Extra Value Drug List. *
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1 List. * Brand Diabetes Levemir 100 units/ml Vial 10mL $ Levemir FlexPen 100 units/ml 15mL $ NovoLog 100 units/ml Vial 10mL $ NovoLog FlexPen Syringe 15mL $ NovoLog 100 units/ml Cartridge 15mL $ NovoLog Mix Vial 10mL $ NovoLog Mix FlexPen Syringe 15mL $ Victoza 2 pk., 18mg/3mL ea. Pen 6mL $ Victoza 3 pk., 18mg/3mL ea. Pen 9mL $ Generic Diabetes Glipizide ER 2.5mg Tablet 30 $11.87 Metformin ER 750mg Tablet 60 $11.87 Glipizide/Metformin mg Tablet 60 $11.87 Glipizide/Metformin 5-500mg Tablet 60 $11.87 Glipizide/Metformin mg Tablet 60 $11.87 Glipizide/Metformin mg Tablet 60 $11.87 Brand Heart Health CRESTOR 10mg Tablet 30 $ CRESTOR 20mg Tablet 30 $ CRESTOR 40mg Tablet 30 $ CRESTOR 5mg Tablet 30 $ Generic Heart Health Losartan 25mg Tablet 30 $11.87 Losartan 50mg Tablet 30 $11.87 Losartan 100mg Tablet 30 $11.87 Losartan/HCT 50/12.5mg Tablet 30 $11.87 Losartan/HCT 100/12.5mg Tablet 30 $11.87 Losartan/HCT 100/25mg Tablet 30 $11.87 Atorvastatin 10mg Tablet 30 $11.87 Atorvastatin 20mg Tablet 30 $11.87 Atorvastatin 40mg Tablet 30 $11.87 s valid as of 6/22/2013 Atorvastatin 80mg Tablet 30 $11.87 Clopidogrel 75mg Tablet 30 $11.87 Brand Devices and Supplies TRUEresult Blood Glucose System 1 ct. Free TRUEtest Glucose Test Strips 50 ct. $19.33 TRUEtest Glucose Test Strips 100 ct. $35.19 OptiChamber Advantage Small Mask OptiChamber Advantage Medium Mask 1 ct. $ ct. $14.90 OptiChamber Advantage 1 ct. $8.53 Brand OTC Mucinex D Extended Relief Tablet 18 $11.46 Mucinex D Extended Relief Tablet 24 $20.11 Delsym 30mg/5mL 5 oz. $9.76 Brand Gastrointestinal Nexium 10mg Packet 30 $ Nexium 20mg Packet 30 $ Nexium 2.5mg Packet 30 $ Nexium 40mg Packet 30 $ Nexium 5mg Packet 30 $ Nexium 20mg Capsule 30 $ Nexium 40mg Capsule 30 $ Vimovo mg Tablet 60 $89.56 Vimovo mg Tablet 60 $89.56 Generic Gastrointestinal Polyeth Glycol 3350 Powder 255 $11.87 Polyeth Glycol 3350 Powder 527 $11.87 * program discount also applies to cash purchases of select over-the-counter items ** program discounts apply only to listed prescriptions. Discounts available only state/federal government health care program. s on List include discounts
2 List. * Generic Gastrointestinal (continued) Diphenoxylate/Atropine mg Tablet 30 $11.87 Loperamide 2mg Capsule 60 $11.87 Hyoscyamine 0.125mg Tablet 30 $11.87 Hyoscyamine Sublingal 0.125mg Tablet 30 $11.87 Hyoscyamine ER 0.375mg Tablet 30 $11.87 Glycopyrrolate 1mg Tablet 60 $11.87 Glycopyrrol 2mg Tablet 60 $11.87 Chlordiazepoxide/Clidinium 5-2.5mg Capsule 30 $11.87 Ranitidine 75mg/5mL Syrup 120 $11.87 Lansoprazole 15mg Capsule 30 $11.87 Lansoprazole 30mg Capsule 30 $11.87 Omeprazole 10mg Capsule 30 $11.87 Omeprazole 20mg Capsule 30 $11.87 Omeprazole 40mg Capsule 30 $11.87 Pantoprazole 20mg Tablet 30 $11.87 Pantoprazole 40mg Tablet 30 $11.87 Sucralfate 1mg Tablet 60 $11.87 Meclizine 12.5mg Tablet 30 $11.87 Meclizine 25mg Tablet 30 $11.87 Ursodiol 300mg Capsule 60 $11.87 Generic Allergy Products Montelukast 4mg Chew 30 $11.87 Montelukast 5mg Tablet 30 $11.87 Montelukast 10mg Tablet 30 $11.87 Brand Asthma-COPD Symbicort mcg Inhaler 1 ct. $ Symbicort mcg Inhaler 1 ct. $ Pulmicort 180mcg FLEXHALER 1 ct. $ Pulmicort 90mcg FLEXHALER 1 ct. $ Generic Cough-Cold-Allergy Amoxicillin 875mg Tablet 20 $ mg Tablet 20 $11.87 s valid as of 6/22/ mg Tablet 20 $ mg/5mL 200mg/5mL 100 $ $ $ $ $11.87 Cephalexin 125mg/5mL 100 $11.87 Cephalexin 125mg/5mL 200 $11.87 Cephalexin 250mg/5mL 100 $11.87 Cephalexin 250mg/5mL 200 $11.87 Azithromycin 250mg Tablet 6 $11.87 Azithromycin 500mg Tablet 3 $11.87 Azithromycin 100mg/5mL 15 $11.87 Azithromycin 200mg/5mL 15 $11.87 Azithromycin 200mg/5mL 23 $11.87 Azithromycin 200mg/5mL 30 $11.87 * program discount also applies to cash purchases of select over-the-counter items ** program discounts apply only to listed prescriptions. Discounts available only state/federal government health care program. s on List include discounts
3 List. * Generic Cough-Cold-Allergy (continued) Clarithromycin 250mg Tablet 20 $11.87 Clarithromycin 500mg Tablet 20 $11.87 Minocycline 50mg Capsule 30 $11.87 Minocycline 100mg Capsule 30 $11.87 Levofloxacin 250mg Tablet 10 $11.87 Levofloxacin 500mg Tablet 10 $11.87 Levofloxacin 750mg Tablet 10 $11.87 Cetirizine 1mg/mL Syrup 120 $11.87 Levocetirizine 5mg Tablet 30 $11.87 Loratadine 5mg/5mL Syrup 120 $11.87 Hydroxyzine HCL 10mg Tablet 60 $11.87 Hydroxyzine HCL 25mg Tablet 60 $11.87 Hydroxyzine HCL 50mg Tablet 60 $11.87 Hydroxyzine HCL 10mg/5mL Solution 120 $11.87 Hydroxyzine PAM 25mg Capsule 60 $11.87 Hydroxyzine PAM 50mg Capsule 60 $11.87 Ciprofloxacn Opthalmic 0.3% Solution 5 $11.87 Gentak Opthalmic 0.3% Ointment 4 $11.87 Ofloxacin Opthalmic 0.3% Solution 5 $11.87 Neo/Poly/Hc Otic 1% 10 $11.87 Neo/Poly/Hc Otic 1% Solution 10 $11.87 Prednisolone 15mg/5mL Syrup 30 $11.87 Prednisolone 15mg/5mL Solution 30 $11.87 Prednisolone 6.7mg/5mL Liquid 30 $11.87 Brand Other CAMBIA 50mg Powder Packet 9 pk. $ Natroba 0.9% Topical 120mL $ Eye Care Alphagan P 0.1% Eye Drops 5mL $81.76 Alphagan P 0.1% Eye Drops 10mL $ Alphagan P 0.1% Eye Drops 15mL $ Combigan Eye Drops 5mL $87.88 Combigan Eye Drops 10mL $ s valid as of 6/22/2013 LUMIGAN 0.03% Eye Drops 2.5mL $90.78 LUMIGAN 0.03% Eye Drops 5mL $ LUMIGAN 0.03% Eye Drops 7.5mL $ LUMIGAN 0.01% Eye Drops 2.5mL $97.77 LUMIGAN 0.01% Eye Drops 5mL $ LUMIGAN 0.01% Eye Drops 7.5mL $ RESTASIS 0.05% Eye Emulsion 30 udv RESTASIS 0.05% Eye Emulsion 60 udv $ Generic Mental Wellness Bupropion SR 100mg Tablet 60 $11.87 Bupropion SR 150mg Tablet 60 $11.87 Bupropion SR 200mg Tablet 60 $11.87 Bupropion XL 150mg Tablet 30 $11.87 Bupropion XL 300mg Tablet 30 $11.87 Carbidopa-Levodopa mg Tablet 90 $11.87 Carbidopa-Levodopa mg Tablet 90 $11.87 Carbamazepine 100mg Chew 90 $11.87 Divalproex 125mg Capsule 90 $11.87 Divalproex EC 125mg Tablet 90 $11.87 Divalproex EC 250mg Tablet 90 $11.87 Divalproex EC 500mg Tablet 90 $11.87 Divalproex ER 250mg Tablet 30 $11.87 Divalproex ER 500mg Tablet 30 $11.87 Donepezil HCL 5mg Tablet 30 $11.87 Donepezil HCL 10mg Tablet 30 $11.87 Escitalopram 5mg Tablet 30 $11.87 Escitalopram 10mg Tablet 30 $11.87 Escitalopram 20mg Tablet 30 $11.87 Gabapentin 100mg Capsule 90 $11.87 * program discount also applies to cash purchases of select over-the-counter items ** program discounts apply only to listed prescriptions. Discounts available only state/federal government health care program. s on List include discounts
4 List. * Generic Mental Wellness (continued) Gabapentin 300mg Capsule 90 $11.87 Gabapentin 400mg Capsule 90 $11.87 Lamotrigine 25mg Tablet 60 $11.87 Lamotrigine 100mg Tablet 60 $11.87 Lamotrigine 150mg Tablet 60 $11.87 Lamotrigine 200mg Tablet 60 $11.87 Levetiracetam 250mg Tablet 60 $11.87 Levetiracetam 500mg Tablet 60 $11.87 Levetiracetam 750mg Tablet 60 $11.87 Levetiracetam 1000mg Tablet 60 $11.87 Levetiracetam 100mg/mL Solution 240 $11.87 Olanzapine 2.5mg Tablet 30 $11.87 Olanzapine 5mg Tablet 30 $11.87 Olanzapine 7.5mg Tablet 30 $11.87 Olanzapine 10mg Tablet 30 $11.87 Olanzapine 15mg Tablet 30 $11.87 Olanzapine 20mg Tablet 30 $11.87 Pramipexole 0.125mg Tablet 60 $11.87 Pramipexole 0.25mg Tablet 60 $11.87 Pramipexole 0.5mg Tablet 60 $11.87 Pramipexole 1mg Tablet 60 $11.87 Pramipexole 1.5mg Tablet 60 $11.87 Quetiapine 25mg Tablet 30 $11.87 Quetiapine 50mg Tablet 30 $11.87 Quetiapine 100mg Tablet 30 $11.87 Quetiapine 200mg Tablet 30 $11.87 Quetiapine 300mg Tablet 30 $11.87 Risperidone 0.25mg Tablet 60 $11.87 Risperidone 0.5mg Tablet 60 $11.87 Risperidone 1mg Tablet 60 $11.87 Risperidone 2mg Tablet 60 $11.87 Risperidone 3mg Tablet 60 $11.87 Risperidone 4mg Tablet 60 $11.87 Risperidone 0.5mg ODT 60 $11.87 Risperidone 1mg ODT 60 $11.87 s valid as of 6/22/2013 Risperidone 2mg ODT 60 $11.87 Risperidone 1mg/mL Solution 30 $11.87 Topiramate 25mg Tablet 60 $11.87 Topiramate 50mg Tablet 60 $11.87 Topiramate 100mg Tablet 60 $11.87 Topiramate 200mg Tablet 60 $11.87 Venlafaxine 37.5mg Tablet 60 $11.87 Venlafaxine 75mg Tablet 60 $11.87 Venlafaxine 100mg Tablet 60 $11.87 Venlafaxine HCL ER 37.5mg Capsule 30 $11.87 Venlafaxine HCL ER 75mg Capsule 30 $11.87 Venlafaxine HCL ER 150mg Capsule 30 $11.87 Generic Oncology & Oncology Support Levofloxacin 250mg Tablet 10 $11.87 Levofloxacin 500mg Tablet 10 $11.87 Levofloxacin 750mg Tablet 10 $11.87 Ketoconazole 200mg Tablet 20 $11.87 Fluconazole 100mg Tablet 10 $11.87 Fluconazole 200mg Tablet 10 $11.87 Fluconazole 10mg/mL 35mL $11.87 Acyclovir 400mg Tablet 30 $11.87 Acyclovir 800mg Tablet 30 $11.87 Valacyclovir 500mg Tablet 20 $11.87 Valacyclovir 1gm Tablet 10 $11.87 Mercaptopurine 50mg Tablet 25 $11.87 Bicalutamide 50mg Tablet 30 $11.87 Anastrozole 1mg Tablet 30 $11.87 Letrozole 2.5mg Tablet 30 $11.87 Megestrol 40mg Tablet 60 $11.87 * program discount also applies to cash purchases of select over-the-counter items ** program discounts apply only to listed prescriptions. Discounts available only state/federal government health care program. s on List include discounts
5 List. * Generic Oncology & Oncology Support (cont.) Megestrol 40mg/mL 240mL $11.87 Ondansetron 4mg ODT 30 $11.87 Ondansetron 8mg ODT 10 $11.87 Ondansetron 4mg Tablet 30 $11.87 Ondansetron 8mg Tablet 30 $11.87 Generic Women s Health Estropipate 0.75mg Tablet 30 $11.87 Norethindrone 5mg Tablet 30 $11.87 Liothyronine 5mcg Tablet 30 $11.87 Liothyronine 25mcg Tablet 30 $11.87 Methimazole 5mg Tablet 30 $11.87 Methimazole 10mg Tablet 30 $11.87 Ibandronate 150mg Tablet 1 $11.87 Metronidazole Vaginal Gel 0.75% 70 $11.87 Terconazole Vaginal Cream 0.40% 45 $11.87 Terconazole Vaginal Cream 0.80% 20 $11.87 Oral Contraceptives Camila Tablet 28 $11.87 Errin Tablet 28 $11.87 Reclipsen Tablet 28 $11.87 Syeda Tablet 28 $11.87 Kelnor Tablet 28 $11.87 Aviane Tablet 28 $11.87 Altavera Tablet 28 $11.87 Nortrel Tablet 0.5 / $11.87 Nortrel Tablet 1 / $11.87 Microgestin Tablet 1 / $11.87 Microgestin Tablet 1.5 / $11.87 Cryselle-28 Tablet 1 / $11.87 Microgestin FE Tablet 1.5 / $11.87 Microgestin FE Tablet 28 $11.87 Enpresse-28 Tablet 28 $11.87 Nortrel 7/7/7 Tablet 28 $11.87 Generic Skin Care Myorisan (isotretinoin) 10mg 30 $96.90 Myorisan (isotretinoin) 20mg 30 $ Myorisan (isotretinoin) 40mg 30 $ * program discount also applies to cash purchases of select over-the-counter items ** program discounts apply only to listed prescriptions. Discounts available only state/federal government health care program. s on List include discounts s valid as of 6/22/2013
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