Rx Outreach Medication List September 2020 Rx Outreach Medication* Similar Medication Available Strengths 30-Day Supply 90-Day Supply 180-Day Supply Acamprosate Calcium DR tablet Campral® 333mg $45 for up to 90 tablets Acyclovir capsule Zovirax® 200mg $10 $13 $20 Acyclovir tablet Zovirax® 400mg, 800mg $10 $13 $20 Acyclovir 5% Ointment Zovirax® 15g $40 per tube Acyclovir 5% Ointment Zovirax® 30g $65 per tube Albuterol Inhalation Solution Proventil® / Ventolin® 0.083%/3mL $15 for up to 75 vials Albuterol Sulfate HFA ProAir HFA® / Proventil® HFA / Ventolin® 90mcg (200 inhalations) $35 per inhaler canister Alclometasone Dipropionate Cream Aclovate® 15gm (0.05%) $15 per tube Alendronate tablet Fosamax® 70mg (once a week dosage) $20 (limit 12) $40 (limit 24) Alfuzosin ER tablet Uroxatral® 10mg (see Uroxatral®) $16 up to 30 tabs / $35 up to 90 tabs Allopurinol tablet Zyloprim® / Aloprim® 100mg, 300mg $10 $13 $20 Alprazolam tablet (CS) Xanax® / Niravam® 0.25mg, 0.5mg, 1mg, 2mg $9 for up to 90 tablets Alprazolam XR tablet (CS) Xanax XR® / Niravam® 0.5mg, 1mg $16 up to 30 tabs / $35 up to 90 tabs Alprazolam XR tablet (CS) Xanax XR® / Niravam® 2mg, 3mg $21 up to 30 tabs / $50 up to 90 tabs Amantadine tablet Symmetrel® 100mg $14 $30 n/a Amitriptyline tablet HCL Elavil® 10mg $15 for up to 90 tablets Amitriptyline tablet Elavil® 25mg, 50mg $20 for up to 90 tablets Amitriptyline tablet Elavil® 75mg, 100mg $16 up to 30 tabs / $35 up to 90 tabs Amitriptyline tablet Elavil® 150mg $20 up to 30 tabs / $50 up to 90 tabs Amlodipine tablet Norvasc® 2.5mg, 5mg, 10mg $11 $20 $40 Amlodipine/Benazepril capsule Lotrel® 5/10mg, 5/20mg, 10/20mg $22 up to 30 caps / $45 up to 90 caps Amlodipine/Benazepril capsule Lotrel® 10/40mg $12 up to 30 caps / $26 up to 90 caps Amlodipine/Olmesartan tablet Azor® 5/20mg, 5/40mg, 10/20mg, 10/40mg $35 for up to 30 tablets Amlodipine/Valsartan tablet Exforge® 5/160mg, 5/320mg, 10/160mg, 10/320mg $25 for up to 30 tablets 5/160/12.5mg, 5/160/25mg, 10/160/12.5mg, 10/160/25mg, $60 for up to 30 tablets Amlodipine/Valsartan/HCTZ tablet Exforge HCT® 10/320/25mg Amoxapine tablet Asendin® 100mg $32 for up to 30 tablets Anastrozole tablet Arimidex® 1mg $14 up to 30 tabs / $30 up to 90 tabs Aricept® tablet Donepezil 23mg $25 Aripiprazole tablet Abilify® 2mg, 5mg, 10mg, 15mg, 20mg, 30mg $25 up to 30 tabs / $60 up to 90 tabs Armodafinil tablet (CS) Nuvigil® 50mg, 150mg, 200mg, 250mg $35 for up to 30 tablets Artificial Tears 1.4% drops (OTC) N/A 15ml bottle (No prescription required) $9 per bottle Aspirin EC tablet (OTC) Bufferin® / Ecotrin® 325mg (No prescription required) $7 for a bottle of 100 Aspirin EC tablet (OTC) Ecotrin® 81mg (No prescription required) $9 for a bottle of 120 Atenolol tablet Tenormin® 25mg, 50mg, 100mg $7 $9 $18 Atenolol/Chlorthalidone tablet Tenoretic® 50/25mg, 100/25mg $10 $13 $20 Atomoxetine HCL capsule Strattera® 10mg, 18mg, 25mg $90 for up to 30 capsules Atomoxetine HCL capsule Strattera® 40mg, 60mg $95 for up to 30 capsules Atomoxetine HCL capsule Strattera® 80mg, 100mg $98 for up to 30 capsules Atorvastatin tablet Lipitor® 10mg, 20mg, 40mg, 80mg $12 $25 $45 Azathioprine tablet Imuran® / Azasan® 50mg $14 up to 30 tabs / $30 up to 90 tabs Azelastine nasal spray Astelin® 137mcg $30 per nasal spray Baclofen tablet Lioresal® 10mg, 20mg $9 $15 n/a Balsalazide Disodium capsule Colazal® / Giazo® 750mg $14 up to 30 caps / $30 up to 90 caps Banzel® Rufinamide 200mg, 400mg tablets; 40mg/mL Oral Suspension Refer to Patient Forms on Website Benazepril tablet Lotensin® 5mg, 10mg, 20mg, 40mg $10 $13 $20 Benazepril/HCTZ tablet Lotensin HCT® 5/6.25mg, 10/12.5mg, 20/12.5mg, 20/25mg $12 $25 $45 Benzonatate capsule Tessalon® / Zonatuss® 100mg $12 for up to 30 capsules Benzonatate capsule Tessalon Perles® 200mg $15 for up to 30 capsules Benztropine tablet Cogentin® 0.5mg, 1mg, 2mg $20 Betamethasone Dipropionate Cream, Aug Diprolene® AF / Alphatrex®/ Diprosone®/ Del-Beta® 15gm $25 per tube Bethanechol tablet Urecholine® 5mg, 10mg, 25mg, 50mg $12 $25 n/a Bicalutamide tablet Casodex® 50mg $12 $35 $65 Bisoprolol/HCTZ tablet Ziac® 2.5/6.25mg, 5/6.25mg, 10/6.25mg $10 $13 $20 Blood Glucose Monitor (Prodigy® Autocode) N/A N/A (No prescription required) One free monitor annually Blood Glucose Monitor Control Sol, Low (Prodigy®) N/A 4ml. Vial (No prescription required) $5 per vial Blood Glucose Test Strips (Prodigy®) N/A Box of 50 (No prescription required) $15 per box Blood Glucose Twist Top Lancets 28G (Prodigy®) N/A Box of 100; min order - 2 boxes (No prescription required) $5 per box; min order $10 Brimonidine Tartrate 0.2% Solution N/A 0.2%/10ml dropper $15 per dropper Bromocriptine tablet Parlodel® 2.5mg $65 for up to 30 tablets Budesonide EC capsule Entocort EC(R)® 3mg $50 for up to 30 capsules Budesonide Inhalation Solution Pulmicort Respules® 0.25mg/2mL $32 for up to 10 vials Budesonide Inhalation Solution Pulmicort Respules® 0.5mg/2mL $37 for up to 10 vials Budesonide Nasal Spray OTC Rhinocort® Allergy OTC 8.6g/32mcg (No prescription required) $22 per bottle (min. 2 bottles) Bumetanide tablet Bumex® 0.5mg, 1mg, 2mg $13 up to 30 tabs / $30 up to 90 tabs Buprenorphine/Naloxone tablet (CS) Zubsolv®/ Suboxone® 2mg/0.5mg (opioid dependence treatment only) $50 for up to 30 tablets Buprenorphine/Naloxone tablet (CS) Zubsolv®/ Suboxone® 8mg/2mg (opioid dependence treatment only) $50 for up to 28 tablets Bupropion HCL SR tablet Wellbutrin SR® 100mg, 150mg, 200mg $30 $65 n/a Bupropion HCL tablet Wellbutrin® 75mg $17 $40 n/a Bupropion HCL tablet Wellbutrin® 100mg $17 up to 30 tabs / $40 up to 90 tabs Bupropion HCL XL tablet Wellbutrin XL® / Zyban® 150mg, $33 for up to 90 tablets Bupropion HCL XL tablet Wellbutrin XL® / Zyban® 300mg $45 for up to 90 tablets Buspirone tablet BuSpar® 5mg, 10mg, 15mg $11 $20 n/a Buspirone tablet BuSpar® 30mg $26 $35 n/a Buspirone tablet BuSpar® 7.5mg $11 up to 30 tabs / $20 up to 90 tabs Calcitonin-Salmon Nasal Spray Miacalcin® 200 units per spray $65 for two (2) bottles Calcitriol capsule Rocaltrol® 0.25mcg $17 for up to 30 capsules Calcitriol capsule Rocaltrol® 0.5mcg $20 for up to 30 capsules Calcium Acetate capsule PhosLo® Gelcap 667mg $13 up to 30 caps / $25 up to 90 caps Candesartan Cilexetil-HCTZ tablet Atacand HCT® 16/12.5mg $40 for up to 30 tablets Candesartan Cilexetil-HCTZ tablet Atacand HCT® 32/12.5mg, 32/25mg $40 for up to 30 tablets Candesartan Cilexetil tablet Atacand® 16mg, 32mg $40 for up to 30 tablets Candesartan Cilexetil tablet Atacand® 4mg, 8mg $30 for up to 30 tablets Capecitabine tablet Xeloda® 150mg $25 for up to 28 tablets Capecitabine tablet Xeloda® 500mg $45 for up to 28 tablets Capsaicin Cream, 0.025% (OTC) Zostrix® 60gm (No prescription required) $12 per tube Captopril tablet Capoten® 100mg $24 up to 30 tabs / $55 up to 90 tabs Captopril tablet Capoten® 12.5mg, 25mg, 50mg $17 up to 30 tabs / $40 up to 90 tabs Carbamazepine ER tablet Tegretol XR® / Equetro® 200mg, 400mg $13 up to 30 tabs / $25 up to 90 tabs Carbamazepine tablet Tegretol® / Epitol® 200mg $13 up to 30 tabs / $25 up to 90 tabs Carbidopa / Levodopa SR tablet Sinemet CR® 25/100mg, 50/200mg $22 $55 n/a Carbidopa / Levodopa tablet Sinemet® / Parcopa® 10/100mg, 25/100mg, 25/250mg $19 $45 $85 12.5/50/200mg, 18.75/75/200mg, 25/100/200mg, Carbidopa/Levodopa/Entacapone tablet Stalevo® $45 for up to 60 tablets 31.25/125/200mg, 37.5/150/200mg, 50/200/200mg Carvedilol tablet Coreg® 3.125mg, 6.25mg, 12.5mg, 25mg $10 $13 $20 Celecoxib capsule Celebrex® 400mg $30 for up to 30 capsules Celecoxib capsule Celebrex® 50mg, 100mg, 200mg $15 for up to 30 capsules Cetirizine HCL tablet - OTC Zyrtec® OTC / Alleroff® 10mg (no prescription required) $10 per bottle of 100 tabs (min. 2 bottles) Cevimeline HCL capsule Evoxac® 30mg $31 up to 30 caps / $80 up to 90 caps Chlordiazepoxide capsule (CS) Librium® 5mg, 10mg, 25mg $15 for up to 180 capsules Chlorpromazine HCL tablet Thorazine® 10mg, 25mg, 50mg, 100m, 200mg $16 $35 n/a Chlorthalidone tablet Hygroton® 25mg, 50mg $16 up to 30 tabs / $35 up to 90 tabs Chlorzoxazone tablet Parafon Forte® DSC / Lorzone® / Parafon® 500mg $14 up to 30 tabs / $25 up to 90 tabs Cilostazol tablet Pletal® 50mg, 100mg $14 $30 $55 Citalopram tablet Celexa® 10mg, 20mg, 40mg $11 $20 n/a Clindamycin HCL capsule Cleocin® 150mg $19 $45 $85 Clobetasol cream 0.05% Temovate® 30g $20 per tube Clomiphene Citrate tablet Clomid® / Serophene® 50mg $30 for up to 30 tablets Clomipramine capsule Anafranil® 25mg, 50mg, 75mg $40 Clonazepam tablet (CS) Klonopin® 0.5mg $9 for up to 90 tablets Clonazepam tablet (CS) Klonopin® 1mg, 2mg $10 for up to 90 tablets Clonidine HCL tablet Catapres® 0.1mg, 0.2mg, 0.3mg $10 $13 $20 Clonidine patch Catapres-TTS® -3 0.3mg/day $80 per pack of 4 Clopidogrel tablet Plavix® 75mg $8 up to 30 tabs / $18 up to 90 tabs Clotrimazole/Betamethasone Cream Lotrisone® 15g (1%/0.05%) $15 per tube Colesevelam HCL tablet Welchol® 625mg $65 for up to 60 tablets Colestipol Micronized tablet Colestid® 1gm $60 for up to 60 tablets Cyclobenzaprine tablet Flexeril® 5mg, 10mg $12 $25 n/a Dalfampridine ER tablet Ampyra® 10mg $60 for up to 60 tablets Darifenacin ER tablet Enablex® 7.5mg, 15mg $60 for up to 30 tablets Desonide ointment 0.05% Tridesilon® 60gm $65 per tube Desvenlafaxine Succ ER tablet Pristiq® 25mg, 50mg, 100mg $40 for up to 30 tablets Dexmethylphenidate HCL tablet (CS) Focalin® 2.5mg $17 up to 30 tabs (30 day supply only) Dexmethylphenidate HCL tablet (CS) Focalin® 5mg $22 up to 30 tabs (30 day supply only) Dexmethylphenidate HCL tablet (CS) Focalin® 10mg $25 up to 30 tabs (30 day supply only) Dextroamphetamine-Amphetamine