340B $4 Formulary 12-10 - La Casa Family Health …

1 340B Pharmacy $4 Formulary Price of most medications is $4. Those items not at $4 reflect different amount charged. ALLERGIES Benzonatate 100mg #14 Cardec 120ml Cetirizine 10mg #30 Fexofenadine 60mg #30 Fexofenadine 180mg #30 Flonase #1-----$10 Loratadine 10mg #30 Promethazine DM 120ml Singulair 10mg #30-------$60 ANTIBIOTICS Amoxicillin 500mg #30 Amoxicillin 250mg/5ml 150ml Amox/Clav 500mg #20------$10 Amox/Clav 875mg #20------$10 Augmentin ES 600mg/5ml #75ml Avelox 400mg #10--------$40 Azithromycin 200mg/5ml 30ml----$10 Azithromycin 500mg #10 ----$10 Azithromycin Pack #6------$10 Azithromycin Tri-Pack #3-----$10 Cephalexin 500mg #30 Ciprofloxacin 500mg #20-----$10 Ciprofloxacin

2 750mg #20-----$10 Clarithromycin 500mg #20 Clindamycin 150mg #60 Doxycycline 100mg #20 Levaquin 250mg #10-------$40 Levaquin 750mg #10-------$40 Metronidazole 250mg #20 Metronidazole 500mg #20 Minocycline 50mg #30 Nitrofurantoin 100mg #20----$10 Phenazopyridine 100mg #30 Phenazopyridine 200mg #30 SMZ/TMP DS 800/160mg #20 Tetracycline 500mg #30 ARTHRITIS/PAIN Acetaminophen 500mg #60 Acetaminophen 650mg #60 Allopurinol 100mg #30 Allopurinol 300mg #30 Aspirin-EC 81mg #90 Aspirin-EC 325mg #90 Baclofen 10mg #30 Colchicine #30 Cyclobenzaprine 5mg #30 Cyclobenzaprine 10mg #30 Diclofenac Sodium DR 50mg #30 Diclofenac Sodium DR 75mg #60 Ergotamine/Caffeine 1/100 #30---$10 Gabapentin 100mg #60 Gabapentin 300mg #60 Gabapentin 400mg #60 Gabapentin 600mg #60 Gabapentin 800mg #60 Hydroxychloroquine 200mg #30 Ibuprofen 400mg #90 Ibuprofen 600mg #90 Ibuprofen 800mg #90 Indomethacin 25mg #30 Indomethacin 50mg #30 Ketorolac 10mg #30-------$10 Leucovorin 25mg #8-------$40 Methotrexate #20 Methylpred.

3 4mg dose pack #21 Nabumetone 500mg #60----$10 Nabumetone 750mg #60----$10 Naproxen 375mg #60 Naproxen 500mg #60 Prednisone 5mg #30 Prednisone 10mg #30 Prednisone 20mg #30 Sulindac 150mg #30 ASTHMA Albuterol nebs #25 (75ml) Albuterol 2mg #30 Albuterol 4mg #30 Combivent #1------$40 Ipratropiu Nebs #25 ( ) Iprat/Albut Nebs #30 Proventil #1----$10 Sodium Chloride Nebs #100---$10 Theophylline 300mg #30------$10 CHOLESTEROL Gemfibrozil 600mg #60 Lovastatin 10mg #30 Lovastatin 20mg #30 Lovastatin 40mg #30 Pravastatin 10mg #30 Pravastatin 20mg #30 Pravastatin 40mg #30 Pravastatin 80mg #30 Simvastatin 10mg #30 Simvastatin 20mg #30 Simvastatin 40mg #30 Simvastatin 80mg #30 Tricor 145mg #30-----$60 Zetia 10mg #30--------$60 DIABETES Actos 15mg #30 Glimepiride 1mg #30 Glimepiride 2mg #30 Glimepiride 4mg #30 Glipizide 5 mg #60 Glipizide 10mg #60 Glipizide XL #30

4 Glipizide XL 5mg #30 Glyburide #60 Glyburide 5mg #60 Metformin 500mg #60 Metformin 850mg #60 Metformin 1000mg #60 Metformin ER 500mg #60 DIABETES/INSULINS Humalog 10ml---------------$40 Humalog Mix 75/25 10ml--$40 Lantus 10ml------------------$40 Novolin 70/30 10ml---------$20 Novolin N 10ml-------------$20 Novolin R 10ml--------------$20 EAR CARE A/B Otic 10ml-------$10 Acetic Acid Otic Sol. 15ml---$20 AceticAcid/Aluminum Acet. 60ml-$20 EYE CARE Acetazolamide 125mg #30 Ciloxan 5ml Ciprodex Otic $40 Erythromycin Opth. Ointment 4grams Gentamicin Soln 5ml Timolol Opth. Drops 10ml Tobradex Opth.

5 5ml------$10 FUNGAL INFECTIONS Clotrimazole 1% Cream 30grams Clotrim/Betamethasone Crm 15gm---$10 Fluconazole 100mg #30 Fluconazole 150mg #1 Loprox Gel .77% 45gm Nystatin Cream 30grams Nystatin Ointment 30grams Nystatin Suspension 60ml Nystatin/Triam. Cream 30grams Nystatin/Triam. Oint 30grams Terbinafine 250mg #30 GASTROINTESTINAL Anusol HC 30grm ----$10 Asacol 400mg #60--------$30 Carafate Susp. 14oz------$30 Cimetidine 800mg #30 Creon 6000 #30----$20 Dicyclomine 10mg #60 Dicyclomine 20mg #60 Docusate Sodium 100mg #60 Docusate Calcium 240mg #60 Entocort EC #30 Famotidine 10mg #30 Famotidine 20mg #30 Famotidine 40mg #30 Hydrocortisone Supp.

6 25 mg #12 Lactulose Syrup 480 ml Metoclopramide 5mg #60 Metoclopramide 10mg #60 Omeprazole 20mg #30---$10 Ondansetron 4mg #30 Oxybutynin 5mg #60 Promethazine #12 Promethazine 25mg #12 Ranitidine 150mg #60 Ranitidine 300mg #60 Sucralfate 1 gram #30 Sulfasalazine 500mg #30 HYPERTENSION/CARDIAC Amiodarone 200mg #30 Amlodipine #30 Amlodipine 5mg #30 Amlodipine 10mg #30 Atenolol 25mg #30 Atenolol 50mg #30 Atenolol 100mg #30 Atenolol/Chlorthalidone 50/25 #30 Atenolol/Chlorthalidone 100/25 #30 Avapro 75mg #30-------$50 Avapro 150mg #30-----$50 Benazepril 10mg #30 Benazepril 20mg #30 Benazepril 40mg #30 Benazepril/HCTZ 10 #30 Benazepril/HCTZ 20 #30 Benazepril/HCTZ 20/25mg #30 Benicar 5mg #30------$20 Benicar 20mg #30----$20 Bisoprolol 10mg #30----$10 Captopril 25mg #60 Carvedilol #60 Carvedilol #60 Carvedilol #60 Carvedilol 25mg #60 Clonidine #30 Clonidine #30 Clonidine #30 Digoxin #30 Digoxin #30 Diltiazem 30mg #60 Diltiazem 60mg #60 Diltiazem 90mg #60 Diltiazem XT 180mg(qd)

7 #30---$10 Doxazosin 2mg #30 Doxazosin 4mg #30 Doxazosin 8mg #30 Enalapril #30 Enalapril 5mg #30 Enalapril 10mg #30 Enalapril 20mg #30 Enalapril/HCTZ 10/25 #30 Felodipine 5mg #30 Furosemide 20mg #30 Furosemide 40mg #30 Furosemide 80mg #30 Hydralazine 10mg #30 Hydralazine 25mg #30 Hydralazine 50mg #30 Hydralazine 100mg #30 Hydrochlorothiazide #30 Hydrochlorothiazide 25mg #30 Hydrochlorothiazide 50mg #30 Isosorbide Dinitrate 5mg #30 Isosorbide Dinitrate 10mg #30 Isosorbide Dinitrate 20mg #30 Isosorbide Mono 10mg #30 Isosorbide Mono 20mg #30 Isosorbide Mono ER 30mg #30 Isosorbide Mono ER 60mg #30 Labetaolol 100mg #60 Labetaolol 200mg #60 Lisinopril #30 Lisinopril 5mg #30 Lisinopril 10mg #30 Lisinopril 20mg #30 Lisinopril 30mg #30 Lisinopril 40mg #30 Lisinopril/HCTZ 10 #30 Lisinopril/HCTZ 20 #30 Lisinopril/HCTZ 20/25mg #30 Lotrel 5/10 #30 Methyldopa 250mg #30 Metolazone #30 Metolazone 5mg #30 Metolazone 10mg #30 Metoprolol Tartrate 25mg #60 Metoprolol Tartrate 50mg #60 Metoprolol Tartrate 100mg #60 Nitroglycerin sublingual #25 Nitroglycerin SR #30 Plavix 75mg #30-------$60 Prazosin 5mg #30 Propranolol

8 10mg #60 Propranolol 20mg #60 Propranolol 40mg #60 Quinapril 5mg #30 Quinapril 10mg #30 Quinapril 20mg #30 Quinapril 40mg #30 Quinapril/HCTZ 20/25 #30 Ramipril 5mg #30 Ramipril 10mg #30 Spironolactone 25mg #30 Spironolactone 100mg #30 Terazosin 1mg #30 Terazosin 5mg #30 Terazosin 10mg #30 Triamterene/HCTZ caps #30 Triamterene/HCTZ tabs #30 Triameterene/HCTZ 75/50mg #30 Verapamil 80mg #30 Warfarin 1mg #30 Warfarin 2mg #30 Warfarin #30 Warfarin 3mg #30 Warfarin 4mg #30 Warfarin 5mg #30 Warfarin 6mg #30 Warfarin #30 Warfarin 10mg #30 Zetia 10mg #30--------$60 MEN S Health Avodart #30------$50 Depo-Testosterone 100/1 #1 Depo-Testosterone 200/1 #1 Finasteride 5mg #30 Levitra 10mg #10-------$10 Levitra 20mg #10--------$40 Minoxidil #30 Flomax #30-------$10 Yohimbine #20---$10 MENTAL Health Amitriptyline 10mg #30 Amitriptyline 25mg #30 Amitriptyline 50mg #30 Amitriptyline 75mg #30 Amitriptyline 100mg #30 Benztropine #30 Benztropine 1mg #30 Bupropion SR 100mg #30 Bupropion SR 150mg #30 Buspirone 5mg #60 Buspirone 10mg #60 Buspirone 15mg #60 Carbamazepine 100mg #60 Carbamazepine 200mg #60 Carbatrol

9 200mg #30 Carbidopa/levodopa 25/100mg #60 Citalopram 10mg #30 Citalopram 20mg #30 Citalopram 40mg #30 Doxepin 50mg #30 Fluoxetine 10mg #30 Fluoxetine 20mg #30 Fluoxetine 40mg #30 Hydroxyzine Pamoate 25mg #30 Hydroxyzine Pamoate 50mg #30 Imipramine 25mg #30 Levetiracetam 250mg #30 Levetiracetam 500mg #30 Lithium Carbonate 150mg #30 Lithium Carbonate 300mg #30 Mirtazapine 15mg #30 Nortriptyline 10mg #30 Nortriptyline 25mg #30 Nortriptyline 75mg #30 Paroxetine 10mg #30 Paroxetine 20mg #30 Paroxetine 40mg #30 Phenytoin 100mg #60-----$10 Risperdal 1mg #30 Risperdal 2mg #30 Risperdal 3mg #30 Sertraline 25mg #30 Sertraline 50mg #30 Sertraline 100mg #30 Trazodone 50mg #30 Trazodone 100mg #30 Trazodone 150mg #30----$10 Valproic Acid 250mg #30 Venlafaxine mg #30 Venlafaxine 75mg #30 Wellbutrin 75mg #30 Wellbutrin 100mg #30 SKIN CONDITIONS Betamethasone Dip.

10 Crm 15gm Betamethasone Dip. lotion 60ml Clobetasol Prop. Cream 30 grams Hydrocortisone 1% Cream 30grams Hydrocortisone Cream 30grams Mupirocin 2% Oint 22 grams Silvadene 1% crm 50gm Triamcinolone Cream 30grams Triamcinolone Oint. 30grams Triamcinolone Oint. 30 grams Triamcinolone Cream 15 grams THYROID CONDITIONS Levothyroxine 25mcg #30 Levothyroxine 50mcg #30 Levothyroxine 75mcg #30 Levothyroxine 88mcg #30 Levothyroxine 100mcg #30 Levothyroxine 112mcg #30 Levothyroxine 125mcg #30 Levothyroxine 137mcg #30 Levothyroxine 150mcg #30 Levothyroxine 175mcg #30 Levothyroxine 200mcg #30 Levothyr