| Analgesics | Naproxen sodium, 220-mg tablet or caplet | Aleve | Temporary relief of minor aches and pains and reduction of fever in persons age 12 years and over | 220 mg every eight to 12 hours | $ 3.00 per 24 |
| 5.00 per 50 |
| 9.00 per 100 |
| Ketoprofen, 12.5-mg tablet | Actron | Temporary relief of minor aches and pains and reduction of fever in persons age 12 years and over | 12.5 mg every four to six hours | 3.00 per 24 |
| 5.00 per 50 |
| 8.00 per 100 |
| Ketoprofen, 12.5-mg tablet | Orudis KT | Temporary relief of minor aches and pains and reduction of fever in persons age 12 years and over | 12.5 mg every four to six hours | 3.00 per 24 |
| 5.00 per 50 |
| 9.00 per 100 |
| Ibuprofen, 100 mg per 5 mL suspension | Children's Motrin | Relief of signs and symptoms of juvenile arthritis, mild to moderate pain in children age 12 years and over and reduction of fever in children age 6 months and over | Based on weight and age of patient | 4.00 per 2 oz |
| 6.00 per 4 oz |
| Ibuprofen, 100 mg per 5 mL suspension | Children's Advil | Relief of signs and symptoms of juvenile arthritis, mild to moderate pain in children age 12 years and over and reduction of fever in children age 6 months and over | Based on weight and age of patient | 3.00 per 2 oz |
| 5.00 per 4 oz |
| Ibuprofen, 200-mg tablet or caplet | Advil, Motrin | Temporary relief of minor aches and pain associated with the common cold, menstrual cramps, headache, toothache, backache and arthritis, and for the reduction of fever | 200 to 400 mg every 4 to six hours, not to exceed 1,200 mg in 24 hours | 3.00 per 24 |
| 5.50 per 50 |
| 9.00 per 100 |
|
| Histamine antagonists | Clemastine fumarate, 1.34-mg tablet | Tavist-1 | Relief of symptoms associated with perennial and seasonal allergic rhinitis, the common cold and allergic and nonallergic pruritus in persons age 12 years and over | 1.34 mg every 12 hours | 4.00 per 8 |
| 6.00 per 16 |
| 11.00 per 32 |
| Cimetidine, 200-mg tablet | Tagamet HB | Prevention of heartburn and acid indigestion in persons age 12 years and over | 200 mg one hour before a meal, up to twice daily | 3.00 per 8 |
| 6.00 per 32 |
| 10.00 per 64 |
| Ranitidine, 75-mg tablet | Zantac 75 | Prevention of heartburn and acid indigestion in persons age 12 years and over | 75 mg one hour before a meal, up to twice daily | 4.00 per 10 |
| 7.00 per 20 |
| Nizatidine, 75-mg tablet | Axid AR | Prevention of heartburn and acid indigestion in persons age 12 years and over | 75 mg one hour before a meal, up to twice daily | 3.00 per 6 |
| 7.00 per 12 |
| 9.00 per 18 |
| Famotidine, 10-mg tablet | Pepcid AC | Prevention and treatment of heartburn and acid indigestion in persons age 12 years and older | 10 mg one hour before a meal, up to twice daily | 3.00 per 6 |
| 5.00 per 10 |
| 7.00 per 18 |
| 9.00 per 30 |
|
| Antifungal medications | Clotrimazole 1%, 100-mg vaginal tablet or applicatorful of cream | Gyne-Lotrimin | Treatment of recurrent vaginal yeast infection in persons age 12 years and over | One vaginal tablet or one applicatorful of cream vaginally once daily | 12.00 per seven-day treatment regimen |
| Clotrimazole 1%, 200-mg vaginal tablet | Gyne-Lotrimin 3 | Treatment of recurrent vaginal yeast infection in persons age 12 years and over | One vaginal tablet once daily | 7.00 per three-day treatment regimen |
| Butoconazole 1% cream | Femstat 3 | Treatment of recurrent vaginal yeast infection in persons age 12 years and over | One applicatorful of cream vaginally once daily | $17.00 per three-day treatment regimen |
| Miconazole nitrate 1%, 100-mg vaginal suppository or applicatorful of cream | Monistat 7 | Treatment of recurrent vaginal yeast infection in persons age 12 years and over | One vaginal suppository or one applicatorful of cream vaginally once daily | 13.00 per seven-day treatment regimen |
| Miconazole nitrate 1%, 200-mg vaginal suppository | Monistat 3 | Treatment of recurrent vaginal yeast infection in persons age 12 years and over | One vaginal suppository once daily | 13.00 per three-day treatment regimen |
|
| Smoking deterrents† | Nicotine transdermal system, 7-mg patch, 14-mg patch, 21-mg patch | Nicoderm CQ | Reduction of symptoms associated with smoking cessation, including nicotine craving, in adults age 18 years and over | One patch daily; taper dosage as recommended by manufacturer | 28.00 per seven-day supply in 7-mg dose |
| 28.00 per seven-day supply in 14-mg dose |
| 28.00 per seven-day supply in 21-mg dose |
| Nicotine transdermal system, 15-mg patch | Nicotrol | Reduction of symptoms associated with smoking cessation, including nicotine craving, in adults age 18 years and over | One patch daily | 25.00 per seven-day supply |
| Nicotine polacrilex gum, 2 mg and 4 mg | Nicorette | Reduction of symptoms associated with smoking cessation, including nicotine craving, in adults age 18 years and over | One piece of gum every one to two hours for weeks one through six, every two to four hours for weeks seven through nine and every four to eight hours for weeks 10 through 12 | 48.00 starter kit (108 pieces) 28.00 refill (48 pieces) |
|
| Mast cell stabilizer | Cromolyn sodium nasal spray, 5.2 mg pser spray | Nasalcrom | Prevention and relief of nasal allergy symptoms in adults and children age 6 years and older | One spray in each nostril three to four times daily as needed, up to six sprays daily | 9.00 |
|
| Topical medications | Minoxidil solution 2% | Rogaine | Hair regrowth | 1 mL applied to scalp twice daily | 30.00 per 2 oz |
| Hydrocortisone acetate 1%, cream‡ | Maximum Strength Cortaid | Temporary relief of itching associated with minor skin irritations, inflammation and rashes | Apply to affected area three to four times daily | 3.00 per 0.5 oz |
| 4.00 per 1 oz |