2
Value-priced medication list (cont.)
Mental Health (cont.)
30 QTY 90 QTY
Tier 3 $15 $30
30 90
BENZTROPINE 1MG TABS 60 180
60 180
60 180
30 90
30 90
30 90
30 90
30 90
30 90
IMIPRAMINE 10MG TABS 60 180
60 180
30 90
60 180
60 180
60 180
60 180
30 90
PAROXETINE 30MG TABS 30 90
30 90
60 180
30 90
SERTRALINE 100MG TABS 30 90
30 90
60 180
Mouth/Throat/Dental
30 QTY 90 QTY
Tier 2 $10 $20
473 1419
Tier 3 $15 $30
100 300
60 180
300 900
Skin Conditions
30 QTY 90 QTY
Tier 1 $7.50 $15
Tier 2 $10 $20
30 90
30 90
30 90
60 180
18
90 270
Tier 3 $15 $30
60 180
60 180
80 240
18
Thyroid Conditions
30 QTY 90 QTY
Tier 2 $10 $20
30 90
30 90
Tier 3 $15 $30
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
30 90
Infections
30 QTY 90 QTY
Tier 1 $7.50 $15
100 300
100 300
30 90
20 60
Tier 2 $10 $20
30 90
30 90
28 84
100 300
28 84
Tier 3 $15 $30
100 300
40 120
30 90
30 90
20 60
100 300
30 90
14 42
20 60
20 60
30 90
28 84
28 84
14 42
200 600
Medical Devices
30 QTY 90 QTY
Tier 3 $15 $30
PROCHAMBER AERO SPACER 1 3
Mental Health
30 QTY 90 QTY
Tier 1 $7.50 $15
AMITRIPTYLINE 10MG TABS 30 90
TRAZODONE 100MG TABS 30 90
Tier 2 $10 $20
30 90
30 90
BENZTROPINE 2MG TABS 30 90
BUSPIRONE 10MG TABS 60 180
60 180
30 90
30
90
30 90
30 90
30 90
90 270
90 270
90 270
30 90
30 90
30 90
30 90
PAROXETINE 10MG TABS 30 90
PAROXETINE 20MG TABS 30 90
30 90
30 90
30 90
30 90
VALUE GENERICS (cont.)
Cough/Cold/Allergy
30 QTY 90 QTY
Tier 1 $7.50 $15
100 300
LORATADINE 10MG TABS 30 90
12 36
Tier 2 $10 $20
30 90
30 90
30 90
240 720
Tier 3 $15 $30
30 90
120 360
16 48
PBM ALLERGY SYRUP 120 360
30 90
Diabetes
30 QTY 90 QTY
Tier 1 $7.50 $15
GLIMEPIRIDE 1MG TABS 30 90
GLIMEPIRIDE 2MG TABS 30 90
30 90
30 90
METFORMIN 1000MG TABS 60 180
90 270
90 270
60 180
Tier 2 $10 $20
GLIMEPIRIDE 4MG TABS 30 90
GLIPIZIDE 10MG TABS 60 180
30 90
30 90
30 90
30 90
60 180
60 180
Tier 3 $15 $30
GLIPIZIDE ER 10MG TABS 30 90
30 90
Ear/Eye Care
30 QTY 90 QTY
Tier 2 $10 $20
10 30
Tier 3 $15 $30
Gastrointestinal Health 30 QTY 90 QTY
Tier 1 $7.50 $15
60 180
Tier 2 $10 $20
60 180
FAMOTIDINE 20MG TABS 60 180
60 180
60 180
Tier 3 $15 $30
90 270
60 180
FAMOTIDINE 40MG TABS 30 90
Gout
30 QTY 90 QTY
Tier 2 $10 $20
ALLOPURINOL 100MG TABS 60 180
Tier 3 $15 $30
ALLOPURINOL 300MG TABS 60 180