nonformulary
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Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B No order needed to change to elixir as long as bioequivalence is the same. (P&T, 11/04) No order needed to change route to via tube as long as drug is non-sustained release. (P&T, 11/04) No order needed to change dilute or concentration on standard drips (7300-VIII-106) NONFORMULARY FORMULARY Accolate bid Accupril 2.5mg or 5 mg Accupril 10, 20, 40, 80 mg Accuzyme ointment Aceon 2, 4, 8, 16 Aciphex 20 mg daily Aclovate 0.05% crm or oint Actonel 5 mg/day Actonel 35 mg/week Advair Diskus 100/50 1 inhalation bid Advair Diskus 250/50 1 inhalation bid Advair Diskus 500/50 1 inhalation bid Advair in Isolation patients Aerozin spray AlitraQ Allegra 60 mg bid or 180 mg q day Allegra-D bid Alternagel (600 mg/5 ml) Ambien CR 12.5mg Ambisome Aminophylline 100 mg qid Aminophylline ordered as 1000mg in 500ml, pharmacy may change to 500mg in 250ml Anaprox (naproxen) 275 mg , 500 mg Ancef 1gm pre-op for pt ≤ 120 kg Ancef 1gm or 2gm pre-op for Pt > 120 kg Ancef IV 500 mg q8h Ancef IV q 6 h Ansaid 50 mg q6h or 100 mh bid Ansaid 100 mg tid Antacid Antara 43 mg, 130 mg Antifungals (oral and topical) Anusol Ointment Anzemet 100mg or 1.8mg/kg IV or PO daily Anzemet 12.5 mg (any interval, prn) Anzemet 25 mg (any interval, prn) Apidra (short acting insulin) Arixtra Singulair 10 mg daily (adults) 5mg daily (peds) Altace 1.25mg Altace 2.5mg, 5 mg, 10 mg, 20 mg (max) Santyl Altace 2.5 mg, 5 mg, 10 mg, 20 mg (max) Prilosec 20 mg daily (except if drug interaction, use Protonix) Tridesilon or Desowen 0.05% Fosamax 35 mg/week Fosamax 70 mg/week Advair HFA 45/21, 2 puffs bid, Except for Isolation pt Advair HFA 115/21, 2 puffs bid, Except for Isolation pt Advair HFA 230/21, 2 puffs bid, Except for Isolation pt Advair Diskus (administered per Resp Care) Benzoin swab Perative Claritin 10 mg daily Claritin-D bid Aluminum hydroxide (320mg/5ml), use ½ ordered dose Ambien 10mg Abelcet (can use whichever is least expensive), ID only Theo-Dur 100 mg tid Same concentration, not a therapeutic interchange Page 1 of 18 P&T approved Naprosyn 375 mg, 500 mg Ancef 2gm pre-op Ancef 3 gm pre-op Ancef IV 1g q8h Ancef IV q 8 h (same # of days/hrs as original order) Naprosyn 375 mg bid Naprosyn 500 mg bid Al, Mg, Simethicone XS See Fenofibrate DC- when Diflucan ordered Tucks Ointment Zofran 24mg po first, then 32mg IV if PO not effective DAILY Zofran 4mg q 8hr (prn) Zofran 8mg q 8hr (prn) No TI, recommend Humalog. CrCl < 30, contraindicated. Cardiac exception for CrCl 20-30, ok x 1 dose, then Clinical Pharmacist to 3/7/2016 11/15/10 5/11/10 5/11/10 5/11/10 5/11/10 5/10/11 5/10/11 7/2012 11/14/11 7/2015 9/4/12 9/8/09 5/11/10 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B TI to Heparin Infusion (implement seq # 693 or # 24683 and sign “per TI”) Asacol (mesalamine) Ascriptin Atacand (candesartan) 4, 8, 16 & 32mg Augmentin 250 mg tid Augmentin chewables Avapro (irbesartan) 75 mg, 150mg, 300 mg Aveenobar Avelox IV (during shortage situations) Delzicol (mesalamine), same dose and frequency Ecotrin Cozaar (losartan) 25 mg, 25mg, 50 mg, 100 mg Augmentin 500 mg bid Use Augmentin susp Cozaar (losartan) 25mg, 50 mg, 100 mg Aveenobath Levaquin IV: CrCl ≥ 50, Levaquin 750 mg IV q 24 hrs CrCl 20-50 Levaquin 750 mg IV q 48 hrs CrCl 10-19, Levaquin 500 mg IV q 48 hrs CrCl < 10 or HD: Levaquin 500 mg IB q 38 hrs Avinza 120, 150, 180 & 210 mg daily MS Contin 60, 75, 90, 100 mg bid Avinza 30, 60, 90 mg daily MS Contin 15, 30, 45 mg bid Axid 150 mg bid Pepcid 20 mg bid Axid 150mg, 300 mh q hs Pepcid 20 mg, 40 mg q hs Banana Bag diluent LR Banana bags diluent is NS Beclovent Azmacort (same puffs and intervals) Beconase AQ regular strength Flonase (same # sprays) daily Benicar (olmesartan) 5, 10, 20 & 40 mg Cozaar (losartan) 25 mg , 25mg, 50 mg, 100 mg Biaxin XL 1000mg DAILY Biaxin 500 mg bid Breast cream (Lanolin) Lansinoh Breast Cream Bufferin (Buffered ASA) Ecotrin Bumex IV 1mg (exception: neonates, no TI) No TI to Demadex IV, call physician Bumex PO 0.5 mg, 1mg, 2mg Demadex PO 5 mg, 10mg, 20 mg BUTT cream (adults) Vasolex Byetta (exenatide) No TI, must call MD. Caduet (combo, use individual products) Amlodipine and atorvastatin Calan Verapamil IR same dose and schedule Calan SR (same total daily dose given qAM) 120 mg po daily Verapamil ER capsules 120 mg po qAM 180 mg po daily Verapamil ER capsules 180 mg po qAM 240 mg po daily Verapamil ER capsules 240 mg po qAM 360 mg po daily Verapamil ER capsules 360 mg (2 x 180 mg) po qAM 120 mg po BID Verapamil ER capsules 240 mg po qAM 180 mg po BID Verapamil ER capsules 360 mg (2 x 180 mg) po qAM 240 mg po BID Verapamil ER capsules 480 mg (2 x 240 mg) po qAM Caphosol (sodium phosphate) Biotene (polyglycitol) Cardura XL 4 and 8mg Cardura 4 and 8mg daily at bed time respectively. Cataflam 50 mg tid Naprosyn 500 mg bid Ceclor 250mg & 500mg caps Ceftin 250mg & 500mg caps Ceclor susp Ceftin susp Page 2 of 18 3/7/2016 10/2013 11/1/10 11/1/10 01/06/15 5/1/12 11/1/10 10/2014 11/14/11 9/8/09 9/4/12 8/14 8/14 11/12 10/6/09 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Cecon (ascorbic acid) 90 mg/ml Cefizox q 12hr Cefotan (q 12 hrs) Cefizox (q 8 or 12 hrs) Cefzil susp Celexa 10mg daily Celexa 20mg, 40mg daily Cephalothin (Keflin) q4h or q6h Cerebyx loading doses (1 gm), during shortage Cerebyx Maintenance Doses, during shortages Cetacaine spray used at bedside Chapstick Chromogen FA Cipro XR 500mg, 1000mg daily Claforan 500mg Claforan (ADULT indications) 1 gm –2 gm Clarinex 5mg daily Claritin D, all strengths Clotrimazole (Gyne-Lotrimin) Combivent 2 puffs q6h Used on ventilator patients only in ICU. Copaxone (glatiramer) Cordran 0.05% crm, oint, lotion Coreg CR 10, 20, 40, 80 mg daily Cortone Covera-HS 180 mg po qHS 240 mg po qHS 360 mg po qHS 480 mg po qHS Cyclocort 0.1% crm or lotion Cyclocort 0.1% ointment D51/4NS (adults only not peds) D50 Shortage, give D10 Dakins Dalmane Page 3 of 18 Vit C (ascorbic acid)100 mg/ml syrup Mefoxin q 8 hrs Mefoxin (q 8 hrs) Mefoxin (q 8 hrs) Ceftin susp Lexapro 5mg daily Lexapro 10mg, 20mg daily Ancef q8h Phenytoin 1 gm 3/3/10 5/11/10 May change maintenance doses (ie. 100mg q 8hr) to generic phenytoin (exception: patient with poor IV access) Cepacol or Chloraseptic spray at bedside Blistex Niferex 15- Forte Cipro 250 mg , 500 mg bid Rocephin 500 mg q 24 hrs Rocephin 1 gm q 24 hrs Claritin 10 mg daily Claritin D 10 mg/240 mg Miconazole Combivent Respimat 1 puff q6 hr Used on ventilator patients only in ICU. No TI, pt to bring own, do not order Kenalog 0.025% oint,crm,lotion Coreg 3.125 mg, 6.25 mg, 12.5 mg, 25 mg bid Solu-cortef 5/10/11 3/2014 9/8/09 8/14 Verapamil ER capsules 180 mg po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM Verapamil ER capsules 480 mg (2 x 240 mg) po qAM Diprosone 0.05% oint Lidex 0.05% crm, oint, soln D51/2NS (adults only- not peds) BG 50-59, give D10, 100 ml* (therapeutic interchange** instead of D50, 20 ml) BG 30-49, give D10, 125 ml* (therapeutic interchange** instead of D50, 25 ml) BG < 30, give D10, 150 ml* (therapeutic interchange **instead of D50, 30 ml) Full Strength = 0.5% Half-Strength = 0.25% Quarter Strength = 0.25% Restoril (same dose, but if pt > 65yo, use 15 mg) 3/7/2016 3/5/13 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Daypro 1200 mg Daypro 600 mg Decaspray 0.04% Demadex IV 5 mg 10 mg 20-60 mg 60-80 mg 100 mg Demerol Denavir ointment Detrol Dexilant 30, 60 mg daily Diflucan IV or PO q12h Dilacor XR Dilantin 300 mg (IV or susp) daily Dilaudid PCAs: when PCA vials on backorder (can’t make) Diovan (valsartan) 40, 80 160 , 320 mg Diprolene 0.05% ointment Diprolene AF 0.05% cream Ditropan XL 5 mg daily Ditropan XL 10 mg daily Ditropan XL 15 mg daily Ditropan XL 20 mg daily Ditropan XL 30 mg daily Dobutrex IV in any soln other than D5W Doral Doribax 500mg q 8hr Naprosyn 500 mg tid Naprosyn 375 mg bid Kenalog aerosol No TI to Bumex IV, call physician 0.5 mg 1 mg 2 mg 3 mg 4 mg 3 day stop Zovirax ointment Detrol LA Prilosec 20mg, 40 mg daily ( if drug interaction, use Protonix) Diflucan q24h (Same DAILY dose) Cardizem CD Dilantin 100 mg q8h (IV or susp) Call MD, use Morphine or Demerol PCA or bolus with Dilaudid Cozaar (losartan) 25 mg , 25mg, 50 mg, 100 mg Temovate 0.05% ointment Temovate 0.05% cream Ditropan 2.5 mg bid Ditropan 5 mg bid Ditropan 5 mg tid Ditropan 7.5 mg tid Ditropan 10 mg tid D5W for diluent (even diabetic pt) Restoril (same dose- but if pt > 65yo use 15 mg) Merrem 1 gm q 8 hr See CrCl chart for renal adjustments Doxidan = Biscodyl Dulera (formoterol and mometasone) Duricef Dyazide EES 400 mg Effexor bid or tid Exception: TF (need immediate release) Elocon 0.1% crm, oint, lotion Emend Dulcolax Symbicort (same dose & interval) Keflex (same dose-double interval ) Maxzide 25 mg E-mycin or erythromycin base Effexor XR daily (same total daily dose) Exception: TF (need immediate release) Lidex 0.05% crm, oint, soln 5 day course: 150mg IV on Day 1 & Day 4 (we do not stock po) L.M.X.4 Tylenol #3 Vesicare (solifenacin) 5 and 10mg once daily Enlon Plus (endrophonium & atropine) Emla cream Empirin # 3 Enablex (darifenacin) 7.5 and 15mg q day Enlon (endrophonium) Page 4 of 18 3/7/2016 10/2014 11/15/10 11/1/10 7/2013 7/2013 8/16/11 10/6/09 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Ensure Clinical Strength Enterals Entex LA Erthromycin (any brand) Erythormycin on backorder Erythormycin ophthalmic 0.5% for neonates on backorder Estraderm patch (q 3 days) Ethyl Chloride spray Famvir (famicyclovir) 125-250 mg bid (suppressive) 500 mg q 8 hr (treatment herpes zoster) 250 mg q 8 hr (treatment genital herpes) Feldene 10 mg, 20 mg daily Fenofibrate, may be given without regard to meals 43mg or 67 mg (or any dose < 100) Ensure Complete See chart at end of this document Entex PSE E-mycin or erthromycin base) Call MD, use Zitromax or Biaxin for tx and Reglan for motility Use azithromycin ophthalmic 130 mg, 134 mg, 200 mg (or any dose > 100) Fenofibrate generic 160 mg TABLET (max dose) If capsules are ordered, dispense tablets Capsules: 43 mg, 67 mg, 130 mg, 134 mg, 200 mg Fenofibric acid 35 mg, 105 mg Fenoglide 40mg, 120mg Ferraheme Fibricor 35mg, 105 mg Flagyl Q6h Flagyl IV (shortage) 500 mg q 8 hrs Fleet Prep Kit 3 (discontinued) Fleet enema Florastor Floxin Otic Folic Acid 0.4 mg Forteo (teriparatide) pen Fosamax 10 mg/day Fosamax 5 mg/day Fragmin Gaviscon liquid Gelusil or Gelusil M Gentamicin /Ampicillin combo for pre-op Page 5 of 18 Climara patch (q 7 days) Fluori-Methan Spray Valtrex 500mg bid 1 gm tid (usually for 7 days) 1 gm bid (usually for 7-10 days) Naprosyn 375 mg, 500 mg tid 9/4/12 9/8/09 10/6/09, 12/2013 Fenofibrate generic 54 mg TABLET , 1:1 interchange (example: Fenoglide 2 tabs of 43 mg will be switched to 2 tabs of 54 mg) Tablets: 54 mg, 160 mg See Fenofibrate See Fenofibrate NO TI, call MD (can use Ferrlicet), do not order See Fenofibrate Flagyl q8h Cleocin IV 900 mg q 8 hrs LoSo Prep Kit Mineral Oil enema: Exception: bowel prep or specific order for “saline” or ”sodium phosphate” Culturelle Ciloxin Opth Folic Acid 1 mg call MD…We will NOT order this outpatient drug Fosamax 70 mg/week Fosamax 35 mg/week Lovenox, see 500-56 Attachment F: Low Molecular Weight Heparin Dosing Guidelines Maalox XS Maalox XS Ancef 2 gm IV x 1 dose or 3 gm x 1 if pt > 120 kg 3/7/2016 9/4/12 9/4/12 10/6/09 9/4/12 6/2014 02/10 11/12 07/11 9/8/09 12/10 10/12 7/15 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B hysterectomy Glynase 1.5 mg, 3 mg, 6 mg Golytely 3 tbsp Granix (TBO- filgastrim) Gyne-Lotrimin H2 antagonist SUSPENSION Halcion 0.125 mg, 0.25 mg Halog 0.1% crm, oint, or soln Heparin IV drip in any soln other than D5W Heparin 5,000 units SQ q 8-12 hrs for prophylaxis Humabid DM , one or two tabs a day (600 mg Guaif– 30mg Methorphan) Hurricaine spray Hycomine Indocin 25 mg (1 tsp) q6h Indocin SR 75mg q12h Insulin Novolog mix 70/30 Insulin, Novolin 70/30 Insulin, Novolin N Insulin, Novolin R Insulin, NovoLog Insulin Sliding Scale (Regular) Integrelin Iron Products Iron products (oral) Isoptin Isoptin SR 120 mg po daily 180 mg po daily 240 mg po daily 360 mg po daily 120 mg po BID 180 mg po BID 240 mg po BID Isopto Tears (5% hydromellose) IV fluids/diluent Juvisync (combo, use individual products) Kadian 20 or 30 mg q 12 hrs Kadian 20 or 30 mg q 24 hrs Kadian 50 mg q 12 hrs Kadian 50 or 60 mg q 24 hrs Kadian 60 mg q 12 hrs Page 6 of 18 Diabeta/micronase 2.5 mg, 5 mg, 10 mg Miralax, 1 packet Neupogen (or Neupogen to Granix, whichever in stock) Miconazole Pepcid 20 mg tabs crushed Restoril 15 mg, 30 mg ( unless pt > 65yo then 15mg) Lidex 0.05% crm, oint, soln D5W for diluent (even diabetic pt),must use orders During shortage situations, TI to: Lovenon 30-40 mg SQ q 24 hrs (dose based on CrCl) Tussibid (1200 mg Guaif – 60mg Methorphan), one tab a day Cetacaine spray…Do not use PRN or at bedside! PV Tuss or QV tussin Ibuprofen 600 mg (2 Tbsp) tid Naprosyn 500 mg bid Humalog 75/25 Humulin 70/30 Humulin N Humulin R Humalog Humalog Aggrastat See chart at end of this document Ferrous Sulfate 325 mg (65 mg elemental iron) or Fergon 27 mg elemental irom Verapamil IR same dose and schedule (same total daily dose given qAM) Verapamil ER capsules 120 mg po qAM Verapamil ER capsules 180 mg po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x180 mg) po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM Verapamil ER capsules 480 mg (2 x 240 mg) po qAM Naure Tears (4% hydromellose) Change to standard diluent (see policy 7300-VIII-106) Januvia plus simvastatin MS Contin 15 mg q 8 hrs MS Contin 15 mg q 12 hrs MS Contin 30 mg q 8 hrs MS Contin 30 mg q 12 hrs MS Contin 45 mg q 8 hrs 3/7/2016 12/2013 9/2/14 8/6/13 12/2013 8/14 8/14 1/4/2011 9/4/12 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Kadian 100 mg q 12 hrs Kadian 100 mg q 24 hrs Kaolin and pectin Kaopectate KCL bolus in fluid other than SWFI KCL supplement 10 mEq, 20 mEq KCL supplement 8mEq Keftab Kovia Kytril 1-2mg Po or IV (any interval) Latisse Lescol 20mg, 40, and 80 mg (per day) Levemir (long acting insulin) Lidex E 0.05% cream Lipofen 50 mg, 150 mg Livalo (pitavastatin) 1, 2, 4 mg LOC (Laxative of Choice) Locold 1% soln Lodine 200 mg bid, tid, qid Lodine 300 mg bid Lodine 300 mg tid or qid Lodine 400 mg bid or tid Lofibra 134 mg, 200 mg, 160 mg Lortab Elixir Lortab (HYDROcodone with 500 mg acetaminophen) MS Contin 60 mg q 8 hrs MS Contin 60 mg q 12 hrs Pepto Bismol Pepto Bismol KCL bolus in SWFI K-dur 10 mEq Micro-K 8 mEq Keflex Accuzyme Zofran 8 mg PO first, then 16 mg IV if PO not effective DAILY Xalatan (latanoprost) Lipitor 10 mg (total daily dose administered q am) Lantus (1:1 conversion) Exception: Allowed for use in GWP only (Catagoty B) Lidex 0.05% crm, oint, soln See Fenofibrate Pravachol (pracastatin) 20, 40, 80 mg No TI. RN to check w/ patient, then call MD to obtain an order. Tridesilon or Desowen 0.05% Naprosyn 375 mg bid Naprosyn 375 mg bid Naprosyn 500 mg bid Naprosyn 500 mg bid See Fenofibrate Hycet Elixir (ml for ml). Both contain 7.5mg Hydrocodone, but Hycet has APAP 325mg and Lortab has APAP 500mg Norco ((HYDROcodone with 325 mg acetaminophen) Lotensin 2.5 mg & 5 mg Altace 1.25mg Lotensin 10 mg, 20 mg, 40mg, 80 mg Altace 2.5mg, 5 mg, 10mg, 30 mg (max) Lovenox (or Heparin, Arixtra or Coumadin) DC Lovenox ordered with “newer” oral anticoagulants that work immediately (Pradaxa, Eliquis or Xarelto) Page 7 of 18 9/4/12 9/4/12 9/8/09 9/4/12 Approve0 3/201, effective 6/4/13 6/2013 01/2012 Lovenox rounding , see 500-56, Attachment F: Dose Rounding, if patient weighs….. Lovenox 1 mg/kg q 12 hrs (< 50 kg) Lovenox 1 mg/kg q 12hrs (50-69 kg) Lovenox 1 mg/kg q 12hrs (70-89 kg) Lovenox 1 mg/kg q 12 hrs (90-109 kg) Lovenox 1 mg/kg q 12 hrs (110-129 kg) Lovenox 1 mg/kg q 12 hrs (130-144 kg) 8/6/13 9/4/12 1/2016 Give 40 mg q 12 hrs 60 mg q 12 hrs 80 mg q 12 hrs 100 mg q 12 hrs 120 mg q 12 hrs 140 mg q 12 hrs 3/7/2016 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Lovenox 1 mg/kg q 12 hrs (145-154 kg) Lovenox 1 mg/kg q 12 hrs (155-169 kg) Lovenox 1 mg/kg q 12 hrs (170 kg and up) Lumigan (any strength) Lunesta 1, 2 mg Lunesta 3mg Maalox and Maalox XS Maalox XS, Plus or TC Macrodantin 100 mg qid Mag Oxide 250 mg and Magtrate 500 mg Mannitol 25% 500 cc Mavik 0.5 mg, 1mg, 2mg, 4mg, 8mg Maxalt 5 mg Maxalt 10 mg Maxiflor 0.05% crm Maxiflor 0.05% ointment Maxipime Meclomen 100 mg tid or qid Meclomen 50 mg qid Menthol 0.25% compounded Merrem (Merrem is FORMULARY and administered over 4 hrs)-TI IS ONLY FOR SHORTAGES 1-2 gm IV q 8 hrs (over 4 hrs) Mevacor 10 mg, 20 mg and 40mg Mevacor 80 mg Micardis (telmisartan) 20mg, 40mg, 80 mg, Minocin IV Mobic (meloxicam) 7.5mg, 15 mg MOM/MO Monopril 5 mg, 10 mg, 20 mg Monopril 40mg-80mg Morphine IV (during shortage), 1-2 mg IV q 3 hrs prn severe pain Morphine prn with CrCl < 30 Mucofen and Mucofen LA MVI (Multi dose vitamins) MVI q day in hyperal during shortage Mylanta or Mylanta II Nafcillin shortage Nalfon 200 mg qid or 300 mg tid Nalfon 300 mg qid or 600 mg tid or qid Namenda (memantine) 5 mg po q day Page 8 of 18 150 mg q 12 hrs 160 mg q 12 hrs 180 mg q 12 hrs (maximum dose) Xalatan (latanoprost) Ambien 5 mg Ambien 10 mg May interchange both in shortage situation Al, Mg, Simethicone XS Macrobid 100 mg bid Mag Ox 400 mg Mannitol 20 % 500 cc Altace 1.25 mg, 2.5mg, 5mg, 10mg, 20 mg (max) Imitrex 50 mg Imitrex 100 mg Diprosone 0.05% oint Lidex 0.05% crm, oint, soln No TI to Fortaz, call MD Naprosyn 500 mg tid Naprosyn 500 mg tid Sarna 5% 8/6/13 10/12 7/2010 Doribax 500 mg IV q 8 hrs Lipitor 10 mg (total daily dose administered q am) Lipitor 20 mg (total daily dose administered q am) Cozaar (losartan) 25mg, 50 mg, 100 mg Doxycycline 100 mg IV q 12 hrs Naprosyn 375 mg, 500 mg bid MOM + MO Lisinopril 5 mg, 10 mg, 20 mg Lisinopril 40 mg Dilaudid IV for non-ICU surgical patients (during shortage) 0.25-0.5 mg IV q 3 hrs prn severe pain DC Morphine, order Dilaudid 0.25 mg IV q 3 hrs prn severe pain Humibid LA See Vitamin Chart at the end of this document MVI in hyperal q M, W, F during shortage Maalox XS Oxacillin Naprosyn 375 mg bid Naprosyn 500 mg bid Namenda XR (memantine) 7 mg po q day 3/7/2016 9/4/12 9/4/12 11/1/10 12/11/12 01/06/15 10/2013 03/2014 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B 5 mg po bid 5 mg po q am, 10 mg po q pm 10 mg po bid Naprosyn 250 mg bid Nasacort (triamcinolone) Nasarel (flunisolide) Nasonex (mometasone) Nature’s Tears (hypromellous) 0.4% NeoCortef 1% ointment Neodecadron crm Nephrocap Neupogen (filgastrim) Nexium PO: 20mg, 40 mg IV: 20mg, 40 mg (daily or bid) Tube: 20mg, 40 mg Niacor, Nicotinic acid short acting Niaspan, Nicotinic acid ER Niferex- 150 Norflex 100 mg bid Norflex 50 mg tid Noroxin 400 mg bid Novolin 70/30 Novolin N Novolin R NovoLog Novolog mix 70/30 Ocuflox eye drops Ofirmev (acetaminophen IV) any dose Optison (perflutren) Orudis 50 mg q6h or 75 mg tid or Oruvail 200 mg daily Oxacillin IV Oyster Shell Calcium Pancreatic Enzymes Parafon Forte DSC 500 mg tid/qid Parafon Forte DSC 750 mg tid Parafon Forte DSC 750 mg qid Paxil CR 12.5 mg , 25 mg, 37.5 mg q day PBs (premixed) q12h or q24h in dextrose PD (Peritoneal Dialysis) fluids: Low magnesium Page 9 of 18 14 mg po q day 21 mg po q day 28 mg po q day Naprosyn 375 mg bid Flonase (fluticasone) 2 sprays in each nostril daily Flonase (fluticasone) 2 sprays in each nostril daily Flonase (fluticasone) 2 sprays in each nostril daily Refresh (carboxymethylcellulose) 1% Cortisporin 1% ointment Neo-Synalar crm Renovite Granix (or Granix to Neupogen, whichever in stock) PO: Prilosec 20 mg, 40 mg except if on Protonix po or drug interaction) IV: Protonix 20mg, 40 mg (daily or bid) Tube: Prevacid 30mg, 60 mg ODT Niacin (same dose) Slo-Niacin (same dose) Ferrous Sulfate 300 mg tid (60mg Fe Flexeril 10 mg tid Flexeril 10 mg bid Cipro 250 mg bid Humulin 70/30 Humulin N Humulin R Humalog Humalog 75/25 Ciloxan eye drops 1 gm IV q 6 hrs x 2 doses in Post-op patients only (not prn) If < 50 kg, or 2-12 y/o, use 15 mg/kg IV q 6 hrs x 2 doses Definity (perflutren), use orders # 27027 Naprosyn 500 mg tid Naprosyn 500 mg tid Nafcillin IV Oyster Shell Calcium with Vit D New starts will be to Pancreaze (Will not stock Creon, Zenpep- use patietn’s own supply) Flexeril 10 mg tid Flexeril 10 mg tid Flexeril 10 mg qid Paxil 10 mg, 20 mg, 40 mg q day Keep in dextrose (even diabetic pts) PD (Peritoneal Dialysis) fluids: High magnesium 3/7/2016 5/1/12 5/1/12 5/1/12 8/7/12 12/2013 11/15/10 7/2014 10/2014 9/7/10 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Pepcid IV (during shortage) 20 mg IV bid Protonix IV 40 mg IV q 24 hrs Pepcid IVPB or continuous infusion Pepcid and PPI together Percocet 20mg (10mg x 2 tabs) Percocet- No strength indicated Percodan Peri-colace Phazyme 95 and 125 Phenylephrine eye drops Phosphate Plamanate Post-op Prophylactic antibiotics “x 3 doses” Potassium PPF (plasmanate) Pramosone 1% crm, oint, lotion Pramosone 2.5% crm, oint, lotion Prevacid PO: 15-30mg, 60 mg IV: none, use Protonix Tube: use Prevacid ODT Prilosec po Primaxin 500 mg, 750 mg, 1gm IV any interval 250 mg IV any interval Pristiq 50 mg, 100 mg Probiotic Procardia 10 mg (short-acting, immediate release) Pepcid IV push over 2 minutes DC PPI unless it is patient’s home med, policy 7300-IV-50 Must call MD (obtain new order for oxycodone plus APAP) Percocet 5 mg (the 5mg is the default strength) Percocet Senekot-S Phazyme 180 During shortage situations: Cyclomydril eye drops Must follow P&T guidelines Albumin 5% Change to “x 2 doses” to not exceed 24 hrs Must follow P&T guidelines Albumin 5% Hydrocortisone 1% cream, oint Hydrocortisone 2% crm or lotion Procrit dose in ESRD Profilnine (3 F-PCC), but will use up current stock Prosom Protonix PO: no TI IV: no TI Tube: 20mg, 40mg, use Prevacid ODT Protonix 40 mg “bid” Page 10 of 18 5/2014 11/1/10 9/2/14 11/15/10 PO: Protonix 20mg, 40 mg IV: Protonix Tube: Prevacid ODT Protonix po Merrem, usual dose 1-2 gm q 8 hrs, 9/2/14 2013 Adjust for CrCl per 7300-VII-40A Effexor XR 37.5mg, 75 mg Culturelle CALL MD due to increased risk of arrythmias, MI & stroke. ALTERNATIVES: Capoten 12.5mg-25mg po q8h prn (onset 5-25min) Catapres 0.1-0.2mg po X 1, then 0.1 mg q1h to max 0.8mg (onset 30-60 min) Vasotec 1.25mg IV over 5 min then q6h prn (onset 15 min) Normodyne 20 mg IVP over 2 min, then 40-80mg q 10 min (onset 5-15 min) Lopressor 2.5-5mg iv q6h Max of 30,000 units per week Kcentra (4-F- PCC) 3/2014 10/2013 Restoril 15mg-30mg (if pt >65yo then 15mg) 11/15/10 PO: dispense as ordered IV: use Protonix Tube: Prevacid ODT 30mg, 60 mg Change to “Q Day”. Exceptions: GI Bleed or “bid is patient’s home dose regimen 3/7/2016 11/2015 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Protonix IV …during shortage 40 mg IV q day Or 40 mg IV bid Use Protonix PO if possible. If not possible, use: Pepcid 20 mg IV bid (adjust for renal as needed) Provigil 100mg, 200mg Psorcon 0.05% cream PV Tussin (hydrocodone) Qvar Inhaler 40 mcg 1-2 puffs bid 80 mcg 1 puff bid 160-320 mcg 1-2 puffs bid Rapaflo (silodosin) 8 mg q day Relafen 1000 mg daily Relafen 750 mg or 1000 mg bid Relafen 1500 mg or 2000 mg daily Remeron (mirtazapine) Solutabs Renagel (sevelamer hydrochloride) Restoril 30 mg in pt > 65yo Rhinocort (budesonide) Risperdal 0.5mg, 1mg, 2mg Robitussin CF Nuvigil 150 mg, 250 mg Temovate 0.05% cream Hycodan (hydrocodone & homatropine) Flovent Inhaler 44 mcg 1-2 puffs bid 110 mcg 1 puff bid 110 mcg 2 puffs bid (max dose) Flomax (tamsulosin) 0.4 mg q day Naprosyn 375 mg bid Naprosyn 500 mg tid Naprosyn 500 mg tid Use generic mirtazapine (7.5mg is no longer manufacturered) Renvela (sevelamer carbonate) Restoril 15mg Flonase (fluticasone) 2 sprays in each nostril daily Risperdal-M 0.5mg, 1mg, 2mg (Orally disintegrating tablets) Call MD- recommend (psuedoephedrine + Cardec DM) + Robitussin Call MD- recommend pseudoephedrine + robitussin Rocephin 250mg,500mg,750mg q24h (if dosing 50mg/kg round up; if dosing 100mg/kg round down) Rocephin 1gm q24h Exception: meningitis (2 gm q 12 hrs or 2 gm q 24 hr is ok) Exception: ID Physician may orders 2gm dose (most likely will be for osteomyelitis (bone and joint infections) or morbidly obese patients. Ativan 0.5mg, 1mg, 2mg Serevent Discus 1 puff bid Niacin ER plus simvastatin Singulair 5mg Theo-Dur 100 mg, 200 mg , 300 mg bid Niaspan 500 mg qhs Slo-bid 125 mg bid Theo-Dur 200 mg bid If patients unable to replace via enteral route, give NaPO4 for PO4 < 2 and K > 4. If K < 4, use KPhosp IV 10/5/10 For patients on Electrolyte Replacement Protocol when IV Phos replacement is necessary 12/13 (ASAP approval Robitussin PE Rocephin < 1g in PEDS (any interval) Rocephin (Adults and Peds) 1 -2 gm q 12 hrs Or 2gm q 24 hrs Serax 10mg, 15mg, 30mg Serevent MDI 2 puffs bid Simcor (combo, use individual ingredients) Singulair 4mg Slo-bid 100 mg, 200 mg, 300 mg bid Slo-Niacin (any dose) Slo-Phyllin 125 mg bid Slo-Phyllin 250 mg bid Sodium Phosphate IV (during shortage) Page 11 of 18 3/7/2016 9-3-13 8/13/13 09/2015 9/8/09 5/1/12 8/6/13 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Solu-Medrol IV ≤ 60 mg /day Sonata (zaleplon) Surfak Synalar 0.01% crm or soln Synalar 0.025% oint Tablets Tagamet 200mg-400mg bid, tid or qid Tagamet 800 mg Tagamet IV any dose any interval Terazol 7 Terbutaline (Brethine) Tetevan (eprosartan) 200mg, 200-400mg, 600mg, 800mg Theo 24 100 mg Theo 24 200 mg Theo 24 300 mg Theo-Dur sprinkles Theophylline** IV drip in any soln other than D5W Theravac Plus mini-enemas Throat sprays and lozenges Tiazac Titralac Tobi (tobramycin) for inhalation (nebulizer) Topicort 0.05% gel Topicort 0.25% cr or oint Topicort LP 0.05% crm Toradol Toradol 30 mg (>65yo, crcl<50,wt<50kg) Page 12 of 18 PO4 = 1.6-2.4 and K+ < 4.5: Potassium Phosphate 15 mM IVPB over 4 hours may be substituted. PO4 < 1.5 and K+ < 4.2: Potassium Phosphate 30 mM IVPB over 6 hours may be substituted. If KCl run is ordered concurrently, omit 20 mEq KCl IV/po for every 15 mM of KPhos. Check to see how much KCl has already been administered. If K+ parameters are outside limits, call MD for alternative instructions. Write order to clarify and coordinate changes between nursing and pharmacy. Predinsone 60 mg po q day Ambien (zolpidem) Colace Tridesilon or Desowen 0.05% Kenalog 0.025% oint,crm,lotion Orally disintegrating tablets if same strength is available Pepcid 20 mg bid Pepcid 40 mg qhs Pepcid IV 20 mg q12h Miconozole (monistat) 7 Only allowed in GWP, call MD & suggest albuterol Cozaar (losartan) 25 mg , 25mg, 50 mg, 100 mg No TI Theophylline 100 mg bid Theophylline 150 mg bid No TI, use elixir D5W for diluent (even diabetic pt) **exception for Drs Weinberg, McGann, Sineway and Kaplan Enimeez mini-enemas (this has no benzocaine) Must be unit dosed. Cepacol spray and lozenges Cardizem CD Tums Use Tobramycin vials, same dose Lidex 0.05% oint Lidex 0.05% crm, oint Lidex 0.05% crm 5 day stop and must follow guidelines Toradol 15 mg (max 60mg/day) 3/7/2016 from P&T Chairs) 01/06/15 11/1/10 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Toradol 60 mg IM (followed by IM doses) Toviaz Toradol 30 mg (followed by IM doses) Detrol LA, not to exceed 2mg in patients taking strong CYP3A4 inhibitors or if CrCl < 30. 12/11/12 Trace element package in TPN during shortage Tracleer (bosentan) Addamel N (European product, approved by FDA) 10/2013 Transderm Nitro patch Travatan 0.004% (travoprost + benzalkonium) Or Travatan Z 0.004% (travoprost) Tricor 54 mg, 160 mg Tridesilon 0.05% oint Triglide 50 mg, 160 mg Trilipix 45mg, 135 mg Tube feedings Tussinex (hydrocodone & phenytoloxamine) Tussi-organidin DM Tuss-Organidin Tylox Ultracet Ultravate 0.05% cr or oint Unasyn (ampicillin/sulbactam) IV shortage During the shortage, call physician. No TI Nitro-Dur patch Xalatan (latanoprost) Uniphyl 400mg daily, 600mg daily Univasc 15 mg and 22.5 mg Univasc 3.75 mg, 7.5 mg, 30 mg, 60mg Urised, 2 tabs (atropine, methenamine, hyoscyamine, methylene blue, benzoic acid) Uroxatrol (alfuzosin) 10 mg po q day Urso 250mg Utira-C Valisone 0.1% crm or lotion Valisone 0.1% oint Vancomycin post op orders “x 2 doses” Vasolex ointment (DC by manufacturer) Vasotec Vasotec IV Page 13 of 18 Patient to use their own home med if possible. No new starts allowed. 8/6/13 See Fenofibrate Kenalog 0.025% oint,crm,lotion See Fenofibrate See Fenofibrate See chart at end of this document Hycodan (hydrocodone & homatropine) Robitussin DM (generic interchange) Robitussin AC (generic interchange) Percocet Ultram 50mg plus Acetaminophen 325mg Temovate 0.05% cr or oint Only during a shortage of Unasyn, call MD and recommend: Gynecological, use Mefoxin or Rocephin + Flagyl Intra-abdominal, use Mefoxin or Rocephin + Flagyl (or Invanz alone if Cephalosporin allergy) Skin and Soft Tissue, use Ancef (or Invanz alone if Cephalosporin allergy) Head and Neck, use Cleocin Theophylline 200mg bid, 300mg bid Altace 5 mg Altace 1.25 mg, 2.5 mg, 10 mg, 20mg (max) Uribel (methenamine, phosphate , hyoscyamine, methylene blue) Flomax (tamsulosin) 0.4 mg po q day Actigall 300mg Uribel (methenamine, phosphate , hyoscyamine, methylene blue) Kenalog 0.025% oint,crm,lotion Diprosone 0.05% oint Vancomycin post op doses “x 1 dose” Venelex (trypsin free) ointment Lisinopril – same dose Formulary- dispense 3/7/2016 9/4/12 9/4/12 9/4/12 9-3-13 09/2015 12015 02/11 9/2015 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Venofer 100mg Venofer 200mg Veramyst (fluticasone) Verelan 120 mg po qAM 180 mg po qAM 240 mg po qAM 360 mg po qAM 480 mg po qAM Verelan PM 100 mg po qHS 200 mg po qHS 300 mg po qHS 400 mg po qHS Vigamox eye drops 3% Vitamins Vitamin K route: IM or Sub Q (EXCEPTION: Neonates may receive IM) Voltaren 25mg-50mg q6-8h Voltaren XR 75 mg bid Vytorin (combo, use individual agents) Wellbutrin SR Westcort 0.2% crm or lotion Xanax XR –Daily (same total daily dose) Xifaxan (rifaximin) 400 mg tid Xopenex q 2hrs, q 4 hrs Xyzal (levocetirizine) 5 mg daily Zantac IV 150mg/day (ie 50mg q8h or LV) Zantac PO 75mg any interval Zantac PO 150, 300 mg Zinacef (750mg-1.5mg q 8hr) Zofran po Zomig 2.5 mg, 5 mg Zosyn any dose for CrCl > 20 Zyban Zyrtec 5 or 10 mg daily Zytrec D Ferrlicet 125 mg in 100ml NS over 1 hr Ferrlicet 250mg in 150-200 ml NS over 2 hrs Flonase (fluticasone) 2 sprays in each nostril daily 10/09 10/09 5/1/12 8/14 Verapamil ER capsules 120 mg po qAM Verapamil ER capsules 180 mg po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM Verapamil ER capsules 480 mg (2 x 240 mg) po qAM 8/14 Verapamil ER capsules 120 mg po qAM Verapamil ER capsules 180 mg po qAM Verapamil ER capsules 300 mg (1 x 120 + 1 x 180 mg) po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM Ciprofloxacin eye drops 3% See chart at end of this document If ordered IM and patient is npo, give SQ. If ordered IM and patient can take orals, give po Naprosyn 500 mg bid Naprosyn 500 mg bid Zetia plus simvastatin Wellbutrin XL (same total dose, administered q day) (maximum of 400mg/day) Kenalog 0.025% oint,crm,lotion Xanax tid (same total daily dose) Xifaxan 550 mg bid Q 6 hrs Allergra 180 mg daily. Pepcid IV 20 mg q12h Pepcid 10mg bid Pepcid 20 mg bid, 40 mh q hs Rocephin 1gm q 24hr Using ODT exlusively Imitrex 50 mg, 100 mg Zosyn 3.375 gm q 8 hr over 4 hrs if CrCl is > 20 Wellbutrin SR Claritin 10 mg Claritin D 10/12 9/4/12 5/10/11 9/8/09 12/09 Verapamil products: do not stock SR tablets Calan Verapamil IR same dose and schedule Page 14 of 18 8/14 3/7/2016 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Isoptin Calan SR 120 mg po daily 180 mg po daily 240 mg po daily 360 mg po daily 120 mg po BID 180 mg po BID 240 mg po BID Isoptin SR 120 mg po daily 180 mg po daily 240 mg po daily 360 mg po daily 120 mg po BID 180 mg po BID 240 mg po BID Covera-HS 180 mg po qHS 240 mg po qHS 360 mg po qHS 480 mg po qHS Verelan 120 mg po qAM 180 mg po qAM 240 mg po qAM 360 mg po qAM 480 mg po qAM Verelan PM 100 mg po qHS 200 mg po qHS 300 mg po qHS 400 mg po qHS If “Per tube” Verapamil IR same dose and schedule (same total daily dose given qAM) Verapamil ER capsules 120 mg po qAM Verapamil ER capsules 180 mg po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM Verapamil ER capsules 480 mg (2 x 240 mg) po qAM (same total daily dose given qAM) Verapamil ER capsules 120 mg po qAM Verapamil ER capsules 180 mg po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x180 mg) po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM Verapamil ER capsules 480 mg (2 x 240 mg) po qAM 8/14 8/14 Verapamil ER capsules 180 mg po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM Verapamil ER capsules 480 mg (2 x 240 mg) po qAM 8/14 Verapamil ER capsules 120 mg po qAM Verapamil ER capsules 180 mg po qAM Verapamil ER capsules 240 mg po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM Verapamil ER capsules 480 mg (2 x 240 mg) po qAM 8/14 Verapamil ER capsules 120 mg po qAM Verapamil ER capsules 180 mg po qAM Verapamil ER capsules 300 mg (1 x 120 + 1 x 180 mg) po qAM Verapamil ER capsules 360 mg (2 x 180 mg) po qAM 8/14 ER 480 mg = immediate release 120 mg (1 x 80 mg + 1 x 40 mg tab) QID ER 360 mg = immediate release 120 mg (1 x 80 mg + 1 x 40 mg tab) TID ER 240 mg = immediate release 80 mg tab TID ER 180 mg = immediate release 60 mg (1 and ½ X 40 mg tab) TID ER 120 mg = immediate release 40 mg tab TID Page 15 of 18 8/14 8/14 3/7/2016 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Enteral and Tube feeding TI Chart Nonformulary Boost Ensure Plus Ensure Ensure Pudding Fibersource Glytrol oral Glucerna oral Glytrol HepaticAid oral Hepatic Aid TF Impact Glutamine Impact Isosource 1.0 Isosource 1.2 Jevity oral Nutren 1.0 TF Nutren 1.0 oral Nutren 2.0 Nutren Jr. oral Nutren Jr. TF Nutren Pulmonary TF Nutren Pulmonary Oral Nutren Renal Nutrihep oral Nutrivent Optimental Peptamen Promod Pivot Pulmocare oral Pulmocare TF Replete oral Suplena TwoCal HN oral Vital HN oral Vivonex Page 16 of 18 Formulary Ensure Complete Ensure Complete Ensure Complete Ensure Pudding Jevity 1.2 Glucerna Shakes Glucerna Shakes Glucerna 1.2 Osmolite Osmolite Vital High Protein Vital High Protein Osmolite Osmolite Ensure Complete Osmolite Ensure Complete TwoCal HN Pediasure Pediasure Osmolite Osmolite Nepro Osmolite Osmolite Vital AF 1.2 Vital AF 1.2 Beneprotein Vital High Protein Ensure Complete Osmolite Ensure Complete Nepro TwoCal HN cans Vital AF 1.2 cans Vital AF 1.2 3/7/2016 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B Inhalation Medication TI (see policy 7300-VII-60) Ordered: Spiriva (tiotropium) - If home medication: - If not a home medication: Atrovent (ipratropium) and Spiriva (tiotropium) Brovana (arformoterol) Dispense: - Continue Spiriva as ordered Therapeutic Interchange to Atrovent 0.5 mg qid DC Spirivia, continue Atrovent - Administer bid with a prn order for albuterol/atrovent If patient’s respiratory status deteriorates and requires > q 4 hrs albuterol/atrovent, DC Brovana and notify physician. DC beta-2 agonists: Serevent (salmeterol), Foradil (formoterol), Brovana (arformoterol), Symbicort (budesonide & formoterol) - Advair (fluticasone & salmeterol) and Other long-acting beta-2 agonists Intal (cromolyn) - If home medication: - If not a home medication: Xopenex (levalbuterol) - Pulmicort (budesonide) and Flovent (proprionate) Mucomyst (acetylcysteine) and Neut (4% sodium bicarbonate ) or Pulmozyme (dornase) - Page 17 of 18 - - Continue Intal (cromolyn) as ordered DC Intal (cromolyn) Administer q 6 hrs W/A and prn. If patient requires shorter frequency, the RC Therapist will notify physician and suggest conversion to albuterol. DC Flovent, continue Pulmicort. DC Mucomyst, continue Neut or Pulmozyme Do not mixed Pulmozyme with other nebulizable medications. Also administer separately in the nebulizer. 3/7/2016 Therapeutic Interchange List Alphabetical Listing Revised 01-2016 See related Restricted Medications, 7300-VII-10, Attachment B VITAMIN and IRON chart Vitamins/Iron Product VITAMINS Multi NON-FORMULARY Examples of non-form products MD might order (use TI to left of product) T.I. (Therapeutic Interchange) Centrum, Ocuvite, Ocuvite with lutein any standard Multivitamin Centrum silver, Optivite, any multivitamin with minerals Thera-Tab B-12 and/or intrinsic factor Folic Acid and/or IRON Chromagen** Ferrex Forte 150 PRENATAL-Calcium and IRON RENAL B complex w/ C vitamin (stress/substance abuse) Iron products (no vitamin component) Stuartnatal 1+1, any prenatal vitamin Prenatal Plus Nephrocap, Metanx, Dialyvite, Diatx, Nephplex Nephro-vite Folbee CZ Geriatric or Minerals Thera-M Hemocyte F, Chromagen FA**, Folbic, Folbee, Foltx, Hemocyte Plus, Hemocyte F, Proferrin Forte, Ferocon, Niferex 150 Forte Vicon C (discontinued), Allbee C Also see Vitamin with iron products above Proferrin ES Ferrous Sulfate 325 mg (65 mg elemental iron) OR Ferrous Gluconate (27 mg elemental iron) * Chewable form available for plain and prenatal MVI ** Trinsicon, Chromagen and Chromagen FA are no longer made by the manufacturer Page 18 of 18 3/7/2016
