Ela DPC Health Membership

Benefits and Services

As a Ela DPC Health member, you have access to the following

medical services, with many covered as part of your monthly

membership fee, unless otherwise indicated

Direct Access

Through the secure Spruce Health app you have

24/7, access to your physician and care team

for your unique needs, including the following:

» Schedule an appointment

» Ask your care team any question about your health

» Check in about a new or ongoing health issue

» Request a prescription refill

» Connect with your provider for video visits

» Complete a Spruce Visit, a type of virtual visit with

a series of questions, and receive treatment for

common medical issues, including allergies, cold

and flu, headache, pink eye, rash, sore throat, & UTI

Common Non-Included Lab Tests

Collected either in office or through a nearby

laboratory partner, LabCorp or Quest, as

directed by provider, with cahs pricing as listed

below:

Basic metabolic panel (BMP): $4

Complete blood count (CBC): $3

Comprehensive metabolic panel (CMP): $4

C-reactive protein (CRP): $5

Hemoglobin, capillary for pediatric patients: $3

Hepatitis C antibody: $9

Visits

Unlimited visits with any provider (physician, nurse,

health coach, medical assistant) of the Ela DPC

Health team at no charge or copay to Member.

Visits can be in-office or virtual via text, phone,

or video.

Lead, capillary for pediatric patients: $7

Lipid (cholesterol) panel: $4

Occult blood test, fecal: $20

Sexually transmitted infection (STI) Panel (chlamydia,

gonorrhea, HIV, syphilis, Hep B): $50

Thyroid stimulating hormone (TSH) w/ reflex free T4: $8

Point-of-Care Lab Tests

Unlimited of the following point-of-care lab tests

as directed by provider at no added cost:

» Glucose test strip (blood sugar)

» Rapid influenza

» Rapid strep

» Urinalysis

» Urine pregnancy test

Urine microalbumin: $8

Urine culture: $8

Additional Non-Included Lab Tests listed on page 3-4.Included Procedures

Unlimited of the following in-office procedures

as directed by provider at no added cost.

» Callus shaving/removal

» Cryotherapy/freezing of lesions

» Ear lavage

» EKG

» Fluorescein eye exam

» Hearing screening

» Incision and drainage

» IUD/Nexplanon insertion/removal (not including device)

» Nail avulsion/removal

» PAP Smear with or without HPV testing (1 per year if uninsured)

» Pulmonary function testing

» Simple wound cleaning and repair, including basic suturing

» Uncomplicated skin tag or skin lesion removal

(not including biopsy)

Vaccinations

Administration of vaccinations as

recommended by the CDC with coverage

through most insurance plans, including

pediatric vaccinations. Confirmation of

coverage provided in advance of visit when

possible, and wholesale cash prices are

also available.

Medications

Our members have access to various

common over-the counter medications at

Ela DPC sold at cost.

Our members haveaccess to over 300

prescription medicationsat wholesale

pricing through our local, innovative partner

Ela Pharmacy, with detailed pricing as

provided on the document

“Rio + Ela DPC Medication Pricing”.

Imaging

Basic x-rays through our imaging partner

Open MRI, not including mammograms or

DEXA scans, are available for $100 per x-

ray. We also maintain cash pricing for CT

scans, MRIs, and ultrasound.

Non-Included Procedures

Access to the following in-office procedures

as directed by provider with transparent pricing:

» Skin biopsy: $50

» Vasectomy: $350

Specialist E-Consultation

We have access to specialist e-consultation

on behalf of our clients through our

partner Thea Health.

Care Coordination and Referrals.

Coordination and guidance for any health care services required outside of the practice, including specialist referrals

and support for Members who are hospitalized or require surgery.

Advocacy and guidance for Member in finding high-quality, low-cost options for any health care services required

outside of the practice where applicable.

*

The benefits and services listed above are reviewed at least annually

and may be revised in accordance with the terms in the Patient Member

Agreement with a focus on optimizing the benefits and services offered

and the experience of our members.

direct

primary

careEla DPC Health Membership

Benefits and Services

Additional Non-Included Lab Tests

Ability to access additional lab tests, as directed by

provider, with wholesale, transparent pricing, including

but not limited to the following:

ACTH, plasma $12.00

Cytomegalovir us, IgG/IgM $45.00

Anti-dsDNA (double-stranded) antibodies $7.00

Dehydroepiandrosterone (DHEA) Sulfate $6.00

Antinuclear antibody (ANA) $5.00

Epstein Barr Virus (EBV) Antibody, Viral Capsid x 2 $ 25.00

Anti-SS-A, Anti-SS-B (Sjogren’s antibodies) $9.00

Erythrocyte sedimentation rate (ESR) $3.00

Bilirubin profile, neonatal $9.00

Estradiol (E2) $7.00

Bilirubin profile $3.00

Ferritin $4.00

Blood type (ABO grouping and Rh(D) typing $6.00

Fibrinogen activity $6.00

Peripheral blood smear, peripheral $20.00

Folate $ 6.00

Borrelia burgdorferi Antibodies,Total by ELISA

w/Reflex to IgG and IgM by Immunoblot $25.00

Follicle-stimulating hormone (FSH) $ 5.00

GGT $3.00

Brain natriuretic peptide (BNP) $35.00

H. pylori stool test – Antigen $40.00

C3+C4 complement levels, serum $15.00

Hepatitis A antibody, IgM $8.00

CA-125 $8.00

Hepatitis A antibody, IgG $8.00

Calcium $3.00

Hepatitis B surface antigen test $6.00

Ceruloplasmin $8.00

Hepatitis B surface antibody $8.00

Clostridium test $ 11.00

Hepatitis B core antibody $8.00

Creatine kinase, CK, total $3.00

Hepatitis C genotype $210.00

Copper $17.00

Hepatitis C RNA, quantitative by PCR $160.00

Cortisol $6.00

Homocysteine $14.00

Culture, wound with gram stain $25.00

Cyclic Citrullinated Peptide (CCP) Antibody, IgG $25.00

Human chorionic gonadotropin (hCG), Beta,

Quantitative $7.00Additional Non-Included Lab Tests (cont.)

Insulin level, fasting $5.00

Iron, transferrin, and total iron binding capacity (TIBC) $4.00

Lead, blood $ 7.00

Lipase $ 6.00

Lipids with particle size (LDL) and graph $ 40.00

Lithium level, serum $ 10.00

Luteinizing hormone (LH) $5.00

Magnesium $4.00

Monospot $7.00

Ova and Parasite $12.00

Parathyroid Hormone, intact $9.00

Phosphorous $3.00

Pinworm exam $25.00

Progesterone $8.00

Prolactin $5.00

Prostate-Specimen Antigen (PSA) test, TOTAL $5.00

Rheumatoid factor (RF) $4.00

RSV test $35.00

SARS-CoV-2 Antibodies, IgG $50.00

SARS-CoV-2 Antigen, PCR $100

SARS-CoV-2 Antigen, rapid $50.00

Sex hormone binding globulin (SHBG) $10.00

Skin biopsy $50.00

Testosterone level, total (women, children) LC/MS $25.00

Testosterone level, total (Male) $6.00

Tetraiodothyroine (T4), total $3.00

hroat culture $7.00

Thyroid antibodies (anti-TPO and anti-thyroglobulin) $16.00

Thyroid receptor antibody $12.00

Trichomonas vaginalis by PCR $32.00

Triiodothyronine (T3), free $4.00

Triiodothyronine (T3), Reverse $17.00

T-spot TB test $50.00

Uric acid, serum $3.00

Urine creatinine, 24 hour $5.00

Urine drug test (UDS Panel Only) $17.00

Urine protein to creatine ratio (random) $9.00

Urine protein, 24 hour $3.00

Varicella zoster antibody, IgG (screen) $11.00

Vitamin B1 $30.00

Vitamin B6 $27.00

Vitamin B12 $6.00

Vitamin D, 25-OH $13.00

Zinc, serum $9.00

direct

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care

ADDENDUM A:

Rio Pharmacy Direct Care

Rio Pharmacy Direct Care is our pharmacy’s approach to delivering convenient, affordable

healthcare services. Super partnership with Ela DPC Health provides you access to the following:

· Our member’s only generic savings program

· Free delivery to work or home

· Medication synchronization

· Free adherence packaging

· 24/7 on-call pharmacy availability

Rio Direct Care’s multi-tiered generic savings program usually lowers the cash price of many

generic medications to $4, $10, or $20, depending on the tier. Convenient, same-day delivery saves

you time and money. Our med sync program allows all maintenance medications to be filled on the

same day every month or every three months. Rio Pharmacy is designed to simplify your life by

providing direct, affordable access to a variety of local pharmacy services.

Rio Pharmacy Direct Care’s generic savings program may be subject to change at any time without notification. Changes

may occur due to variations in market pricing or availability for generic drugs.

©Blue Ridge Pharmacy, Inc 2020Allergies

Cetirizine 10 mg – 30 ($3.99)

Cetirizine children’s – 120 mL ($4.99)

Fexofenadine 180 mg – 30 ($30.00)

Fluticasone nasal spray – 1 bottle ($12.99)

Loratadine 10 mg – 90 ($2.99)

Tier 1 ($4)

Diphenhydramine 25 mg, 50 mg – 30

Tier 2 ($10)

Hydroxyzine Hcl 10 mg, 25 mg, 50 mg – 30

Levocetirizine 5 mg – 30

Antibiotics

Azithromycin 250 mg – 6 ($6.50)

Doxycycline 100 mg tabs – 30 ($13.99)

SMZ/TMP DS – 14 ($3.50)

Tier 1 ($4)

Amoxicillin 250 mg, 500 mg cap – 20

Amoxicillin susp 125mg/5mL, 250mg/5mL – 1 bottle (100 mL)

Amoxicillin susp 200 mg/5mL, 400 mg/5mL – 1 bottle (100 mL)

Cephalexin 250 mg – 28

Cephalexin caps 500 mg – 20

Ciprofloxacin 250 mg, 500 mg – 14

Levofloxacin 250 mg – 7

SMZ/TMP SS – 14

Tier 2 ($10)

Amoxicillin 875 mg – 20

Amox/clav 875/125 mg – 20

Amox/clav susp 200mg/5mL, 400mg/5 mL – 100 mL

Azithromycin 500 mg – 3

Cefdinir 300 mg – 20

Clindamycin 150 mg, 300 mg – 21

Doxycycline hyclate caps 50 mg, 100 mg – 20

Doxycycline monohydrate caps 50 mg, 100 mg – 20

Levofloxacin 500 mg, 750 mg – 7

Metronidazole 250 mg, 500 mg – 14

Penicillin VK 250 mg – 40

Penicillin VK 500 mg – 20

Tier 3 ( $20)

Amox/clav 500/125 mg – 20Amox/clav susp 600mg/5mL – 125 mL

Azithromycin susp 100 mg/5 mL – 15 mL

Azithromycin susp 200 mg/5 mL – 30 mL

Cefuroxime 250 mg, 500 mg – 14

Cephalexin susp 125mg/5mL, 250 mg/5mL – 100 mL

Nitrofurantoin monohydrate/macrocrystals 100 mg – 10

Arthritis, Gout, + Pain

Acetaminophen children’s – 120 mL ($2.99)

Acetaminophen 500 mg – 100 ($5.50)

Ibuprofen 200 mg – 100 ($2.99)

Ibuprofen children’s – 120 mL ($3.99)

Meloxicam 15 mg – 14 ($1.99)

Tier 1 ($4)

Cyclobenzaprine 5 mg, 10 mg – 30

Meloxicam 7.5 mg – 14

Tier 2 ($10)

Allopurinol 100 mg, 300 mg – 30

Baclofen 10 mg, 20 mg – 30

Carisoprodol 350 mg – 30

Diclofenac sodium 50 mg, 75 mg – 30

Gabapentin 100 mg, 300 mg, 400 mg – 90

Ibuprofen 400 mg – 100

Ibuprofen 600 mg, 800 mg – 50

Indomethacin 25 mg, 50 mg – 30

Methocarbamol 500 mg, 750 mg – 90

Naproxen 250 mg, 500 mg – 60

Tier 3 ($20)

Butalbital/APAP/caffeine – 30

Celecoxib 100 mg, 200 mg – 60

Gabapentin 600 mg – 90

Gabapentin 800 mg – 60

Pregabalin 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg, 300 mg – 30

Tizanidine 2 mg, 4 mg – 90

Asthma + Respiratory

Albuterol inhaler – 18 GM ($55.00)

Budesonide Nebs 0.25 mg/2 mL, 0.5 mg/2 mL – 30 nebs ($65.00)

Montelukast 10 mg – 30 ($3.50)

Wixela Inhub 100-50 mcg (generic Advair) – 1 inhaler ($110.00)

Wixela Inhub 250-50 mcg (generic Advair) – 1 inhaler ($125.00)

Wixela Inhub 500-50 mcg (generic Advair) – 1 inhaler ($165.00)Tier 2 ($10)

Albuterol 0.083% Nebs – 25 vials

Ipratropium 0.02% Nebs – 25 vials

Airial Spacer Chamber – 1 (item #380287)

Optichamber PediatricMask (spacer) – 1 (item #061168, 062802)

Tier 3 ($20)

Iprat/Alb 0.5/3mg/3mL Nebs – 60 vials

Cholesterol

Atorvastatin 20 mg – 30 ($6.99)

Pravastatin 20 mg – 30 ($9.99)

Tier 1 ($4)

Atorvastatin 10 mg – 30

Lovastatin 10 mg, 20 mg – 30

Simvastatin 5 mg, 10 mg, 20 mg, 40 mg – 30

Tier 2 ($10)

Ezetimibe 10 mg – 30

Gemfibrozil 600 mg – 60

Lovastatin 40 mg – 30

Pravastatin 10 mg, 40 mg, 80 mg – 30

Rosuvastatin 5 mg, 10 mg, 20 mg, 40 mg – 30

Simvastatin 80 mg – 30

Tier 3 ($20)

Atorvastatin 40 mg, 80 mg – 30

Fenofibrate 48 mg (tab), 54 mg (tab), 67 mg (micro cap), 145 mg (tab), 160 mg (tab) – 30

Cough + Cold

Benzonatate 100 mg cap – 20 ($5.50)

Tier 1 ($4)

Guaifenesin 400 mg – 60

Tier 2 ($10)

Benzonatate 200 mg cap – 20

Diabetes

Tier 1 ($4)

Alcohol prep pads – 100

Easy Touch Twist lancets (30G, 32G, 33G) – 100Glipizide 5 mg – 60

Metformin 500 mg, 850 mg, 1000 mg – 60

Metformin ER 500 mg – 60

Tier 2 ($10)

Easy Touch BG test strips – 50

Embrace BG test strips – 50

Glimepiride 1 mg, 2 mg, 4 mg – 30

Glipizide 10 mg – 60

Glipizide XL 2.5 mg, 5 mg, 10 mg – 30

Glyburide 1.25, 2.5 mg, 5 mg – 30

Pioglitazone 15 mg, 30 mg, 45 mg – 30

Tier 3 ($20)

Easy Touch Glucose meter – 1

Embrace Glucose meter – 1

Ear & Eye Health

Tier 2 ($10)

Diclofenac 0.1% soln – 5 mL

Gentamicin 0.3% soln – 5 mL

Latanoprost 0.005% – 2.5 mL

Tobramycin 0.3% soln – 5 mL

Trimethoprim/polymyxin B soln – 10 mL

Tier 3 ($20)

Bacitracin/polymyxin B oint – 3.5 GM

Brimonidine 0.2% soln – 15 mL

Ciprofloxacin 0.3% soln – 5 mL

Erythromycin 0.5% oint – 3.5 GM

Ketorolac 0.5% soln – 5 ML

Neo/poly B/bacitracin ophth. oint – 3.5 GM

Neo/poly B/dex oint – 3.5 GM

Neo/poly B/dex susp – 5 mL

Neo/poly B/HC oint – 3.5 GM

Neo/poly B/HC soln – 5 mL

Ofloxacin 0.3% soln – 5 mL

Olopatadine 0.1% soln – 5 mL

Fungal Infections

Tier 1 ($4)

Fluconazole 150 mg – 1Tier 2 ($10)

Fluconazole 100 mg – 14

Terbinafine 250 mg – 30

Tier 3 ($20)

Fluconazole 200 mg -14

Gastrointestinal Health

Omeprazole 20 mg – 30 ($4.99)

Ondansetron ODT 4 mg – 15 ($4.50)

Pantoprazole 20 mg, 40 mg – 30 ($6.50)

Tier 1 ($4)

Docusate sodium 100 mg – 60

Famotidine 20 mg – 60

Metoclopramide 5 mg, 10 mg – 30

Ondansetron 4 mg, 8 mg – 10

Promethazine 12.5 mg, 25 mg – 15

Ranitidine tabs 75 mg, 150 mg – 60

Tier 2 ($10)

Docusate sodium 250 mg – 60

Famotidine 10 mg, 40 mg – 60

Omeprazole 40 mg – 30

Ondansetron ODT 8 mg – 15

Prochlorperazine 5 mg, 10 mg – 15

Ranitidine tabs 300 mg – 60

Tier 3 ($20)

Dicyclomine 10 mg, 20 mg – 90

Esomeprazole 20 mg, 40 mg – 30

Sucralfate 1 gram – 60

Heart Health + Blood Pressure

Amlodipine 5 mg – 30 ($2.50)

HCTZ 25 mg – 30 ($1.99)

Lisinopril 10 mg – 30 ($2.99)

Losartan 25 mg – 30 ($3.99)

Metoprolol succinate ER 25 mg – 30 ($12.99)

Metoprolol tartrate 25 mg – 60 ($2.50)

Tier 1 ($4)Amlodipine 2.5 mg, 10 mg – 30

Aspirin 81 mg, 325 mg – 30

Atenolol 25 mg – 30

Benazepril 5 mg, 10 mg, 20 mg, 40 mg – 30

Carvedilol 3.125mg, 6.25mg, 12.5mg, 25mg – 60

Clonidine 0.1 mg, 0.2 mg – 30

Doxazosin 1 mg, 2 mg, 4 mg, 8 mg – 30

Furosemide 20 mg, 40 mg – 30

Guanfacine 1 mg – 30

HCTZ 12.5 mg, 50 mg – 30

Lisinopril 5 mg, 20 mg, 40 mg – 30

Lisinopril/HCTZ 20/12.5mg, 20/25mg -30

Losartan 50 mg, 100 mg – 30

Metoprolol tartrate 50 mg, 100 mg – 60

Olmesartan 5 mg – 30

Ramipril 2.5 mg, 5 mg – 30

Tier 2 ($10)

Amiodarone 200 mg – 30

Amlodipine/benazepril 2.5/10mg, 5/10mg, 5/20mg, 5/40mg, 10/20mg – 30

Atenolol 50 mg, 100 mg – 30

Bisoprolol/HCTZ 2.5/6.25 mg, 5/6.25 mg – 30

Chlorthalidone 25 mg, 50 mg – 30

Clonidine 0.3 mg – 30

Clopidogrel 75 mg – 30

Enalapril 2.5 mg, 5 mg, 10 mg, 20 mg – 30

Enalapril/HCTZ 5/12.5 mg, 10/25 mg

Hydralazine 10 mg, 25 mg, 50 mg – 90

Irbesartan 75 mg, 150 mg – 30

Irbesartan/HCTZ 150/12.5mg – 30

Isosorbide MN ER 30 mg, 60 mg – 30

Labetalol 100 mg, 200 mg, 300 mg – 30

Losartan/HCTZ 50/12.5mg,100/12.5mg, 100/25mg – 30

Nifedipine ER 30 mg, 60 mg – 30

Prazosin 1 mg – 30

Ramipril 1.25 mg, 10 mg – 30

Olmesartan 20 mg, 40 mg – 30

Spironolactone 25 mg, 50 mg – 30

Terazosin 1 mg, 2 mg, 5 mg, 10 mg – 30

Triamterene/HCTZ tab 37.5/25mg, 75/50mg – 30

Torsemide 5 mg, 10 mg, 20 mg, 100 mg – 30

Valsartan 40 mg – 30

Verapamil 80 mg, 120 mg – 60

Warfarin 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg – 30

Tier 3 ($20)

Bisoprolol/HCTZ 10/6.25mg – 30Bumetanide 0.5mg, 1mg – 30

Digoxin 0.125 mg, 0.25 mg – 30

Diltiazem ER (Cartia XT) 120 mg, 180 mg, 240 mg caps – 30

Guanfacine 1 mg – 30

Guanfacine ER 1 mg, 2 mg, 3 mg, 4 mg – 30

Hydralazine 100 mg – 90

Irbesartan 300 mg – 30

Isosorbide MN ER 120 mg – 30

Metoprolol succinate ER 50 mg, 100 mg, 200 mg – 30

Nifedipine ER 90 mg – 30

Nitroglycerin SL 0.4 mg – 25

Olmesartan 40 mg – 30

Olmesartan/HCTZ 20/12.5mg, 40/25mg – 30

Prasugrel 10 mg – 30

Prazosin 2 mg, 5 mg – 30

Propranolol 10 mg, 20 mg, 40 mg – 60

Sotalol 80 mg – 60

Spironolactone 100 mg – 30

Valsartan 80 mg, 160 mg, 320 mg – 30

Valsartan/HCTZ 80/12.5mg, 160/12.5mg, 160/25mg, 320/12.5mg, 320/25mg – 30

Verapamil ER 120 mg, 180 mg, 240 mg – 30

Men’s Health

Sildenafil 20 mg – 30 ($14.50)

Tier 2 ($10)

Dutasteride 0.5 mg – 30

Finasteride 1 mg, 5 mg – 30

Tadalafil 2.5 mg, 5 mg – 30

Tamsulosin 0.4 mg – 30

Mental Health

Bupropion XL 150 mg – 30 ($12.50)

Citalopram 20 mg – 30 ($3.50)

Escitalopram 10 mg – 30 ($6.99)

Tier 1 ($4)

Buspirone 5 mg, 10 mg, 15 mg – 30

Citalopram 10 mg, 40 mg – 30

Donepezil 5 mg, 10 mg – 30

Fluoxetine 10 mg, 20 mg caps – 30

Lamotrigine 25 mg, 100 mg – 30

Lithium 150 mg, 300 mg – 30Paroxetine 10 mg, 20 mg – 30

Sertraline 25 mg, 50 mg, 100 mg – 30

Topiramate 25 mg, 50 mg, 100 mg – 30

Trazodone 50 mg – 30

Quetiapine 25 mg, 50 mg – 30

Risperidone 0.25 mg, 0.5 mg – 30

Tier 2 ($10)

Amitriptyline 10 mg, 25 mg, 50 mg – 30

Benztropine 0.5 mg, 1 mg, 2 mg – 30

Bupropion 75 mg – 60

Clozapine 25 mg – 30

Divalproex DR 125 mg, 250 mg, 500 mg – 30

Doxepin 10 mg, 25 mg – 30

Duloxetine 20 mg, 30 mg, 60 mg – 30

Escitalopram 5 mg, 20 mg – 30

Fluoxetine 40 mg caps – 30

Hydroxyzine pam 25 mg, 50 mg caps – 30

Lamotrigine 150 mg, 200 mg – 30

Levetiracetam 250 mg, 500 mg, 750 mg – 60

Lithium 600 mg – 30

Lithium ER 300 mg, 450 mg – 30

Mirtazapine 15 mg, 30 mg, 45 mg – 30

Nortriptyline 10 mg, 25 mg, 50 mg, 75 mg – 30

Topiramate 200 mg – 30

Trazodone 100 mg, 150 mg – 30

Venlafaxine ER caps 37.5 mg, 75 mg, 150 mg – 30

Olanzapine 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg – 30

Paroxetine 30 mg, 40 mg – 30

Phenytoin ER 100 mg – 30

Quetiapine 100 mg, 200 mg, 300 mg, 400 mg – 30

Quetiapine XR 50 mg – 30

Risperidone 1 mg, 2 mg, 3 mg, 4 mg – 30

Tier 3 ($20)

Amitriptyline 75 mg, 100 mg – 30

Aripiprazole 2 mg, 5 mg, 10 mg, 20 mg – 30

Bupropion 100 mg – 60

Bupropion XL 300 mg – 30

Buspirone 7.5 mg – 30

Carbamazepine 200 mg – 30

Carbamazepine ER 100 mg 30

Clozapine 50 mg, 100 mg – 30

Divalproex ER 250 mg, 500 mg – 30

Doxepin 50 mg – 30

Haloperidol 0.5 mg, 1 mg, 2 mg, 5 mg – 30

Levetiracetam 1000 mg – 60Memantine 5 mg, 10 mg – 60

Oxcarbazepine 150 mg, 300 mg – 60

Valproic acid 250 mg – 90

Venlafaxine 37.5 mg, 50 mg, 75 mg, 100 mg – 60

Quetiapine XR 150 mg, 200 mg, 300 mg – 30

Skin Conditions

Tier 1 ($4)

Hydrocortisone cream 1% – 30 GM

Tier 2 ($10)

Betamethasone cream .05% – 15 GM

Hydrocortisone cream 2.5% – 30 GM

Mupirocin ointment 2% – 22 GM

Nystatin cream 100,000 units – 15 GM

Nystatin powder 100,000 units – 15 GM

Triamcinolone cream 0.025% – 80 GM

Triamcinolone cream 0.1% – 30 GM

Triamcinolone cream 0.5% – 15 GM

Tier 3 ($20)

Betamethasone cream 0.1% – 15 GM

Clobetasol ointment .05% – 30 GM

Silver sulfadiazine cream 1% – 50 GM

Thyroid

Tier 2 ($10)

Methimazole 5 mg, 10 mg – 30

Nature Throid ½ GR (32.5 mg) – 30

Tier 3 ($20)

200mcg – 30

Levothyroxine 25mcg, 50mcg, 75mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg,

Nature Throid ¾ GR (48.75 mg), 1 GR (65 mg), 2 GR (130 mg) – 30

Viral Infections

Oseltamivir 75 mg – 10 ($55.00)

Tier 2 ($10)

Acyclovir 200 mg, 400 mg, 800 mg – 30

Tier 3 ($20)

Valacyclovir 500 mg, 1000 mg – 30Vitamins & Supplements

Tier 1 ($4)

Ferrous sulfate 325 mg – 60

Folic acid 1 mg – 30

Magnesium oxide 250 mg, 400 mg, 500 mg – 30

Prenatal plus – 30

Vit D2 50,000 units – 4

Therems multivitamin – 30

Tier 2 ($10)

Potassium Cl ER 10 mEq, 20 mEq – 30

Vitamin B12 1000mcg/mL inj – 1 mL

Women’s Health/Contraception

Tier 2 ($10)

Anastrozole 1 mg – 30

Alyacen 1/0.035mg tabs – 28

Alyacen 7/7/7 tabs (triphasic) – 28

Estradiol 0.5 mg, 1 mg, 2 mg – 30

Heather 0.35mg tabs – 28

Medroxyprogesterone 2.5 mg, 5 mg, 10 mg – 30

Sprintec 0.25/0.035mg tabs – 28

Tamoxifen 10 mg – 30

Tri-Lo Mili tabs (triphasic) – 28

Tri-Sprintec tabs (triphasic) – 28

Vienva 0.1/0.02mg tabs – 28

Tier 3 ($20)

Aranelle tabs (triphasic) – 28

Briellyn 0.4/0.035mg tabs – 28

Cryselle-28 0.3/0.03mg tabs – 28

Levonorgestrel/ethinyl estradiol tabs (triphasic) – 28

Marlissa 0.15/0.03mg tabs – 28

Microgestin Fe 1/0.02mg tabs – 28

Microgestin Fe 1.5/0.03mg tabs – 28

Progesterone 100 mg – 30

Reclipsen 0.15/0.03mg tabs – 28

Tamoxifen 20 mg – 30

Syeda 3/0.03mg tabs – 28

Zovia 1/0.035mg tabs – 28

Miscellaneous

Amphetamine salts tabs 10 mg, 15 mg, 20 mg, 30 mg – 60 ($30.00)

Mixed amphetamine salts ER caps 10 mg, 30 mg – 30 ($80.00)Mixed amphetamine salts ER caps 20 mg – 30 ($50.00)

Tier 1 ($4)

Prednisone 10 mg – 20

Tier 2 ($10)

Alendronate 10 mg – 30

Alendronate 70 mg – 4

Ibandronate 150 mg – 1

Chlorhexidine rinse 0.12% – 473 mL

Gavilax powder 3350 – 510 GM

Meclizine 25 mg – 30

Megestrol 20 mg, 40 mg – 30

Methylprednisolone 4 mg pack – 21

Pramipexole 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1.5 mg – 30

Ropinirole 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg – 30

Sumatriptan 25 mg, 50 mg, 100 mg – 9

Zolpidem 5 mg, 10 mg – 30

Tier 3 ($20)

Carbidopa/levodopa 10/100mg, 25/100 mg – 120

Carbidopa/levodopa 25/250 mg – 90

Cilostazol 100 mg – 30

Dexmethylphenidate tabs 2.5 mg, 5 mg, 10 mg – 60

Hydroxychloroquine 200 mg – 30

Methylphenidate 5 mg, 10 mg, 20 mg – 60

Oxybutynin 5 mg – 30

Oxybutynin ER 5 mg, 10 mg, 15 mg – 30

PEG 3350 Bowel Prep Soln – 4000 mL

Risedronate 35 mg – 4

Rizatriptan 5 mg, 10 mg – 18ADDENDUM B:

House Stock Over-the-Counter Medications

APAP 500 mg tabs, 500 count (item #859926) – $5.00

APAP 325 mg tabs, 1000 count (item #864959) – $6.00

Children’s APAP 160 mg/5 mL elixir, 118 mL (item #858456) – $3.00

Ibuprofen 200 mg tabs, 500 count (item #368399) – $7.00

Ibuprofen 100 mg/5 mL suspension, 120 mL (item #197541) – $4.00

Simply Saline nasal spray, 44 mL (item #535070) – $4.00

Fluticasone 50 mcg nasal spray, 18 GM (item #768994) – $13.00

Cetirizine 10 mg tabs, 100 count (item #513648) – $4.00

Loratadine 10 mg tabs, 100 count (item #889063) – $4.00

Ranitidine 150 mg, 60 count (item #797548) – $11.00

Hydrocortisone cream 1%, 30 GM (item #223644) – $2.00

Gaia elderberry syrup, 3 oz: $12.00

Daily-Vite multivitamin, 100 count (item #080259) – $2.00

Prenatal vitamin, 100 count (item #724351) – $3.00

ACE Compression knee support (item #884700) – $7.00

ACE Compress ankle brace (item #879494, 879486) – $6.00

Ankle stabilizer (similar to ASO brace) (item #133769, 125211, 120030, 137505, 114702) – $16.00

Air cast ankle stirrup (item #312850, 546002) – $47.00

ACE wrist brace (Item #576652) – $13.00

ACE bandage 2” (item #547950) – $3.00

ACE bandage 4”(item #547976) – $5.00

Post-op shoes (item #242511, 240226, 244996, 258418, 259079, 255869, 252767) – $22.00

Surelife blood pressure wrist cuff (item #607960) – $14.00

Surelife arm blood pressure monitor (item #607986) – $30.00