Value-Priced Medication List

In addition to the discounts on thousands of brand-name and most other generic medications that Walgreens Prescription Savings Club members enjoy, club members receive greater discounts on three-tiers of value priced generics.*

The price for a generic drug is based on its tier and whether it is a 30-day or 90-day supply.†

The price may be as low as:

? 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)

VALUE GENERICS

Antifungal

Quantity

Drug Name Tier 30 90

FLUCONAZOLE 150MG TAB 2 1 3

TERBINAFINE 250MG TAB 2 30 90

Antiviral

Quantity

Drug Name Tier 30 90

ACYCLOVIR 200MG TAB 2 60 180

Arthritis or Pain

Quantity

Drug Name Tier 30 90

BACLOFEN 10MG TAB 3 90 270

CYCLOBENZAPRINE 5MG TAB 2 30 90

CYCLOBENZAPRINE 10MG TAB 2 30 90

DICLOFENAC SODIUM 50MG TAB 3 60 180

DICLOFENAC SODIUM 75MG EC TAB 3 60 180

DICLOFENAC SODIUM 100MG ER TAB 3 30 90

FLURBIPROFEN 100MG TAB 3 60 180

IBUPROFEN 100MG/5ML ORAL SUSP 2 120 360

IBUPROFEN 400MG TAB 2 90 270

IBUPROFEN 600MG TAB 2 60 180

IBUPROFEN 800MG TAB 2 60 180

INDOMETHACIN 25MG CAP 2 60 180

INDOMETHACIN 50MG CAP 1 30 90

KETOPROFEN 50MG CAP 3 90 270

KETOPROFEN 75MG CAP 3 60 180

KETOROLAC 10MG TAB 2 15 45

KETOROLAC 30MG/ML INJ, 2ML 3 15 45

MELOXICAM 7.5MG TAB 2 30 90

MELOXICAM 15MG TAB 2 30 90

NABUMETONE 500MG TAB 3 60 180

NAPROXEN 250MG TAB 1 60 180

NAPROXEN 375MG TAB 1 60 180

NAPROXEN 500MG TAB 1 60 180

NAPROXEN 375MG DR TAB 3 60 180

NAPROXEN DR 500MG TAB 3 60 180

SULINDAC 150MG TAB 3 60 180

TIZANIDINE 2MG TAB 3 60 180

Asthma

Quantity

Drug Name Tier 30 90

ALBUTEROL 0.083% INH SOLN 25X3ML 2 75 225

ALBUTEROL 0.5% INH SOL 20ML 2 20 60

ALBUTEROL SULF INH SOLN 1.25MG/3ML 3 90 270

ALBUTEROL SULFATE SYRUP (2MG/5ML) 1 120 360

AMINOPHYLLINE 100MG TAB 2 60 180

Asthma (cont.)

Quantity

Drug Name Tier 30 90

AMINOPHYLLINE 200MG TAB 2 60 180

DYPHYLLINE-GG 100-100 ELIXIR 2 240 720

DYPHYLLIN-GG TAB 3 30 90

IPRATROPIUM INHAL SOLN 60 X 2.5ML 2 75 225

Blood Pressure/Heart Health

Quantity

Drug Name Tier 30 90

AMILORIDE 5MG / HCTZ 50MG TAB 2 30 90

AMIODARONE 200MG TAB 1 30 90

AMLODIPINE BESYLATE 2.5MG TAB 2 30 90

AMLODIPINE BESYLATE 5MG TAB 2 30 90

AMLODIPINE BESYLATE 10MG TAB 2 30 90

AMLODIPINE-BENAZ 2.5/10MG CAP 3 30 90

AMLODIPINE-BENAZ 5/10MG CAP 3 30 90

AMLODIPINE-BENAZ 5/20MG CAP 3 30 90

AMLODIPINE-BENAZ 10/20MG CAP 3 30 90

ATENOLOL 100MG TAB 1 30 90

ATENOLOL 25MG TAB 2 60 180

ATENOLOL 50MG TAB 2 60 180

ATENOLOL/CHLORTHALIDONE 50/25 TAB 3 30 90

BENAZEPRIL 5MG TAB 2 30 90

BENAZEPRIL 10MG TAB 2 30 90

BENAZEPRIL 20MG TAB 2 30 90

BENAZEPRIL 40MG TAB 2 30 90

BISOPROLOL FUMARATE 5MG TAB 2 30 90

BISOPROLOL/HCTZ 2.5MG/6.25MG TAB 2 30 90

BISOPROLOL/HCTZ 5MG/6.25MG TAB 2 30 90

BISOPROLOL/HCTZ 10MG/6.25MG TAB 2 30 90

CARTIA 120MG XT CAP 3 30 90

CARVEDILOL 3.125MG TAB 2 60 180

CARVEDILOL 6.25MG TAB 2 60 180

CARVEDILOL 12.5MG TAB 2 60 180

CARVEDILOL 25MG TAB 2 60 180

CILOSTAZOL 50MG TAB 3 60 180

CILOSTAZOL 100MG TAB 3 60 180

CLONIDINE 0.1MG TAB 2 60 180

CLONIDINE 0.2MG TAB 2 60 180

CLONIDINE 0.3MG TAB 2 60 180

DILTIAZEM 30MG TAB 2 60 180

DILTIAZEM 60MG TAB 3 60 180

DILTIAZEM 90MG TAB 3 60 180

DILTIAZEM 120MG TAB 2 30 90

DILTIAZEM ER 120MG CAP 3 30 90

DIPYRIDAMOLE 50MG TAB 3 60 180

DOXAZOSIN 1MG TAB 3 30 90

DOXAZOSIN 2MG TAB 3 30 90

DOXAZOSIN 4MG TAB 3 30 90

ENALAPRIL 2.5MG TAB 2 60 180

ENALAPRIL 5MG TAB 2 60 180

ENALAPRIL 10MG TAB 3 60 180

ENALAPRIL-HCTZ 5-12.5MG TAB 2 60 180

Blood Pressure/Heart Health (cont.)

Quantity

Drug Name Tier 30 90

ENALAPRIL-HCTZ 10-25MG TAB 2 30 90

FELODIPINE 2.5MG TAB 3 30 90

FOSINOPRIL 10MG TAB 2 30 90

FOSINOPRIL 20MG TAB 2 30 90

FOSINOPRIL 40MG TAB 2 30 90

FUROSEMIDE 8MG/ML SOLN 3 120 360

FUROSEMIDE 10MG/ML ORAL SOLN 60ML 3 90 270

FUROSEMIDE 20MG TAB 1 60 180

FUROSEMIDE 40MG TAB 1 60 180

FUROSEMIDE 80MG TAB 1 30 90

GUANFACINE 1MG TAB 2 30 90

GUANFACINE 2MG TAB 2 30 90

HYDRALAZINE 10MG TAB 1 60 180

HYDRALAZINE 25MG TAB 2 60 180

HYDRALAZINE 50MG TAB 3 90 270

HYDROCHLOROTHIAZIDE 12.5MG CAP 2 30 90

HYDROCHLOROTHIAZIDE 12.5MG TAB 3 30 90

HYDROCHLOROTHIAZIDE 25MG TAB 1 30 90

HYDROCHLOROTHIAZIDE 50MG TAB 1 30 90

INDAPAMIDE 1.25MG TAB 2 30 90

INDAPAMIDE 2.5MG TAB 2 30 90

ISOSORBIDE DINITRATE 2.5MG SL TAB 2 30 90

ISOSORBIDE DINITRATE 5MG SUBL TAB 3 120 360

ISOSORBIDE MONONITRATE 10MG TAB 3 60 180

ISOSORBIDE MONONITRATE 20MG TAB 3 60 180

ISOSORBIDE MONONITRATE 30MG ER TAB 2 30 90

ISOSORBIDE MONONITRATE 60MG ER TAB 2 30 90

LISINOPRIL 2.5MG TAB 2 30 90

LISINOPRIL 5MG TAB 2 30 90

LISINOPRIL 10MG TAB 1 30 90

LISINOPRIL 20MG TAB 1 30 90

LISINOPRIL 30MG TAB 2 30 90

LISINOPRIL 40MG TAB 2 30 90

LISINOPRIL-HCTZ 10/12.5MG TAB 2 30 90

LISINOPRIL-HCTZ 20/12.5MG TAB 2 30 90

LISINOPRIL-HCTZ 20/25MG TAB 2 30 90

LOSARTAN/HCTZ 100/12.5MG TAB 3 30 90

METHYLDOPA 250MG TAB 3 60 180

METHYLDOPA 500MG TAB 3 60 180

METOPROLOL TARTRATE 25MG TAB 2 60 180

METOPROLOL TARTRATE 50MG TAB 2 60 180

METOPROLOL TARTRATE 100MG TAB 2 60 180

PENTOXIFYLLINE 400MG ER TAB 3 60 180

PRAZOSIN 1MG CAP 3 30 90

PROPAFENONE 150MG TAB 3 90 270

PROPRANOLOL 60MG TAB 3 60 180

QUINAPRIL 5MG TAB 2 30 90

QUINAPRIL 10MG TAB 2 30 90

QUINAPRIL 20MG TAB 2 30 90

QUINAPRIL 40MG TAB 2 30 90

QUINAPRIL/HCTZ 10-12.5MG TAB 3 30 90

RAMIPRIL 1.25MG CAP 3 30 90

Blood Pressure/Heart Health (cont.)

Quantity

Drug Name Tier 30 90

SOTALOL 120MG TAB 2 60 180

SOTALOL 160MG TAB 3 60 180

SPIRONOLACTONE 25MG TAB 2 30 90

SPIRONOLACTONE 50MG TAB 2 30 90

TERAZOSIN 1MG CAP 2 30 90

TERAZOSIN 2MG CAP 2 30 90

TERAZOSIN 5MG CAP 2 30 90

TERAZOSIN 10MG CAP 2 30 90

TICLOPIDINE 250MG TAB 3 60 180

TORSEMIDE 5MG TAB 3 30 90

TORSEMIDE 10MG TAB 3 30 90

TORSEMIDE 20MG TAB 3 30 90

TORSEMIDE 100MG** TAB 3 30 90

TRANDOLAPRIL 1MG TAB 2 30 90

TRANDOLAPRIL 2MG TAB 1 30 90

TRANDOLAPRIL 4MG TAB 2 30 90

TRIAMTERENE 37.5MG/ HCTZ 25MG CAP 2 30 90

TRIAMTERENE 37.5MG/ HCTZ 25MG TAB 3 30 90

TRIAMTERENE 75MG/ HCTZ 50MG TAB 1 30 90

VERAPAMIL 40MG TAB 3 60 180

VERAPAMIL 80MG TAB 1 30 90

VERAPAMIL 120MG TAB 2 30 90

VERAPAMIL ER 100MG CAP (24 HR) 3 30 90

WARFARIN SOD 1MG TAB 2 30 90

WARFARIN SOD 2.5MG TAB 2 30 90

WARFARIN SOD 2MG TAB 2 30 90

WARFARIN SOD 3MG TAB 2 30 90

WARFARIN SOD 4MG TAB 2 30 90

WARFARIN SOD 5MG TAB 2 30 90

WARFARIN SOD 6MG TAB 2 30 90

WARFARIN SOD 7.5MG TAB 2 30 90

WARFARIN SOD 10MG** TAB 2 30 90

Cholesterol

Quantity

Drug Name Tier 30 90

FENOFIBRATE 54MG TAB 3 30 90

GEMFIBROZIL 600MG TAB 3 60 180

LOVASTATIN 10MG TAB 1 30 90

LOVASTATIN 20MG TAB 1 30 90

LOVASTATIN 40MG TAB 1 30 90

PRAVASTATIN 10MG TAB 2 30 90

PRAVASTATIN 20MG TAB 2 30 90

PRAVASTATIN 40MG TAB 3 30 90

PRAVASTATIN 80MG TAB 3 30 90

SIMVASTATIN 5MG TAB 2 30 90

SIMVASTATIN 10MG TAB 2 30 90

SIMVASTATIN 20MG TAB 2 30 90

SIMVASTATIN 40MG TAB 3 30 90

SIMVASTATIN 80MG TAB 3 30 90

Cough/Cold/Allergy

Quantity

Drug Name Tier 30 90

ALLER-CHLOR 4MG TAB 1 100 300

BENZONATATE 100MG CAP 2 30 90

BENZONATATE 200MG CAP 3 30 90

CETIRIZINE 1MG/ML SYRUP 3 120 360

CYPROHEPTADINE 2MG/5ML SYRUP 3 120 360

DE-CHLOR DM LIQUID 2 120 360

DE-CHLOR DR SYRUP 2 180 540

DEHISTINE SYRUP 3 240 720

DIPHENHYDRAMINE 50MG CAP 2 30 90

FLUTICASONE NASAL SP (120INH) 16GM 3 16 48

LORATADINE 10MG TAB 1 30 90

NOHIST TAB 3 30 90

ORGAN-I NR 200MG TAB 3 120 360

PBM ALLERGY SYRUP 3 120 360

PHENYLTOLOXAMINE PE CPM SYRUP 2 240 720

PROMETHAZINE 12.5MG TAB 2 30 90

PROMETHAZINE 25MG TAB 1 12 36

PROMETHAZINE 50MG TAB 2 60 180

PROMETHAZINE DM SYRUP 2 180 540

Cough/Cold/Allergy (cont.)

Quantity

Drug Name Tier 30 90

QUARTUSS DM DROPS 30ML 3 30 90

QV-ALLERGY SYRUP 3 240 720

REME TUSSIN DM SYRUP 3 150 450

SILDEC PE-DM SYRUP 1 120 360

SILDEC-PE SYRUP 1 120 360

SUPRESS-DX PED DROPS 30ML 3 30 90

TRIPOHIST LIQUID 3 120 360

Diabetes

Quantity

Drug Name Tier 30 90

GLIMEPIRIDE 1MG TAB 1 30 90

GLIMEPIRIDE 2MG TAB 1 30 90

GLIMEPIRIDE 4MG TAB 1 30 90

GLIPIZIDE 5MG TAB 1 30 90

GLIPIZIDE 10MG TAB 1 60 180

GLIPIZIDE ER 10MG TAB 3 30 90

GLIPIZIDE XL 2.5MG TAB 3 60 180

GLIPIZIDE XL 5MG TAB 3 30 90

GLYBURIDE 1.25MG TAB 1 30 90

GLYBURIDE 2.5MG TAB 2 30 90

GLYBURIDE 5MG TAB 2 30 90

GLYBURIDE MICRO 1.5MG TAB 1 30 90

GLYBURIDE MICRO 3MG TAB 1 30 90

GLYBURIDE MICRO 6MG TAB 1 30 90

GLYBURIDE/METFORMIN 1.25/250MG TAB 1 60 180

GLYBURIDE/METFORMIN 2.5/500MG TAB 1 60 180

GLYBURIDE/METFORMIN 5/500MG TAB 3 90 270

METFORMIN 500MG TAB 1 90 270

METFORMIN 850MG TAB 1 90 270

METFORMIN 1000MG TAB 1 90 270

METFORMIN ER 500MG 24HR TAB 1 60 180

METFORMIN ER 750MG 24HR TAB 3 60 180

Ear Care

Quantity

Drug Name Tier 30 90

ACETIC ACID 2% OTIC SOLN 3 15 45

ANTIPYRINE BENZOCAINE OTIC SOL 15ML 2 15 45

Eye Care

Quantity

Drug Name Tier 30 90

BACITRACIN/POLYMYX OPHTHOINT 3.5GM 3 3.5 10.5

CROMOLYN SODIUM 4% OPHTH SOLN 10ML 3 10 30

CYCLOPENTOL 1% OPTH SOLN 15ML 3 15 45

DORZOLAMIDE 2% OPHTH SOLN 10ML 3 10 30

ERYTHROMYCIN OPHTH OINT 3.5GM 2 3.5 10.5

GENTAMICIN 0.3% OPHTH SOLN 5ML 2 5 15

KETOROLAC 0.5% OPHTH SOLN 5ML 3 5 15

LEVOBUNOLOL 0.5% OPTH SOLN 5ML 2 5 15

PILOCARPINE 0.5% OPHTH SOLN 3 15 45

POLYMYXIN-B/TRIMETHOPRIMOPHTH SOLN 2 10 30

SULFACETAMIDE NA 10% OPH SOL 15ML 2 15 45

TIMOLOL MALEATE .25% OPHTH SOL 5ML 2 5 15

TIMOLOL MALEATE 0.5% OPHTH SOLN 5ML 2 5 15

TOBRAMYCIN 0.3% OPH SOL 5ML 2 5 15

TROPICAMIDE 1% OP SOLN 3 15 45

Gastrointestinal Health

Quantity

Drug Name Tier 30 90

CIMETIDINE 300MG TAB 3 60 180

CIMETIDINE ORAL LIQ 300MG/5ML 3 240 720

DICYCLOMINE 10MG CAP 2 90 270

DICYCLOMINE 20MG TAB 1 60 180

Gastrointestinal Health (cont.)

Quantity

Drug Name Tier 30 90

DOC-Q-LACE 100MG CAP 2 60 180

FAMOTIDINE 20MG TAB 2 60 180

FAMOTIDINE 40MG TAB 3 30 90

GENERLAC 10GM/15ML SOLN 2 237 711

LACTULOSE 10GM/15ML SOLN 3 473 1,419

METOCLOPRAMIDE 5MG TAB 2 60 180

METOCLOPRAMIDE 10MG TAB 2 60 180

METOCLOPRAMIDE HCL 5MG/5ML SOLN 1 60 180

NIZATIDINE 150MG CAP 3 60 180

NIZATIDINE 300MG CAP 3 30 90

OMEPRAZOLE 20MG CAP 3 30 90

RANITIDINE 150MG TAB 2 60 180

RANITIDINE 300MG TAB 2 30 90

RANITIDINE 15MG/ML (75MG/5ML) SYRUP 3 120 360

Gout

Quantity

Drug Name Tier 30 90

ALLOPURINOL 100MG TAB 2 60 180

ALLOPURINOL 300MG TAB 3 60 180

Infections

Quantity

Drug Name Tier 30 90

AMOX-CLAV 400MG CHEW TAB 3 20 60

AMOX-CLAV 200MG/5ML SUSP 100ML 3 100 300

AMOX-CLAV 400MG/5ML SUSP 100ML 3 100 300

AMOX-CLAV ES 600MG/5ML SUSP 125ML 3 125 375

AMOXICILLIN 250MG CAP 1 30 90

AMOXICILLIN 500MG CAP 1 30 90

AMOXICILLIN 125MG CHEWABLE TAB 2 30 90

AMOXICILLIN 250MG CHEW TAB 3 40 120

AMOXICILLIN 125MG/5ML SUSP 80ML 2 150 450

AMOXICILLIN 125MG/5ML SUSP 100ML 2 150 450

AMOXICILLIN 125MG/5ML SUSP 150ML 2 150 450

AMOXICILLIN 200MG/5ML SUSP 75ML 1 100 300

AMOXICILLIN 200MG/5ML SUSP 100ML 1 100 300

AMOXICILLIN 250MG/5ML SUSP 80ML 1 150 450

AMOXICILLIN 250MG/5ML SUSP 100ML 1 150 450

AMOXICILLIN 250MG/5ML SUSP 150ML 1 150 450

AMOXICILLIN 400MG/5ML SUSP 50ML 1 100 300

AMOXICILLIN 400MG/5ML SUSP 75ML 1 100 300

AMOXICILLIN 400MG/5ML SUSP 100ML 1 100 300

AMOXICILLIN 500MG TAB 3 30 90

AMOXICILLIN 875MG TAB 3 20 60

AMPICILLIN 250MG CAP 2 40 120

AMPICILLIN 500MG CAP 3 60 180

CEFACLOR 250MG CAP 3 30 90

CEFADROXIL 500MG CAP 3 20 60

CEFPROZIL 125MG/5ML SUSP 50ML 3 100 300

CEFPROZIL 125MG/5ML SUSP 75ML 3 100 300

CEFPROZIL 125MG/5ML SUSP 100ML 3 100 300

CEPHALEXIN 250MG CAP 1 28 84

CEPHALEXIN 500MG CAP 1 30 90

CIPROFLOXACIN 250MG TAB 1 14 42

CIPROFLOXACIN 500MG TAB 1 20 60

CIPROFLOXACIN 750MG TAB 3 20 60

CLINDAMYCIN 150MG CAP 3 30 90

CLINDAMYCIN 300MG CAP 3 28 84

DOXYCYCLINE MONOHYDRATE 50MG TAB 3 30 90

DOXYCYCLINE MONOHYDRATE 100MG TAB 3 30 90

METRONIDAZOLE 250MG TAB 2 28 84

METRONIDAZOLE 500MG TAB 3 14 42

MINOCYCLINE 50MG CAP 3 60 180

PENICILLIN VK 125MG/5ML SOLN 100ML 1 200 600

PENICILLIN VK 125MG/5ML SOLN 200ML 1 200 600

PENICILLIN VK 250MG/5ML SOLN 100ML 1 100 300

PENICILLIN VK 250MG/5ML SOLN 200ML 1 100 300

PENICILLIN VK 250MG TAB 1 30 90

PENICILLIN VK 500MG TAB 1 20 60

SMZ/TMP REGULAR STRENGTH TAB 1 28 84

SULFAMETH/TRIMETHOPRIM 800/160 TAB 2 28 84

TRIMETHOPRIM 100MG TAB 3 30 90

Medical Devices

Quantity

Drug Name Tier 30 90

PROCHAMBER AERO SPACER 3 1 3

Mental Health

Quantity

Drug Name Tier 30 90

AMITRIPTYLINE 10MG TAB 1 30 90

AMITRIPTYLINE 25MG TAB 2 30 90

AMITRIPTYLINE 50MG TAB 3 30 90

BENZTROPINE 0.5MG TAB 2 30 90

BENZTROPINE 1MG TAB 3 60 180

BENZTROPINE 2MG TAB 2 30 90

BUSPIRONE 5MG TAB 2 60 180

BUSPIRONE 10MG TAB 2 60 180

BUSPIRONE 15MG TAB 3 60 180

CITALOPRAM 10MG TAB 2 30 90

CITALOPRAM 20MG TAB 2 30 90

CITALOPRAM 40MG TAB 2 30 90

CLOZAPINE 25MG TAB 3 30 90

DIVALPROEX DR 125MG TAB 3 90 270

DOXEPIN 10MG CAP 2 30 90

DOXEPIN 25MG CAP 2 30 90

DOXEPIN 50MG CAP 3 30 90

DOXEPIN HCL 10MG/ML CONC 118ML 3 90 270

FLUOXETINE 10MG CAP 1 30 90

FLUOXETINE 20MG CAP 1 30 90

FLUOXETINE 40MG CAP 1 30 90

FLUOXETINE 10MG TAB 1 30 90

FLUOXETINE 20MG/5ML LIQUID 3 150 450

FLUPHENAZINE 2.5MG TAB 3 30 90

FLUPHENAZINE 5MG TAB 3 30 90

FLUVOXAMINE 25MG TAB 3 30 90

FLUVOXAMINE 100MG TAB 3 60 180

GABAPENTIN 100MG CAP 2 90 270

GABAPENTIN 300MG CAP 3 90 270

GABAPENTIN 400MG CAP 3 90 270

GABAPENTIN 250MG/5ML SOLN 3 236 708

HALOPERIDOL 0.5MG TAB 3 60 180

HALOPERIDOL 1MG TAB 2 30 90

HALOPERIDOL 2MG TAB 3 30 90

HALOPERIDOL 2MG/ML CONCENTRATE 3 135 405

HYDROXYZINE 10MG/5ML SYRUP 3 240 720

HYDROXYZINE HCL 10MG TAB 3 60 180

HYDROXYZINE HCL 25MG TAB 2 30 90

HYDROXYZINE HCL 50MG TAB 3 30 90

HYDROXYZINE PAMOATE 25MG CAP 3 90 270

IMIPRAMINE 10MG TAB 3 60 180

IMIPRAMINE 25MG TAB 3 60 180

IMIPRAMINE 50MG TAB 3 30 90

LAMOTRIGINE 5MG CHEWABLE TAB 3 150 450

LAMOTRIGINE 25MG CHEWABLE TAB 3 180 540

LITHIUM CARBONATE 150MG CAP 3 60 180

LITHIUM CARBONATE 300MG CAP 2 90 270

LITHIUM CARBONATE 300MG TAB 3 60 180

LITHIUM CARBONATE 600MG CAP 3 60 180

LITHIUM CARBONATE ER 450MG TAB 3 60 180

METHOCARBAMOL 500MG TAB 2 30 90

METHOCARBAMOL 750MG TAB 3 60 180

MIRTAZAPINE 15MG TAB 1 30 90

MIRTAZAPINE 30MG TAB 3 30 90

NORTRIPTYLINE 10MG CAP 2 30 90

NORTRIPTYLINE 25MG CAP 2 30 90

NORTRIPTYLINE 50MG CAP 3 60 180

NORTRIPTYLINE 75MG CAP 3 30 90

PAROXETINE 10MG TAB 2 30 90

PAROXETINE 20MG TAB 2 30 90

PAROXETINE 30MG TAB 3 30 90

PRAMIPEXOLE 0.125MG TAB 3 30 90

Mental Health (cont.)

Quantity

Drug Name Tier 30 90

PRAMIPEXOLE 0.25MG TAB 3 30 90

PRAMIPEXOLE 0.5MG TAB 3 60 180

PRAMIPEXOLE 1MG TAB 3 60 180

PRAMIPEXOLE 1.5MG TAB 3 60 180

PRIMIDONE 50MG TAB 3 60 180

PROCHLORPERAZINE 5MG TAB 2 30 90

PROCHLORPERAZINE 10MG TAB 2 30 90

ROPINIROLE 0.25MG TAB 3 60 180

ROPINIROLE 3MG TAB 3 30 90

SERTRALINE 25MG TAB 2 30 90

SERTRALINE 50MG TAB 3 30 90

SERTRALINE 100MG TAB 3 30 90

THIORIDAZINE 25MG TAB 3 30 90

THIORIDAZINE 50MG TAB 3 30 90

TRAZODONE 50MG TAB 2 30 90

TRAZODONE 100MG TAB 1 30 90

TRAZODONE 150MG TAB 2 30 90

TRIHEXYPHENIDYL 2MG TAB 2 60 180

TRIHEXYPHENIDYL 5MG TAB 3 90 270

VALPROIC ACID 250MG/5ML SYRUP 3 540 1620

VENLAFAXINE 25MG TAB 3 60 180

VENLAFAXINE 37.5MG TAB 3 60 180

VENLAFAXINE 50MG TAB 3 60 180

VENLAFAXINE 75MG TAB 3 60 180

VENLAFAXINE 100MG TAB 3 60 180

Mouth/Throat/Dental

Quantity

Drug Name Tier 30 90

CHLORHEXIDINE ORAL RINSE 473ML 2 473 1419

LIDOCAINE VISCOUS 2% ORAL SOL 100ML 2 100 300

PILOCARPINE 5MG TAB 3 90 270

SF 5000 PLUS 1.1% CREAM 51GM 3 60 180

SOD FLUORIDE 0.2% MINT SOLUTION 2 473 1419

STANNOUS FLUORIDE 0.63% RINSE 3 300 900

Skin Conditions

Quantity

Drug Name Tier 30 90

BENZOYL PEROXIDE 5% AQ GEL 60GM 3 60 180

BETAMETHASONE VAL 0.1% CRM 15GM 3 15 45

CICLOPIROX TOPICAL SUSPENSION 30ML 3 30 90

CICLOPIROX TOPICAL SUSPENSION 60ML 3 60 180

FLUTICASONE 0.005% OINT 30GM 3 30 90

HYDROCORTISONE 1% CREAM 28.35GM 2 28.35 85.05

HYDROCORTISONE 1% OINT 28.35GM 2 28.35 85.05

HYDROCORTISONE 2.5% CREAM 30GM 2 30 90

HYDROCORTISONE 2.5% OINT 28.35GM 3 60 180

HYPERCARE 20% SOL DAB-O-MATIC 60ML 3 60 180

MELQUIN 3% SOLN 30ML 3 30 90

MOMETASONE 0.1% OINT 15GM 3 15 45

MOMETASONE 0.1% OINT 45GM 3 45 135

MOMETASONE 0.1% TOPICAL SOLN 30ML 3 30 90

MOMETASONE 0.1% TOPICAL SOLN 60ML 3 60 180

NYSTATIN OINT 15GM 3 15 45

SALICYLIC AC 6% SHAMPOO 177ML 3 177 531

SELENIUM SULFIDE 2.5% SHAMPOO (LOTN) 2 118 354

TRIAMCINOLONE 0.025% CREAM 15GM 1 15 45

TRIAMCINOLONE 0.5% CREAM 15GM 2 15 45

TRIAMCINOLONE 0.1% CREAM 80GM 2 80 240

TRIAMCINOLONE 0.1% OINT 80GM 3 80 240

UREA 40% LOTION 236.6ML 3 236.6 709.8

UREA 50% NAIL GEL 18ML 3 18 54

Thyroid Conditions

Quantity

Drug Name Tier 30 90

LEVOTHROID 0.1MG TAB 2 30 90

LEVOTHYROXINE 0.025MG (25MCG) TAB 2 30 90

LEVOTHYROXINE 0.05MG (50MCG) TAB 2 30 90

LEVOTHYROXINE 0.075MG (75MCG) TAB 2 30 90

LEVOTHYROXINE 0.088MG (88MCG) TAB 2 30 90

LEVOTHYROXINE 0.100MG (100MCG) TAB 2 30 90

LEVOTHYROXINE 0.112MG (112MCG) TAB 2 30 90

LEVOTHYROXINE 0.125MG (125MCG) TAB 2 30 90

LEVOTHYROXINE 0.137MG (137MCG) TAB 2 30 90

LEVOTHYROXINE 0.150MG (150MCG) TAB 2 30 90

LEVOTHYROXINE 0.175MG (175MCG) TAB 2 30 90

LEVOTHYROXINE 0.2MG (200MCG) TAB 2 30 90

LEVOTHYROXINE 0.3MG (300MCG) TAB 2 30 90

METHIMAZOLE 5MG TAB 2 30 90

METHIMAZOLE 10MG TAB 3 30 90

NATURE-THROID 0.5GR (32.5MG) TAB 2 60 180

Urinary Health

Quantity

Drug Name Tier 30 90

OXYBUTYNIN 5MG/5ML SYRUP 3 240 720

OXYBUTYNIN ER 5MG TAB 3 30 90

OXYBUTYNIN ER 15MG TAB 3 30 90

Vitamins and Nutritional Health

Quantity

Drug Name Tier 30 90

FABB TAB 3 30 90

FE C PLUS TAB 3 30 90

FEROTRIN CAP 3 60 180

FERREX 150 FORTE CAP 2 45 135

FLUORIDE 0.25MG F CHEWABLE TAB 2 120 360

FLUORIDE 0.5MG F CHEWABLE TAB 1 30 90

FLUORIDE 1.0MG F CHEWABLE TAB 2 30 90

FOLBECAL TAB 3 30 90

FOLBEE PLUS TAB 3 30 90

FOLBEE TAB 3 30 90

FOLIC ACID 1MG TAB 1 30 90

HEMATINIC/ FA TAB 2 30 90

HEMATINIC PLUS TAB 10 X 10 3 30 90

KLOR-CON 10MEQ TAB 3 30 90

MULTIGEN FOLIC TAB 3 30 90

MULTIGEN TAB 3 30 90

MULTIVIT/F 0.25MG CHEWABLE TAB 2 30 90

MULTI-VITA-F 0.5MG CHEW TAB 1 30 90

MULTI-VIT/FLUORIDE 1MG CHEW TAB 2 30 90

MULTIVITAMINS W/ FL 1.0MG CHEW TAB 3 30 90

MULTIVITS W/FL 1MG & IRON CHEW TAB 1 30 90

NATALCARE PLUS TAB (1MG FOLIC ACID) 1 30 90

OB-NATAL ONE CAP 3 30 90

POLY-IRON 150 CAP 2 60 180

POLY-IRON 150 FORTE CAP 3 45 135

POTASSIUM CL 10MEQ ER TAB 3 30 90

PRENAFIRST TAB 3 30 90

PRENATAB FA TAB 3 30 90

PRENATAL 19 TAB 2 30 90

PRENATAL PLUS TAB 3 30 90

RE DUALVIT F CAP 3 30 90

RE PRENATAL MULTIVIT W/IRON CHEW TB 3 30 90

RENA-VITE RX TAB 1 30 90

RENAL SOFTGEL CAP 3 30 90

THEROBEC PLUS TAB 3 30 90

VINATE AZ TAB 3 30 90

VINATE CARE CHEWABLE TAB 3 30 90

VINATE C TAB 3 30 90

VINATE GT TAB 2 30 90

VINATE M TAB 2 30 90

VINATE ONE TAB 2 30 90

VITAMIN B-12 100MCG TAB 1 100 300

VITAMIN D 50,000IU CAP 1 4 12AVERAGE SAVINGS-
90-day supply of a value-priced generic	Tier 1		$50.41
Tier 2		$52.54
Tier 3		$118.08
Commonly prescribed quantities of all other generics		$21.79
Brand-name drugs		$31.16