FORMULARY: THERAPEUTIC CATEGORY LISTING* *Most current Formulary List of Drugs can be found: 1. DUH intranet [click on DRH (Duke Regional Hospital), Departments and Services, Pharmacy, then Lincoln Community Health Center Formulary] https://intranet.dm.duke.edu/hospitals/drh/pharmacy/Document%20Library/LCHC%20Formulary.pdf 2. LCHC website (http://www.lincolnchc.org/secondary/drug-formulary.html) 3. PADC website (http://www.projectaccessdurham.org/), then click on the Lincoln Pharmacy formulary. 4. LCHC Intranet/ Pharmacy Department/ Formulary of Drugs Use Ctrl-F to quickly search the listing for a specific item. Rx Pathways Plan
Pfizer drugs are available to uninsured patients who are at or below 400% of the federal poverty level. Only a dispensing fee is charged. NOTE: These medications are labeled as “RxP”.
Patient Assistance Program
Patients who meet specific eligibility requirements may receive formualry medications through manufacturer-sponsored patient assistance programs (PAPs). Medications labeled as “PAP” are available to eligible patients through manufacturer-sponsored PAPs. These medications may not be readily available and may require up to an 8-week processing period.
HIV Patient Assistance Program
EI Clinic may access medications through for qualified patients. For patients that do not qualify for ADAP, HIV medications may be obtained from manufacturer programs. http://epi.publichealth.nc.gov/cd/hiv/docs/ADAPProgrammanual.pdf
Project Access Durham County
Project Access Durham County (PADC) serves eligible low-income, uninsured Durham residents who have specialty medical care needs. PADC enrolls members based on referrals from a primary care provider at Lincoln Community Health Center (LCHC). PADC patients are eligible for LCHC formulary medications.
Lab Monitoring
Some formulary drugs require laboratory monitoring and are labeled as “LAB”.
Safety in Lactation
Lactation safety data from American Academy of Pediatrics (www.aap.org)
Medicaid Preferred Drug List
http://www.ncdhhs.gov/dma/pharmacy/PDL.pdf
Medicaid Prior Authorizations
https://www.nctracks.nc.gov/content/public/providers.html
Hazardous Drugs
Drugs identified by National Institute of Occupational Safety and Health as hazardous are labeled as “HD”. Use caution when handling. (http://www.cdc.gov/niosh/docs/2014138/pdfs/2014-138.pdf)
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Therapeutic Category
Medication
Brand Name
Pharmacologic Category
ALZHEIMER DISEASE
Donepezil Tablet 10mg
Aricept
ALZHEIMER DISEASE
Memantine extended release tablet 14mg PAP Memantine extended release tablet 21mg PAP Memantine extended release tablet 28mg PAP Memantine extended release tablet 7mg PAP Pregabalin Capsule 150mg
Namenda XR
Lyrica
Acetylcholinesterase Inhibitor (Central) N-Methyl-D-Aspartate Receptor Antagonist N-Methyl-D-Aspartate Receptor Antagonist N-Methyl-D-Aspartate Receptor Antagonist N-Methyl-D-Aspartate Receptor Antagonist Anticonvulsant, Analgesic
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
C
?
+
B
?
-
B
?
-
B
?
-
B
?
-
C
?
-
Pregabalin Capsule 75mg
Lyrica
Anticonvulsant, Analgesic
C
?
-
Gabapentin Capsule 100mg
Neurontin
Anticonvulsant, Neuropathic pain (unlabeled)
C
?
-
ANAGESICS AND ANTIPYRETICS
Gabapentin Capsule 300mg
Neurontin
Anticonvulsant, Neuropathic pain (unlabeled)
C
?
-
ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS
Acetaminophen Suspension 160mg/5mL Acetaminophen Tablet 325mg Tramadol Tablet 50mg
Tylenol Susp
Miscellaneous
120 mL
B
+
Tylenol
Miscellaneous
#100 tabs
B
+
+
Ultram
Nonopioid Analgesic
C
-
+
Ibuprofen Suspension 100mg/5mL Ibuprofen Tablet 400mg
Motrin
NSAID
+
Motrin
NSAID
B (D in 3rd trimester) B (D in 3rd trimester)
ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS
Indomethacin Capsule 25mg Indomethacin Capsule 50mg Naproxen Sodium Tablet 500mg Celecoxib Capsule 200mg
Indocin
NSAID
+
Indocin
NSAID
+
-
Naprosyn
NSAID
+
+
Celebrex
NSAID, COX-2 Inhibitor
?
-
Acetaminophen/Codeine Tab 300mg/30mg Hydrocodone and Acetaminophen Tab 5mg/325mg
Tylenol With Codeine #3 Norco
Opioid
B (D in 3rd trimester) B (D in 3rd trimester) B (D in 3rd trimester) C (D in 3rd trimester) C
+ (taste may be unacceptable) -
?
+
Opioid
C
?
+
ALZHEIMER DISEASE ALZHEIMER DISEASE ALZHEIMER DISEASE ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS ANAGESICS AND ANTIPYRETICS
RxP
RxP
RxP
Namenda XR Namenda XR Namenda XR
Package Size (if applicable)
90 day supply PAP 90 day supply PAP 90 day supply PAP 90 day supply PAP
+
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 28
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
ANAGESICS AND ANTIPYRETICS ANTIANEMIA AGENTS
Capsaicin Cream 0.075%
Capzasin, Zostrix
Topical Analgesic
Ferrous Sulfate Drops 75mg/mL (15mg/mL elemental) Ferrous Sulfate Elixer 220mg/5mL (44mg/5mL elemental)
60 gm
?
?
Iron Preparations
50mL
+
+
Iron Preparations
480mL
+
+
ANTIANEMIA AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS
Ferrous Sulfate Tablet 325mg (65mg elemental) Pregabalin Capsule 150mg
Iron Preparations
#100 tabs
+
+
+
Lyrica
Anticonvulsant, Analgesic
C
?
-
Pregabalin Capsule 75mg
Lyrica
Anticonvulsant, Analgesic
C
?
-
Gabapentin Capsule 100mg
Neurontin
Anticonvulsant, Neuropathic pain (unlabeled)
C
?
-
ANTICONVULSANT AGENTS
Gabapentin Capsule 300mg
Neurontin
Anticonvulsant, Neuropathic pain (unlabeled)
C
?
-
ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS ANTICONVULSANT AGENTS
Phenobarbital Tablet 30mg
Barbiturate
D
-
+
ANTIANEMIA AGENTS
RxP
RxP
Crush/ Split
Phenytoin Sodium Capsule 100mg LAB, HD Phenytoin Sodium Chewable tablet 50g LAB, HD Carbamazepine Tablet 200mg LAB, HD Divalproex Sodium Tablet 250mg LAB, HD Lamotrigine Tablet 25mg
Dilantin
Hydantoin
D
+
-
Dilantin Infatabs Tegretol
Hydantoin
D
+
+
Miscellaneous
D
+
+
Depakote
Miscellaneous
X
?
-
Lamictal
Miscellaneous
C
-
+
Lamotrigine Tablet 100mg
Lamictal
Miscellaneous
C
-
+
Lamotrigine Tablet 50mg
Lamictal
Miscellaneous
C
-
Lamotrigine Tablet 200mg
Lamictal
Miscellaneous
C
-
+
Topiramate Tablet 200mg
Topamax
Miscellaneous
D
?
ANTICONVULSANT AGENTS
Topiramate Tablet 25mg
Topamax
Miscellaneous
D
?
- (taste may be unacceptable) - (taste may be unacceptable)
ANTIDEPPRESSANT AGENTS
Mirtazapine Tablet 30mg
Remeron
Alpha2 Antagonist
C
?
PAP
PAP
LAB, HD
LAB, HD
90 day supply PAP 90 day supply PAP
+
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Therapeutic Category
Medication
Brand Name
Pharmacologic Category
ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS
Bupropion Tablet 100mg
Wellbutrin
Fluoxetine Capsule 20mg
Prozac
Sertraline Tablet 50mg
Zoloft
Sertraline Tablet 100mg
Zoloft
Trazadone Tablet 50mg
Desyrel
Duloxetine Capsule 20mg
Cymbalta
ANTIDEPPRESSANT AGENTS
Duloxetine Capsule 30mg
ANTIDEPPRESSANT AGENTS
ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDEPPRESSANT AGENTS ANTIDOTE ANTIDOTE ANTIDOTE ANTIDOTE ANTIDOTE
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
Dopamine Reuptake Inhibitor
C
-
+
Selective Serotonin Reuptake Inhibitor Selective Serotonin Reuptake Inhibitor Selective Serotonin Reuptake Inhibitor Serotonin Reuptake Inhibitor/Antagonist Serotonin/Norepinephrine Reuptake Inhibitor
C (- in 3rd trimester) C (- in 3rd trimester) C (- in 3rd trimester) C
-
-
+
+
+
+
-
+
120 day supply PAP
C
?
- (may open & mix w/ applesauce, NOT choclate)
Cymbalta
Serotonin/Norepinephrine Reuptake Inhibitor
120 day supply PAP
C
?
- (may open & mix w/ applesauce, NOT choclate)
Duloxetine Capsule 60mg
Cymbalta
Serotonin/Norepinephrine Reuptake Inhibitor
120 day supply PAP
C
?
- (may open & mix w/ applesauce, NOT choclate)
Amitriptyline Tablet 25mg
Elavil
Tricyclic
D
-
+
Amitriptyline Tablet 50mg
Elavil
Tricyclic
D
-
+
Doxepin Capsule 25mg
Sinequan
Tricyclic
C
-
-
Doxepin Capsule 50mg
Sinequan
Tricyclic
C
-
-
Imipramine Tablet 10mg
Tofranil
Tricyclic
D
-
+
Imipramine Tablet 25mg
Tofranil
Tricyclic
D
-
+
Nortriptyline Tablet 25mg
Pamelor
Tricyclic
D
+
+
Epinephrine IM Injection 0.15mg/0.15mL Epinephrine IM Injection 0.3mg/0.3mL Diphenhydramine Capsule 25mg Diphenhydramine Capsule 50mg Diphenhydramine Elixer 12.5ml/5mL
EpiPen
Alpha/Beta Adrenergic Agonist
C
-
EpiPen
Alpha/Beta Adrenergic Agonist
C
-
Benadryl
Antihistamine
B
-
-
Benadryl
Antihistamine
B
-
-
Benadryl
Antihistamine
B
-
PAP
PAP
PAP
Package Size (if applicable)
2 AutoInjectors 2 AutoInjectors
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Therapeutic Category
Medication
Brand Name
Pharmacologic Category
ANTIEMETIC/ANTIVERTIGO AGENTS ANTIEMETIC/ANTIVERTIGO AGENTS ANTIEMETIC/ANTIVERTIGO AGENTS ANTIEMETIC/ANTIVERTIGO AGENTS ANTI-INFECTIVES
Ondansetron Tablet 4mg
Zofran
Meclizine Tablet 12.5mg
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
5-HT3 Receptor Antagonist
B
?
+
Antivert
Anticholinergic, Antihistamine
B
?
+
Promethazine Suppository 25mg Promethazine Tablet 25mg
Phenergan
C
-
C
-
Nystatin Cream 100,000 units/gm Nystatin Suspension 100,000 units/mL
Mycostatin
Antidopaminergic, Phenothiazine Antidopaminergic, Phenothiazine Antifungal
15 gm
C
?
Nilstat
Antifungal
60 mL bottle
C
?
ANTI-INFECTIVES
Fluconazole Tablet 200mg
Diflucan
Antifungal
C (single dose vag candida), D all other indications
+
ANTI-INFECTIVES
Griseofulvin Susp 125mg/5mL Terbinafine Cream 1% LAB Terbinafine Tablet 250mg
Grifulvin
Antifungal
C
?
Lamisil AT Lamisil
Antifungal Antifungal
B B
? -
+
Albendazole Tablet 200mg Levofloxacin Tablet 500mg Hydroxychloroquine Tablet 200mg Acyclovir Suspension 200mg/5mL Cefdinir Suspension 250mg/5mL Cephalexin Capsule 250mg Cephalexin Suspension 250mg/5ml Acyclovir Capsule 200mg Azithromycin Suspension 200mg/5mL Azithromycin Tablet 250mg Clarithromycin Tablet 500mg Clindamycin Capsule 150mg Clindamycin Oral Solution 75mg/5mL Clindamycin Topical Solution 1%
Albenza Levaquin Plaquenil
Antihelmintic Anti-Infective Antimalarial
C C C
? ? +
+ + +
Zovirax
Antiviral
B
+
Omnicef
Cephalosporin
B
?
Keflex
Cephalosporin
B
?
Keflex
Cephalosporin
B
?
Zovirax Zithromax
Diuretic Macrolide
B B
+ ?
-
Zithromax
Macrolide
B
?
+
Biaxin
Macrolide
C
?
+
Cleocin
Miscellaneous
B
?
+
Cleocin
Miscellaneous
100 mL
B
?
Cleocin-T
Miscellaneous
60 mL
B
?
ANTI-INFECTIVES
ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES
HD
LAB
Phenergan
Package Size (if applicable)
15 gm
+
-
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Therapeutic Category
Medication
Brand Name
Pharmacologic Category
ANTI-INFECTIVES
Metronidazole Tablet 500mg Amoxicillin Capsule 250mg Amoxicillin Suspension 250mg/5mL Amoxicillin/Clavulanic Acid Tablet 875mg/125mg Penicillin VK Suspension 250mg/5mL Penicillin VK Tablet 500mg Ciprofloxacin Ophth Soln 0.3%
Flagyl
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
Miscellaneous
B
?
+
Amoxil Amoxil
Penicillin Penicillin
B B
+ +
-
Augmentin
Penicillin
B
?
+
Pen-Vee K
Penicillin VK
B
?
Veetids Cipro
Penicillin VK Quinolone
? ?
+
Ciprofloxacin Tablets 500mg
Cipro
Quinolone
B C (but teratogenicity unlikely) C (but teratogenicity unlikely)
ANTI-INFECTIVES
?
+
ANTI-INFECTIVES
Sulfamethoxazole/ Trimethoprim Suspension 200mg-40mg/5mL Sulfamethoxazole/ Trimethoprim Tablet 800mg/160mg
Septra Suspension
Sulfonamide
C
+
Septra DS
Sulfonamide
C
+
Sulfasalazine Tablet 500mg Doxycycline Tablet 100mg Tetracycline HCl Capsule 250mg Nitrofurantoin Capsule 100mg Tamoxifen Tablet 10mg LAB
Sulfazine, Azulfadine Vibramycin Achromycin
Sulfonamide
D
-
+
Tetracycline Tetracycline Antibiotics; Acne
D D
? -
+ -
Macrobid
Urinary
B
+?
-
Nolvadex
Anti-estrogen
D
-
-
Anastrozole Tablet 1mg
Arimidex
Aromatase Inhibitor
X
-
Trihexphenidyl Tablet 2mg
Artane
Anticholinergic
C
-
+
Carbidopa/Levodopa Tablet 25mg/100mg
Sinemet
Dopamine Agonist
C
-
+
ANTIPSYCHOTIC AGENTS
Lurasidone Tablet 20mg
Latuda
Atypical, mixed serotonindopamine antagonist
90 day supply PAP
B
?
+
ANTIPSYCHOTIC AGENTS
Lurasidone Tablet 40mg
Latuda
Atypical, mixed serotonindopamine antagonist
90 day supply PAP
B
?
+
ANTIPSYCHOTIC AGENTS
Lurasidone Tablet 60mg
Latuda
Atypical, mixed serotonindopamine antagonist
90 day supply PAP
B
?
+
ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES
ANTI-INFECTIVES
ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTI-INFECTIVES ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS
HD
PAP,LAB, HD
PAP
PAP
PAP
Package Size (if applicable)
5 mL bottle
90 day supply PAP
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Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
ANTIPSYCHOTIC AGENTS
Lurasidone Tablet 80mg
Latuda
Atypical, mixed serotonindopamine antagonist
90 day supply PAP
B
?
+
ANTIPSYCHOTIC AGENTS
Lurasidone Tablet 120mg
Latuda
Atypical, mixed serotonindopamine antagonist
90 day supply PAP
B
?
+
ANTIPSYCHOTIC AGENTS
Quetiapine tablet 25mg
LAB
Seroquel
Atypical, Serotonin/Dopamine Receptor Antagonist
C
-
+
ANTIPSYCHOTIC AGENTS
Quetiapine tablet 50mg
LAB
Seroquel
Atypical, Serotonin/Dopamine Receptor Antagonist
C
-
+
ANTIPSYCHOTIC AGENTS
Quetiapine tablet 100mg
Seroquel
Atypical, Serotonin/Dopamine Receptor Antagonist
C
-
+
ANTIPSYCHOTIC AGENTS
Quetiapine tablet 200mg
Seroquel
Atypical, Serotonin/Dopamine Receptor Antagonist
C
-
+
ANTIPSYCHOTIC AGENTS
Quetiapine tablet 300mg
Seroquel
Atypical, Serotonin/Dopamine Receptor Antagonist
C
-
+
ANTIPSYCHOTIC AGENTS
Quetiapine extended release tablet 50mg PAP, LAB
Seroquel XR
Atypical, Serotonin/Dopamine Receptor Antagonist
90 day supply PAP
C
-
-
ANTIPSYCHOTIC AGENTS
Quetiapine extended release tablet 150mg
Seroquel XR
Atypical, Serotonin/Dopamine Receptor Antagonist
90 day supply PAP
C
-
-
ANTIPSYCHOTIC AGENTS
Quetiapine extended release tablet 200mg
Seroquel XR
Atypical, Serotonin/Dopamine Receptor Antagonist
90 day supply PAP
C
-
-
ANTIPSYCHOTIC AGENTS
Quetiapine extended release tablet 300mg
Seroquel XR
Atypical, Serotonin/Dopamine Receptor Antagonist
90 day supply PAP
C
-
-
ANTIPSYCHOTIC AGENTS
Quetiapine extended release tablet 400mg
Seroquel XR
Atypical, Serotonin/Dopamine Receptor Antagonist
90 day supply PAP
C
-
-
ANTIPSYCHOTIC AGENTS
Risperidone 0.5mg HD
Risperdal
Atypical, Serotonin/Dopamine Receptor Antagonist
C
-
+
ANTIPSYCHOTIC AGENTS
Risperidone 1mg HD
Risperdal
Atypical, Serotonin/Dopamine Receptor Antagonist
C
-
+
ANTIPSYCHOTIC AGENTS
Risperidone 2mg HD
Risperdal
Atypical, Serotonin/Dopamine Receptor Antagonist
C
-
+
ANTIPSYCHOTIC AGENTS
Lithium Carbonate Capsule 300mg LAB
Eskalith
Bipolar Disorder
D
-
-
PAP
PAP
LAB
LAB
LAB
PAP,
LAB
PAP,
LAB
PAP,
LAB
PAP,
LAB
90 day supply
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Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
available ANTIPSYCHOTIC AGENTS ANTIPSYCHOTIC AGENTS ANTIPSYCHOTIC AGENTS ANXIOLYTICS, SEDATIVES, HYPNOTICS ANXIOLYTICS, SEDATIVES, HYPNOTICS
Haloperidol Tablet 1mg
Haldol
Typical, D2 Antagonist
C
-
+
Haloperidol Tablet 2mg
Haldol
Typical, D2 Antagonist
C
-
+
Trifluoperazine Tablet 2mg
Stelazine
Typical, D2 Antagonist
C
-
+
Buspirone Tablet 15mg
Buspar
Antianxiety Agent
B
-
+
Diphenhydramine 50mg
Benadryl
Antihistamine
B
-
-
ANXIOLYTICS, SEDATIVES, HYPNOTICS ANXIOLYTICS, SEDATIVES, HYPNOTICS
Diphenhydramine Capsule 25mg
Benadryl
Antihistamine
B
-
-
Diphenhydramine Elixer 12.5ml/5mL
Benadryl
Antihistamine
B
-
ANXIOLYTICS, SEDATIVES, HYPNOTICS ANXIOLYTICS, SEDATIVES, HYPNOTICS
Hydroxyzine HCL Syrup 10mg/5mL
Atarax
Antihistamine
C
-
Hydroxyzine HCL Tablet 25mg
Atarax
Antihistamine
C
-
+
ANXIOLYTICS, SEDATIVES, HYPNOTICS ANXIOLYTICS, SEDATIVES, HYPNOTICS
Hydroxyzine HCL Tablet 50mg
Atarax
Antihistamine
C
-
+
Diazepam Tablets 5mg
Valium
Benzodiazepine
D
-
+
ANXIOLYTICS, SEDATIVES, HYPNOTICS ANXIOLYTICS, SEDATIVES, HYPNOTICS
Oxazepam Capsule 15mg
Serax
Benzodiazepine
D
-
-
CARDIOVASCULAR DRUGS
Lisinopril Tablet 5mg
CARDIOVASCULAR DRUGS
Lisinopril Tablet 10mg
CARDIOVASCULAR DRUGS
Lisinopril Tablet 20mg
Melatonin Tablet 3mg
Neurohormone, indole
#120
-
-
Zestril
ACE-Inhibitor
D
?
+
LAB
Zestril
ACE-Inhibitor
D
?
+
LAB
Zestril
ACE-Inhibitor
90 day supply available 90 day supply available 90 day supply available
D
?
+
LAB
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Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
CARDIOVASCULAR DRUGS
Lisinopril Tablet 40mg
Zestril
ACE-Inhibitor
90 day supply available 90 day supply available 90 day supply available
D
?
+
CARDIOVASCULAR DRUGS
Lisinopril/HCTZ Tablet 20/12.5mg LAB
Zestoretic
ACE-Inhibitor/ Diuretic, Thiazide
D
?
+
CARDIOVASCULAR DRUGS
Lisinopril/HCTZ Tablet 20/25mg LAB
Zestoretic
ACE-Inhibitor/ Diuretic, Thiazide
D
?
+
CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS
Methyldopa Tablet 250mg
Aldomet
Doxazosin Tablet 2mg
Cardura
Alpha Adrenergic Inhibitor, Alpha2 Adrenergic Agonist Alpha1 Blocker
B
+
+
90 day supply available 90 day supply available
C
?
+
CARDIOVASCULAR DRUGS
Doxazosin Tablet 8mg
Cardura
Alpha1 Blocker
C
?
+
CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS
Prazosin Capsule 1mg
Minipress
Alpha1 Blocker
C
?
-
Prazosin Capsule 2mg
Minipress
Alpha1 Blocker
C
?
-
Prazosin Capsule 5mg
Minipress
Alpha1 Blocker
C
?
-
Clonidine Tablet 0.1mg
Catapres
Alpha2 Adrenergic Agonist
C
?
+
CARDIOVASCULAR DRUGS
Clonidine Tablet 0.2mg
Catapres
Alpha2 Adrenergic Agonist
C
?
+
CARDIOVASCULAR DRUGS
Clonidine Tablet 0.3mg
Catapres
Alpha2 Adrenergic Agonist
C
?
+
CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS
Losartan Tablet 100mg
Cozaar
Angiotensin Receptor Blocker
D
?
+
Losartan Tablet 25mg
Cozaar
Angiotensin Receptor Blocker
D
?
+
Losartan Tablet 50mg
Cozaar
Angiotensin Receptor Blocker
D
?
+
Amiodarone Tablet 200mg
Cordarone
Antiarrhythmic
D
-
+
Digoxin Tablets 0.125mg
Lanoxin
Antiarrhythmic
C
+
+
Digoxin Tablets 0.25mg
Lanoxin
Antiarrhythmic
C
+
+
Enoxaparin SQ Injection 30mg PAP, LAB Enoxaparin SQ Injection 40mg PAP, LAB
Lovenox
Anticoagulant
B
+
Lovenox
Anticoagulant
B
+
LAB
LAB
LAB
LAB
90 day supply available 90 day supply available 90 day supply available
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 35
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS
Enoxaparin SQ Injection 60mg PAP, LAB Enoxaparin SQ Injection 80mg PAP, LAB Enoxaparin SQ Injection 100mg PAP, LAB Enoxaparin SQ Injection 120mg PAP, LAB Enoxaparin SQ Injection 150mg PAP, LAB Warfarin Tablet 5mg LAB
Lovenox
Preg Cat
Safety in Lactation (www.aap.org)
Anticoagulant
B
+
Lovenox
Anticoagulant
B
+
Lovenox
Anticoagulant
B
+
Lovenox
Anticoagulant
B
+
Lovenox
Anticoagulant
B
+
Coumadin
Anticoagulant
Use caution
+
PAP
Zetia
?
+
Gemfibrozil Tablet 600mg
Lopid
Antihyperlipidemic, 2Azetidinone Antihyperlipidemic, Fibric Acid
- (1st trimester), C C C
?
+
Atorvastatin Tablet 10mg
Lipitor
X
-
+
Atorvastatin Tablet 20mg
Lipitor
X
-
+
Atorvastatin Tablet 40mg
Lipitor
X
-
+
Atorvastatin Tablet 80mg
Lipitor
X
-
+
Clopidogrel Tablet 75mg
Plavix
Antihyperlipidemic, HMG-CoA Reductase Inhibitor Antihyperlipidemic, HMG-CoA Reductase Inhibitor Antihyperlipidemic, HMG-CoA Reductase Inhibitor Antihyperlipidemic, HMG-CoA Reductase Inhibitor Antiplatelet
B
?
+
Atenolol Tablet 100mg
Tenormin
Beta Blocker
D
-
-
CARDIOVASCULAR DRUGS
Atenolol Tablet 50mg
Tenormin
Beta Blocker
D
-
-
CARDIOVASCULAR DRUGS
Carvedilol Tablet 3.125mg
Coreg
Beta Blocker w/ alpha blocking ability
C
?
+
CARDIOVASCULAR DRUGS
Carvedilol Tablet 12.5mg
Coreg
Beta Blocker w/ alpha blocking ability
C
?
+
CARDIOVASCULAR DRUGS
Carvedilol Tablet 25mg
Coreg
Beta Blocker w/ alpha blocking ability
C
?
+
CARDIOVASCULAR DRUGS
Metoprolol Tartrate Tablet 25mg
Lopressor
Beta Blocker
C
?
+
CARDIOVASCULAR DRUGS
Metoprolol Tartrate Tablet 50mg
Lopressor
Beta Blocker
C
?
+
Ezetimibe tablet 10mg
Package Size (if applicable)
90 day supply PAP
90 day supply available 90 day supply available 90 day supply available 90 day supply available 90 day supply available 90 day supply available 90 day supply available
Crush/ Split
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 36
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
CARDIOVASCULAR DRUGS
Propranolol Tablet 10mg
Inderal
Beta Blocker
CARDIOVASCULAR DRUGS
Propranolol Tablet 40mg
Inderal
Beta Blocker
CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS
Amlodipine Tablets 10mg
Norvasc
Calcium Channel Blocker
90 day supply available 90 day supply available
C
+
+
C
+
+
C
?
+
Amlodipine Tablets 5mg
Norvasc
Calcium Channel Blocker
C
?
+
Diltiazem HCl XR 180mg Capsule Diltiazem HCl XR 240mg Capsule Nifedipine XL Tablet 30mg
Cardizem CD
Calcium Channel Blocker
C
+
-
Cardizem CD
Calcium Channel Blocker
C
+
-
Procardia XL
Calcium Channel Blocker
C
-
-
Nifedipine XL Tablet 60mg
Procardia XL
Calcium Channel Blocker
C
-
-
Nifedipine XL Tablet 90mg
Procardia XL
Calcium Channel Blocker
C
-
-
Verapamil SR Tablet 180mg Verapamil SR Tablet 240mg Acetazolamide Tablet 500mg ER 12 hr Furosemide Tablet 40mg
Calan SR
Calcium Channel Blocker
C
-
+ split/- crush
Calan SR
Calcium Channel Blocker
C
-
+ split/- crush
Diamox Sequels Lasix
Carbonic Anhydrase Inhibitor
C
-
+
C
?
+
CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS
Spironolactone Tablet 25mg HD Spironolactone/HCTZ Tablet 25mg/25mg HD Hydrochlorothiazide Tablet 25mg
Aldactone
Diuretic, Potassium Sparing
D
+
+
Aldactazide
D
+
+
Hydrodiuril
Diuretic, Potassium Sparing / Thiazide Diuretic, Thiazide
+
+
CARDIOVASCULAR DRUGS
Hydrochlorothiazide Tablet 50mg
Hydrodiuril
Diuretic, Thiazide
B (D is used in pregnancyinduced HTN) B (D is used in pregnancyinduced HTN)
+
+
CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS
Aspirin Tablet 325 mg (enteric coated) Aspirin Tablet 81mg (enteric coated) Hydralazine Tablet 25mg
Ecotin
Salicylate
D
?
-
Ecotin
Salicylate
#100 tablets #120 tabs
D
?
-
Apresoline
Vasodilator
C
+
+
CARDIOVASCULAR DRUGS
Hydralazine Tablet 50mg
Apresoline
Vasodilator
90 day supply available 90 day supply
C
+
+
Diuretic, Loop
90 day supply available
90 day supply available 90 day supply available
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 37
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
available CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS CARDIOVASCULAR DRUGS DEVICE DEVICE DEVICE DEVICE
Isosorbide Dinitrate Tablet 10mg Isosorbide Dinitrate Tablet 20mg Isosorbide Dinitrate Tablet 40mg Nitroglycerin SL Tablet 0.4mg Nitroglycerin Transdermal Patch 0.2mg/hr Nitroglycerin Transdermal Patch 0.4mg/hr Nitroglycerin Transdermal Patch 0.6mg/hr Nasal Aspirator Nasal Irrigation Kit Peak Flow Meter Pill Box
Isordil
Vasodilator
C
?
+
Isordil
Vasodilator
C
?
+
Isordil
Vasodilator
C
?
+
Nitrostat
Vasodilator
#100 tabs
C
?
Transderm Nitro Transderm Nitro Transderm Nitro
Vasodilator
#30 patches
C
?
-
Vasodilator
#30 patches
C
?
-
Vasodilator
#30 patches
C
?
-
+ + + +
+ + + +
DEVICE DEVICE
Spacer Spacer, with mask
Aerochamber Aerochamber,
+ +
+ +
DEVICE
Syringes 31ga 5/16" 0.5mL Syringes 31ga 5/16" 1mL Tablet Cutter Electrolyte Solution
Monoject
+
+
+ ?
+ ?
DEVICE DEVICE ELECTROLYTE SUPPLEMENT ELECTROLYTE SUPPLEMENT ELECTROLYTE SUPPLEMENT ENDOCRINE AND METABOLIC AGENTS
Neti Pot
Monoject Pedialyte/ Infalyte
Treatment of Dehydration
1,000 mL
Potassium Chloride Liquid 20 mEq/15mL Potassium Chloride Tablet 8mEq Finasteride Tablet 5mg HD
Klor-Con
Treatment of Hypokalemia
C
?
-
Proscar
Androgen Hormone Inhibitor, 5 Alpha-Reductase Inhibitor
X
-
- (hazardous agent)
ENDOCRINE AND METABOLIC AGENTS
Metformin Tablet 1000mg
Glucophage
Antidiabetic, Biguanide
B
?
+
ENDOCRINE AND METABOLIC AGENTS
Sitagliptin Tablet 100mg
Januvia
Anti-diabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhib
90 day supply available 90 day supply PAP
B
?
-
ENDOCRINE AND METABOLIC AGENTS
Sitagliptin Tablet 25mg
Januvia
Anti-diabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhib
90 day supply PAP
B
?
-
LAB
PAP
PAP
Treatment of Hypokalemia
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 38
Therapeutic Category
Medication
ENDOCRINE AND METABOLIC AGENTS
Sitagliptin Tablet 50mg
ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
Januvia
Anti-diabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhib
90 day supply PAP
B
?
-
Insulin Aspart 100units/mL Insulin Lispro 100units/mL Insulin Regular 100units/mL Insulin Glulisine 100units/mL PAP Insulin Aspart Protamine and Insulin Aspart 100units/mL Insulin Lispro Protamine and Insulin Lispro 100units/mL Insulin NPH and Insulin Regular 100units/mL Insulin NPH 100units/mL
Novolog
NovoLog Mix 70/30
Antidiabetic, Insulin Rapid-Acting Antidiabetic, Insulin Rapid-Acting Antidiabetic, Insulin Short-Acting Antidiabetic, Insulin Rapid-Acting Antidiabetic, Insulin Combination
B/C
+
B/C
+
B/C
+
B/C
+
B/C
+
Humalog Mix 75/25
Antidiabetic, Insulin Combination
B/C
+
Novolin 70/30
Antidiabetic, Insulin
B/C
+
Novolin NPH
Antidiabetic, Insulin
B/C
+
Insulin Detemir 100units/mL Insulin Glargine 100units/mL Insulin Regular 100units/mL Glipizide ER Tablet 10mg
Levemir
Antidiabetic, Insulin
B/C
+
Lantus
Antidiabetic, Insulin
B/C
+
Novolin Regular
Antidiabetic, Insulin
B/C
+
Glucotrol XL
Antidiabetic, Sulfonylurea
C
?
-
Glipizide ER Tablet 5mg
Glucotrol XL
Antidiabetic, Sulfonylurea
C
?
-
Pioglitazone Tablet 15mg
Actos
Antidiabetic, Thiazolidinedione
C
?
+
Pioglitazone Tablet 30mg
Actos
Antidiabetic, Thiazolidinedione
C
?
+
Alendronate Tablet 4mg
Fosamax
Biphosphonates, Osteoporosis
#4 tabs
C
-
+
Norethindrone/ E. Estradiol (triphasic) Tablet 0.5-0.75-1mg/0.035mg HD
Ortho-Novum 7/7/7
Contraceptive Hormone, Combination
#28 tabs
X/D
-
+
Norgestrol / E. Estradiol Tablet 0.3mg/0.03mg HD Medroxyprogesterone Acetate Tablet 10mg HD Norethindrone Tablet 0.35mg HD
Lo-Ovral
Contraceptive Hormone, Combination Contraceptive Hormone, Progestin Contraceptive Hormone, Progestin
#28 tabs
X
-
+
X
+
+
X
- (may start 6 wks after pregnancy)
+
PAP
LAB
LAB
Humalog Novolin R Apidra
Provera Nor-Q-D
90 day supply PAP
90 day supply PAP
#28 tabs
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 39
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
ENDOCRINE AND METABOLIC AGENTS
Norgestrol / E. Estradiol for postcoital contraception
LCHC version of Plan B
Contraceptive, POSTCOITAL (4 tab w/in 72 hrs unprotected sex, followed by 4 tabs 12 hrs later)
#8 tabs
X
-
+
ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS
Clobetasol Ointment 0.05% Estrogens, conjugated Tablet 0.625mg HD Estrogens, conjugated Tablet 1.25mg HD Prednisolone Syrup 15mg/mL Prednisone Tablet 20mg
Temovate
Corticosteroid
30gm
C
?
Premarin
Estrogen
X
-
+
Premarin
Estrogen
X
-
+
Prelone
Glucocorticoids
C
+
Deltasone
Glucocorticoids
C
+
+
Prednisone Tablet 5mg
Deltasone
Glucocorticoids
C
+
+
ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS
Leuprolide IM Injection 11.25mg PAP,LAB, HD Leuprolide IM Injection 22mg PAP,LAB, HD Leuprolide IM Injection 30mg PAP,LAB, HD Colchicine Tablet 0.6mg HD
Lupron
Gonadotropin Releasing Hormone Agonist Gonadotropin Releasing Hormone Agonist Gonadotropin Releasing Hormone Agonist Gout
X
-
X
-
X
-
C
?
+
Allopurinol Tablet 100mg
Zyloprim
Gout, Xanthine Oxidase Inhibitors
C
+
+
ENDOCRINE AND METABOLIC AGENTS
Allopurinol Tablet 300mg
Zyloprim
Gout, Xanthine Oxidase Inhibitors
C
+
+
ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS ENDOCRINE AND METABOLIC AGENTS
Megestrol Acetate Susp 40mg/mL HD Levothyroxine 0.1 mg Tablet LAB Levothyroxine 0.112 mg Tablet LAB Levothyroxine 0.125 mg Tablet LAB Levothyroxine 0.15 mg Tablet LAB Levothyroxine 0.175 mg Tablet LAB Levothyroxine 0.2 mg Tablet LAB
Megace
Progestin
D
?
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Lupron Lupron Colcrys
90 day supply available 90 day supply PAP 90 day supply PAP 90 day supply PAP
90 day supply available 90 day supply available
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 40
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
ENDOCRINE AND METABOLIC AGENTS EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT
Methimazole Tablet 10mg
Tapazole
Thyroid
Gentamicin Sulfate Ophth Soln 3mg/mL Lidocaine (Viscous) Oral Solution 2% Brimonidine Tartrate Ophthalmic 0.2% Timolol Maleate Ophth Soln 0.5% Dorzolamide 2%
Garamycin
Aminoglycoside
Xylocaine
Pilocarpine Ophth Soln 4%
Pilocar
Latanoprost Ophth Sol 0.005% Chlorhexidine Oral Rinse 0.12% Erythromycin 5mg/gm
Xalatan
EYE, EAR, NOSE, AND THROAT EYE, AND EYE, AND EYE, AND EYE, AND EYE, AND EYE, AND EYE, AND
EAR, NOSE, THROAT EAR, NOSE, THROAT EAR, NOSE, THROAT EAR, NOSE, THROAT EAR, NOSE, THROAT EAR, NOSE, THROAT EAR, NOSE, THROAT
EYE, EAR, NOSE, AND THROAT
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
D
+
+
5 mL
C
?
Analgesic
100 mL
B
+
Alphagan
Antiglaucoma, Alpha2 Agonist
5 mL
B
?
Timoptic
5 mL
C
+
10 mL
C
-
15 mL
C
?
2.5 mL
C
?
Peridex
Antiglaucoma, Beta-Adrenergic Blocker Antiglaucoma, Carbonic Anhydrase Inhibitor Antiglaucoma, Cholinergic Agent Antiglaucoma, Prostaglandin Inhibitor Anti-infective
480 mL
B
?
Ilotycin
Anti-infective
3.5 gm
B
+
Polymyxin/Trimethoprim Ophth Soln 10,000 units1mg/mL Neomycin/Polymyxin B/Hydrocortisone Otic Susp Carbamide Peroxide Otic Drops 6.5% Fluticasone Propionate Nasal Spray 50mcg/spray Ketorolac 0.5% Ophth Soln Prednisolone Acetate Ophth Soln 1% Hydrocortisone, Nystatin, Diphenhydramine Susp Saline Nose Spray
Polytrim
Anti-infective
10 mL
C
?
Cortisporin Otic
Anti-infective, Corticosteroid
Otic 10mL
?
?
Debrox
Cerumenolytic
15 mL
?
?
Flonase
Corticosteroid
16 gm
C
?
Acular
Corticosteroid
5 mL
C
?
Pred Forte
Corticosteroid
15 mL
C
?
Duke's Mouthwash Saline Spray
Corticosteroid, Antifungal, Antihistamine Irrigation
120 mL per bottle 45 mL
?
-
+
+
Artificial Tear Drops
Artificial Tears
Lubricant
+
+
Artificial Tear Ointment
Duratears
Lubricant
15 Ml 90 day supply available 3.5 gm 90 day supply available
+
+
Trusopt
Package Size (if applicable)
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 41
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT EYE, EAR, NOSE, AND THROAT GASTROINTESTINAL DRUGS
Atropine Ophth Soln 1%
Atropine
Mydriatic
Ketotifen Ophth Soln 0.025% Naphazoline Ophth Soln 0.1% Naphazoline/Pheniramine Ophth Soln 0.025%/0.3% Magnesium/Aluminum/ Simethicone Suspension
Zaditor
GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS
15 mL
C
+
5 mL
C
?
Vasocon
Antihistamine, Mast Cell Stabilizer Vasoconstrictor
15 mL
C
?
Vasocon-A
Vasoconstrictor/Antihistamine
15 mL
C
?
Maalox Max Strength
Antacid
480 mL
C
?
Dicyclomine Capsules 10mg Diphenoxylate/Atropine Sulf Tablets 2.5/0.025mg Bismuth Subsalicylate Tablet 262mg Loperamide Tablet 2mg
Bentyl
Anticholinergic
B
-
-
Lomotil; Lonox
Antidiarrheal
C
-
-
Pepto-Bismol
Antidiarrheal
#30 tabs
D
?
+
Imodium
Antidiarrheal
#12 tabs
C
+
+
Simethicone Drops 40mg/0.6mL Lactulose Syrup 10gm/15mL Lubiprostone Capsule 24mcg PAP Ranitidine Syrup 15mg/mL
Mylicon
Antiflatulent
30 mL
C but +
?
Duphalac Syrup
Constipation, Chronic
B
?
Amitiza
Constipation, IBS
C
?
Zantac
Histamine H2 Antagonist
B
?
Ranitidine Tablet 150mg
Zantac
Histamine H2 Antagonist
B
?
+
GASTROINTESTINAL DRUGS
Ranitidine Tablet 300mg
Zantac
Histamine H2 Antagonist
B
?
+
GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS
Bisacodyl Tablet 5mg
Dulcolax
Laxative, Diphenylmethane
C
?
-
Glycerin 1 gm suppository
Pedia-Lax Rectal Sani-Supp Adult Rectal MiraLax
Laxative, Osmotic
A
+
+
Laxative, Osmotic
A
+
+
Laxative, Osmotic
255 gm
C
?
GoLytely
Laxative, Osmotic (for Bowel Prep) Laxative, Bulk
4,000 mL
C
?
284 gm
+
?
Glycerin 2 gm suppository Polyethylene Glycol Polyethylene Glycol with Electrolytes Psyllium Hydrophilic Powder
Metamucil
90 day supply PAP
90 day supply available 90 day supply available
Crush/ Split
-
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 42
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
GASTROINTESTINAL DRUGS
Pancreatic Enzymes Capsule Lipase/Protease/Amylase 12k/38k/60k PAP
Creon
Pancreatic Enzymes
GASTROINTESTINAL DRUGS
Pancreatic Enzymes Capsule Lipase/Protease/Amylase 24k/76k/120k PAP
Creon
GASTROINTESTINAL DRUGS
Pancreatic Enzymes Capsule Lipase/Protease/Amylase 6k/19k/30k PAP
GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GASTROINTESTINAL DRUGS GENITOURINARY AGENTS GENITOURINARY AGENTS GENITOURINARY AGENTS GENITOURINARY AGENTS MIGRAINE AGENTS
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
90 day supply PAP
C
?
- (can be opened and given with applesauce or pudding)
Pancreatic Enzymes
90 day supply PAP
C
?
- (can be opened and given with applesauce or pudding)
Creon
Pancreatic Enzymes
90 day supply PAP
C
?
- (can be opened and given with applesauce or pudding)
Metoclopramide Tablet 10mg Omeprazole Capsule 20mg
Reglan
Prokinetic
B
?
+
Prilosec
Proton Pump Inhibitor
C
?
-
Docusate Sodium Capsule 100mg
Colace
Stool Softener
C
?
- (taste may be unacceptable)
Tamsulosin 0.4mg Capsule
Flomax
Alpha1 Blocker
B
+
-
Phenazopyridine Tablet 100mg, 97.5mg or 95mg Tolterodine Tartrate extended release tablet 4mg RxP Oxybutynin Chloride Tablet 5mg Butalbital, Acetaminophen and Caffeine Tablet 50mg/325mg/40mg
Pyridium
Analgesic, Urinary
B
?
+
Detrol LA
Anticholinergic, Urinary
C
-
-
Ditropan
Antispasmodic, Urinary
B
?
+
Note: Fioricet changed strength April 2014 and no longer has a generic
Migraine Combinations
C
-
+
Relpax
6 tabs per box
C
?
+
PhosLo
Serotonin 5-HT1 Receptor Agonist Calcium, Phosphate Binder
C
?
-
Kayexalate
Treatment of Hyperkalemia
60 mL per bottle
C
?
Rocaltrol
Vitamin D Analog
C
?
RxP
MIGRAINE AGENTS
Eletriptan Tablet 40mg
NEPHROLOGY
Calcium Acetate Capsule 667mg Sodium Polystyrene Sulfonate Susp 15gm/60mL Calcitriol Capsule 0.5mcg
NEPHROLOGY NEPHROLOGY
#100 caps
-
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 43
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
NEPHROLOGY
Paricalcitol Capsule 1mcg
Zemplar
Vitamin D Analog
C
?
-
NEPHROLOGY
Paricalcitol Capsule 2mcg
Zemplar
Vitamin D Analog
C
?
-
NEPHROLOGY
Paricalcitol Capsule 4mcg
Zemplar
Vitamin D Analog
C
?
-
NUTRIENTS AND NUTRITIONAL AGENTS NUTRIENTS AND NUTRITIONAL AGENTS
Calcium (elemental) Tablet 500mg
Calcium
Calcium Supplement
90 day supply PAP 90 day supply PAP 90 day supply PAP #60 tabs per bottle
+ (? 1st trimester)
?
+
Magnesium Oxide Tablet 400mg (240mg elemental)
MagOx
Hypomagnesemia
#120
A
+
+
NUTRIENTS AND NUTRITIONAL AGENTS NUTRIENTS AND NUTRITIONAL AGENTS
Thiamine Tablet 100mg
Various
Nutritional Supplement
#100 tabs
A
+
+
Cyanocobalamin Tablets 500mcg
Vitamin B12
Vitamin
#130 tabs
C
+
+
NUTRIENTS AND NUTRITIONAL AGENTS NUTRIENTS AND NUTRITIONAL AGENTS
Folic Acid Tablet 1mg
Vitamin
A
+
+
Multivitamin Drops with Iron
Poly-vi-sol
Vitamin
90 day supply available 50 mL
+
+
NUTRIENTS AND NUTRITIONAL AGENTS NUTRIENTS AND NUTRITIONAL AGENTS
Multivitamin Tablet, Adult
Centrum
Vitamin
#100 tabs
+
+
+
Multivitamin tablet, Children
Flinstones
Vitamin
#100 tabs
+
+
+
NUTRIENTS AND NUTRITIONAL AGENTS NUTRIENTS AND NUTRITIONAL AGENTS
Omega-3 Fatty Acids (180 EPA / 120 DHA)
Fish Oil
Vitamin
#100 caps
C
?
-
Prenatal Vitamins
Natalins RX
Vitamin
#100 tablets
+
+
+
NUTRIENTS AND NUTRITIONAL AGENTS NUTRIENTS AND NUTRITIONAL AGENTS
Vitamin D3 Tablet 400 IU
Vitamin
#100 tabs
C
Avoid high doses
Vitamin D3 Tablet 1,000 IU
Vitamin
#100 tabs
C
Avoid high doses
NUTRIENTS AND NUTRITIONAL AGENTS RESPIRATORY AGENTS
Vitamin D3 Tablet 50,000 IU
Vitamin
#100 caps
C
Avoid high doses
Antihistamine
120 mL
B
-
PAP
PAP
PAP
Cetirizine Solution 1mg/mL
Zyrtec
-
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 44
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
RESPIRATORY AGENTS
Cetirizine Tablet 10mg
Zyrtec
Antihistamine
B
-
+
RESPIRATORY AGENTS
Loratadine Tablet 10mg
Claritin
Antihistamine
B
+
+
RESPIRATORY AGENTS
Triprolidine/ Pseudoephedrine Tablet 2.5mg/60mg Benzonatate Capsule 100mg Fluticasone Propionate/Salmeterol Diskus 100/50 PAP
Actifed
Antihistamine and Decongestant (Alpha/Beta Adrenergic Agonist) Antitussive
#30 tablets 90 day supply available #30 tabs 90 day supply available #24 tabs
- (1st trimester), C
?
+
#20 caps
C
?
-
Advair Diskus
Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant
90 day supply PAP
C
?
Fluticasone Propionate/Salmeterol Diskus 250/50 PAP Fluticasone Propionate/Salmeterol Diskus 500/50 PAP
Advair Diskus
Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant
90 day supply PAP
C
?
Advair Diskus
Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant
90 day supply PAP
C
?
RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS
Ipratropium Bromide MDI 17mcg/actuation PAP Ipratropium Bromide Nebulizer Soln 0.02% Tiotropium Bromide Cap for inhalation 18mcg PAP Albuterol MDI
Atrovent
Bronchodilator, Anticholinergic
B
?
Atrovent
Bronchodilator, Anticholinergic
B
?
Spiriva
Bronchodilator, Anticholinergic
C
-
Proventil, Ventolin, ProAir
Bronchodilator, Beta2Adrenergic Agonist
MDI: 90 day supply PAP 25 vials per box 90 day supply PAP 6.7 gm
C
?
RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS
Albuterol Nebulizer Solution 0.083% Albuterol Syrup 2mg/5mL
Proventil, Ventolin Proventil, Ventolin Slo-bid
#25
C
?
C
?
C
+
-
C
+
-
C
+
-
QVAR
Bronchodilator, Beta2Adrenergic Agonist Bronchodilator, Beta2Adrenergic Agonist Bronchodilator, Xanthine Derivative Bronchodilator, Xanthine Derivative Bronchodilator, Xanthine Derivative Corticosteroids, Inhalant
8.7 gm
C
?
Flovent
Corticosteroids, Inhalant
C
?
Flovent
Corticosteroids, Inhalant
90 day supply PAP 90 day supply PAP
C
?
RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS
Theophylline Capsule 100mg LAB Theophylline Capsule 200mg LAB Theophylline Capsule 300mg LAB Beclomethasone MDI Fluticasone Propionate MDI 110mcg/puff PAP Fluticasone Propionate MDI 220mcg/puff PAP
Tessalon Perles
Slo-bid Slo-bid
-
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 45
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RESPIRATORY AGENTS RHEUMATOLOGY
Fluticasone Propionate MDI 44mcg/puff PAP Pseudoephedrine Syrup 30mg/5mL Pseudoephedrine Tablet 30mg Pseudoephedrine Tablet 60mg Oxymetazoline Nasal Spray 0.05% Guaifenesin Tablet 200mg
Flovent
Corticosteroids, Inhalant
90 day supply PAP
Sudafed
Afrin
Decongestant (Alpha/Beta Adrenergic Agonist) Decongestant (Alpha/Beta Adrenergic Agonist) Decongestant (Alpha/Beta Adrenergic Agonist) Decongestant (topical)
Humibid
Expectorant
Montelukast Tablet 10mg
Singulair
Methotrexate Tablet 2.5mg LAB, HD
RHEUMATOLOGY SKELETAL MUSCLE RELAXANT SKELETAL MUSCLE RELAXANT SKELETAL MUSCLE RELAXANT SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS
Preg Cat
Safety in Lactation (www.aap.org)
C
?
C
+
C
+
+
C
+
+
15 mL
C
?
#100 tabs
C
+
+
Leukotriene Inhibitor
B
?
+
Rheumatrex
Disease Modifying Antirheumatic Drug (DMARD)
X
-
+
Adalimumab Injection 40mg PAP,LAB Cyclobenzaprine Tablets 5mg Methocarbamol Tablet 500mg Baclofen Tablet 10mg
Humira
B
-
-
Flexeril
Tumor Necrosis Factor Blocking Agent Centrally Acting
B
?
+
Robaxin
Centrally Acting
C
?
+
Lioresal
Skeletal Muscle Relaxant
C
+
+
Benzoyl Peroxide Gel 5%
Panoxyl
Acne
42.5 gm
C
?
Tretinoin Cream 0.05% HD
Retin-A
Acne
45 gm
D
-
Antibiotic, Topical
15 gm
B
?
Bactroban
Antibiotic, Topical
22 gm
B
?
Ketoconazole 2% Shampoo Miconazole Cream 2%
Nizoral
Antifungal
120 mL
C
?
Micatin
Antifungal
30 gm
+
?
Nystatin Cream 100,000 units/gm Terconazole Vaginal Cream 0.8% Silver Sulfadiazine
Mycostatin
Antifungal
15 gm
C
?
Terazol-3
Antifungal
20 gm
C
-
Silvadene
Anti-infective
20 gm
B
-
Piperonyl Butoxide and Pyrethrum Extract Kit Permethrin Cream 5%
Rid Shampoo
Antiparasitic Agent, Pediculocide Antiparasitic Agent, Scabicidal
120 mL
C
?
60 gm
B
?
Bacitracin Ointment 500 units/gm Mupirocin 2% Ointment
Sudafed Sudafed
Elimite
#24 tabs
90 day supply PAP
Crush/ Split
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 46
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SMOKING CESSATION SMOKING CESSATION SMOKING CESSATION SMOKING CESSATION SMOKING CESSATION SMOKING CESSATION SMOKING CESSATION SMOKING CESSATION
Imiquimod Cream 5%
Aldara
?
Temovate
#12 singleuse packets 50mL
C
Clobetasol Solution 0.05%
Anti-viral, topical immunomodulator Corticosteroid
C
?
Fluocinonide Cream 0.05% Hydrocortisone Cream 1%
Lidex
Corticosteroid
30 gm
C
-
Corticosteroid
30 gm
C
?
Corticosteroid
20 gm
C
?
Corticosteroid
30 gm
Anusol-HC
Corticosteroid
#12 per box
C
?
Aristocort; Kenalog Oralone
Corticosteroid
C
?
Corticosteroid
15 gm, 80 gm 5 gm
C
?
Sebulex
Dandruff
120 mL
C
-
Premarin
Estrogen
30 gm
X
-
Metrogel
Miscellaneous
45 gm
B
?
Moisturizing Cream
Eucerin
Moisturizing
120 gm
+
+
Zinc Oxide Ointment 20%
Desitin
Ointment
30 gm
+
+
Selenium Sulfide Lotion 2.5% Bupropion Tablet 100mg
Selsun
120 mL
C
?
Wellbutrin
Tinea Versicolor; Dandruff; Seborrheic Dermatitis Dopamine Reuptake Inhibitor
C
-
Nicotine Gum 2mg
Nicorette Gum
Nicotine Product
110 pieces
C
-
Nicotine Gum 4mg
Nicorette Gum
Nicotine Product
110 pieces
C
-
Nicotine Transdermal Patch 14mg Nicotine Transdermal Patch 21mg Nicotine Transdermal Patch 7mg Varenicline Tablet Starter Pack RxP VareniclineTablet Continuing Pack RxP
Nicoderm CQ
Nicotine Product
#14 patches
D
-
Nicoderm CQ
Nicotine Product
#14 patches
D
-
Nicoderm CQ
Nicotine Product
#14 patches
D
-
Chantix
Partial Nicotine Agonist
C
-
+
Chantix
Partial Nicotine Agonist
C
-
+
Hydrocortisone Cream 2.5 % Hydrocortisone Ointment 1% Hydrocortisone Suppository 25mg Triamcinolone Acetonide Cream 0.1% Triamcinolone Acetonide Dental Paste 0.1% Sulfur/Salicylic Acid Shampoo 2%/2% Estrogens, conjugated Cream 0.625mg/gm HD Metronidazole Gel 0.05%
Crush/ Split
+
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 47
Therapeutic Category
Medication
Brand Name
Pharmacologic Category
STIMULANT
Dextroamphetamine /Amphetamine Tabs 10mg Methylphenidate HCl Tablet 5mg
Adderall Ritalin
STIMULANT
Package Size (if applicable)
Preg Cat
Safety in Lactation (www.aap.org)
Crush/ Split
ADHD, Narcolepsy
C
-
+
ADHD, Narcolepsy
C
?
+
Updated: June 13th, 2016
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\REVISED for 2016 book\REVISED for 2016 book\7. Formulary of Drugs (Therapeutic).docx 48
