HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Acetaminophen Acetaminophen Acetaminophen Acetaminophen/Oxycodone Acetaminophen/Oxycodone Acetaminophen/Codeine #3 Acetaminophen/Hydrocodone Acetaminophen/Hydrocodone Acetaminophen/Hydrocodone Acetaminophen/Hydrocodone bitartrate Acetic acid Acetic acid/Hydrocortisone Acyclovir Acyclovir Acyclovir Albuterol HFA (IDP) tablet, MDI, solution, UD Albuterol liquid Albuterol solution neb Albuterol Unit Dose Albuterol-ipratropium Inhaler Alclometasone Cream Alclometasone Ointment Alendronate Alendronate Allopurinol Allopurinol Amantadine Amantadine Amikacin Amikacin Aminosalicylic acid

Tylenol Tylenol Tylenol Percocet Percocet Tylenol #3 Norco Norco Norco

325 mg 500 mg 650 mg 325 mg-10 mg 325 mg-5 mg 300 mg-30 mg 325 mg-5 mg 325 mg-7.5 mg 325 mg-10 mg

Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic

Acetaminophen Acetaminophen Acetaminophen Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic

Vicodin

500 mg-5 mg

Analgesic

Narcotic

Vosol Vosol HC Zovirax Zovirax Zovirax Proventil HFA (IDP) Ventolin Proventil Proventil Combivent MDI Aclovate Aclovate Fosamax Fosamax Zyloprim Zyloprim Symmetrel Symmetrel Amikin Amikin Paser

15 ml drops 2%-1% 200 mg 400 mg 800 mg

Otic Otic Antimicrobials Antimicrobials Antimicrobials

Antiviral Antiviral Antiviral

90 mcg

Respiratory

Inhaler

2 mg/5 ml (120 cc) 5 mg/ml (20 cc bottle) 0.83 mg/ml

Respiratory Respiratory Respiratory Respiratory Anti-inflammatory Agents Anti-inflammatory Agents Osteoporosis Osteoporosis Gout Gout Neurologic Neurologic Antimicrobials Antimicrobials Antimicrobials

45 gm 45 gm 70 mg 35 mg 300 mg 100 mg 50 mg/5 ml (120 cc) 100 mg 1000 mg/4 ml (4 cc) 500 mg/2 ml (2 cc) 4g

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Nebulizer soln

Parkinson Parkinson Aminoglycoside Aminoglycoside Antitubercular Page 1 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Amiodarone Amiodarone Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amlodipine Amlodipine Amlodipine Amoxicillin Amoxicillin Amoxicillin Amoxicillin Amoxicillin Amoxicillin-clavulanate Amoxicillin-clavulanate Amoxicillin-clavulanate Antipyrene, Benzocaine, Glycerine dehyd Aspirin (acetylsalicylic acid, ASA) Aspirin (acetylsalicylic acid, ASA) Atenolol Atenolol Atenolol

Cordarone Cordarone Elavil Elavil Elavil Elavil Elavil Norvasc Norvasc Norvasc Amoxil Amoxil Amoxil Amoxil Amoxil Augmentin Augmentin Augmentin

400 mg 200 mg 50 mg 25 mg 10 mg 75 mg 100 mg 5 mg 2.5 mg 10 mg 500 mg 250 mg/5 ml (150 cc) 250 mg 125 mg/5 ml (80 cc) 400 mg/5 ml 500 mg-125 mg 875 mg-125 mg 200 mg/5 ml (100 cc)

Cardiovascular Cardiovascular Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Cardiovascular Cardiovascular Cardiovascular Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials

Antiarrythmic Antiarrythmic Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Penicillins Penicillins Penicillins Penicillins Penicillins Penicillins Penicillins Penicillins

Auralgan

10 ml drops

Otic

Tenormin Tenormin Tenormin

325 mg 81 mg 50 mg 25 mg 100 mg

Analgesic Analgesic Cardiovascular Cardiovascular Cardiovascular

Atorvastatin

Lipitor

10 mg

Cardiovascular

Atorvastatin

Lipitor

20 mg

Cardiovascular

Atorvastatin

Lipitor

40 mg

Cardiovascular

Atorvastatin

Lipitor

80 mg

Cardiovascular

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Salicylates Salicylates Beta Blockers Beta Blockers Beta Blockers Cholesterol Lowering Agents Cholesterol Lowering Agents Cholesterol Lowering Agents Cholesterol Lowering Agents Page 2 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Azathioprine Azithromycin Baclofen Baclofen Beclomethasone dipropionate Beclomethasone dipropionate Belladonna alkaloids, phenobarbital Benztropine mesylate Benztropine mesylate Benztropine mesylate Benztropine mesylate Bismuth subsalicylate-metronidazoletetracycline Brimonidine tartrate solution Brinzolamide Bromocriptine Buprenorphine Buprenorphine Buprenorphine Buprenorphine Buprenorphine

Imuran Zithromax Lioresal Lioresal Qvar Qvar Donnatal Cogentin Cogentin Cogentin Cogentin

50 mg 250 mg 10 mg 20 mg 80 mcg 40 mcg 16.2 mg 2 mg 1 mg 0.5 mg 1 mg/ml (inj)

Immunosupressive Antimicrobials Analgesic Analgesic Respiratory Respiratory GI Neurologic Neurologic Neurologic Neurologic

Macrolides Muscle Relaxant Muscle Relaxant Steroid inhaler Steroid inhaler Antispasmodics Parkinson Parkinson Parkinson Parkinson

Alphagan Azopt Parlodel Butrans Butrans Butrans Butrans Subutex

0.2% 1% suspension 2.5 mg 10 mcg/hr 15 mcg/hr 5 mcg/hr 7.5 mcg/hr 2 mg

Ophthalmic Ophthalmic Hypoprolactinemic Analgesic Analgesic Analgesic Analgesic Analgesic

Buprenorphine/naloxone

Suboxone

2 mg-0.5 mg

Analgesic

Buprenorphine/naloxone

Suboxone

8 mg-2 mg

Analgesic

Bupropion XL Bupropion XL Buproprion IR, SR Buproprion IR, SR Buproprion IR, SR Buproprion IR, SR Buproprion IR, SR Buspirone HCI

Wellbutrin XL Wellbutrin XL Wellbutrin SR Wellbutrin SR Wellbutrin SR Wellbutrin SR Wellbutrin SR BuSpar

150 mg 300 mg 150 mg 75 mg 100 mg 200 mg 300 mg 5 mg

Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric

Helidac

Helicobacter pylori agent

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Glaucoma Glaucoma Opiate Agonist Opiate Agonist Opiate Agonist Opiate Agonist Opiate Agonist Mixed Opiate Agonist/Antagonist Mixed Opiate Agonist/Antagonist Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Other Page 3 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Buspirone HCI Buspirone HCI Buspirone HCI Butalbital/APAP/Caffeine Calcitriol Calcitriol Calcium acetate Capsaicin Capsaicin Capsaicin Captopril Captopril Captopril Captopril Carbamazepine Carbamazepine Carbamazepine Carbidopa/levodopa Carbidopa/levodopa Carbidopa/levodopa Carbidopa/levodopa LA Carbidopa/levodopa LA Carisoprodol Carvedilol Carvedilol Carvedilol Carvedilol Celecoxib Celecoxib Celecoxib Celecoxib Cephalexin Cephalexin

BuSpar BuSpar BuSpar Fioricet Rocaltrol Rocaltrol Phoslo

10 mg 15 mg 30 mg 50 mg-325 mg-40 mg 0.25 mcg 0.5 mcg 667 mg 0.025% cream 0.075% cream 0.1% cream 50 mg 25 mg 12.5 mg 100 mg 200 mg 100 mg 100 mg/5 ml 25 mg-250 mg 25 mg-100 mg 10 mg-100 mg 50-200 mg 25-100 mg 250 mg 6.25 mg 3.125 mg 12.5 mg 25 mg 100 mg 200 mg 400 mg 50 mg 250 mg/5 ml (100 cc) 250 mg

Psychiatric Psychiatric Psychiatric Analgesic Vitamin Vitamin Phosphate binder Derm Derm Derm Cardiovascular Cardiovascular Cardiovascular Cardiovascular Psychiatric Psychiatric Psychiatric Neurologic Neurologic Neurologic Neurologic Neurologic Muscle Relaxant Cardiovascular Cardiovascular Cardiovascular Cardiovascular Analgesic Analgesic Analgesic Analgesic Antimicrobials Antimicrobials

Other Other Other Misc

Capoten Capoten Capoten Capoten Tegretol Tegretol Tegretol Sinemet Sinemet Sinemet Sinemet CR Sinemet CR Soma Coreg Coreg Coreg Coreg Celebrex Celebrex Celebrex Celebrex Keflex Keflex

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Analgesic Analgesic Analgesic ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor Mood Stabilizer Mood Stabilizer Mood Stabilizer Parkinson Parkinson Parkinson Parkinson Parkinson Beta Blockers Beta Blockers Beta Blockers Beta Blockers NSAID NSAID NSAID NSAID Cephalosporins Cephalosporins Page 4 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Cephalexin Cephalexin Chlorpromazine Chlorpromazine Chlorpromazine Chlorpromazine Chlorpromazine Chlorpromazine Chlorpromazine Chlorthalidone Chlorthalidone Cimetidine Ciprofloxacin Ciprofloxacin Ciprofloxacin eye drop Citalopram Hydrobromide Citalopram Hydrobromide Citalopram Hydrobromide Citalopram Hydrobromide Clarithromycin Clindamycin Clindamycin Clindamycin topical gel, lotion Clindamycin topical solution Clobetasol lotion Clobetasol propionate Clobetasol propionate Clobetasol propionate Clomipramine Clomipramine Clomipramine Clonazepam (SCH IV) Clonazepam (SCH IV)

Keflex Keflex Thorazine Thorazine Thorazine Thorazine Thorazine Thorazine Thorazine Thalitone Thalitone Tagamet Cipro Cipro Ciloxan Celexa Celexa Celexa Celexa Biaxin Cleocin Cleocin Cleocin Cleocin-T Temovate Temovate Temovate Temovate Anafranil Anafranil Anafranil Klonopin Klonopin

125 mg/5 ml (200 cc) 500 mg 50 mg 25 mg 200 mg 100 mg 10 mg 30 mg/ml 100 mg/ml 25 mg 50 mg 400 mg 500 mg 250 mg 0.3% 40 mg 20 mg 10 mg 10 mg/5 ml 500 mg 150 mg 300 mg 1% 1% (60 cc) 0.05% 0.05% crm (15 Gms) 0.05% oint (30 Gms) 0.05% oint (15 Gms) 75 mg 50 mg 25 mg 2 mg 1 mg

Antimicrobials Antimicrobials Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Cardiovascular Cardiovascular GI Antimicrobials Antimicrobials Ophthalmic Psychiatric Psychiatric Psychiatric Psychiatric Antimicrobials Antimicrobials Antimicrobials Derm Derm Derm Derm Derm Derm Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric

Cephalosporins Cephalosporins Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Diuretics Diuretics H2 blockers Quinolones Quinolones

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Antidepressant Antidepressant Antidepressant Antidepressant Misc Misc Acne Acne Antiinflammatory Antiinflammatory Antiinflammatory Antidepressant Antidepressant Antidepressant Benzos Benzos Page 5 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Clonazepam (SCH IV) Clonidine HCI tabs Clonidine HCI tabs Clonidine HCI tabs Clopidogrel Colchicine Conjugated Estrogen Cream Cortisporin otic soln Cortisporin otic susp Cromolyn inhaler Cyclobenzaprine Cycloserine Dextroamphetamine/amphetamine Dextroamphetamine/amphetamine Dextroamphetamine/amphetamine Dextroamphetamine/amphetamine Diabetes supplies - glucometer Diabetes supplies - lancets Diabetes supplies - syringes/needles Diabetes supplies - test strips Diabetes supplies - testing control solution Diazepam (SCH IV) Diazepam (SCH IV) Diazepam (SCH IV) Diclofenac Diclofenac Dicloxacillin Dicloxacillin Dicyclomine Dicyclomine Digoxin Digoxin

Klonopin Catapres Catapres Catapres Plavix Colcrys Premarin

0.5 mg 0.1 mg 0.2 mg 0.3 mg 75 mg 0.6 mg 0.625 mg/g crm (43 Gm) 1%-0.35%-10000u/mL (10 ml) drops (10 ml) 14.2 Gm 10 mg 250 mg 10 mg 15 mg 20 mg 30 mg

Psychiatric Cardiovascular Cardiovascular Cardiovascular Platelet aggregation inhibitor Gout Hormone Replacement Otic Otic Respiratory Analgesic Antimicrobials Psychiatric Psychiatric Psychiatric Psychiatric Diabetes Diabetes Diabetes Diabetes

Benzos Central Alpha Agonist Central Alpha Agonist Central Alpha Agonist

Intal Flexeril Seromycin Adderall XR Adderall XR Adderall XR Adderall XR

Muscle Relaxant Antitubercular Stimulant Stimulant Stimulant Stimulant

Diabetes Valium Valium Valium Voltaren Voltaren Dynapen Dynapen Bentyl Bentyl Lanoxin Lanoxin

5 mg 2 mg 10 mg 50 mg 75 mg 500 mg 250 mg 20 mg 10 mg 0.25 mg 0.125 mg

Psychiatric Psychiatric Psychiatric Analgesic Analgesic Antimicrobials Antimicrobials GI GI Cardiovascular Cardiovascular

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Benzos Benzos Benzos NSAID NSAID Penicillins Penicillins Antispasmodics Antispasmodics Glycosides Glycosides Page 6 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Dilitiazem HCI Diltiazem

Cardizem LA Cardizem Cardizem CD, Dilacor Xr, Cartia XL, Dilt-CD Cardizem CD, Dilacor Xr, Cartia XL, Dilt-CD Cardizem SR Cardizem SR Cardizem SR Cardizem SR Cardizem CD Cardizem CD Cardizem CD Cardizem CD Cardizem CD Cardizem CD Cardizem CD Cardizem CD Benadryl Benadryl Benadryl Lomotil Lomotil Persantine Persantine Persantine Depakote DR Depakote DR Depakote DR Depakote ER Depakote ER

180 mg 120 mg

Cardiovascular Cardiovascular

Calcium Channel Blockers Calcium Channel Blockers

90 mg

Cardiovascular

Calcium Channel Blockers

60 mg

Cardiovascular

Calcium Channel Blockers

300 mg 240 mg 180 mg 120 mg 360 mg 90 mg 60 mg 300 mg 30 mg 240 mg 180 mg 120 mg 25, 50 mg capsules 12.5 mg/ 5ml 50 mg/ml (inj) 2.5 mg-0.025 mg 2.5 mg-0.025 mg/5 ml (60 ml) 25 mg 50 mg 75 mg 125 mg 500 mg 250 mg 250 mg 500 mg

Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy GI GI Cardiovascular Cardiovascular Cardiovascular Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric

Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Antihistamine Antihistamine Antihistamine Antidiarrhea Antidiarrhea Anticoagulants Anticoagulants Anticoagulants Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer

Diltiazem

Diltiazem Diltiazem SR Diltiazem SR Diltiazem SR Diltiazem SR Diltiazem CD Diltiazem CD Diltiazem CD Diltiazem CD Diltiazem CD Diltiazem CD Diltiazem CD Diltiazem CD Diphenhydramine Diphenhydramine Diphenhydramine Diphenoxylate-atropine Diphenoxylate-atropine (SCH V) Dipyridamole Dipyridamole Dipyridamole Divalproex sodium Divalproex sodium Divalproex sodium Divalproex sodium Divalproex sodium

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Page 7 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Doxazosin mesylate Doxazosin mesylate Doxazosin mesylate Doxazosin mesylate Doxepin HCL Doxepin HCL Doxepin HCL Doxepin HCL Doxepin HCL Doxepin HCL Doxycycline Doxycycline Duloxetine Duloxetine Duloxetine Duloxetine Econazole Econazole Econazole Enalapril maleate Enalapril maleate Enalapril maleate Enalapril maleate Enalapril maleate/Hctz Enalapril maleate/Hctz Erythromycin eye ointment Erythromycin gel or solution Erythromycin stearate Erythromycin stearate Erythromycin stearate Estradiol Estradiol Estradiol

Cardura Cardura Cardura Cardura Sinequan Sinequan Sinequan Sinequan Sinequan Sinequan Doryx Vibramycin Doryx Vibramycin Cymbalta Cymbalta Cymbalta Cymbalta Spectazole Spectazole Spectazole Vasotec Vasotec Vasotec Vasotec Vaseretic Vaseretic

8 mg 4 mg 2 mg 1 mg 50 mg 25 mg 10 mg 75 mg 100 mg 150 mg 50 mg 100 mg 20 mg 30 mg 40 mg 60 mg 1% crm 15 Gm (15 Gm) 1% crm 85 Gm (85 Gm) 1% crm 30 Gm (30 Gm) 5 mg 20 mg 2.5 mg 10 mg 10 mg-25 mg 5 mg-12.5 mg 5 mg / Gm (3.5 Gm) 2% 500 mg 250 mg 333 mg 2 mg 1 mg 0.5 mg

Cardiovascular Cardiovascular Cardiovascular Cardiovascular Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Antimicrobials Antimicrobials Psychiatric Psychiatric Psychiatric Psychiatric Antimicrobials Antimicrobials Antimicrobials Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Ophthalmic Derm Antimicrobials Antimicrobials Antimicrobials Hormone Replacement Hormone Replacement Hormone Replacement

Alpha-1 blocker Alpha-1 blocker Alpha-1 blocker Alpha-1 blocker Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Tetracyclines Tetracyclines Antidepressant Antidepressant Antidepressant Antidepressant Antifungals Antifungals Antifungals ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor Antihypertensive Antihypertensive

Erygel Ery-Tab Ery-Tab Ery-Tab Estrace Estrace Estrace

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Acne Macrolides Macrolides Macrolides

Page 8 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Ethambutol Ethambutol Ethionamide Famotidine Famotidine

Myambutol Myambutol Trecator Pepcid Pepcid

400 mg 100 mg 250 mg 20 mg 40 mg

Antimicrobials Antimicrobials Antimicrobials GI GI

Fenofibrate

Tricor

145 mg

Cardiovascular

Fenofibrate

Tricor

48 mg

Cardiovascular

Finasteride Fluconazole Fluconazole Fluconazole Fludrocortisone Fludrocortisone Flunisolide Fluocinolone acetonide Fluocinolone acetonide Fluocinolone acetonide Fluocinolone acetonide Fluocinolone acetonide Fluocinonide Fluocinonide Fluocinonide Fluocinonide Fluocinonide Fluocinonide Fluocinonide Fluoxetine Fluoxetine Fluoxetine Fluoxetine Fluphenazine

Proscar Diflucan Diflucan Diflucan Florinef Florinef Nasarel Synalar Synalar Synalar Synalar Synalar Lidex Lidex Lidex Lidex Lidex Lidex Lidex Prozac Prozac Prozac Prozac Prolixin

5 mg 200 mg 150 mg 100 mg 0.2 mg 0.1 mg 25 mcg/spray (0.025%) 0.025% cream 0.01% cream 0.025% ointment 0.01% ointment 0.025%, 0.01% solution, 60 ml 0.05% gel (60 gm) 0.05% solution 60 ml 0.05% oint (60 gm) 0.05% oint (30 gm) 0.05% oint (15 gm) 0.05% cream (60 gm) 0.05% cream (30 gm) 20 mg 10 mg 40 mg 20 mg/5 ml 5 mg/ml

Genitourinary Antimicrobials Antimicrobials Antimicrobials Adrenals Endocrine Cold, Cough, Allergy Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric

Antitubercular Antitubercular Antitubercular H2 Antagonists H2 Antagonists Cholesterol Lowering Agents Cholesterol Lowering Agents 5-alpha reductase inhibitor Antifungals Antifungals Antifungals

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Nasal Steroids Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antidepressant Antidepressant Antidepressant Antidepressant Antipsychotic Page 9 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Fluphenazine Fluphenazine Fluphenazine Fluphenazine Fluphenazine decanoate Fluticasone propionate Folic Acid Furosemide Furosemide Furosemide Gabapentin Gabapentin Gabapentin Gabapentin

Prolixin Prolixin Prolixin Prolixin Prolixin Flonase

Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Respiratory Vitamin Cardiovascular Cardiovascular Cardiovascular Neurologic Neurologic Neurologic Neurologic

Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Nasal Inhaler

Lasix Lasix Lasix Neurontin Neurontin Neurontin Neurontin

0.5 mg/ml 2.5 mg 10 mg 1 mg 25 mg/ml (inj) 50 mcg/spray 800 MicroGrams 80 mg 40 mg 20 mg 300 mg 100 mg 400 mg 600 mg

Gemfibrozil

Lopid

600 mg

Cardiovascular

Gentamicin eye drops Glipizide Glipizide Glyburide Glyburide Glyburide Griseofulvin micro liquid Griseofulvin ultramicro Griseofulvin ultramicro Guaifenesin/Codeine Haloperidol Haloperidol Haloperidol Haloperidol Haloperidol Haloperidol Haloperidol

Garamycin Glucotrol Glucotrol Micronase Diabeta Micronase Diabeta Micronase Diabeta Grifulvin V Grisactin Fulvicin Grisactin Fulvicin Robitussin AC Haldol Haldol Haldol Haldol Haldol Haldol Haldol

0.3% (5 ml) 5 mg 10 mg 5 mg 2.5 mg 1.25 mg 125 mg/5 mL (120 ml) 250 mg 125 mg 100 mg-10 mg/5 ml 5 mg 2 mg 1 mg 0.5 mg 2 mg/ml (15 ml) 2 mg/ml (120 ml) 10 mg

Ophthalmic Diabetes Diabetes Diabetes Diabetes Diabetes Antimicrobials Antimicrobials Antimicrobials Cold, Cough, Allergy Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Diuretics Diuretics Diuretics Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Cholesterol Lowering Agents Sulfonylureas Sulfonylureas Sulfonylureas Sulfonylureas Sulfonylureas Antifungals Antifungals Antifungals Antitussive Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Page 10 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Haloperidol Haloperidol decanoate Haloperidol decanoate Hydralazine Hydralazine Hydralazine Hydralazine Hydrochlorothiazide Hydrochlorothiazide Hydrochlorothiazide Hydrocortisone Hydrocortisone Hydrocortisone Hydrocortisone Hydrocortisone cream Hydrocortisone ointment Hydrocortisone Suppositories Hydroxychloroquine Hydroxyzine HCL Hydroxyzine HCL Hydroxyzine HCL Hydroxyzine HCL Ibuprofen Ibuprofen Ibuprofen Imipramine Imipramine Imipramine Indomethacin Indomethacin Insulin 70/30 Insulin glargine Insulin Lispro

Haldol Haldol Haldol Apresoline Apresoline Apresoline Apresoline Esidrix Esidrix Microzide HC HC HC HC Cortizone Cortizone Cortizone Plaquenil Atarax Atarax Atarax Atarax Motrin Motrin Motrin Tofranil Tofranil Tofranil Indocin Indocin Humulin, Novolin Lantus Humalog

20 mg 50 mg/ml (inj) 100 mg/ml (inj) 50 mg 25 mg 100 mg 10 mg 25 mg 50 mg 12.5 mg cap 2.5% lotion 5 mg 10 mg 20 mg 2.5% 2.5% 25 mg 200 mg 25 mg 10 mg 10 mg/5 ml (120 ml) 50 mg 400 mg 600 mg 800 mg 50 mg 25 mg 10 mg 50 mg 25 mg U100 (10 ml) 100 IU/mL 100U/mL

Psychiatric Psychiatric Psychiatric Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Derm Derm Derm Derm Derm Derm GI Rheumatology Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Analgesic Analgesic Analgesic Psychiatric Psychiatric Psychiatric Analgesic Analgesic Diabetes Diabetes Diabetes

Antipsychotic Antipsychotic Antipsychotic Other Vasodilators Other Vasodilators Other Vasodilators Other Vasodilators Diuretics Diuretics Diuretics Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Antihistamine Antihistamine Antihistamine Antihistamine NSAID NSAID NSAID Antidepressant Antidepressant Antidepressant NSAID NSAID Insulin Product Insulin Product Insulin Product Page 11 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Insulin NPH Insulin Regular Insulin Regular

Humulin N Humulin R Humulin R Humulin R Kwikpen Atrovent Inh Sol Atrovent INH INH INH Isordil Isordil Isordil Isordil Imdur Imdur Imdur Imdur Imdur Nizoral Nizoral Nizoral Nizoral Nizoral Alaway Trandate Trandate Trandate Duphalac Lamictal Lamictal Lamictal Lamictal

U100 (10 ml) U100 (10 ml) U500

Diabetes Diabetes Diabetes

Insulin Product Insulin Product Insulin Product

U500

Diabetes

Insulin Product

500 mcg (3 cc/amp) 18mcg/dose MDI (14gm) 300 mg 100 mg 10 mg / ml 5 mg 20 mg 10 mg 30 mg 60 mg 30 mg 10 mg 20 mg 120 mg 200 mg (tabs) 2% crm (60 Gm) 2% crm (30 Gm) 2% crm (15 Gm) 2% shampoo 0.025% 200 mg 100 mg 300 mg 10g/15 ml syrup 25 mg tab 200 mg tab 150 mg tab 100 mg tab

Respiratory Respiratory Antimicrobials Antimicrobials Antimicrobials Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Ophthalmic Cardiovascular Cardiovascular Cardiovascular GI Neurologic Neurologic Neurologic Neurologic

Nebulizer soln Asthma Antitubercular Antitubercular Antitubercular Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Antifungals Antifungals Antifungals Antifungals Antifungals

Insulin Regular Ipratropium bromide 0.02% Ipratropium MDI Isoniazid Isoniazid Isoniazid Isosorbide dinitrate Isosorbide dinitrate Isosorbide dinitrate Isosorbide dinitrate Isosorbide mononitrate IR, SR Isosorbide mononitrate IR, SR Isosorbide mononitrate IR, SR Isosorbide mononitrate IR, SR Isosorbide mononitrate IR, SR Ketoconazole Ketoconazole Ketoconazole Ketoconazole Ketoconazole Ketotifen Labetalol HCL Labetalol HCL Labetalol HCL Lactulose Lamotrigine Lamotrigine Lamotrigine Lamotrigine

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Beta Blockers Beta Blockers Beta Blockers Laxatives Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Page 12 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Latanoprost Levetiracetam Levetiracetam Levetiracetam Levofloxacin Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Lidocaine Lidocaine Lidocaine Lidocaine Linezolid Lisinopril Lisinopril Lisinopril Lisinopril Lisinopril Lisinopril Lisinopril/Hctz Lisinopril/Hctz Lisinopril/Hctz Lithium carbonate Lithium carbonate

Xalatan Keppra Keppra Keppra Levaquin Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl

0.005% 500 mg 750 mg 1000 mg 500 mg 0.3 mg 0.2 mg 0.175 mg 0.15 mg 0.125 mg 0.112 mg 0.1 mg 0.088 mg 0.075 mg 0.050 mg 0.025 mg 0.137 mg 4% cream 4% solution 5% cream 5% ointment 600 mg 5 mg 20 mg 40 mg 2.5 mg 10 mg 30 mg 10 mg-12.5 mg 20 mg-12.5 mg 20 mg-25 mg 300 mg 150 mg

Ophthalmic Neurologic Neurologic Neurologic Antimicrobials Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Derm Derm Derm Derm Antimicrobials Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Psychiatric Psychiatric

Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Anesthetic Anesthetic Anesthetic Anesthetic Oxazolidinone ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor Antihypertensive Antihypertensive Antihypertensive Mood Stabilizer Mood Stabilizer

Zyvox Prinivil, Zestril Prinivil, Zestril Prinivil, Zestril Prinivil, Zestril Prinivil, Zestril Prinivil, Zestril Zestoretic Zestoretic Zestoretic Eskalith CR Eskalith CR

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Page 13 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Lithium carbonate Lithium carbonate Loratadine Lorazepam (SCH IV) Lorazepam (SCH IV) Lorazepam (SCH IV) Losartan Losartan Losartan Losartan/Hctz Losartan/Hctz Losartan/Hctz

Eskalith SR Eskalith SR Claritin Ativan Ativan Ativan Cozaar Cozaar Cozaar Hyzaar Hyzaar Hyzaar

300 mg 450 mg 10 mg 2 mg 1 mg 0.5 mg 25 mg 50 mg 100 mg 100 mg-12.5 mg 100 mg-25 mg 50 mg-12.5 mg

Psychiatric Psychiatric Antihistamine Psychiatric Psychiatric Psychiatric Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular

Mood Stabilizer Mood Stabilizer

Lovastatin

Mevacor

10, 20, 40 mg

Cardiovascular

Loxapine Meclizine Medroxyprogesterone Medroxyprogesterone Medroxyprogesterone Mesalamine Metformin Metformin Metformin Metformin ER Metformin ER Metformin ER Methadone Methadone Methimazole Methimazole Methocarbamol Methocarbamol Methotrexate

Loxitane Antivert Provera Provera Provera Asacol Glucophage Glucophage Glucophage Glucophage XR Glucophage XR Glucophage XR

5, 10, 25, 50 mg 25 mg tabs 5 mg 2.5 mg 10 mg 400 mg 500 mg 850 mg 1000 mg 500 mg 750 mg 1000 mg 5 mg 10 mg 5 mg 10 mg 500 mg 750 mg 2.5 mg

Psychiatric Neurologic Hormone Replacement Hormone Replacement Hormone Replacement GI Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Analgesic Analgesic Endocrine Endocrine Analgesic Analgesic Chemotherapy

Tapazole Tapazole Robaxin Robaxin Rheumatrex

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Benzos Benzos Benzos Angiotensin II Blocker Angiotensin II Blocker Angiotensin II Blocker Antihypertensive Antihypertensive Antihypertensive Cholesterol Lowering Agents Antipsychotic Misc

Anti-inflammatory bowel Biguanides Biguanides Biguanides Biguanides Biguanides Biguanides Narcotic Narcotic Thyroid Thyroid Muscle Relaxant Muscle Relaxant Page 14 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Methyldopa Methyldopa Methylphenidate long-acting Methylphenidate long-acting Methylphenidate long-acting Methylphenidate long-acting Methylphenidate short acting Methylphenidate short acting Methylphenidate short acting Metoclopramide Metoclopramide hcl Metolazone Metolazone Metolazone Metoprolol succinate Metoprolol succinate Metoprolol succinate Metoprolol tartrate Metoprolol tartrate Metoprolol tartrate Metronidazole Metronidazole Metronidazole cream Metronidazole cream Metronidazole topical gel Mirtazapine Mirtazapine Mirtazapine Misoprostol Misoprostol Montelukast Montelukast Morphine sulfate liquid

Aldomet Aldomet Ritalin LA Ritalin LA Ritalin LA Ritalin LA Ritalin Ritalin Ritalin Reglan Reglan Zaroxolyn Zaroxolyn Zaroxolyn Toprol XL Toprol XL Toprol XL Lopressor Lopressor Lopressor Flagyl Flagyl Metrocream Metrocream Metrogel Remeron Remeron Remeron Cytotec Cytotec Singulair Singulair MS

500 mg 250 mg 10 mg 20 mg 30 mg 40 mg 10 mg 20 mg 30 mg 10 mg 5 mg 5 mg 10 mg 2.5 mg 50 mg 25 mg 100 mg 50 mg 100 mg 25 mg 250 mg 500 mg 0.075% 0.75% 0.75% 45 mg 30 mg 15 mg 100 mg 200 mg 5 mg chew 10 mg 20 mg/5 ml

Cardiovascular Cardiovascular Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric GI GI Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Antimicrobials Antimicrobials Antimicrobials Derm Derm Psychiatric Psychiatric Psychiatric GI GI Respiratory Respiratory Analgesic

Central Alpha Agonist Central Alpha Agonist Stimulant Stimulant Stimulant Stimulant Stimulant Stimulant Stimulant Antiemetic Antiemetic Diuretics Diuretics Diuretics Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Misc Misc Misc Acne Acne Antidepressant Antidepressant Antidepressant

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Page 15 of 23

Narcotic

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Morphine sulfate short acting Morphine sulfate short acting Morphine sulfate SR Morphine sulfate SR Morphine sulfate SR Morphine sulfate SR Moxifloxacin Mupirocin Nabumetone Naloxone Naloxone Naproxen Naproxen Naproxen Niacin IR & ER tabs only Niacin IR & ER tabs only Niacin IR & ER tabs only Nicotine Gum Nicotine Gum Nicotine Lozenge Nicotine Lozenge Nicotine Patches- 28 weeks Nicotine Patches- 28 weeks Nicotine Patches- 28 weeks

MS MS Oramorph SR Oramorph SR Oramorph SR Oramorph SR Avelox Bactroban Relafen Narcan Narcan Naprosyn Naprosyn Naprosyn

15 mg 30 mg 15 mg 30 mg 60 mg 100 mg 400 mg 2% ointment 750 mg 0.4 mg/ml 1 mg/ml 250 mg 375 mg 500 mg 500 mg 100 mg 250 mg 2 mg 4 mg 2 mg 4 mg 7 mg 14 mg 21 mg

Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Antimicrobials Derm Analgesic Toxicology Agents Toxicology Agents Analgesic Analgesic Analgesic Cardiovascular Cardiovascular Cardiovascular Smoking deterrents Smoking deterrents Smoking deterrents Smoking deterrents Smoking deterrents Smoking deterrents Smoking deterrents

Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic Quinolones Antimicrobial NSAID Opiate Antagonists Opiate Antagonists NSAID NSAID NSAID

90 mg

Cardiovascular

Calcium Channel Blockers

60 mg

Cardiovascular

Calcium Channel Blockers

30 mg

Cardiovascular

Calcium Channel Blockers

50 mg 100 mg 100 mg

Antimicrobials Antimicrobials Antimicrobials

Misc Misc Misc

Nifedipine SR Nifedipine SR Nifedipine SR Nitrofurantoin macrocryst Nitrofurantoin macrocryst Nitrofurantoin monohydrate

NicoDerm NicoDerm NicoDerm Procardia, Adalat CC, Nifediac Procardia, Adalat CC, Nifediac Procardia, Adalat CC, Nifediac Macrodantin Macrodantin Macrobid

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Page 16 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Nitroglycerine SL Norethindrone Nortriptyline Nortriptyline Nortriptyline Nortriptyline Nystatin (cream or ointment) Nystatin oral suspension Olanzapine Olanzapine Omeprazole Oseltamivir Oseltamivir Oxybutynin Paroxetine Paroxetine Paroxetine Paroxetine Paroxetine Penicillin VK Penicillin VK Penicillin VK Penicillin VK Penicillin VK Pentoxifylline ER Permethrin cream Perphenazine Perphenazine Perphenazine Perphenazine Perphenazine Phenazopyridine HCL Phenazopyridine HCL

Nitrostat Aygestin Pamelor Pamelor Pamelor Pamelor

0.4 mg 5 mg 75 mg 50 mg 25 mg 10 mg

Zyprexa Zyprexa Prilosec Tamiflu Tamiflu Ditropan Paxil Paxil Paxil Paxil Paxil Veetids Veetids Veetids Veetids Veetids Trental Elimite Trilafon Trilafon Trilafon Trilafon Trilafon Pyridium Pyridium

100,000 units/ml 5 mg 2.5mg 20 mg 75mg 12 mg/ml 5 mg 40 mg 20 mg 30 mg 10 mg 10 mg/5 ml 500 mg 250 mg/5 ml (100 cc) 250 mg 125 mg/5 ml (200 cc) 250 mg/5 ml (150 cc) 400 mg 5% (60 Gm) 8 mg 4 mg 2 mg 16 mg / 5 cc (120 ml) 16 mg 200 mg 100 mg

Cardiovascular Hormone Replacement Psychiatric Psychiatric Psychiatric Psychiatric Derm Antimicrobials Psychiatric Psychiatric GI Antimicrobials Antimicrobials Genitourinary Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Hemorrheologic Agents Derm Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Genitourinary Genitourinary

Nitrate Vasodilators Progestins Antidepressant Antidepressant Antidepressant Antidepressant Antifungals Antifungals Antipsychotic Antipsychotic PPI Antiviral Antiviral

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Penicillins Penicillins Penicillins Penicillins Penicillins Scabicide and Lice Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic

Page 17 of 23

HealthPAC Formulary Current as of July 2016

Generic Name Phenobarbital (SCH IV) Phenobarbital (SCH IV) Phenobarbital (SCH IV) Phenobarbital (SCH IV) Phenytoin Phenytoin Pioglitazone hydrochloride Pioglitazone hydrochloride Pioglitazone hydrochloride Polyethylene glycol Polyethylene glycol Polyethylene glycol electrolyte solution Polymyxin b- trimethoprim Polymyxin b- trimethoprim Potassium chloride Potassium chloride tabs Potassium chloride tabs Potassium chloride tabs

Brand Name

Strength

Class I

Class II

Dilantin Dilantin Actos Actos Actos Miralax Miralax

30 mg 100 mg 60 mg 15 mg 100 mg 50 mg 15 mg 30 mg 45 mg 238 g 510 g

Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Diabetes Diabetes Diabetes GI GI

Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Thiazolidinediones Thiazolidinediones Thiazolidinediones

Mix Golytely

240 g

GI

Prep

Polytrim Polytrim

10 mL drops 3.5 gm ointment 10% (480 cc)

Ophthalmic Ophthalmic Cardiovascular

Potassium Supplement

8 mEq

Cardiovascular

Potassium Supplement

20 mEq

Cardiovascular

Potassium Supplement

10 mEq

Cardiovascular

Potassium Supplement Cholesterol Lowering Agents

K-Tab, K-Dur, Slow-K, Klor-con K-Tab, K-Dur, Slow-K, Klor-con K-Tab, K-Dur, Slow-K, Klor-con

Pravastatin

Pravachol

20, 40, 80 mg tabs

Cardiovascular

Praziquantel Prazosin Prazosin Prazosin Prednisolone Prednisolone ophth solu or susp Prednisone Prednisone Prednisone

Biltricide Minipress Minipress Minipress Prelone

600 mg 1 mg 2 mg 5 mg 15mg/5ml oral sol 1% 1 mg 2.5 mg 5 mg

Anthelmintics Cardiovascular Cardiovascular Cardiovascular Endocrine Ophthalmic Endocrine Endocrine Endocrine

Deltasone Deltasone Deltasone

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Alpha-blockers Alpha-blockers Alpha-blockers Glucocorticoids Glucocorticoids Glucocorticoids Glucocorticoids Page 18 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Prednisone Prednisone Prednisone Primidone Primidone Probenecid Prochlorperazine Prochlorperazine Prochlorperazine Promethazine HCI Promethazine HCI Promethazine HCI Promethazine HCI Promethazine HCI Promethazine HCI Promethazine/VC/DM Propranolol HCL Propranolol HCL Propranolol HCL Propranolol HCL Propranolol HCL Propylthiouracil Pyrazinamide Pyridoxine Pyridoxine Quetiapine fumarate Quetiapine fumarate Quetiapine fumarate Quetiapine fumarate Quetiapine fumarate Quetiapine fumarate Ranitidine Ranitidine

Deltasone Deltasone Deltasone Mysoline Mysoline Benemid Compazine Compazine Compazine Phenergan Phenergan supp Phenergan Phenergan Phenergan syrup Phenergan

20 mg 10 mg 50 mg 50 mg 250 mg 500 mg 25 mg supp 10 mg 5 mg 50 mg 25 mg supp 25 mg 12.5 mg supp 6.25 mg/5 ml (120 ml) 12.5 mg

Glucocorticoids Glucocorticoids Glucocorticoids Anticonvulsant Anticonvulsant

Inderal Inderal Inderal Inderal Inderal PTU

80 mg 40 mg 20 mg 10 mg 60 mg 50 mg 500 mg 25 mg 100 mg 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg 300 mg 150 mg

Endocrine Endocrine Endocrine Neurologic Neurologic Gout GI GI GI GI GI GI GI GI GI Cold, Cough, Allergy Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Endocrine Antimicrobials Vitamin Vitamin Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric GI GI

Vitamin B5 Vitamin B6 Seroquel Seroquel Seroquel Seroquel Seroquel Seroquel Zantac Zantac

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Antiemetic Antiemetic Antiemetic Antiemetic Antiemetic Antiemetic Antiemetic Antiemetic Antiemetic Antitussive Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Thyroid Antitubercular

Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic H2 blockers H2 blockers Page 19 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Rifampin Rifampin Rifapentine Risperidone Risperidone Risperidone Risperidone Risperidone Risperidone Salmeterol xinafoate Salsalate Salsalate Selenium sulfide lotion Sertraline Sertraline Sertraline Sertraline

Rifadin Rifadin Priftin Risperdal Risperdal Risperdal Risperdal Risperdal Risperdal Serevent Diskus

300 mg 150 mg 150 mg 1 mg 1 mg/ml solution 0.5 mg 2 mg 3 mg 4 mg 50 mcg 750 mg 500 mg 2.50% 20 mg/ml 25 mg 50 mg 100 mg

Antimicrobials Antimicrobials Antimicrobials Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Respiratory Analgesic Analgesic Derm Psychiatric Psychiatric Psychiatric Psychiatric

Antitubercular Antitubercular Antitubercular Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Asthma Salicylates Salicylates Anti-seborrhea Antidepressant Antidepressant Antidepressant Antidepressant

1% crm

Derm

Other

Silver sulfadiazine

Selsun Zoloft Zoloft Zoloft Zoloft Flint SSD, Silvadene

Simvastatin

Zocor

40 mg

Cardiovascular

Simvastatin

Zocor

20 mg

Cardiovascular

Simvastatin

Zocor

10 mg

Cardiovascular

Sitagliptin

Januvia

100 mg

Diabetes

Sitagliptin

Januvia

25 mg

Diabetes

Sitagliptin

Januvia

50 mg

Diabetes

Spironolactone Spironolactone

Aldactone Aldactone

25 mg 50 mg

Cardiovascular Cardiovascular

Cholesterol Lowering Agents Cholesterol Lowering Agents Cholesterol Lowering Agents Dipeptidyl Peptidase 4 (DPP-4) Inhibitor Dipeptidyl Peptidase 4 (DPP-4) Inhibitor Dipeptidyl Peptidase 4 (DPP-4) Inhibitor Diuretics Diuretics

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Page 20 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Class I

Class II

Spironolactone Sucralfate Sulfacetamide sodium eye drop sol Sulfacetamide sodium eye ointment Sulfamethxzl/Trimethoprim Sulfamethxzl/Trimethoprim Sulfamethxzl/Trimethoprim DS Sulfasalazine Sulindac Sulindac Sumatriptan Sumatriptan Sumatriptan Tamoxifen Tamsulosin Temazepam (SCH IV) Temazepam (SCH IV) Terazosin HCL Terazosin HCL Terazosin HCL Terazosin HCL Testosterone Inj Testosterone Inj Tetracycline Tetracycline Theophylline Theophylline Thiothixene Thiothixene Thiothixene Thiothixene Thiothixene Thiothixene

Aldactone Carafate Sulamyd Sulamyd Septra Bactrim Septra Azulfidine Clinoril Clinoril Imitrex Imitrex Imitrex Soltamox Flomax Restoril Restoril Hytrin Hytrin Hytrin Hytrin Depo Testosterone Depo Testosterone Sumycin Sumycin Theo-Dur Theo-Dur Navane Navane Navane Navane Navane Navane

100 mg 1 Gm 10% 10% 400 mg-80 mg 200 mg-40 mg/5 ml (60 ml) 800 mg-160 mg 500 mg 200 mg 150 mg 50 mg 25 mg 100 mg 10 mg 0.4 mg 30 mg 15 mg 5 mg 2 mg 1 mg 10 mg 100 mg/ml 200 mg/ml 500 mg 250 mg 300 mg 200 mg 5 mg 20 mg 2 mg 10 mg 1 mg 5 mg/ml

Cardiovascular GI Ophthalmic Ophthalmic Antimicrobials Antimicrobials Antimicrobials GI Analgesic Analgesic Neurologic Neurologic Neurologic Hormone Replacement Genitourinary Psychiatric Psychiatric Genitourinary Genitourinary Genitourinary Genitourinary Hormone Replacement Hormone Replacement Antimicrobials Antimicrobials Respiratory Respiratory Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric

Diuretics

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Sulfas Sulfas Sulfas Anti-inflammatory bowel NSAID NSAID Migraine Migraine Migraine Alpha-blockers Hypnotic Hypnotic

Tetracyclines Tetracyclines

Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Page 21 of 23

HealthPAC Formulary Current as of July 2016

Generic Name

Brand Name

Strength

Ticlopidine

Ticlid

250mg

Timolol Maleate eye drops Timolol Maleate eye drops Tobramycin ophthal soln. Tramadol Trazodone Trazodone Trazodone

Ultram, Rybix Desyrel Desyrel Desyrel

Tretinoin

Retin-A

Triamcinolone cream, ointment, or lotion Triamcinolone cream, ointment, or lotion Triamterene/Hctz Triamterene/Hctz Trifluoperazine Trifluoperazine Trifluoperazine Trihexyphenidyl Trihexyphenidyl Trihexyphenidyl Ursodiol Venlafaxine Venlafaxine XR Venlafaxine XR Venlafaxine XR Verapamil Verapamil LA Verapamil SR Verapamil SR Verapamil SR

0.5% 0.25% 0.3% 50 mg 50 mg 150 mg 100 mg 0.01%, 0.025%, 0.05%, 0.1% cream, gel

Class I Platelet aggregation inhibitor Ophthalmic Ophthalmic Ophthalmic Analgesic Psychiatric Psychiatric Psychiatric

Class II

Glaucoma Glaucoma Misc Antidepressant Antidepressant Antidepressant

Derm

Acne

Kenalog, Aristocort 0.10%

Derm

Antiinflammatory

Kenalog, Aristocort 0.025%

Derm

Antiinflammatory

Maxzide Maxzide Stelazine Stelazine Stelazine Artane Artane Artane Actigall Effexor IR Effexor XR Effexor XR Effexor XR Isoptin Isoptin Calan SR Calan SR Calan SR

Cardiovascular Cardiovascular Psychiatric Psychiatric Psychiatric Neurologic Neurologic Neurologic GI Psychiatric Psychiatric Psychiatric Psychiatric Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular

Diuretics Diuretics Antipsychotic Antipsychotic Antipsychotic Parkinson Parkinson Parkinson

37.5 mg-25 mg 75 mg-50 mg 5 mg 2 mg 10 mg 5 mg 2 mg/5 ml 2 mg 300 mg 25 mg 75 mg 37.5 mg 100 mg 120 mg 180 mg 240 mg 180 mg 120 mg

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Antidepressant Antidepressant Antidepressant Antidepressant Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Page 22 of 23

HealthPAC Formulary Current as of July 2016

Generic Name Vitamin B6 Vitamin D Vitamin K Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Zolpidem Zolpidem

Brand Name

Strength

Class I

Class II

Calciferol Phytonadione Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Ambien Ambien

50 mg 50,000 units 5 mg tab 1 mg 10 mg 2 mg 2.5 mg 3 mg 4 mg 5 mg 6 mg 7.5 mg 10 mg 5 mg

Vitamin Vitamin Vitamin Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Psychiatric Psychiatric

Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Hypnotic Hypnotic

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines.

Page 23 of 23