL
PREDNISOLONE SOD PHOS 5MG/5ML SOL
PREDNISONE 1MG TAB
PREDNISONE 2.5MG TAB
PREDNISONE 5MG TAB
PREDNISONE 10MG** TAB
PREDNISONE 20MG TAB
PREDNISONE 5MG TAB PACK 21’S
PREDNISONE 10MG TAB PACK 21’S
3
3
2
2
2
2
2
3
3
2
2
2
2
3
2
3
2
2
2
1
2
2
2
90
60
12
473
473
60
12
30
45
30
30
30
30
60
30
120
90
60
30
30
30
21
21
270
180
36
1419
1419
180
36
90
135
90
90
90
90
180
90
360
270
180
90
90
90
63
63
Value-Priced Medication List (cont.)
Value BranD-naMe
insulins
LEVEMIR FLEXPEN
LEVEMIR 100 UNITS/ML VIAL
NOVOLIN N 100 UNITS/ML VIAL
NOVOLIN R 100 UNITS/ML VIAL
NOVOLIN 70/30 100 UNIT/ML VIAL
NOVOLOG MIX 70/30 VIAL
NOVOLOG MIX 70/30 FLEXPEN
NOVOLOG FLEXPEN
NOVOLOG PENFILL 3 ML
NOVOLOG 100 UNIT/ML VIAL
Price
1 BOX
1 VIAL
1 VIAL
1 VIAL
1 VIAL
1 VIAL
1 BOX
1 BOX
1 BOX
1 VIAL
$189.49
$99.89
$50.29
$50.29
$50.29
$113.59
$220.44
$220.44
$217.46
$113.59
liFesTYle MeDicaTiOns
5
The average savings on purchase of
a 90-Day supply of a value-priced generic
covered by the Prescription Savings Club at:
Tier 1 ($10) $35.68
Tier 2 ($20) $38.56
Tier 3 ($30) $79.13
The average savings for purchase of
commonly prescribed quantities of all other
generics covered by the Prescription Savings
Club that are not value-priced is $18.97.
The average savings for purchase of
commonly prescribed quantities of brandname drugs covered by the Prescription
Savings Club is $28.58.
Birth control – special Price at $12 for 1-month supply
MONONESSA TAB
TRINESSA TAB
Quantity
28
28
$21.99 for 1-month supply
MICROGESTIN 1.5/30 FE TAB
MICROGESTIN 1/20 FE TAB
28
28
$23.99 for 1-month supply
NECON 1/35 TAB
RECLIPSEN 0.15MG-30MCG TAB
LOW-OGESTREL TAB
28
28
28
$24.99 for 1-month supply
JOLIVETTE 0.35MG TAB
28
$25.99 for 1-month supply
LEVORA 0.15/30 TAB
LUTERA TAB
28
28
Discounted Lifestyle Medications
CIALIS 5MG TAB (QTY 6)
CIALIS 10MG TAB (QTY 6)
CIALIS 20MG TAB (QTY 6)
VIAGRA 50MG TAB (QTY 6)
VIAGRA 100MG TAB (QTY 6)
PROPECIA 1MG (PRO PAK) TAB
LATISSE 0.03% OPHTH SOLN
Price
$28.99
$151.99
$151.99
$139.99
$139.99
$67.99
$106.99
**Membership fee required ($20 individual or $35 family per year). Persons receiving benefits from Medicare, Medicaid or other federal or state healthcare programs are
ineligible. Some restrictions apply to 10% bonus. Pet medications are for human-equivalent medications only. Membership may be cancelled within 30 days of issue date for
a full refund. If by the end of the 1-year membership, member has not achieved total savings on all purchases made with the PSC card of eligible pharmacy and Walgreens­
branded items and services that is equal to or greater than membership fee, member is eligible for store credit equal to the difference between membership fee and the
member’s total savings. For complete terms and conditions, call 1-866-922-7312 or visit Walgreens.com/rxsavingsclub. Walgreen Co., 200 Wilmot Rd., Deerfield, IL 60015.
ThIS PRogRaM DoeS noT ConSTITuTe InSuRanCe.
**List of drugs is not all-inclusive. ask your Walgreens pharmacist if your medication is a value-priced generic.
12AF0027
As of 3/12