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.
Use Ctrl-F to quickly search the listing for a specific item.
Rx Pathways Plan
Pfizer drugs are available to patients who are 200% or below federal poverty level.
Only a dispensing fee is charged. NOTE: These drugs may only be prescribed to
sliding scale A through E patients not covered by insurance nor Private Pay. These
medications are labeled as “RxP”.
Patient Assistance Program
Patients who meet specific eligibility requirements may receive certain 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 8week processing period.
HIV Patient Assistance Program
EIC patients who do not qualify for ADAP may receive HIV drugs listed on the ADAP
formulary through manufacturer-sponsored patient assistance programs. The EIC
provider and PAP coordinator at EIC will assist patients in obtaining these drugs.
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.
Some formulary drugs require laboratory monitoring and are labeled as “LAB”.
Lactation safety data from American Academy of Pediatrics (www.aap.org)
Lab Monitoring
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 cution when handling.
(http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf)
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24
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
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25
+
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
ANTIDEPPRESSANT
AGENTS
Mirtazapine Tablet 30mg
Remeron
Alpha2 Antagonist
C
?
+
Bupropion Tablet 100mg
Wellbutrin
Dopamine Reuptake Inhibitor
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
Fluoxetine Capsule 20mg
Prozac
Sertraline Tablet 100mg
Zoloft
Trazadone Tablet 50mg
Desyrel
Duloxetine Capsule 20mg
Cymbalta
Selective Serotonin Reuptake
Inhibitor
Selective Serotonin Reuptake
Inhibitor
Serotonin Reuptake
Inhibitor/Antagonist
Serotonin/Norepinephrine
Reuptake Inhibitor
ANTIDEPPRESSANT
AGENTS
Duloxetine Capsule 30mg
Cymbalta
ANTIDEPPRESSANT
AGENTS
Duloxetine Capsule 60mg
ANTIDEPPRESSANT
AGENTS
ANTIDEPPRESSANT
AGENTS
ANTIDEPPRESSANT
AGENTS
ANTIDEPPRESSANT
AGENTS
ANTIDEPPRESSANT
AGENTS
ANTIDEPPRESSANT
AGENTS
ANTIDEPPRESSANT
AGENTS
ANTIDOTE
ANTIDOTE
ANTIDOTE
ANTIDOTE
ANTIDOTE
ANTIEMETIC/ANTIVERTIGO AGENTS
ANTIEMETIC/ANTIVERTIGO AGENTS
ANTIEMETIC/ANTIVERTIGO AGENTS
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
C (- in 3rd
trimester)
C (- in 3rd
trimester)
C
-
-
+
+
-
+
120 day
supply PAP
C
?
- (may open &
mix w/
applesauce,
NOT choclate)
Serotonin/Norepinephrine
Reuptake Inhibitor
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)
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
Ondansetron Tablet 4mg
EpiPen
Alpha/Beta Adrenergic Agonist
C
-
EpiPen
Alpha/Beta Adrenergic Agonist
C
-
Benadryl
Antihistamine
B
-
-
Benadryl
Antihistamine
B
-
-
Benadryl
Antihistamine
B
-
Zofran
5-HT3 Receptor Antagonist
B
?
+
Meclizine Tablet 12.5mg
Antivert
Anticholinergic, Antihistamine
B
?
+
Promethazine Suppository
25mg
Phenergan
Antidopaminergic,
Phenothiazine
C
-
PAP
PAP
PAP
Package
Size (if
applicable)
2 AutoInjectors
2 AutoInjectors
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27
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
ANTIEMETIC/ANTIVERTIGO AGENTS
ANTI-INFECTIVES
Promethazine Tablet 25mg
Phenergan
Nystatin Cream 100,000
units/gm
Nystatin Suspension
100,000 units/mL
Mycostatin
Antidopaminergic,
Phenothiazine
Antifungal
Nilstat
Antifungal
ANTI-INFECTIVES
Fluconazole Tablet 200mg
Diflucan
ANTI-INFECTIVES
Griseofulvin Susp
125mg/5mL
Terbinafine Cream 1% LAB
Terbinafine Tablet 250mg
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%
Metronidazole Tablet
500mg
Amoxicillin Capsule 250mg
Amoxicillin Suspension
250mg/5mL
Amoxicillin/Clavulanic Acid
Tablet 875mg/125mg
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
ANTI-INFECTIVES
ANTI-INFECTIVES
ANTI-INFECTIVES
ANTI-INFECTIVES
HD
LAB
Package
Size (if
applicable)
Preg Cat
Safety in
Lactation
(www.aap.org)
C
-
15 gm
C
?
60 mL bottle
C
?
Antifungal
C (single dose
vag candida),
D all other
indications
+
Grifulvin
Antifungal
C
?
Lamisil AT
Lamisil
Antifungal
Antifungal
B
B
?
-
+
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
?
Flagyl
Miscellaneous
B
?
+
Amoxil
Amoxil
Penicillin
Penicillin
B
B
+
+
-
Augmentin
Penicillin
B
?
+
15 gm
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28
Crush/ Split
+
-
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
ANTI-INFECTIVES
Penicillin VK Suspension
250mg/5mL
Penicillin VK Tablet 500mg
Ciprofloxacin Ophth Soln
0.3%
Pen-Vee K
Penicillin VK
Preg Cat
Safety in
Lactation
(www.aap.org)
B
?
Veetids
Cipro
Penicillin VK
Quinolone
B
C (but
teratogenicity
unlikely)
?
?
+
ANTI-INFECTIVES
Ciprofloxacin Tablets
500mg
Cipro
Quinolone
?
+
Sulfonamide
C (but
teratogenicity
unlikely)
C
ANTI-INFECTIVES
Sulfamethoxazole/
Trimethoprim Suspension
200mg-40mg/5mL
Septra
Suspension
+
ANTI-INFECTIVES
Sulfamethoxazole/
Trimethoprim Tablet
800mg/160mg
Sulfasalazine Tablet
500mg
Doxycycline Tablet 100mg
Tetracycline HCl Capsule
250mg
Nitrofurantoin Capsule
100mg
Tamoxifen Tablet 10mg LAB
Septra DS
Sulfonamide
C
+
Sulfazine,
Azulfadine
Vibramycin
Achromycin
Sulfonamide
D
-
+
Tetracycline
Tetracycline Antibiotics; Acne
D
D
?
-
+
-
Macrobid
Urinary
B
+?
-
Nolvadex
Anti-estrogen
D
-
-
Hydroxyurea Tablet
500mg LAB, HD
Anastrozole Tablet 1mg
Hydrea
Antimetabolite
D
-
- (powder is
toxic)
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
?
+
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
?
+
ANTI-INFECTIVES
ANTI-INFECTIVES
ANTI-INFECTIVES
ANTI-INFECTIVES
ANTI-INFECTIVES
ANTI-INFECTIVES
ANTINEOPLASTIC
AGENTS
ANTINEOPLASTIC
AGENTS
ANTINEOPLASTIC
AGENTS
ANTIPARKINSON
AGENTS
ANTIPARKINSON
AGENTS
HD
PAP,LAB, HD
PAP
PAP
PAP
PAP
PAP
Package
Size (if
applicable)
5 mL bottle
90 day
supply PAP
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Crush/ Split
Therapeutic
Category
Medication
ANTIPSYCHOTIC
AGENTS
Quetiapine tablet 25mg
ANTIPSYCHOTIC
AGENTS
Quetiapine tablet 50mg
ANTIPSYCHOTIC
AGENTS
Brand Name
Pharmacologic Category
LAB
Seroquel
LAB
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
Atypical, Serotonin/Dopamine
Receptor Antagonist
C
-
+
Seroquel
Atypical, Serotonin/Dopamine
Receptor Antagonist
C
-
+
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
-
-
ANTIPSYCHOTIC
AGENTS
ANTIPSYCHOTIC
AGENTS
ANTIPSYCHOTIC
AGENTS
Haloperidol Tablet 1mg
Haldol
Typical, D2 Antagonist
C
-
+
Haloperidol Tablet 2mg
Haldol
Typical, D2 Antagonist
C
-
+
Trifluoperazine Tablet 2mg
Stelazine
Typical, D2 Antagonist
C
-
+
LAB
LAB
LAB
PAP,
LAB
PAP,
LAB
PAP,
LAB
PAP,
LAB
Package
Size (if
applicable)
90 day
supply
available
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30
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
ANXIOLYTICS,
SEDATIVES,
HYPNOTICS
ANXIOLYTICS,
SEDATIVES,
HYPNOTICS
Buspirone Tablet 15mg
Buspar
Diphenhydramine 50mg
ANXIOLYTICS,
SEDATIVES,
HYPNOTICS
ANXIOLYTICS,
SEDATIVES,
HYPNOTICS
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
Antianxiety Agent
B
-
+
Benadryl
Antihistamine
B
-
-
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
Melatonin Tablet 3mg
Package
Size (if
applicable)
Neurohormone, indole
#120
-
-
Zestril
ACE-Inhibitor
D
?
+
LAB
Zestril
ACE-Inhibitor
D
?
+
Lisinopril Tablet 20mg
LAB
Zestril
ACE-Inhibitor
D
?
+
CARDIOVASCULAR
DRUGS
Lisinopril Tablet 40mg
LAB
Zestril
ACE-Inhibitor
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
90 day
supply
available
90 day
supply
available
90 day
supply
available
90 day
supply
available
90 day
supply
available
90 day
supply
available
D
?
+
LAB
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
31
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
Methyldopa Tablet 250mg
Aldomet
Doxazosin Tablet 2mg
Cardura
Alpha Adrenergic Inhibitor,
Alpha2 Adrenergic Agonist
Alpha1 Blocker
CARDIOVASCULAR
DRUGS
Doxazosin Tablet 8mg
Cardura
Alpha1 Blocker
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
Prazosin Capsule 1mg
Minipress
Alpha1 Blocker
Prazosin Capsule 2mg
Minipress
Prazosin Capsule 5mg
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
B
+
+
C
?
+
C
?
+
C
?
-
Alpha1 Blocker
C
?
-
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
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
30mg PAP, LAB
Enoxaparin SQ
40mg PAP, LAB
Enoxaparin SQ
60mg PAP, LAB
Enoxaparin SQ
80mg PAP, LAB
Enoxaparin SQ
100mg PAP, LAB
Enoxaparin SQ
120mg PAP, LAB
Enoxaparin SQ
150mg PAP, LAB
Injection
Lovenox
Anticoagulant
B
+
Injection
Lovenox
Anticoagulant
B
+
Injection
Lovenox
Anticoagulant
B
+
Injection
Lovenox
Anticoagulant
B
+
Injection
Lovenox
Anticoagulant
B
+
Injection
Lovenox
Anticoagulant
B
+
Injection
Lovenox
Anticoagulant
B
+
LAB
LAB
LAB
Package
Size (if
applicable)
90 day
supply
available
90 day
supply
available
90 day
supply
available
90 day
supply
available
90 day
supply
available
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
32
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
Warfarin Tablet 5mg
Coumadin
Anticoagulant
PAP
Zetia
Gemfibrozil Tablet 600mg
Lopid
Antihyperlipidemic, 2Azetidinone
Antihyperlipidemic, Fibric Acid
Atorvastatin Tablet 10mg
Lipitor
Atorvastatin Tablet 20mg
Lipitor
Atorvastatin Tablet 40mg
Lipitor
Atorvastatin Tablet 80mg
Lipitor
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
Atenolol Tablet 100mg
Tenormin
Beta Blocker
CARDIOVASCULAR
DRUGS
Atenolol Tablet 50mg
Tenormin
Beta Blocker
CARDIOVASCULAR
DRUGS
Carvedilol Tablet 3.125mg
Coreg
Beta Blocker w/ alpha blocking
ability
CARDIOVASCULAR
DRUGS
Carvedilol Tablet 12.5mg
Coreg
Beta Blocker w/ alpha blocking
ability
CARDIOVASCULAR
DRUGS
Carvedilol Tablet 25mg
Coreg
Beta Blocker w/ alpha blocking
ability
CARDIOVASCULAR
DRUGS
Metoprolol Tartrate Tablet
25mg
Lopressor
Beta Blocker
CARDIOVASCULAR
DRUGS
Metoprolol Tartrate Tablet
50mg
Lopressor
Beta Blocker
CARDIOVASCULAR
DRUGS
Propranolol Tablet 10mg
Inderal
Beta Blocker
CARDIOVASCULAR
DRUGS
Propranolol Tablet 40mg
Inderal
Beta Blocker
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
Amlodipine Tablets 10mg
Norvasc
Calcium Channel Blocker
Amlodipine Tablets 5mg
Norvasc
Diltiazem HCl XR 180mg
Capsule
Cardizem CD
LAB
Ezetimibe tablet 10mg
Package
Size (if
applicable)
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
- (1st
trimester), C
C
Use caution
+
?
+
C
?
+
X
-
+
X
-
+
X
-
+
X
-
+
B
?
+
D
-
-
D
-
-
C
?
+
C
?
+
C
?
+
C
?
+
C
?
+
C
+
+
C
+
+
C
?
+
Calcium Channel Blocker
C
?
+
Calcium Channel Blocker
C
+
-
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
90 day
supply
available
90 day
supply
available
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
33
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
Diltiazem HCl XR 240mg
Capsule
Nifedipine XL Tablet 30mg
Cardizem CD
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
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
C
+
+
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
Isosorbide Dinitrate Tablet
10mg
Isosorbide Dinitrate Tablet
20mg
Isosorbide Dinitrate Tablet
40mg
Nitroglycerin SL Tablet
0.4mg
Nitroglycerin Transdermal
Patch 0.2mg/hr
Isordil
Vasodilator
90 day
supply
available
90 day
supply
available
C
?
+
Isordil
Vasodilator
C
?
+
Isordil
Vasodilator
C
?
+
Nitrostat
Vasodilator
#100 tabs
C
?
Transderm
Nitro
Vasodilator
#30 patches
C
?
Diuretic, Loop
Package
Size (if
applicable)
90 day
supply
available
90 day
supply
available
90 day
supply
available
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
34
-
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
Package
Size (if
applicable)
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
CARDIOVASCULAR
DRUGS
CARDIOVASCULAR
DRUGS
DEVICE
DEVICE
DEVICE
DEVICE
Nitroglycerin Transdermal
Patch 0.4mg/hr
Nitroglycerin Transdermal
Patch 0.6mg/hr
Nasal Aspirator
Nasal Irrigation Kit
Peak Flow Meter
Pill Box
Transderm
Nitro
Transderm
Nitro
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
PAP
Januvia
Anti-diabetic, Dipeptidyl
Peptidase IV (DPP-IV) Inhib
90 day
supply PAP
B
?
-
ENDOCRINE AND
METABOLIC AGENTS
Sitagliptin Tablet 50mg
PAP
Januvia
Anti-diabetic, Dipeptidyl
Peptidase IV (DPP-IV) Inhib
90 day
supply PAP
B
?
-
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
Insulin Glargine
100units/mL PAP
Insulin Glulisine
100units/mL PAP
Insulin NPH 100units/mL
Lantus
Antidiabetic, Insulin
B/C
+
Apidra
Antidiabetic, Insulin
90 day
supply PAP
90 day
supply PAP
B/C
+
Novolin NPH
Antidiabetic, Insulin
B/C
+
Insulin NPH and Insulin
Regular 100units/mL
Insulin Regular
100units/mL
Novolin 70/30
Antidiabetic, Insulin
B/C
+
Novolin Regular
Antidiabetic, Insulin
B/C
+
LAB
PAP
Treatment of Hypokalemia
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
35
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
Glipizide ER Tablet 10mg
Glucotrol XL
Glipizide ER Tablet 5mg
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
Antidiabetic, Sulfonylurea
C
?
-
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
Norgestrol / E. Estradiol
Tablet 0.3mg/0.03mg HD
Medroxyprogesterone
Acetate Tablet 10mg HD
Norethindrone Tablet
0.35mg HD
Ortho-Novum
7/7/7
Contraceptive Hormone,
Combination
#28 tabs
X/D
-
+
Lo-Ovral
Contraceptive Hormone,
Combination
Contraceptive Hormone,
Progestin
Contraceptive Hormone,
Progestin
#28 tabs
X
-
+
X
+
+
#28 tabs
X
+
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
- (may start 6
wks after
pregnancy)
-
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
C
+
+
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
ENDOCRINE AND
METABOLIC AGENTS
LAB
LAB
Provera
Nor-Q-D
Lupron
Lupron
Colcrys
Gout, Xanthine Oxidase
Inhibitors
Package
Size (if
applicable)
90 day
supply
available
90 day
supply PAP
90 day
supply PAP
90 day
supply PAP
90 day
supply
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\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
C
+
+
D
?
available
ENDOCRINE AND
METABOLIC AGENTS
Allopurinol Tablet 300mg
Zyloprim
Gout, Xanthine Oxidase
Inhibitors
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
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
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
Methimazole Tablet 10mg
Megace
Progestin
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Levoxyl
Thyroid
A
+
+
Tapazole
Thyroid
D
+
+
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
5 mL
C
?
Xylocaine
Analgesic
100 mL
B
+
Alphagan
Antiglaucoma, Alpha2 Agonist
5 mL
B
?
Timoptic
5 mL
C
+
10 mL
C
-
Pilocarpine Ophth Soln 4%
Pilocar
15 mL
C
?
Latanoprost Ophth Sol
0.005%
Chlorhexidine Oral Rinse
0.12%
Erythromycin 5mg/gm
Xalatan
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%
Polytrim
Anti-infective
10 mL
C
?
Cortisporin Otic
Anti-infective, Corticosteroid
Otic 10mL
?
?
Debrox
Cerumenolytic
15 mL
?
?
EYE, EAR, NOSE,
AND THROAT
EYE, EAR, NOSE,
AND THROAT
Trusopt
90 day
supply
available
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\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)
EYE,
AND
EYE,
AND
EYE,
AND
EYE,
AND
EYE,
AND
EYE,
AND
Fluticasone Propionate
Nasal Spray 50mcg/spray
Ketorolac 0.5% Ophth
Soln
Prednisolone Acetate
Ophth Soln 1%
Hydrocortisone, Nystatin,
Diphenhydramine Susp
Saline Nose Spray
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
+
+
EYE, EAR, NOSE,
AND THROAT
Artificial Tear Ointment
Duratears
Lubricant
+
+
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
15 Ml
90 day
supply
available
3.5 gm
90 day
supply
available
15 mL
C
+
Ketotifen Ophth Soln
0.025%
Naphazoline Ophth Soln
0.1%
Naphazoline/Pheniramine
Ophth Soln 0.025%/0.3%
Magnesium/Aluminum/
Simethicone Suspension
Zaditor
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
?
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
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
?
EAR, NOSE,
THROAT
EAR, NOSE,
THROAT
EAR, NOSE,
THROAT
EAR, NOSE,
THROAT
EAR, NOSE,
THROAT
EAR, NOSE,
THROAT
90 day
supply PAP
90 day
supply
available
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
38
Crush/ Split
-
+
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
Package
Size (if
applicable)
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
GASTROINTESTINAL
DRUGS
Ranitidine Tablet 300mg
Zantac
Histamine H2 Antagonist
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
Bisacodyl Tablet 5mg
Dulcolax
Laxative, Diphenylmethane
90 day
supply
available
B
?
+
C
?
-
Glycerin 1 gm suppository
Pedia-Lax
Rectal
Sani-Supp
Adult Rectal
MiraLax
Laxative, Osmotic
A
+
+
Laxative, Osmotic
A
+
+
Laxative, Osmotic
255 gm
C
?
Polyethylene Glycol with
Electrolytes
Psyllium Hydrophilic
Powder
Pancreatic Enzymes
Capsule
Lipase/Protease/Amylase
12k/38k/60k PAP
GoLytely
4,000 mL
C
?
Metamucil
Laxative, Osmotic (for Bowel
Prep)
Laxative, Bulk
284 gm
+
?
Creon
Pancreatic Enzymes
90 day
supply PAP
C
?
- (can be
opened and
given with
applesauce or
pudding)
GASTROINTESTINAL
DRUGS
Pancreatic Enzymes
Capsule
Lipase/Protease/Amylase
24k/76k/120k PAP
Creon
Pancreatic Enzymes
90 day
supply PAP
C
?
- (can be
opened and
given with
applesauce or
pudding)
GASTROINTESTINAL
DRUGS
Pancreatic Enzymes
Capsule
Lipase/Protease/Amylase
6k/19k/30k PAP
Creon
Pancreatic Enzymes
90 day
supply PAP
C
?
- (can be
opened and
given with
applesauce or
pudding)
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
GASTROINTESTINAL
DRUGS
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)
GENITOURINARY
AGENTS
GENITOURINARY
AGENTS
GENITOURINARY
AGENTS
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
Pyridium
Analgesic, Urinary
B
?
+
Detrol LA
Anticholinergic, Urinary
C
-
-
Ditropan
Antispasmodic, Urinary
B
?
+
GENITOURINARY
AGENTS
Glycerin 2 gm suppository
Polyethylene Glycol
#100 caps
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
39
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
MIGRAINE AGENTS
Butalbital, Acetaminophen
and Caffeine Tablet
50mg/325mg/40mg
Note: Fioricet
changed
strength April
2014 and no
longer has a
generic
Migraine Combinations
MIGRAINE AGENTS
Eletriptan Tablet 40mg
Relpax
6 tabs per
box
NEPHROLOGY
PhosLo
Kayexalate
Treatment of Hyperkalemia
60 mL per
bottle
NEPHROLOGY
Calcium Acetate Capsule
667mg
Sodium Polystyrene
Sulfonate Susp
15gm/60mL
Calcitriol Capsule 0.5mcg
Serotonin 5-HT1 Receptor
Agonist
Calcium, Phosphate Binder
Rocaltrol
Vitamin D Analog
NEPHROLOGY
Paricalcitol Capsule 1mcg
Zemplar
Vitamin D Analog
NEPHROLOGY
Paricalcitol Capsule 2mcg
Zemplar
Vitamin D Analog
NEPHROLOGY
Paricalcitol Capsule 4mcg
Zemplar
Vitamin D Analog
NUTRIENTS AND
NUTRITIONAL
AGENTS
NUTRIENTS AND
NUTRITIONAL
AGENTS
Calcium (elemental)
Tablet 500mg
Calcium
Calcium Supplement
Magnesium Oxide Tablet
400mg (240mg elemental)
MagOx
Hypomagnesemia
NUTRIENTS AND
NUTRITIONAL
AGENTS
NUTRIENTS AND
NUTRITIONAL
AGENTS
Thiamine Tablet 100mg
Various
Cyanocobalamin Tablets
500mcg
Vitamin B12
NUTRIENTS AND
NUTRITIONAL
AGENTS
NUTRIENTS AND
NUTRITIONAL
AGENTS
Folic Acid Tablet 1mg
Multivitamin Drops with
Iron
Poly-vi-sol
NUTRIENTS AND
NUTRITIONAL
AGENTS
NUTRIENTS AND
NUTRITIONAL
AGENTS
Multivitamin Tablet, Adult
NUTRIENTS AND
NUTRITIONAL
AGENTS
NEPHROLOGY
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
C
-
+
C
?
+
C
?
-
C
?
C
?
-
C
?
-
C
?
-
C
?
-
+ (? 1st
trimester)
?
+
#120
A
+
+
Nutritional Supplement
#100 tabs
A
+
+
Vitamin
#130 tabs
C
+
+
Vitamin
A
+
+
Vitamin
90 day
supply
available
50 mL
+
+
Centrum
Vitamin
#100 tabs
+
+
+
Multivitamin tablet,
Children
Flinstones
Vitamin
#100 tabs
+
+
+
Omega-3 Fatty Acids (180
EPA / 120 DHA)
Fish Oil
Vitamin
#100 caps
C
?
-
RxP
PAP
PAP
PAP
Package
Size (if
applicable)
90 day
supply PAP
90 day
supply PAP
90 day
supply PAP
#60 tabs per
bottle
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
40
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
Package
Size (if
applicable)
Preg Cat
Safety in
Lactation
(www.aap.org)
Crush/ Split
NUTRIENTS AND
NUTRITIONAL
AGENTS
NUTRIENTS AND
NUTRITIONAL
AGENTS
Prenatal Vitamins
Natalins RX
Vitamin
#100 tablets
+
+
+
Vitamin D3 Tablet 400 IU
Vitamin
#100 tabs
C
Avoid high doses
NUTRIENTS AND
NUTRITIONAL
AGENTS
NUTRIENTS AND
NUTRITIONAL
AGENTS
Vitamin D3 Tablet 1,000
IU
Vitamin
#100 tabs
C
Avoid high doses
Vitamin D3 Tablet 50,000
IU
Vitamin
#100 caps
C
Avoid high doses
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
Cetirizine Solution
1mg/mL
Cetirizine Tablet 10mg
Zyrtec
Antihistamine
120 mL
B
-
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
Albuterol Nebulizer
Solution 0.083%
Proventil,
Ventolin
Bronchodilator, Beta2Adrenergic Agonist
C
?
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
Tessalon Perles
#25
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
41
-
-
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RESPIRATORY
AGENTS
RHEUMATOLOGY
Albuterol Syrup 2mg/5mL
Proventil,
Ventolin
Slo-bid
QVAR
Bronchodilator, Beta2Adrenergic Agonist
Bronchodilator, Xanthine
Derivative
Bronchodilator, Xanthine
Derivative
Bronchodilator, Xanthine
Derivative
Corticosteroids, Inhalant
Fluticasone Propionate
MDI 110mcg/puff PAP
Fluticasone Propionate
MDI 220mcg/puff PAP
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
Flovent
Corticosteroids, Inhalant
Flovent
Corticosteroids, Inhalant
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
Preg Cat
Safety in
Lactation
(www.aap.org)
C
?
C
+
-
C
+
-
C
+
-
8.7 gm
C
?
90 day
supply PAP
90 day
supply PAP
90 day
supply PAP
C
?
C
?
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
?
Antibiotic, Topical
22 gm
B
?
Theophylline Capsule
100mg LAB
Theophylline Capsule
200mg LAB
Theophylline Capsule
300mg LAB
Beclomethasone MDI
Bacitracin Ointment
500 units/gm
Mupirocin 2% Ointment
Slo-bid
Slo-bid
Sudafed
Sudafed
Bactroban
Package
Size (if
applicable)
#24 tabs
90 day
supply PAP
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
42
Crush/ Split
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
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
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
?
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
-
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%
Elimite
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
43
Crush/ Split
+
Therapeutic
Category
Medication
Brand Name
Pharmacologic Category
Package
Size (if
applicable)
SMOKING
CESSATION
SMOKING
CESSATION
SMOKING
CESSATION
SMOKING
CESSATION
SMOKING
CESSATION
SMOKING
CESSATION
STIMULANT
Nicotine Gum 4mg
Nicorette Gum
Nicotine Product
Nicotine Transdermal
Patch 14mg
Nicotine Transdermal
Patch 21mg
Nicotine Transdermal
Patch 7mg
Varenicline Tablet Starter
Pack RxP
VareniclineTablet
Continuing Pack RxP
Dextroamphetamine
/Amphetamine Tabs 10mg
Methylphenidate HCl
Tablet 5mg
Nicoderm CQ
STIMULANT
Preg Cat
Safety in
Lactation
(www.aap.org)
110 pieces
C
-
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
-
+
Adderall
ADHD, Narcolepsy
C
-
+
Ritalin
ADHD, Narcolepsy
C
?
+
Updated: February 2nd, 2016
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2015\7. Formulary of Drugs (Therapeutic).docx
44
Crush/ Split