University of Hawai'i - September 2016 v45. Walmart $4/$10 list We are ONLINE! Go to

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1 University of Hawai'i - September 2016 v45 PLANS CVS mark UHC Evercare CLASSES PAGES Allergy (antihistamine, nasal steroids)...1 Antibiotics Anticoagulants (&platelet InhibitorS).4 Asthma/COPD...5 Birth Control...6 Cholesterol...7 Depression...8 Dermatology (steroid creams) Diabetes Ear...13 Heartburn...14 Hypertension Insomnia...17 Migraine...18 Psychotics (anti-psychotics)...19 Smoking Cessation...20 We are ONLINE! Go to Sponsored by: Univ. of Hawaii JABSOM Family Medicine and Community Health Univ. of Hawaii Chair for Health Services Quality Research Pacific Health Research & Education Institute Dr. Chien-Wen Tseng, MD and Dr. Camlyn Masuda, Pharm D. cwtseng@hawaii.edu, (808) Ala Moana Blvd Ste. 815, Honolulu, HI Walmart $4/$10 list

2 ALLERGIES Non-sedating anti-histamines Zyrtec cetirizine $16 for 365 tabs OTC Clarinex desloratadine $204 OTC $5-$10 Allegra fexofenadine $33 for 150 tab (Aller-Fex) OTC Xyzal levocetirizine $8 generic $5-$10 Claritin loratadine $13 for 365 tabs (Aller- Tec) walmart $4 OTC Non-sedating anti-histamines with pseudophedrine must fail loratadine & cetirizine Zyrtec-D 12hr Allegra-D 12hr Allegra-D 24 hr Claritin-D 12hr Claritin-D 24 hr cetirizine/ pseudoephedrine fexofenadine/ pseudoephedrine fexofenadine/ pseudoephedrine loratadine/ pseudoephedrine loratadine/ pseudoephedrine $15/ 12 tab () OTC $ avail* OTC $ avail* OTC $14/ 10 tabs $16/ 10 tabs *Could find price at Costco website or website Nasal steroids OTC OTC???? Alavert D 24h Beconase AQ beclomethasone $187 Rhinocort AQ budesonide $135 therapy, age < 4 trial fluticasone + flunisolide Nasarel flunisolide, nasal $45 Flonase fluticasone $45 for 3 OTC Nasonex mometasone $195 $15-20 $5-$10 Nasacort AQ triamcinolone $100 : Rhinocort AQ -- age 4 or younger AND fail fluticasone or flunisolide in prior 6 months. Highlighted drugs - by all 6 plans Sept 2016 v45 p. 1

3 Penicillins and Cephalosporins ANTIBIOTICS (1 of 2) Trimox Augmentin Pen-Vee K Keflex (1st gen) Quinolones amoxicillin amoxicillin / clavulanate penicillin VK cephalexin $6 $70 $15 $10 Cipro ciprofloxacin $7 Levaquin levofloxacin $19 (tabs) Avelox, Moxeza moxifloxacin $845/30 pill * QUEST - moxifloxacin - needs recent 14 day trial of cipro, levo, or ofloxacin Tetracyclines Adoxa doxycycline $85/50 caps Macrolides Zithromax azithromycin $10 250mg #6 Sulfonamides Bactrim DS trimethoprim / sulfamethoxazole Other Antimicrobials $7 Cleocin clindamycin $12 150mg, 300mg Cleocin Vaginal clindamycin vaginal $88 cream & supp Zyvox linezolid $3033 (#20) $15 - up to 30 tabs Macrobid nitrofurantoin BID $58 Highlighted drugs - by all 6 plans Sept 2016 v45 p. 2

4 Antifungals ANTIBIOTICS (2 of 2) Diflucan fluconazole $6/1 tab (150mg) Walmart Sporanox itraconazole $102 Nizoral ketoconazole $35 Nizoral Topical ketoconazole cream or shampoo $17 (120ml) Flagyl metronidazole $17 Metrogel Mycostatin Lamisil metronidazole vaginal gel nystatin topical, pwdr terbinafine $32 (70 g) $18 (15g ) $16 Walmart $4 Anti-Virals Zovirax acyclovir $7 Famvir famciclovir $42?* Cytovene ganciclovir $ avail 500mg vial?* 5 up to 7 days Valtrex valacyclovir $37 (tabs) *Conflicting information on CVS website. Highlighted drugs - by all 6 plans Sept 2016 v45 p. 3

5 Anticoagulants/Platelet Inhibitors (30 days) CVS (State ) Eliquis apixaban $15-20 Plavix clopidogrel $12 Pradaxa dabigatran $328(60 cap) $15-20 $15-20 Xarelto rivaroxaban $322 (30 tab) $15-20 $ pills/yr * : Xarelto. 10mg - 35 per 35 days, 1 fill per 90d. 15mg - 42 per 21 days, 1 fill per 90d Highlighted drugs - by all 6 plans Sept 2016 v45 p. 4

6 Beta Agonists (1 inhaler) $56 (Walmart Proair albuterol inhaler $15-20 $15-20 neb$4) Proventil albuterol inhaler $66 $30 $30-55 Ventolin albuterol inhaler $58 $30 $15-20 Maxair pirbuterol inhaler $175 $30 Arcapta indacaterol $215 $15-20 Striverdi olodaterol $163 $30 $15-20 Xopenex HFA levalbuterol $60 Proair $30-55 $239 for 60 Foradil formoterol $15-20 $15-20 caps Serevent salmeterol $242 $15-20 $30-55 Inhaled Steroids (1 inhaler) QVAR beclomethasone $190 (40mcg) Pulmicort budesonide $192 flexhaler CVS (State ) $15-20 $15-20 $15-20 flexhaler $15-20 Pulmicort Respules neb only age < 8y Arnuity Ellipta fluticasone furoate $195 $15-20 Flovent Diskus/HFA fluticasone propionate $193 (110mcg) - HFA only $15-20 Diskus HFA $15-20 Diskus, HFA Asmanex mometasone $204 $15-20 $15-20 Combinations/Others (1 inhaler) age < 11 $249 (neb Atrovent Ipratropium bromide $4Walmart) Spiriva nebs HFA handihaler Spiriva tiotropium $336 ( $15-20 $15-20 respimat) Incruse Ellipta umeclidinium $245 $30-55 Anoro Ellipta umeclidinium/vilaterol $305 $15-20 $30-55 Intal (neb) cromolyn sodium (neb) $124 nebs? nebs Combivent albuterol/ ipratropium $307 $15-20 $15-20 fluticasone propionate/ $253 (45-21 Diskus, $15-20 Diskus, Advair Diskus/HFA $15-20 salmeterol HFA) HFA Diskus, HFA HFA fluticasone furoate/ Breo Ellipta $288 Advair $15-20 vilanterol Symbicort budesonide/ formoterol $270 ( ) Advair $15-20 Dulera mometasone/formoterol $264 $15-20 $15-20 Singulair montelukast $22 therapy Accolate zafirlukast $136 / 60 tabs therapy needs PA Spacers E-Z Spacer, Vortex, Air Zone, Aerochamber spacers $44 Easivent ASTHMA - which brand? Aerochamber $10 Air Zone EZ Spacer Vortex Aerochambe r Vortex : Singulair and Accolate -- Needs trial of intranasal steroid or formulary asthma agent. : Symbicort, Advair Diskus, Dulera -- Needs 30 day trial inhaled steroid Health. Breo Ellipta, Dulera - trial of 30 day inhaled steroids or trial of 60 day long-acting beta2 agonist or anticholinergic. Aerochambe r, EZ spacer, Easivent, Optichamber Easivent, Vortex Sept 2016 v45 p. 5

7 Monophasic BIRTH CONTROL Ethinyl estradiol (EE mcg) (30 days) Alesse, Aviane Loestrin (Junel) 1/20 Yaz, Gianvi 20 EE 0.1 levonorgestrel 20 EE 1.0 norethindrone 20 EE 3.0 drospirenone $19 levonest- 28 (Walmart $9) $97 Loestrin 21 Aviane Junel $45 Loryna Gianvi -5 Aviane -5 Junel -5 Gianvi -$10 Alesse Aviane Alesse Loestrin 1/20 Junel Loestrin 1/20-10 Yaz Yaz Gianvi Desogen, Apri, Ortho-Cept, Enskyce Yasmin, Ocella, Syeda Nordette, Altavera, Kurvelo Lo/ovral, Low- Ogestrel, Elinest 30 EE 0.15 desogestrel 30 EE 3.0 drospirenone 30 EE 0.15 levonorgestrel 30 EE 0.3 norgestrel $22 CVS (Walmart $9 Enskyce) Apri $57 Syeda Ocella $29 Altavera (Walmart $4 Altavera $20 Elinest Elinest -5 Apri -5 Ocella -5 Altavera -5 Low- Ogestrel -10 Desogen -10 Yasmin Apri Apri Ortho-cept Yasmin Ocella Altavera Nordette Low- Ogestrel Lo/ovral Ortho-Cyclen, Mononessa, sprintec Progestin only Nor-QD, Heather, Micronor, Errin, Camila, Aygestin 35 EE 0.25 norgestimate norethindrone Others/HPV Vaccine $29 Sprintec (Walmart $9) $20 Heather walmart $9 Sprintec Camila -5 Mononessa -5 Heather -10 Nor- Q-D Mononess a Aygestin Orthocyclen Orthocyclen Ortho micronor (30 days) Ella ulipristal $43-20 Plan B One (emergency contraception) OrthoEvra (patch/wk) NuvaRing (vaginal ring) levonorgestrel 1.5mg norelgestromin/ethinyl estradiol 0.12 etonogstrel / ethinyl estradiol Longs $40 - OTC age > 18. N/a at Costco $113 (3 patch) OTC $111 levonorgestr el 0.75mg Trial of OCP first Trial of OCP first -5 levo norgestrel -20 Xulane -10 Ella Plan B one (2/year) Plan B one- -10 levonorges trel 1.5mg ortho evra $ Gardasil Human Papillomavirus Quadrivalent Vaccine $155/inj year old $15-20 F yr, M yr year old Ages 9-26 M & F Sept 2016 v45 p. 6

8 Statins CHOLESTEROL GENERIC (30 days) Lipitor atorvastatin $15 (10mg) Mevacor lovastatin $6 ( 10,20mg) Pravachol pravastatin $44 Crestor rosuvastatin $200 $15-20 Zocor simvastatin $8 : Lipitor -- Must fail simvastatin, pravastatin, lovastatin. Walmart: Pravastatin -- 10mg $4, 20mg-$4, 40mg-$10. Others (30 days) Niaspan niacin SR (QD) $111 OTC Lopid gemfibrozil $7 Lofibra, Antara fenofibrate, micronized $150 (antara 130mg #30)?* Tricor fenofibrate $19 (54mg) fenofibrate tabs fenofibrate tabs trial statin OR 90d of gemfibrozil Colestid colestipol $46 ran cholestyramine $55 cans only WelChol colesevelam $494 (3.75g #30) $15-20 $30-55 Zetia ezetimibe $210 $15-20 $30-55 Vytorin ezetimibe/ simvastatin *Conflicting information on CVS website. Health: Vytorin -- Must fail 90d simvastatin (40mg,80mg) or atorvastatin. trial 30d statin $217?* $30-55 Highlighted drugs - by all 6 plans Sept 2016 v45 p. 7

9 SSRI DEPRESSION Celexa citalopram $6 Lexapro escitalopram $7 Prozac fluoxetine $6 Prozac weekly fluoxetine weekly $173/ 4 tab?* 10mg & 20mg caps Luvox fluvoxamine $20?* Luvox CR fluvoxamine ER $220?* Paxil paroxetine $6 (Walmart $10) Paxil CR paroxetine ER $80 Zoloft sertraline $12 SNRIs/Others Wellbutrin SR (BID) Wellbutrin XL (QD) bupropion SR $21 Budeprion bupropion XL $27 100,200mg only Pristiq desvenlafaxine $114 $15-20 $30-55 fail 2 generics Cymbalta duloxetine $247 $ , 300mg Remeron mirtazapine $15 tabs only Serzone nefazodone $44?* Effexor (bid) venlafaxine $15 Effexor XR (QD) venlafaxine ER $90 *Conflicting information on CVS website. Highlighted drugs - by all 6 plans Sept 2016 v45 p. 8

10 Very high potency DERMATOLOGY (1 of 2) Diprolene Temovate, Cormax Temovate E Ultravate a. betamethasone d. 0.05%, gel clobetasol 0.05%, clobetasol 0.05% emollient cream halobetasol p. 0.05% $67 (15g) $77 $21 (30gm) $80 $82 (15gm), gel gel,, gel gel,, soln gel, gel, soln, $30-55 cream cream High potency Betatrex () betamethasone valerate 0.1% $62 lotion, lotion, Cyclocort amcinonide 0.1% lotion $244 lotion, Diprolene AF a. betamethasone d. 0.05% cream $90 cream $30 $30-55 cream cream cream Diprolene Diprosone, Maxivate ( ) Florone, Maxiflor, Psorcon B Kenalog Lidex Lidex E Topicort a. betamethasone d. 0.05% lotion, gel betamethasone d. 0.05% diflorasone 0.05% triamcinolone a. 0.5% fluocinonide 0.05%, gel fluocinonide 0.05% emollient cream desoximetasone 0.25% cream/, 0.05% gel $90 lotion $30 $70 $75 (15gm) $12 (15g) $10, sol, gel $15-20 Apexicon E $41 cream?* $70 cream, gel only crm//lot cream cream 0.25% crm/, 0.05%gel lotion lotion, gel lotion, lotion, cream crm,gel,,soln gel, cream only gel,,soln soln cream gel,, soln cream Sept 2016 v45 p. 9

11 Medium potency DERMATOLOGY (2 of 2) Betatrex Cutivate Diprosone, Maxivate (lotion) Elocon Kenalog Locoid Synalar 0.025% Topicort LP Westcort betamethasone v. 0.1% lotion fluticasone p. 0.05% betamethasone d. 0.05% lotion mometasone f. 0.1% lotion, triamcinolone a. 0.1% or 0.025% hydrocortisone butyrate 0.1% cream fluocinolone a % desoximetasone 0.05% cream hydrocortisone v. 0.2% (15gm) $15 $18 $51 cream lotion $11 (15gm) $10 $35 lotion lotion,, lotion, lotion lotion cream lot $30-55 lotion $30-55 $36 $43 (15g) $53, soln gel, lotion lotion, lotion, lotion lotion lotion lot, lot, 0.1%, crm, soln lotion,, soln, soln, cream cream cream cream Highlighted - - by all 6 plans Low potency Aclovate Cetacort, Hytone Desowen alclometasone d. 0.05% hydrocortisone 1% or 2.5% crm,, lotion desonide 0.05%, lotion $26 $8 (30g) $89 lotion, $30-55, lot crm,gel, lot,, soln lot, 1% crm/lot/, 2.5%lot/ cream only Cream 0.5,1,2.5. Lotion 1,2.5 Synalar fluocinolone a. 0.01% soln *Conflicting information on UHC Evercare website. Highlighted - - by all 6 plans $36 soln soln oil, soln Sept 2016 v45 p. 10

12 Metformin DIABETES (1 of 2) Glucophage metformin $7 (500mg) Glucophage XR metformin ER $7 (500mg) Metaglip metformin/glipizide $25 Glucovance metformin/glyburide $7 Sulfonylurea Amaryl glimepiride Glucotrol glipizide $6 $6 Glucotrol XL glipizide ER $17 Micronase, Diabeta Glynase glyburide glyburide micronized $6 $11 TZD/Others Actos pioglitazone $15 (15mg) therapy must fail metformin Duetact ACTOplus met pioglitazone/ glimepiride pioglitazone/metf ormin $293 $255 therapy therapy must fail metformin Byetta exenatide $474 (3ml) $30 $30-$55 * Bydureon exenatide ER $514 (8ml) $15-20 $15-20 Victoza liraglutide $440 6ml #0 $15-20 $15-20 Tradjenta linagliptin $338 $15-20 $30-$55 must fail metformin must fail metformin must fail metformin must fail metformin must fail metformin Januvia sitagliptin $322 $15-20 $15-20 Janumet sitagliptin/metfor min $331 $15-20 $15-20 Janumet XR sitagliptin/metfor min ER $190 $15-20 $15-20 Kombiglyze XR saxagliptin/metfo rmin $343 $30 $15-20 Onglyza saxagliptin $316 $30 $15-20 : Actos, Duetact, ACTOplusmet - trial of metformin or metformin/combination drugs in last 60 days Health : PA & therapy - Must fail 90 day trial of metformin 1500mg : Victoza - recent 60d trial of metformin or sulfonylurea. Actoplus met and Duetact - recent 30d of Actos AND metformin/glimepiride. * * * * Sept 2016 v45 p. 11

13 Insulin DIABETES (2 of 2) Apidra glulisine (rapid) $210 10ml, $430 15ml pen vial, pen vial, pen $15-20 vial * vial, pen Humalog lispro (rapid) $ ml, $423 15ml pen vial, pen vial, pen * vial, pen vial Humalog Mix 50/50 lispro mix (int/reg) $131 10ml, $841 15ml pen vial, pen?* * vial vial Humalog Mix 75/25 lispro mix (int/reg) $158 10ml, $423 15ml pen vial, pen?* * vial, pen vial Humulin 70/30 Humulin N NPH/reg mix NPH (intermediate) $90 10ml, $385 15ml pen $309 15ml pen OTC vial, pen?* * vial, pen vial OTC vial, pean?* * vial, pen vial Humulin R insulin (regular) $89 vial OTC vial vial vial vial Lantus Levemir Novolin 70/30 Novolin N Novolin R Novolog Novolog 70/30 glargine (longacting) detemir (long acting) NPH/reg mix (int/reg) NPH (intermediate) insulin (regular) aspart (rapid) aspart mix (int/reg) $240 10ml, $371 15ml pen vial, pen vial, pen vial, pen * vial, pen Tuojeo Solostar* $189 10ml vial, pen * $25 $5 - $10 OTC vial Walmart vial, pen * vial vial $29 $5 - $10 OTC vial Walmart vial, pen * vial vial $28 $5 - $10 OTC vial Walmart vial, pen * vial vial $197 10ml, $375 15ml pen vial, pen $15-20 * pen vial $ ml pen vial, pen $15-20 * vial, pen vial *. Insulins - says which which insulin is, but if both vial and pen forms are. *UHC. Both lantus pen and vial unless fail trial of Tuojeo solostar pen. Glucometers (10 ml vial) Accu-Chek Aviva Plus, Accu-Chek Compact Plus free meter* foote Bayer Breeze 2/ Bayer Contour free meter* Freestyle Lite/ Freestyle Freedom Lite free meter* covers strips meter Freestyle, Freestyle Lite Freestyle Freedom Lite (kit & strips) foote Freestyle Precision? One touch ultra (Ultra 2 or Ultra mini) free meter* Ultra, Ultramini, Ultra, Verio Sure, Fast Take, Verio, Ultra foote 1 strip/day if no insulin - glucometer. Website and customer service both say accu-chek (AvivaPlus, Compact, Nano 100 stp/30d) and freestyle (Precision), but pharmacists tell us onetouch glucometer/lancets (verio, ultra2, ultramini). *** : Accu-Chek or One Touch glucometers- call Sept 2016 v45 p. 12

14 Ear antibiotics EAR Cipro HC Otic ciprofloxacin/ hydrocortisone $104 (10ml) $15-20 $30-55 Ciprodex ciprofloxacin/ dexamethasone $163 $15-20 $30-55 must fail ofloxacin Coly-Mycin S Otic neomycin/ hydrocortisone $85 $30-55 $30-55 Cortisporin Otic Cortisporin TC Otic neomycin/polymyxin B/hydrocortisone (susp, soln) neomycin/colistin/hy drocortisone $18 $78 $30-55 $30-55 Domeboro Otic, Star-Otic acetic acid/ aluminum acetate $ avail Floxin Otic Ofloxacin, otic $27 Vosol HC Otic acetic acid/ hydrocortisone $95 Walmart Vosol Otic acetic acid $36 Others Americane Auralgan, Benzotic Benzocaine Cerumenex Cortic ND Debrox Ear-Dry Swim-Ear Highlighted - benzethonium chloride/ glycerine / benzocaine antipyrine / benzocaine benzocaine triethanolamine hydrocortisone/ pramoxine hcl/ chloroxylenol carbamide peroxide 6.5% boric acid/ isopropyl alcohol glycerin / isopropyl alcohol - by all 6 plans $ available $ 18 $ available $ available $ available $6 OTC $ available $ available OTC? carbamide 6.5% OTC OTC Sept 2016 v45 p. 13

15 HEARTBURN/ GERD Tagamet cimetidine $23 (180tab) (Walmart $10) OTC Pepcid famotidine $16 Axid nizatidine $46 (60 tabs) Zantac ranitidine $12 OTC capsule Pepcid AC OTC OTC 150mg Proton-pump Inhibitors (PPI) Nexium esomeprazole $256 Prevacid lansoprazole $21 Nexium 24h 22.3mg cap capsule $15-20 nexium packets 90/yr Prilosec omeprazole $11 OTC caps Protonix pantoprazole $14 Aciphex rabeprazole $55 Walmart $30-55 fail 2 generic PPI * : Prevacid -- must fail 30 day omeprazole 40mg AND pantoprazole 40mg within prior 180 days. Highlighted - - by all 6 plans Sept 2016 v45 p. 14

16 HTN - Ace Inhibitors Lotensin benazepril $15 Vasotec enalapril $10 Monopril fosinopril $11 Walmart Prinivil, Zestril lisinopril $7 Accupril quinapril $16 Altace ramipril $11 ACE inhibtors with HCT Lotensin HCT benazepril/hct $12 Vaseretic enalapril/hct $21 Monopril HCT fosinopril/hct $38 Zestoretic lisinopril/hct $6 Accuretic quinapril/hct $21 HTN - ARBs Atacand candesartan $97 Avapro irbesartan $10 Cozaar losartan $10 Benicar olmesartan medoxomil $137 $15-20 $30-55 fail losartan, valsartan Micardis telmisartan $32 Diovan valsartan $137 ARBs with HCT Atacand HCT candesartan/hct $128 $30-55 Avalide irbesartan/hct $167 Hyzaar losartan/hct $13 Benicar HCT olmesartan medoxomilhydrochlorothiazide $180 $15-20 $30-55 Micardis HCT telmisartan/hct $106 Diovan HCT valsartan/hct $15 Highlighted - - by all 6 plans Sept 2016 v45 p. 15

17 Cardioselective HTN - beta blockers Tenormin atenolol $6 Zebeta bisoprolol $12?* Lopressor Toprol XL metoprolol tartrate metoprolol succinate ER $12 50mg and 100mg $19 Lopressor HCT metoprolol HCT $37?* Bystolic nebivolol $97 $15-20 Non-cardioselective Ziac bisoprolol/hct Coreg (bid) carvedilol $12 walmart $10 $6?* Coreg CR (qd) carvedilol ER $52 $15-20 $15-20 Trandate labetalol $26 (200mg 30 tab)?* Inderal propranolol $6 Inderal LA propranolol ER $73 Inderide (HCT) propranolol/ HCT $31?* Highlighted - Dihydropyridines - by all 6 plans HTN - calcium channel blockers Norvasc amlodipine $8 Plendil felodipine $19?* Dynacirc isradipine BID $65?* Dynacirc CR isradipine CR $73?* Procardia XL/ Adalat CC nifedipine ER (QD) Non-dihydropyridines $27 Cardizem CD diltiazem ER $85 Calan SR verapamil SR $13 Chlorthalidone Hygroton chlorthalidone $30 Sept 2016 v45 p. 16

18 Benzodiazepine INSOMNIA Xanax alprazolam $12 age > 18 Xanax XR alprazolam ER $29 age > 18 Librium chlordiazepoxide $12 Klonopin clonazepam $9 Valium diazepam $12 age > 1 Prozom estazolam $18 Dalmane flurazepam $18 Ativan lorazepam $11 age > 12 Restoril temazepam $11 Halcion triazolam $14 age > 18y 15mg, 30mg Benzodiazepine Receptor Agonist (non-benzo benzodiazepine) Lunesta eszopiclone $34 w/ coupon $ tab/m Sonata zaleplon $22?* Ambien zolpidem $12 30 tabs/ month age > 18, 31 pills/m Ambien CR zolpidem ER $85 $30-55 Note: -- Benadryl, Unisom (doxylamine), etc., are over the counter and included here. Others Desyrel trazodone $6 CVS (State ) Oleptro trazodone ER $15 therapy $30 Rozerem ramelteon $290 $30 *Conflicting information on CVS website. age > mg must fail 2 generics Sept 2016 v45 p. 17

19 Triptan MIGRAINE HEADACHES (6 tab) Axert almotriptan $49 (12 tab) 40 Relpax eletriptan $234 (6tab)?* 12tab/30d $ tab/30d Frova frovatriptan $438 (9tab) Amerge naratriptan $83 (9tab) Maxalt rizatriptan $119 (3tab) Imitrex Oral sumatriptan $20 (9tab) Imitrex Nasal sumatriptan $313 Imitrex Injection sumatriptan $264 (2 ml) (9 per 30d) (6 per 30d) (1.5 per 30d) Zomig zolmitriptan $235 (3tab) $ tab/30d 9tab/30d 12tab/30d 9tab/30d 12spray/ 30d 8inj/30d $ tab/30d 12 tab/30d fail imitrex 18 tab/30d fail imitrex must fail sumatriptan ages tab/30d 9 tab/31d 24 spray/30d 12 injection/3 0d 12 tab/30d fail imitrex 12 spray/31d 4 inj/31d trial sumatripta n 50mg tabs - trial sumatripta n limit 9 per 23d? 6 per 23d 4mg and 6mg Zomig Nasal zolmitriptan $ avail $15-20 Ergotamine Cafergot Migranal caffeine/ ergotamine dihydroergotamin e nasal $ spray/ 30d $20 $2734 (8ml) $15-20 $30-55 Acetaminophen/dichloralphenazone/isometheptene Duradrin Midrin Highlighted - acetaminophen/dichlora lphenazone/isomethept ene acetaminophen/dichlora lphenazone/isomethept ene - by all 6 plans $52 Migragesic 8 units (1 kit)/month $52 Migragesic Sept 2016 v45 p. 18

20 Atypical PSYCHOTIC (anti-psychotics) Abilify aripiprazole $872 tab Abilify Discmelt aripiprazole orally dissolving $825 Saphris (BID) asenapine $390 $15?* $30?* $ require ICD10 - require ICD10 age > 6 age > 18 Clozaril (BID) clozapine $33 age > 18 FazaClo ODT clozapine orally disintegrating $620 $5?* Fanapt (BID) Iloperidone $790 $30 $30-55 Latuda lurasidone $730 $15-20 $30-55 $30-55 age > 18 - require ICD10 - require ICD10 age > 18 age > 18 Zyprexa olanzapine $17 age > 13 Zyprexa Zydis (ODT) olanzapine orally disintegrating $75 $5?* age > 13 Symbyax olanzapine/ fluoxetine $155 $5?* $30-55? age > 18 Invega paliperidone $755 $30?* - require ICD10 age > 12 Seroquel (BID) quetiapine $11 age > 10 Seroquel XR quetiapine ER $1,130 $15-20 $ require ICD10 age > 10 Risperdal risperidone $16 age > 5 Risperdal M-tab risperidone orally disolving $10 $5?* Geodon (BID) ziprasidone $146 (capsule) age > 18 Highlighted - - by all 6 plans Sept 2016 v45 p. 19

21 SMOKING CESSATION Zyban, Wellbutrin SR, Budeprion SR, Buproban Chantix Nicoderm CQ Nicorette Gum Nicorette Lozenge, Commit bupropion HCL $21 -$10 age 18+ varenicline tartrate nicotine patches, nicotine transdermal nicotine gum, debroxnicotine gum nicotine lozenge $244 start, $125 continue pack $16 Walmart $55 Walmart $31 Walmart OTC OTC OTC therapy therapy therapy? $15-20 age 18+ OTC OTC OTC age 18+ age 18+ Nicotrol NS (nasal spray) nicotine nasal spray $73 $30 $30-55 Nicotrol Inhaler nicotine inhaled, cartridge $265 $30 $30-55 *Conflicting information on CVS website. Highlighted drugs - by all 6 plans Sept 2016 v45 p. 20

22 Retail Prescription Program Drug List Revised 8/12/2016 $ 4, 30-day $ 10, 90-day $ 4, 30-day $ 10, 90-day Price Matters New Men s Health Category Convenience Free Home Delivery Our $4 prescriptions have saved our customers over $3 billion The program is available to everyone, no membership required More affordable options for men $9 Finasteride for 30 tablets Easy Pay saves you time at the checkout counter Ready Reminders send you a free text message when your prescription is ready Auto Refill your prescriptions and save time Mailed right to your home, no matter where you live Free shipping Find out more at Walmart.com/pharmacy Allergies & Cold and Flu Benzonatate 100mg cap Loratadine 10mg tab Promethazine DM syrup ml ml Antibiotic Treatments Amoxicillin 125mg/5ml susp (80ml bottle) Amoxicillin 125mg/5ml susp (100ml bottle) Amoxicillin 125mg/5ml susp (150ml bottle) Amoxicillin 200mg/5ml susp (50ml bottle) Amoxicillin 200mg/5ml susp* (75ml bottle) Amoxicillin 200mg/5ml susp* (100ml bottle) Amoxicillin 250mg/5ml susp (80ml bottle) Amoxicillin 250mg/5ml susp (100ml bottle) Amoxicillin 250mg/5ml susp (150ml bottle) Amoxicillin 400mg/5ml susp (50ml bottle) Amoxicillin 400mg/5ml susp* (75ml bottle) Amoxicillin 400mg/5ml susp* (100ml bottle) Amoxicillin 250mg cap Amoxicillin 500mg cap Cephalexin 250mg cap Cephalexin 500mg cap Ciprofloxacin 250mg tab Ciprofloxacin 500mg tab* Penicillin VK 250mg tab Penicillin VK 125mg/5ml susp (100ml bottle) Penicillin VK 125mg/5ml susp* (200ml bottle) SMZ-TMP 400mg-80mg tab SMZ-TMP DS 800mg-160mg tab $ 4, 30-day $ 10, 90-day $ 4, 30-day $ 10, 90-day Arthritis & Pain Allopurinol 100mg tab Allopurinol 300mg tab Baclofen 10mg tab* Cyclobenzaprine 5mg tab Cyclobenzaprine 10mg tab Dexamethasone 0.5mg tab Dexamethasone 0.75mg tab Dexamethasone 4mg tab Diclofenac DR 75mg tab* Ibuprofen 100mg/5ml susp* ml ml Ibuprofen 400mg tab Ibuprofen 600mg tab* Ibuprofen 800mg tab Indomethacin 25mg cap* Meloxicam 7.5mg tab Meloxicam 15mg tab Naproxen 375mg tab* Naproxen 500mg tab* Asthma Albuterol 2mg tab Albuterol 4mg tab Albuterol 2mg/5ml syrup ml ml Albuterol 0.083% nebulizer soln* (25x3ml vials) $ 9/30-day Albuterol 0.5% nebulizer soln* (20ml bottle) Ipratropium 0.02% nebulizer soln* (25x2.5ml vials) Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some generic drugs at commonly prescribed dosages. Higher dosages cost more. Prices for some drugs by the Prescription Program may be higher and may vary in some states. Restrictions apply. See Program Details or your Walmart Pharmacist for details. Free language assistance services available for prescription drug information at Walmart pharmacies in New York. Contact your Walmart pharmacy for details. * Prices may be higher in CA, HI, MN, MT, PA, TN and WI. Prepackaged drugs are only in unit sizes specified on Drug List. See Program Details or your Walmart Pharmacist for details. Revised 8/12/ Wal-Mart Stores, Inc. Page 1 of 5

23 $ 4, 30-day $ 10, 90-day $ 4, 30-day $ 10, 90-day Cholesterol Lovastatin 10mg tab Lovastatin 20mg tab* Diabetes Glimepiride 1mg tab Glimepiride 2mg tab Glimepiride 4mg tab Glipizide 5mg tab Glipizide 10mg tab* Glyburide 2.5mg tab Glyburide 5mg tab (blue) Glyburide 5mg tab (green) Glyburide, micronized 3mg tab Glyburide, micronized 6mg tab Metformin 500mg tab Metformin 850mg tab Metformin 1000mg tab* Metformin 500mg ER tab* Fungal Infections Fluconazole 150mg tab Nystatin cream* (15gm tube) Nystatin cream* (30gm tube) Terbinafine 250mg tab* Gastrestinal Health Dicyclomine 10mg cap Dicyclomine 20mg tab Famotidine 20mg tab Lactulose syrup* ml ml Metoclopramide 10mg tab Metoclopramide syrup ml ml Promethazine 25mg tab* Promethazine plain syrup* ml ml Ranitidine 150mg tab Ranitidine 300mg tab Glaucoma & Eye Erythromycin op. ment (3.5gm tube) * Gentak 0.3% op. soln Gentamicin 0.3% op. soln (5ml bottle) Levobunolol 0.5% op soln (5ml bottle) * Neomycin/Polymyxin/Dexamethasone 0.1% op. ment* (3.5gm tube) Neomycin/Polymyxin/Dexamethasone 0.1% op. susp* (5ml bottle) Pilocarpine 1% op. soln* (15ml bottle) * Pilocarpine 2% op. soln* (15ml bottle) * Polymyxin Sulfate/TMP op. soln* (10ml bottle) Sulfacet Sodium 10% op. soln* (15ml bottle) Timolol Maleate 0.25% op. soln (5ml bottle) Timolol Maleate 0.5% op soln (5ml bottle) Tobramycin 0.3% op. soln (5ml bottle) Heart Health & Blood Pressure Atenolol 25mg tab Atenolol 50mg tab Atenolol 100mg tab Benazepril 5mg tab Benazepril 10mg tab Benazepril 20mg tab Benazepril 40mg tab Bisoprolol-HCTZ 2.5mg-6.25mg tab Bisoprolol-HCTZ 5mg-6.25mg tab Bisoprolol-HCTZ 10mg-6.25mg tab Carvedilol 3.125mg tab Carvedilol 6.25mg tab Carvedilol 12.5mg tab Carvedilol 25mg tab Clonidine 0.1mg tab Clonidine 0.2mg tab Enalapril-HCTZ 5mg-12.5mg tab* Furosemide 20mg tab Furosemide 40mg tab Furosemide 80mg tab Guanfacine 1mg tab Hydralazine 10mg tab Hydralazine 25mg tab Hydrochlorothiazide(HCTZ)12.5mg cap Hydrochlorothiazide (HCTZ) 25mg tab Hydrochlorothiazide (HCTZ) 50mg tab Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some generic drugs at commonly prescribed dosages. Higher dosages cost more. Prices for some drugs by the Prescription Program may be higher and may vary in some states. Restrictions apply. See Program Details or your Walmart Pharmacist for details. Free language assistance services available for prescription drug information at Walmart pharmacies in New York. Contact your Walmart pharmacy for details. * Prices may be higher in CA, HI, MN, MT, PA, TN and WI. Prepackaged drugs are only in unit sizes specified on Drug List. See Program Details or your Walmart Pharmacist for details. Revised 8/12/ Wal-Mart Stores, Inc. Page 2 of 5

24 $ 4, 30-day $ 10, 90-day $ 4, 30-day $ 10, 90-day Indapamide 1.25mg tab Indapamide 2.5mg tab Isosorbide Mononitrate 30mg ER tab* Isosorbide Mononitrate 60mg ER tab* Lisinopril-HCTZ 10mg-12.5mg tab Lisinopril-HCTZ 20mg-12.5mg tab* Lisinopril-HCTZ 20mg-25mg tab* Lisinopril 2.5mg tab Lisinopril 5mg tab Lisinopril 10mg tab Lisinopril 20mg tab Methyldopa 250mg tab* Metoprolol Tartrate 25mg tab Metoprolol Tartrate 50mg tab Metoprolol Tartrate 100mg tab* Sotalol HCL 80mg tab* Spironolactone 25mg tab* Terazosin 1mg cap Terazosin 2mg cap Terazosin 5mg cap Terazosin 10mg cap Triamterene-HCTZ 75mg-50mg tab Triamterene-HCTZ 37.5mg-25mg tab Verapamil 80mg tab Verapamil 120mg tab Warfarin 1mg tab Warfarin 2mg tab Warfarin 2.5mg tab Warfarin 3mg tab Warfarin 4mg tab Warfarin 5mg tab* Warfarin 6mg tab Warfarin 7.5mg tab Warfarin 10mg tab Men s Health $ 9/30-day Finasteride 5mg Mental Health Amitriptyline 10mg tab Amitriptyline 25mg tab* Amitriptyline 50mg tab* Amitriptyline 75mg tab* Amitriptyline 100mg tab* Benztropine 2mg tab Buspirone 5mg tab Buspirone 10mg tab* Citalopram 20mg tab Citalopram 40mg tab Fluoxetine 10mg cap* Fluoxetine 10mg tab* Fluoxetine 20mg cap* Fluoxetine 40mg cap* Haloperidol 0.5mg tab Haloperidol 1mg tab Haloperidol 2mg tab Haloperidol 5mg tab Lithium Carbonate 300mg cap* Nortriptyline 10mg cap* Nortriptyline 25mg cap* Paroxetine 10mg tab* Paroxetine 20mg tab* Prochlorperazine 10mg tab Trazodone 50mg tab Trazodone 100mg tab Trazodone 150mg tab* Trihexyphenidyl 2mg tab Skin Conditions Hydrocortisone 1% cream ( g tube) Hydrocortisone 2.5% cream (30gm tube) Silver Sulfadiazine 1% cream* (50gm tube) Triamcinolone 0.025% cream (15gm tube) Triamcinolone 0.025% cream (80gm tube) Triamcinolone 0.1% cream (15gm tube) Triamcinolone 0.1% cream (80gm tube) Triamcinolone 0.1% ment (15gm tube) Triamcinolone 0.1% ment (80gm tube) Triamcinolone 0.5% cream (15gm tube) Thyroid Conditions Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some generic drugs at commonly prescribed dosages. Higher dosages cost more. Prices for some drugs by the Prescription Program may be higher and may vary in some states. Restrictions apply. See Program Details or your Walmart Pharmacist for details. Free language assistance services available for prescription drug information at Walmart pharmacies in New York. Contact your Walmart pharmacy for details. * Prices may be higher in CA, HI, MN, MT, PA, TN and WI. Prepackaged drugs are only in unit sizes specified on Drug List. See Program Details or your Walmart Pharmacist for details. Revised 8/12/ Wal-Mart Stores, Inc. Page 3 of 5

25 $ 4, 30-day $ 10, 90-day $ 4, 30-day $ 10, 90-day Levothyroxine 25mcg tab Levothyroxine 50mcg tab Levothyroxine 75mcg tab Levothyroxine 88mcg tab Levothyroxine 100mcg tab Levothyroxine 112mcg tab Levothyroxine 125mcg tab Levothyroxine 137mcg tab Levothyroxine 150mcg tab Levothyroxine 175mcg tab* Levothyroxine 200mcg tab* Viruses Acyclovir 200mg cap* Alendronate SOD 35mg tab $ 9,. 30-day $ 24,.. 90-day.. 12 Alendronate SOD 70mg tab Clomiphene 50mg tab Other Medical Conditions Chlorhexidine Gluconate 0.12% soln (473ml bottle) Isoniazid 300mg tab* Lidocaine 2% viscous solution (100ml bottle) Megestrol 20mg tab* Prednisone 2.5mg tab* Prednisone 5mg tab* Vitamins & Nutritional Health Folic Acid 1mg tab Mag 64 64mg tab* Magnesium Oxide 400mg tab Prenatal Plus qty 30* Sodium Fluoride.25mg chewable* (120ct bottle) N/A Women s Health Estradiol 0.5mg tab Estradiol 1mg tab Estradiol 2mg tab* MedroxyprogesteroneAcetate 2.5mg tab Medroxyprogesterone Acetate 5mg tab Medroxyprogesterone Acetate 10mg tab Oral Levonorgestrel/Ethinyl Contraceptives Estradiol $ 9,. 28-day.. 28 Kurvelo Norethindrone USP 0.35mg Enskyce Jencycla Pirmella 1/ Pirmella 7/7/ Sprintec Tri-Sprintec Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some generic drugs at commonly prescribed dosages. Higher dosages cost more. Prices for some drugs by the Prescription Program may be higher and may vary in some states. Restrictions apply. See Program Details or your Walmart Pharmacist for details. Free language assistance services available for prescription drug information at Walmart pharmacies in New York. Contact your Walmart pharmacy for details. * Prices may be higher in CA, HI, MN, MT, PA, TN and WI. Prepackaged drugs are only in unit sizes specified on Drug List. See Program Details or your Walmart Pharmacist for details. Revised 8/12/ Wal-Mart Stores, Inc. Page 4 of 5

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