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Allergies & Cold and Flu
$5 (30-day) $10 (90-day)
Benzonatate 100mg cap………………………………….14……………………42
Ganituss DM Syrup……………………………………….120ml…………….360ml
Loratadine 10mg tab………………………………………30…………………90
Promethazine DM syrup…………………………………120ml…………….360ml
Antibiotic Treatments
$5 (30-day)
Amoxicillin 125mg/5ml susp……………………………80ml
Amoxicillin 125mg/5ml susp………………………….100ml
Amoxicillin 125mg/5ml susp………………………….150ml
Amoxicillin 200mg/5ml susp………………………….50ml
Amoxicillin 200mg/5ml susp………………………….75ml
Amoxicillin 200mg/5ml susp………………………….100ml
Amoxicillin 250mg/5ml susp………………………….80ml
Amoxicillin 250mg/5ml susp………………………….100ml
Amoxicillin 250mg/5ml susp………………………….150ml
Amoxicillin 400mg/5ml susp………………………….50ml
Amoxicillin 400mg/5ml susp………………………….75ml
Amoxicillin 400mg/5ml susp………………………….100ml
Amoxicillin 250mg cap……………………………………30
Amoxicillin 500mg cap……………………………………30
Cephalexin 250mg cap……………………………………28
Cephalexin 500mg cap……………………………………30
Ciprofloxacin 250mg tab…………………………………14
Ciprofloxacin 500mg tab…………………………………20
Doxycycline Hyclate 50mg cap…………………………30
Doxycycline Hyclate 100mg cap……………………….20
Doxycycline Hyclate 100mg tab……………………….20
Pen VK 250mg tab………………………………………28
Pen VK 125mg/5ml susp…………………………….100ml
Pen VK 125mg/5ml susp…………………………….200ml
Pen VK 250mg/5ml susp…………………………….100ml
SMZ-TMP 200mg-40mg/5ml susp…………………120ml
SMZ-TMP 400mg-80mg tab………………………….28
SMZ-TMP 800mg-160mg tab…………………………20
Tetracycline 250mg cap……………………………….60
Tetracycline 500mg cap……………………………….60
**Program pricing is limited to certain manufactures of this medication. See Pharmacist for details.

Formulary Version 1-4-12
Arthritis & Pain
$5 (30-day) $10 (90-day)
Allopurinol 100mg tab……………………………….30……………………90
Allopurinol 300mg tab……………………………….30……………………90
Baclofen 10mg tab……………………………………30…………………….90
Cyclobenzaprine 5mg tab………………………….30…………………….90
Cyclobenzaprine 10mg tab…………………………30…………………….90
Dexamethasone 0.5mg tab…………………………30…………………….90
Dexamethasone 0.75mg tab……………………….12…………………….36
Dexamethasone 4mg tab…………………………….6…………………….18
Ibuprofen 100mg/5ml susp……………………….120ml……………….360ml
Ibuprofen 400mg tab……………………………….90…………………….270
Ibuprofen 600mg tab……………………………….60…………………….180
Ibuprofen 800mg tab……………………………….30…………………….90
Meloxicam 7.5mg tab……………………………….30…………………….90
Meloxicam 15mg tab…………………………………30……………………90
Naproxen 375mg tab…………………………………60……………………180
Naproxen 500mg tab…………………………………60……………………180
Asthma
$5 (30-day) $10 (90-day)
Albuterol 4mg tab…………………………………….60…………………….180
Albuterol 2mg/5ml syrup………………………….120ml………………….360ml
Cholesterol
$5 (30-day) $10 (90-day)
Lovastatin 10mg tab………………………………….30…………………….90
Lovastatin 20mg tab………………………………….30…………………….90
Pravastatin 10mg tab…………………………………30…………………….90
Pravastatin 20mg tab…………………………………30…………………….90
Pravastatin 40mg tab…………………………………30…………………….90
Diabetes
$5 (30-day) $10 (90-day)
Chlorpropamide 100mg tab……………………….30……………………….90
Glimepiride 1mg tab…………………………………30……………………….90
Glimepiride 2mg tab……………………………….30……………………….90
Glimepiride 4mg tab……………………………….30……………………….90
Glipizide 5mg tab……………………………………30……………………….90
Glipizide 10mg tab.60.180
Glyburide 2.5mg tab……………………………….30………………………90
Glyburide 5mg tab………………………………….30………………………90
Glyburide, micronized 3mg tab………………….30………………………90
Glyburide, micronized 6mg tab………………….30………………………90
Metformin 500mg tab………………………………60……………………….180
Metformin 850mg tab………………………………60……………………….180
Metformin 1000mg tab…………………………….60……………………….180
Metformin 500mg ER tab………………………….60………………………180
**Program pricing is limited to certain manufactures of this medication. See Pharmacist for details.
Formulary Version 1-4-12

Fungal Infections
$5 (30-day) $10 (90-day)
Fluconazole 150mg tab…………………………….………….1…………………….3
Nystatin/Triamcin cream……………………………………30gm……………….90gm
Nystatin/Triamcin oint………………………………………15gm……………….45gm
Nystatin cream……………………………………………….15gm……………….45gm
Nystatin cream…………………………………………………30gm……………….90gm
Nystatin oint……………………………………………………15gm……………….45gm
Nystatin oint……………………………………………………30gm……………….90gm
Terbinafine 250mg tab……………………………………….30…………………….90
Gastrointestinal Health
$5 (30-day) $10 (90-day)
Belladonna Alkaloid/PB tab……………………………….60…………………….180
Cimetidine 800mg tab……………………………………….30…………………….90
Cytra2 solution……………………………………………….180mg……………….540ml
Dicyclomine 10mg cap……………………………………….90…………………….270
Dicyclomine 20mg cap……………………………………….60…………………….180
Famotidine 20mg tab…………………………………………60……………………180
Lactulose syrup……………………………………………….273ml……………….711ml
Metoclopramide 10mg tab………………………………….60…………………….180
Metoclopramide syrup………………………………………60ml………………….180ml
Promethazine 25mg tab…………………………………….12………………………36
Promethazine plain syrup………………………………….180ml………………….540ml
Ranitidine 150mg tab……………………………………….60……………………….180
Ranitidine 300mg tab……………………………………….30……………………….90
Glaucoma & Eye Care
$5 (30-day) $10 (90-day)
Atropine Sulfate 1% op soln…………………………….5ml……………………….15ml
Gentamicin 0.3% op soln……………………………….5ml……………………….15ml
Levobunolol 0.5% op soln……………………………….5ml……………………….15ml
Neomycin/Polymyxin/Dexameth 0.1% op oint…….3.5gm…………………….10.5gm
Pilocarpine 1% op soln………………………………….15ml……………………….45ml
Pilocarpine 2% op soln………………………………….15ml……………………….45ml
Polymyxin Sulfate/TMP op sol……………………….10ml……………………….30ml
Sulfacet Sodium 10% op sol………………………….15ml……………………….45ml
Timolol Maleate 0.25% op soln……………………….5ml……………………….15ml
Timolol Maleate 0.5% op soln…………………………5ml…………………………15ml
Tobramycin 0.3% op soln………………………………5ml…………………………15ml
Heart Health & Blood Pressure
$5 (30-day) $10 (90-day)
Amiloride-HCTZ 5mg-50mg tab…………………………30…………………………90
Atenolol-Chlorthalidone 50mg-25mg tab…………….30…………………………90
Atenolol-Chlorthalidone 100mg-25mg tab……………30…………………………90
Atenolol 25mg tab………………………………………….30…………………………90
Atenolol 50mg tab………………………………………….30…………………………90
Atenolol 100mg tab……………………………………….30…………………………90
Benazepril 5mg tab……………………………………….30…………………………90

**Program pricing is limited to certain manufactures of this medication. See Pharmacist for details.

Formulary Version 1-4-12
Heart Health & Blood Pressure
$5 (30-day) $10 (90-day)
Benazepril 10mg tab………………………………………30…………………….90
Benazepril 20mg tab…………………………………….30………………………90
Benazepril 40mg tab…………………………………….30………………………90
Bisoprolol-HCTZ 2.5mg-6.25mg tab………………….30………………………90
Bisoprolol-HCTZ 5mg-6.25mg tab…………………….30………………………90
Bisoprolol-HCTZ 10mg-6.25mg tab………………….30………………………90
Bumetanide 0.5mg tab………………………………….30………………………90
Bumetanide 1mg tab…………………………………….30………………………90
Captopril 12.5mg tab…………………………………….60………………………180
Captopril 25mg tab………………………………………60……………………….180
Captopril 50mg tab………………………………………60……………………….180
Captopril 100mg tab…………………………………….60……………………….180
Cavedilol 3.125mg tab………………………………….60……………………….180
Cavedilol 6.25mg tab………………………………….60……………………….180
Cavedilol 12.5mg tab………………………………….60……………………….180
Cavedilol 25mg tab…………………………………….60…………………………180
Clonidine 0.1mg tab………………………………….30…………………………90
Clonidine 0.2mg tab………………………………….30………………………….90
Digoxin 0.125mg tab…………………………………30………………………….90
Digoxin 0.25mg tab………………………………….30………………………….90
Diltiazem 30mg tab………………………………….60………………………….180
Diltiazem 60mg tab………………………………….60………………………….180
Diltiazem 90mg tab………………………………….60………………………….180
Diltiazem 120mg tab……………………………….30………………………….90
Doxazosin 1mg tab………………………………….30………………………….90
Doxazosin 2mg tab………………………………….30………………………….90
Doxazosin 4mg tab………………………………….30………………………….90
Doxazosin 8mg tab………………………………….30………………………….90
Enalapril-HCTZ 5mg-12.5mg tab……………….30………………………….90
Enalapril 2.5mg tab……………………………….30……………………………90
Enalapril 5mg tab………………………………….30……………………………90
Enalapril 10mg tab…………………………………30……………………………90
Enalapril 20mg tab…………………………………30……………………………90
Furosemide 20mg tab………………………………30………………………….90
Furosemide 40mg tab………………………………30………………………….90
Furosemide 80mg tab………………………………30………………………….90
Guanfacine 1mg tab……………………………….30………………………….90
Hydralazine 10mg tab………………………………30………………………….90
Hydralazine 25mg tab………………………………30………………………….90
Hydrochlorothiazide (HCTZ) 12.5mg cap………30………………………….90
Hydrochlorothiazide (HCTZ) 25mg tab………….30…………………………90
Hydrochlorothiazide (HCTZ) 50mg tab………….30…………………………90
Indapamide 1.25mg tab……………………………30…………………………90
Indapamide 2.5mg tab…………………………….30………………………….90
Isosorbide Mononitrate 60mg ER tab………….30………………………….90
Lisinopril-HCTZ 10mg-12.5mg tab…………….30…………………………90
Lisinopril-HCTZ 20mg-12.5mg tab………………30……………………….90
Lisinopril-HCTZ 20mg-25mg tab…………………30……………………….90
Lisinopril 2.5mg tab…………………………………30……………………….90
Lisinopril 5mg tab……………………………………30……………………….90
**Program pricing is limited to certain manufactures of this medication. See Pharmacist for details.

Formulary Version 1-4-12
Heart Health & Blood Pressure
$5 (30-day) $10 (90-day)
Lisinopril 10mg tab………………………………………….30………………………90
Lisinopril 20mg tab………………………………………….30………………………90
Methyldopa 250mg tab.60.180
Methyldopa 500mg tab………………………………….30………….………….90
Metoprolol tartrate 25mg tab…………………………….60…………………….180
Metoprolol Tartrate 50mg tab…………………………….60…………………….180
Metoprolol Tartrate 100mg tab………………………….60…………………….180
Nadolol 20mg tab……………………………………………30………………………90
Nadolol 40mg tab……………………………………………30………………………90
Prazosin HCL 1mg cap…………………………………….30………………………90
Prazosin HCL 2mg cap…………………………………….30………………………90
Prazosin HCL 5mg cap…………………………………….30………………………90
Propranolol 10mg tab…………………………………….60…………………….180
Propranolol 20mg tab…………………………………….60…………………….180
Propranolol 40mg tab…………………………………….60…………………….180
Propranolol 80mg tab…………………………………….60…………………….180
Sotalol HCL 80mg tab…………………………………….30…………………….90
Spironolactone 25mg tab…………………………………30…………………….90
Terazosin 1mg cap………………………………………….30…………………….90
Terazosin 2mg cap………………………………………….30…………………….90
Terazosin 5mg cap………………………………………….30…………………….90
Terazosin 10mg cap……………………………………….30…………………….90
Triamterene-HCTZ 37.5mg-25mg tab & cap…………30…………………….90
Triamterene-HCTZ 75mg-50mg tab……………………30…………………….90
Verapamil 80mg tab……………………………………….30…………………….90
Verapamil 120mg tab…………………………………….30……………………90
Warfarin 1mg tab……………………………………………30……………………90
Warfarin 2mg tab……………………………………………30……………………90
Warfarin 2.5mg tab…………………………………………30……………………90
Warfarin 3mg tab……………………………………………30……………………90
Warfarin 4mg tab……………………………………………30……………………90
Warfarin 5mg tab……………………………………………30……………………90
Warfarin 6mg tab……………………………………………30……………………90
Warfarin 7.5mg tab…………………………………………30……………………90
Warfarin 10mg tab………………………………………….30……………………90
Mental Health
$5 (30-day) $10 (90-day)
Amitriptyline 10mg tab…………………………………….30………………….90
Amitriptyline 25mg tab…………………………………….30………………….90
Amitriptyline 50mg tab…………………………………….30………………….90
Amitriptyline 75mg tab…………………………………….30………………….90
Amitriptyline 100mg tab………………………………….30………………….90
Benztropine 2mg tab……………………………………….30………………….90
Buspirone 5mg tab………………………………………….60…………………180
Buspirone 10mg tab……………………………………….60…………………180
Carbamazepine 200mg tab……………………………….60………………….180
Citalopram 20mg tab……………………………………….30…………………90
Citalopram 40mg tab……………………………………….30…………………90
Doxepin HCL 10mg cap…………………………………….30…………………90
**Program pricing is limited to certain manufactures of this medication. See Pharmacist for details.
Formulary Version 1-4-12

Mental Health
$5 (30-day) $10 (90-day)
Doxepin HCL 25mg cap…………………………………….30…………………90
Doxepin HCL 50mg cap…………………………………….30…………………90
Fluoxetine 10mg tab……………………………………….30…………………90
Fluoxetine 10mg cap……………………………………….30…………………90
Fluoxetine 20mg cap……………………………………….30…………………90
Fluoxetine 40mg cap……………………………………….30…………………90
Fluphenazine 1mg tab………………………………………30…………………90
Haloperidol 0.5mg tab………………………………………30…………………90
Haloperidol 1mg tab…………………………………………30…………………90
Haloperidol 2mg tab…………………………………………30…………………90
Haloperidol 5mg tab…………………………………………30…………………90
Lithium Carbonate 300mg cap……………………………90……………….270
Nortriptyline 10mg cap…………………………………….30……………….90
Nortriptyline 25mg cap………………………………………30……………….90
Paroxetine 10mg tab………………………………………….30……………….90
Paroxetine 20mg tab………………………………………….30……………….90
Prochlorperazine 10mg tab………………………………….30……………….90
Thioridazine 25mg tab……………………………………….30……………….90
Thioridazine 50mg tab……………………………………….30……………….90
Thiothixene 2mg cap…………………………………………30……………….90
Trazodone 50mg tab…………………………………………30……………….90
Trazodone 100mg tab……………………………………….30…………………90
Trazodone 150mg tab……………………………………….30…………………90
Trihexyphenidyl 2mg tab………………………………….60…………………180
Skin Conditions
$5 (30-day) $10 (90-day)
Fluocinonide 0.05% cream……………………………….15gm……………….45gm
Fluocinonide 0.05% cream……………………………….30gm……………….90gm
Gentamicin 0.1% cream………………………………….15gm……………….45gm
Gentamicin 0.1% oint…………………………………….15gm……………….45gm
Hydrocortisone 1% cream…………………………………1…………………….3 tubes
Hydrocortisone 2.5% cream………………………………30gm……………….90gm
Silver Sulfadiazine 1% cream…………………………….50gm……………….150gm
Triamcinolone 0.025% cream…………………………….15gm……………….45gm
Triamcinolone 0.025% cream…………………………….80gm……………….240gm
Triamcinolone 0.1% cream……………………………….15gm……………….45gm
Triamcinolone 0.1% cream……………………………….80gm……………….240gm
Triamcinolone 0.1% oint………………………………….15gm……………….45gm
Triamcinolone 0.1% oint………………………………….80gm……………….240gm
Triamcinolone 0.5% cream………………………………15gm…………………45gm
**Program pricing is limited to certain manufactures of this medication. See Pharmacist for details.
Formulary Version 1-4-12

Thyroid Conditions
$5 (30-day) $10 (90-day)
Levothyroxine 25mcg tab………………………………….30…………………….90
Levothyroxine 50mcg tab………………………………….30…………………….90
Levothyroxine 75mcg tab………………………………….30…………………….90
Levothyroxine 88mcg tab………………………………….30…………………….90
Levothyroxine 100mcg tab……………………………….30…………………….90
Levothyroxine 112mcg tab……………………………….30…………………….90
Levothyroxine 125mcg tab……………………………….30…………………….90
Levothyroxine 137mcg tab……………………………….30…………………….90
Levothyroxine 150mcg tab……………………………….30………………………90
Levothyroxine 175mcg tab……………………………….30………………………90
Levothyroxine 200mcg tab……………………………….30………………………90
Viruses
$5 (30-day) $10 (90-day)
Acyclovir 200mg cap……………………………………….30………………………90

Vitamins & Nutritional Health
$5 (30-day) $10 (90-day)
Folic Acid 1mg tab………………………………………….30………………………90
Mag 64 tab…………………………………………………….60…………………….180
Mag Ox 400mg tab………………………………………….30………………………90
Prenatal Plus qty 30…………………………………………30…………………….90
Potassium Chloride 10% liquid………………………….473ml……………….1419ml
Sodium Fluoride 0.25mg chewable………………………120ct…………………n/a
Women’s Health
$5 (30-day) $10 (90-day)
Estradiol 0.5mg tab…………………………………………….30……………………90
Estradiol 1mg tab……………………………………………….30……………………90
Estradiol 2mg tab……………………………………………….30……………………90
Medroxyprogesterone Acetate 2.5mg tab…………………30…………………….90
Medroxyprogesterone Acetate 5mg tab……………………30…………………….90
Medroxyprogesterone Acetate 10mg tab………………….10…………………….30
Alendronate Sod 35mg tab………………………………….4………………………12
Alendronate Sod 70mg tab………………………………….4………………………12
Clomiphene 50mg tab…………………………………………5………………………15
**Program pricing is limited to certain manufactures of this medication. See Pharmacist for details.
Formulary Version 1-4-12

Other Medical Conditions
$5 (30-day) $10 (90-day)
Chlorhexidine Gluconate 0.12% sol…………………………473ml……………1419ml
Isoniazid 300mg tab………………………………………….30………………….90
Lidocaine 2% viscous sol………………………………………100……………….300
Megestrol 20mg tab…………………………………………….30…………………90
Oxybutynin 5mg tab…………………………………………….60……………….180
Phenazopyridine 100mg tab……………………………………6………………….18
Phenazopyridine 200mg tab……………………………………30…………………90
Prednisone 2.5mg tab……………………………………………30…………………90
Prednisone 5mg tab………………………………………………30…………………90
Prednisone 10mg tab…………………………………………….30…………………90
Prednisone 20mg tab…………………………………………….30………………….90
**Program pricing is limited to certain manufactures of this medication. See Pharmacist for details.
Formulary Version 1-4-12
The $5 prescription Program covers up to the quantity specified for each eligible drug. Most quantities are based on a course of therapy at commonly prescribed dosages. Prices for greater than the specified quantity are prorated based on the $5 Prescription Program price. Only eligible drugs will be covered under plan. List may change at any given time. Western Drug reserves the right to modify or discontinue this program or modify the terms and conditions of the program at any time without notice.

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