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SCHC Formulary 2005

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Table of Contents

Analgesics 4 Antipyretics 4 Skeletal Muscle Relaxants 7 Cox-2 Inhibitors 4 Rheumatoid Arthritis Agents 7 Local Anesthetics 4 Triptans 7 NSAIDs 5 Urinary Analgesics 7 Opioids 6 Anti-Infectives 8 Antihelmintics 8 Miscellaneous 10 Antifungals 8 Penicillins 11 Antivirals 9 Quinolones 12 Cephalosporins 9 Sulfonamides 12 Macrolides 10 Tetracyclines 12 Cardiovascular 13 ACE Inhibitors 13 Cardiac Glycosides 16 ARBs 13 Antianginals 16 Diuretics 14 Blood Modifiers 17 ACE/Diuretic Combos 14 Statins 18 Alpha-1 Blockers 15 Fibrates 18 Central Alpha Blockers 15 Miscellaneous 18 Beta Blockers 15 ACE/Statin Combinations 18 CCBs 16 Dental 19 Dermatology 20 Acne Preps 20 Antivirals 22 Antibiotics 20 Diaper Rash 22 Anorectal Preparations 21 Emollients 22 Antifungals 21 Keratolytics 23 Anti-Inflammatory 22 Scabicides/Pediculicides 23 Antiseborrheics 22 Vaginal Preps 23 Diabetes 24 Oral Antidiabetics 24 Supplies 25 Insulin 25

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Table of Contents Endocrine 26 Antigout 26 Thyroid Agents 26 Corticosteroids 26 Vitamins/Electrolytes 27 Osteoporosis Agents 26 ENT 28 Antihistamines 28 OticsCough Preps 29 Antihist/Decongest 29 Cough Preparations 30 GI 31 Antacids 31 Cathartics 32 Antidiarrheals 31 H2 Antagonists 33 Antiemetics 32 ProtonPump Inhibitors 33 HIV 34 Appetite Stimulants 34 NNRTIs 34 NRTIs 34 Protease Inhibitors 34 Neurology 35 Anticonvulsants 35 Migraine Agents 36 AntiParkinson Agents 36 OB/GYN 37 Contraceptives 37 Progestins 37 Estrogens 37 Opthamology 38

Psychiatry 39 Antidepressants 39 Sedatives/Hypnotics 41 Psychotherapeutics 40 Pulmonary 42 Antiasthmatics 42 Inhalants 42 Urology 43 Enuresis/Incontinence 43 Erectile Dysfunction 43

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ANALGESICS COST TO PATIENT

SCHC Formulary

ANTIPYRETICS 1) acetaminophen (Tylenol) 325mg 500mg 160mg/5ml 80mg/0.8ml 2) aspirin 81mg EC 325mg 325mg EC 3) tramadol (Ultram) 50mg 4) butalbital/APAP/caffeine (Esgic) 50/325/40mg

COX II INHIBITOR 1)*Celebrex (celecoxib) 100mg 200mg

LOCAL ANESTHETICS 1) lidocaine 2% (Viscous Xylocaine)

120 –6.15 120 –4.85 120ml – 4.55 30ml – 6.15 30 - 4.19 30 – 4.15 30 – 4.35 30 - 6.79 30 –8.05 60 – 91.09/$6.00 60 – 151.05/$6.00 100ml – 12.75

ANALGESICS

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ANALGESICS COST TO PATIENT

SCHC

Formulary

NSAIDS (NONSTEROIDAL ANTI-INFLAMMATORY DRUGS)

1) Children’s Motrin (ibuprofen) 100mg/5ml susp 2) ibuprofen (Motrin) 400mg 600mg 800mg 3) indomethacin (Indocin) 25mg 5) naproxen (Naprosyn) 375mg 500mg 6) nabumetone (Relafen) 500mg 4) piroxicam (Feldene) 20mg

120ml – 7.15 90 – 7.65 90 – 8.29 100 – 9.95 30 – 6.65 60 – 9.79 60 – 10.05 30 –14.59 60 – 8.05

ANALGESICS

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Analgesics

ANALGESICS COST TO PATIENT

SCHC

Formulary

OPIOIDS 1) hydrocodone/APAP (Vicodin) 5/500mg (Lorcet) 10/650mg 2) propoxyphene napsylate/APAP (Darvocet-N 100) 100/650mg 3) APAP w/codeine (Tylenol #3) 300/30mg 120/12mg/5ml elixir 4) oxycodone/APAP 5/500mg 5) methadone 5mg 10mg 6) morphine sulfate ER 15mg 30mg 7) Duragesic patch (fentanyl) 25mcg 50mcg 75mcg

30 – 6.85 30 – 8.05 30 – 6.75 30 – 7.75 120ml – 7.55 30 – 6.95 60 – 10.05 60 – 12.05 60 – 14.55 60 – 63.65 5 – 57.35 5 – 128.75 5 – 115.09

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ANALGESICS COST TO PATIENT

SCHC

Formulary

RHEUMATOID ARTHRITIS

AGENTS 1) methotrexate (folic acid antagonist) 2.5mg

SKELETAL MUSCLE RELAXANTS

1) carisoprodol (Soma) 350mg 2) cyclobenzaprine (Flexeril) 10mg 3) methocarbamol (Robaxin) 750mg

TRIPTANS 1) Imitrex (sumatriptan) 50mg 100mg 2) *Relpax (eletriptan) 20mg 40mg

URINARY ANALGESICS 1) phenazopyridine (Pyridium) 200mg

30 – 11.65 100 –10.49 100 –8.39 100 –14.45 9 -197.45 9 -197.45 $6.00 12 -181.85 / $6.00 6 – 6.05

Analgesics

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Antibiotics

ANTI-INFECTIVES COST TO PATIENT

SCHC

Formulary

ANTIFUNGALS 1) nystatin (Mycostatin) 100,000 units/ml susp 2) GrifulvinV (griseofulvin) 125mg/5ml susp 3) Mycelex (clotrimazole) 10mg troches 4) fluconazole (Diflucan) 100mg 150mg 5) Lamisil (terbinafine) 250mg

ANTIHELMENTIC 1) mebendazole (Vermox) 100mg

60ml – 18.69 120ml – 51.56 30 – 62.49 14 – 9.69 (14 –111.95) 1 – 5.99 30 – 165.99 1 – 9.75

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Antibiotics

ANTI-INFECTIVES COST TO PATIENT

SCHC

Formulary

ANTIVIRALS 1) amantadine (Symmetrel) 100mg 50mg/5ml 2) acyclovir (Zovirax) 400mg 3) Valtrex (valacyclovir) 500mg 1000mg

CEPHALOSPORINS

1st Generation 1) cephalexin (Keflex) 250mg 125mg/5ml susp 250mg/5ml susp

2nd Generation 1) Ceftin (cefuroxime) 250mg 500mg 2) Cefzil (cefprozil) 250mg/5ml

20 – 7.95 120ml – 11.15 50 – 18.59 10 – 23.19 21 – 45.05 40 – 9.79 200ml – 16.19 200ml – 19.35 20 – 33.35 20 – 62.35 100ml – 90.55

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Antibiotics

ANTI-INFECTIVES

COST TO PATIENT

SCHC

Formulary

MACROLIDES 1)Ery-Tab (erythromycin base, enteric coated) 250mg 333mg 500mg 2) E.E.S. (erythromycin ethylsuccinate) 200mg/5ml susp 400mg/5ml susp 3) E.E.S. w/sulfisoxazole (Pediazole) 200/600mg/5ml 4) *Zithromax (azithromycin) 250mg Z-pack Tri-Pak 100mg/5ml 200mg/5ml

MISCELLANEOUS 1) clindamycin (Cleocin) 150mg 2) Macrodantin (nitrofurantoin) 100mg 3) metronidazole (Flagyl) 250mg 500mg

40 – 18.59 40 – 17.85 20 – 19.25 120ml – 8.09 120ml – 9.95 100ml - 12.29 200ml – 14.59 12 – 84.05 / $6.00 6 – 45.29 / $6.00 3 -45.29 / $6.00 15ml -32.55 / $6.00 15ml – 32.75 / $6.00 22.5ml -32.55 / $6.00 30ml -32.65 / $6.00 80 – 10.49 28 – 36.89 21 – 6.75 14 – 7.65

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Antibiotics

ANTI-INFECTIVES COST TO PATIENT

SCHC

Formulary

PENICILLINS 1) amoxicillin (Amoxil) 250mg chewable 500mg 125mg/5ml 125mg/5ml Amoxil 250mg 250mg/5ml 250mg/5ml 2) amoxicillin/clavulanate potassium (Augmentin) 500mg 875mg Augmentin XR 1000mg 400mg/5ml Augmentin ES 600mg/5ml Augmentin ES 600mg/5ml 3) dicloxacillin (Dynapen) 250mg 4) penicillin V K (Veetids) 250mg 500mg 125mg/5ml 250mg/5ml

30 – 10.89 30 – 6.65 100 –6.95 150 –6.79 30 –6.69 100ml – 6.79 150ml – 7.65 20 – 12.00 20 – 14.19 40 - 113.29 100ml - 34.95 125ml - 45.25 200ml - 75.89 40 – 10.25 40 – 8.09 40 –11.29 200ml – 8.29 200ml – 8.35

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Antibiotics

ANTI-INFECTIVES COST TO PATIENT

SCHC

Formulary

QUINOLONES 1) Cipro (ciprofloxacin) 500mg 2) Levaquin (levofloxin) 500mg

SULFONAMIDES 1) trimethoprim w/ sulfamethoxazole (SMZ-TMP, Bactrim) 800/160mg DS 400/80mg SS 200/40mg/5ml

TETRACYCLINES

1) doxycycline (Vibramycin) 100mg 2) tetracycline (Sumycin) 500mg

20 – 5.95 10 - 82.55 20 – 6.89 20 – 6.69 120ml – 10.15 20 – 6.65 40 – 7.85

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Cardiovascular

ANTIHYPERLIPIDEMIC AGENTS COST TO PATIENT

SCHC

Formulary

ACE INHIBITORS 1) quinapril (Accupril) 10mg 20mg 40mg *Accupril 5mg,10mg 20mg,40mg 2) enalapril (Vasotec) 5mg 10mg 20mg 3) lisinopril (Prinivil, Zestril) 5mg 10mg 20mg 30mg 40mg

ARBs 1) Cozaar (losartan) 25mg 50mg 2) Benicar (olmesartan) 20mg 40mg

30 – 28.55 30 – 28.35 30 – 28.39 90 – 6.00 90 – 6.00 30 – 5.85 30 – 6.75 30 – 6.75 30 – 6.89 30 – 8.25 30 – 7.65 30 – 10.45 30 – 10.25 30 – 12.95 30 – 40.75 30- 24.59 30- 28.75

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Cardiovascular

BLOOD MODIFIERS COST TO PATIENT

SCHC

Formulary

DIURETICS 1) furosemide (Lasix) 20mg 40mg 80mg 2) hydrochlorothiazide (HydroDiuril) 25mg 50mg 3) triamterene/HCTZ (Maxzide - cap) 37.5/25mg (Dyazide - tab) 75/50mg 4) spironolactone (Aldactone) 25mg 100mg 5)Zaroxolyn(metolazone) 5mg 6) Inspra (eplerenone) SHARING CARE ONLY

25mg 50mg

COMBINATION ACE/DIURETIC

1) lisinopril-HCTZ (Zestoretic) 10/12.5mg 20/12.5mg 20/25mg

30 – 6.59 30 - 6.25 30 – 6.95 30 – 6.55 30 – 6.65 30 – 6.69 30 – 5.99 30 – 10.29 30 – 22.35 30 – 15.89 6.00 6.00 30 – 10.05 30 – 8.35 30 – 11.15

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ANTIHYPERTENSIVES COST TO PATIENT

SCHC FORMULARY

Centrally Acting Antiadrenergic Agents

1) clonidine (Catapress) 0.1mg 0.3mg

ANTIADRENERGIC AGENTS

- ALPHA 1 BLOCKERS 1) doxazosin (Cardura) 2mg, 4mg 8mg *Cardura 2mg, 4mg, 8mg 2) terazosin (Hytrin) 2mg 5mg 10mg

BETA BLOCKERS - NONSPECIFIC

1) atenolol (Tenormin) 25mg 50mg 100mg 2) nadolol (Corgard) 20mg 3) propranolol (Inderal) 20mg 40mg

BETA AND ALPHA 1

BLOCKERS 1) labetalol (Normodyne) 200mg

BETA BLOCKERS -

CARDIOSELECTIVE 1) metoprolol (Lopressor) 50mg 100mg 2) Coreg (carvedilol) 3.125mg 6.25mg 12.5mg

90 – 10.29 90 – 11.55 30 – 6.15 30 – 11.15 90 – 6.00 30 – 12.49 30 – 12.49 30 – 12.49 30 – 6.55 30 – 6.65 30 – 7.59 60 – 15.95 60 – 7.69 60 – 8.39 30 – 9.59 60 – 8.25 60 – 6.99 60- 104.05 60- 104.05 60- 104.05

Cardiovascular

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Cardiovascular

SCHC

Formulary

CALCIUM CHANNEL BLOCKERS 1) diltiazem(Dilacor XR) 120mg 180mg 240mg 300mg 2) Nifediac CC(nifedipine) 30mg 60mg 90mg 3) Norvasc (amlodipine) 2.5mg 5mg 10mg

CARDIAC GLYCOSIDES

1) Digitek (digoxin) 0.125mg 0.25mg

ANTIANGINAL AGENTS 1) Nitrostat SL (nitroglycerin) 0.4mg 2) isosorbide dinitrate (ISDN) 20mg 3) isosorbide mononitrate ER (Imdur) 60mg

30 – 15.75 30 – 14.39 30 – 15.55 30 – 36.19 30 – 20.65 30 – 32.39 30 – 64.39 30 – 43.49 30 – 43.35 30 – 66.75 30 – 8.09 30 – 7.95 25 – 8.49 90 – 18.49 90 – 11.45

ANTIHYPERTENSIVES COST TO PATIENT

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SCHC Formulary

BLOOD MODIFIERS 1) warfarin (Coumadin) 1mg 2mg 2.5mg 3mg 4mg 5mg 6mg 7.5mg 10mg 2) Plavix (clopidogrel) 75mg 3) ferrous sulfate (elemental iron) 325mg (65mg) 220mg/5ml elixir (44mg) 75mg/0.6ml drops (15mg elem.) 4) ferrous gluconate 324mg(38mg elem.) 5) iron polysaccharide (Niferex) 150mg 6) pentoxifylline (Trental) 400mg

30 – 10.05 30 – 10.39 30 – 10.35 30 – 11.59 30 – 10.45 30 – 10.15 30 – 11.09 30 -- 11.05 30 – 10.45 30 - 99.35 100 – 5.59 120ml – 6.25 50ml – 9.79 100 – 7.29 60 – 7.85 90 – 14.59

ANTIHYPERTENSIVES COST TO PATIENT

Cardiovascular

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Cardiovascular

ANTIHYPERTENSIVES COST TO PATIENT

SCHC

Formulary

STATINS 1) *Lipitor (atorvastatin) 10mg 20mg 40, 80mg 2) Pravachol (pravastatin) 10mg 20mg 40mg 80mg 3) Zocor (simvastatin) 40mg 4) Lovastatin (mevacor) 20mg 40mg

FIBRATES 1) gemfibrozil (Lopid) 600mg

MISCELLANEOUS 1) Niaspan 500mg 2) cholestyramine powder (Questran) 378g can 3) Zetia (ezetimibe) 10mg

COMBINATION CALCIUM CHANNEL BLOCKER/

STATIN 1) *Caduet (amlodipine/atorvastatin) 5/10mg 5/20mg 5/40mg 5/80mg 10/10mg 10/20mg 10/40mg 10/80mg

30 – 64.95 / $6.00 30 – 98.89 / $6.00 30 – 98.89 / $6.00 30 – 53.39 30 – 54.99 30 – 63.25 30 – 82.59 30 -101.39 11.29 18.25 60 – 17.95 30 - 14.35 1 can – 32.09 30 - 75.89 30 – 101.39/$6.00 30 – 104.35/$6.00 30 – 104.35/$6.00 30 – 104.35/$6.00 30 – 102.55/$6.00 30 – 104.35/$6.00 30 – 104.35/$6.00 30 – 104.35/$6.00

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Dental

DENTAL PRODUCTS

COST TO PATIENT

SCHC

Formulary

1) chlorhexidine gluconate (Peridex) 2) Triamcinolone acetonide 0.1% dental paste 3) Prevident

16oz – 7.79 5gm – 8.35 51g – 14.00

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DERMATOLOGY

ACNE PREPARATIONS COST TO PATIENT

SCHC FORMULARY

TOPICALS 1) benzoyl peroxide Gel 5% 10% 2) clindamycin (Cleocin) 1% topical soln 3) Benzamycin gel 5-3%

ANTIBIOTICS 1) bacitracin oint 500u/g 2) Triple Antibiotic Oint. 3) silversulfadiazine (Silvadene) 1% crm 4) Bactroban 2% oint 2% cream 2% cream

45 g – 6.79 45 g – 6.95 60 ml – 7.75 47g – 34.95 30g – 4.79 30g – 9.59 85g – 11.45 22g – 22.05 15g – 32.19 30g – 57.89

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SCHC

Formulary

ANORECTAL PREPARATIONS

1) AnucortHC (hydrocortisone) 25mg supp.

ANTIFUNGALS 1) clotrimazole 1% crm 2) nystatin 100,000u/g cream Oint 2) Nystatin/Triamcinolone (Mycolog II) 100,000u/g 0.1% cream 3) Loprox Cream (ciclopir-oxolamine) 0.77% crm. 4) Lotrisone (clotrimazole/betamethasone) cream 5) ketoconazole (Nizoral) cream 2% shampoo

12 – 10.05 45g – 9.59 30g – 6.89 30g – 7.55 15g – 6.25 30g – 6.89 15g – 11.25 30g – 11.35 15g – 13.95 45g – 17.55 15g – 20.59 30g – 21.99 120 ml – 23.99

DERMATOLOGY COST TO PATIENT

Dermatology

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Dermatology

SCHC

Formulary

ANTI-INFLAMMATORY 1) betamethasone valerate (Valisone) 0.1% cream 0.1% ointment 2) hydrocortisone cream 0.5% 0.5% 1% 2.5% 3) clobetasol (Temovate) 0.05% scalp application 4) triamcinolone (Kenalog) 0.025% cr. 0.1% cream 0.1% cream 0.1% oint 0.1% oint

ANTISEBORRHEICS 1) selenium sulfide (Selsun) 2.5% susp.

ANTIVIRAL 1) Zovirax oint 5%

DIAPER RASH 1) A&D Oint

EMOLLIENTS/VEHICLS 1) Aveeno (colloidal oatmeal) 30g packets 2) Lanaphillic Ointment Plain w/10% urea

45 g – 8.19 45 g – 8.09 15g – 4.35 30g – 4.75 30 g – 4.75 20 g – 6.95 25 ml – 21.49 80 gm – 8.25 15 gm – 6.19 80 gm – 7.75 15 gm – 6.25 80 gm – 8.05 120 ml – 8.25 3g – 10.15 15g – 32.85 120 g – 7.55 8 – 12.50 454g – 14.65 454g – 16.19

DERMATOLOGY COST TO PATIENT

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Dermatology

SCHC

Formulary

KERATOLYTICS 1) Wart Remover (17% salicyclic

acid) liquid 2) Condylox Gel 0.5%

SCABICIDES/PEDICULICIDES

1) permethrin (Elimite) 2) Lindane (Kwell) Shampoo 3) Nix Shampoo (permethrin)

VAGINAL PREPARATIONS 1) clotrimazole 1% cream 2) Metro-Gel (metronidazole) 0.75% crm 3) miconazole (Monistat-7) 2% cream 4) Premarin (conjugated estrogens) vaginal crm

120 g – 8.25 120 g – 8.50 60 – 11.75 60ml – 97.45 59ml – 10.85 15g – 8.19 60 g – 9.59 70g – 15.95 30g – 7.65 45g – 9.55 42.5g – 28.35

DERMATOLOGY COST TO PATIENT

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Diabetes

ANTIDIABETIC AGENTS

(ORAL) COST TO PATIENT

SCHC

Formulary

BIGUANIDES 1) metformin (Glucophage) 500mg 850mg 1000mg ER (Glucophage XR) 500mg

SULFONYLUREAS

1) Glipizide ER (Glucotrol XL) 2.5mg 5mg 10mg 2) *Glucotrol XL (glipizide ER) 2.5, 5, 10mg 3) Glyburide 5mg

GLITAZONES

1) Avandia (rosiglitazone) 4mg 8mg 2) Actos (pioglitazone) 15mg 30mg 45mg

COMBINATIONS

1) glyburide/metformin (Glucovance) 2.5/500mg 5/500mg

60 – 11.25 60 – 13.99 60 – 15.85 60 – 8.49 30 – 12.49 30 – 12.75 30 – 19.15 90 – 6.00 30 – 7.69 30 – 78.59 30 – 141.35 30 – 36.85 30 – 140.55 30 – 129.75 60 – 26.25 60 – 31.79

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Diabetes

DIABETES COST TO PATIENT

SCHC

Formulary

INSULIN 1) Novolin N 2) Novolin R 3) Novolin 70/30 4) Novolog 5) Novolog 70/30 6) Novolog PenFills 7) Lantus

DIABETIC SUPPLIES 1) Alcohol Preps 2) Glucagon Kit 3) Monoject Syringes 0.5cc 1cc 4) Vitalet Lancets 5) Accu-Check Active Monitor 6) Accu-Check strips 7) NovoFine- 30 disposable needles

10ml – 17.65 10ml – 17.89 10ml – 18.05 10ml – 48.55 10ml – 54.95 15ml – 85.89 10ml – 46.29 100 – 5.09 1 – 64.95 100 – 18.05 100 – 15.15 100 – 9.55 1 – 19.15 50 – 22.99 100 – 40.59

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Endocrine

ENDOCRINE COST TO PATIENT

SCHC

Formulary

ANTIGOUT 1) allopurinol (Zyloprim) 100mg 300mg

CORTICOSTEROIDS 1) prednisone (Deltasone) 1mg 5mg 10mg 20mg 2) prednisolone (Prelone) 5mg/15ml liq. 3) Flonase (fluticasone) MDI (120 doses) 4) methylprednisolone (Medrol) Dosepak

OSTEOPOROSIS 1) Fosamax 70mg 2) Evista 60mg 3) Boniva 150mg

THYROID 1) Levothyroxine (Levoxyl) 0.025mg 0.05mg 0.075mg 0.088mg 0.1mg 0.112mg 0.125mg 0.137mg 0.15mg 0.175mg 0.2mg

30 – 6.85 30 – 8.25 30 – 10.15 30 – 6.09 30 – 6.55 30 – 6.79 120ml – 9.75 16gm – 35.55 21 – 7.59 4 – 65.89 30 – 70.45 1 -- 79.55 30 – 6.79 30 – 7.69 30 – 7.85 30 – 6.09 30 – 6.05 30 –5.89 30 – 6.09 30 – 6.19 30 – 6.19 30 – 5.99 30 – 6.19

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Endocrine

VITAMINS/ELECTROLYTES COST TO PATIENT

SCHC

Formulary

1) Calcium carbonate 600mg w/Vit. D 200 IU 2) Certagen (Centrum) 3) Children’s Chewable Vitamin animal shapes w/Fe 4) Folic Acid 1mg 5) Multivitamin tabs 6) NatalCare Plus 7) polyvitamin drops w/iron 8) potassium chloride 10mEq (Klor-Con) 20mEq (K-Dur) 9) Rocaltrol (calcitriol) 0.25mcg 10) Vitamin B1(thiamine)100mg 11) Vitamin B3(niacin) 500mg 12) Vitamin B6(pyridoxine) 50mg 13) Vitamin B12(cyanocobalamin) 1000mcg/ml MDV 14) Vitamin E 400 IU soft gel 15) Mephyton (vitamin K) 5mg tab

60 – 5.00 60 – 5.25 100 – 6.19 100 – 5.29 100 – 5.45 30 – 6.85 100 – 5.45 100 – 5.45 100 – 11.65 50 ml – 6.59 50 ml – 6.05 60 – 12.79 60 – 12.29 30 – 30.79 100 – 5.45 100 – 5.79 100 – 5.19 10 ml – 7.79 100 – 7.05 30 -- 24.69

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ENT

ANTIHISTAMINES COST TO PATIENT

SCHC

Formulary

1) chlorpheniramine (Aller-Chlor) 4mg

Controlled-release 12mg 2) diphenhydramine (Benadryl) 25mg 12.5mg/5ml elixir 3) meclizine (Antivert) 12.5, 25mg 4) hydroxyzine (Atarax) 25mg 10mg/5ml syr. 5) promethazine Syrup (Phenergan) 6.25mg/5ml 6) Zyrtec (cetirizine) 10mg 1mg/ml syrup

60 – 4.25 60 – 8.35 30 – 4.35 120ml – 4.45 30 – 6.59 30 – 14.75 120ml – 9.69 120ml – 8.45 30 – 59.45 120ml – 32.95

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ENT

ANTIHISTAMINE/DECONGESTANT COMBINATIONS

COST TO PATIENT

SCHC

Formulary

1) chlorpheniramine/pseudoephedrine (Deconamine SR) 120/8mg SR 2) carbinoxamine/pseudoephedrine (Cardec-S) 60/4mg/5ml syrup 25/2mg/ml oral drops AF,SF 3) Zyrtec D (cetirizine/pseudo.) 5/120mg

OTICS 1) A/B Otic Drops (Allergen) soln 2) neomycin/polymyx/HC (Cortisporin) susp Soln 3) Acetic Acid/HC Otic soln 4) Ear Wax Treatment Drops 5) Cipro HC (ciprofloxacin-hydrocortisone) susp

30 – 6.89 120ml – 10.25 30ml – 10.00 60 – 59.00 15ml – 6.85 10ml – 6.75 10ml – 14.75 10ml – 12.25 15ml – 6.89 10ml – 53.99

30 30

COUGH PREPARATIONS COST TO PATIENT

SCHC

Formulary

1) benzonatate (Tessalon Perles) 100mg 2) Cardec DM, Rondec DM (brompheniramine/PSE/DM) 60/4/15mg/5ml syrup 25/2/4mg/ml drops 3) Mucinex (guaifenesin LA) 600mg 4) Guaifenex DM (guaifenesin/DM) 600/30mg SR 1) Guiafenesin/DM (Guiatuss DM, Robitussin DM) 100/10mg/5ml 2) Deconsal II (guaifenesin/pseudoephedrine) 600/60mg SR 5) promethazine DM (Phenergan/DM) 6.25/15/5ml 7%ETOH 6) guaifenesin/codeine (Guiatuss AC, Robitussin AC) 100/10mg/5ml liquid SF 7) promethazine w/codeine (Phenergan w/codeine) 6.25/10mg/5ml 7%ETOH

30 – 16.25 120ml – 7.75 30ml – 8.49 40 – 13.55 30 – 7.65 120ml – 4.59 30 – 6.59 30ml – 7.75 120ml – 6.95 120ml – 8.05

ENT

31 31

GI COST TO PATIENT

SCHC

Formulary

ANTACIDS 1) Aluminum/magnesium/simethicone (Mylanta) 200/200/20mg/5ml susp

ANTIDIARRHEALS 1) Bismuth Chewable tabs 2) Genasyme (simethicone) 40mg/0.6ml drops 3) loperamide (Imodium) 2mg 4) diphenoxylate/atropine (Lomotil) 2.5/0.025mg 5) Pediatric Electrolyte Soln (Pedialyte)

360ml – 8.00 30 – 5.49 30ml – 8.25 30 – 6.79 30 – 8.19 1000ml – 6.09

GI

32 32

GI

GI COST TO PATIENT

SCHC

Formulary

ANTIEMETICS 1) meclizine (Antivert) 12.5, 25mg 2) prochlorperazine (Compazine) 5mg 25mg supp. 4) promethazine (Phenergan) 25mg 12.5mg supp 25mg supp 6.25mg/5ml 5) Marinol (dronabinol) 5mg

CATHARTICS 1) docusate sodium 100mg 2) magnesium citrate (Citroma) liquid SF 3) Milk of Magnesia susp 4) Vegetable Laxative Powder (psyllium hydrophilic mucilloid) 5) Colyte solution 6) Miralax 7) Enulose (lactulose)

30 – 6.59 30 – 6.25 12 – 40.85 20 – 9.99 12 – 24.55 12 – 26.69 120ml – 8.45 60 – 204.85 60 – 4.49 300 ml – 5.15 480 ml – 5.25 283g – 6.55 4L – 10.89 255g – 16.35 480ml -- 11.29

33 33

GI

GI COST TO PATIENT

SCHC

Formulary

H2 ANTAGONISTS 1) ranitidine (Zantac) 150mg

MISCELLANEOUS 1) bismuth subsalicylate (Pepto-Bismol) chew tab 2) dicyclomine (Bentyl) 10mg 20mg 3) metoclopramide (Reglan) 10mg 4) sucralfate (Carafate) 1gm

PROTON PUMP INHIBITORS 1) Prevacid (lansoprazole) 15mg 30mg 2) Protonix (rabeprazole) 40mg 3) Prilosec OTC 20mg

60 – 8.29 30 – 5.49 120 – 10.29 120 – 12.09 120 – 13.79 120 – 18.39 30 – 157.29 30 – 71.89 30 – 69.09 14 – 11.05

34 34

HIV MEDICATIONS COST TO PATIENT

SCHC FORMULARY

APPETITE STIMULANTS 1) Marinol (dronabinol) 5mg

NUCLEOSIDE REVERSE

TRANSCRIPTASE INHIBITORS 1) Combivir (lamivudine/zidovudine)

150/300mg 2) Epivir (lamivudine) 150mg 300mg 3) Videx EC (didanosine) 250mg 400mg 4) Trizivir (abacavir/lamivudine/zidovudine) 300/150/300mg 4) Zerit (stavudine) 20mg 40mg 5) Ziagen (abacavir) 300mg

NON-NUCLEOSIDE

REVERSE TRANSCRIPTASE INHIBITORS

1) Sustiva (efavirenz) 600mg 2) Viramune (nevirapine) 200mg

PROTEASE INHIBITORS 1) Norvir (ritonavir) 100mg SG 2) Viracept (nelfinavir) 250mg 625mg 3) Lexiva (fosamprenavir) 700mg 4) Crixivan (indinavir) 400mg

60 – 204.85 60 – 478.59 60 – 244.15 60 – 499.25 60 – 324.65 60 – 477.15 60 – 794.49 30 – 230.45 30 – 244.95 60 – 327.85 30 – 368.75 60 – 259.50 60 – 147.89 60 – 129.05 60 – 357.69 60 – 476.49 60 – 200.75

HIV

35 35

ANTICONVULSANTS COST

TO PATIENT

SCHC Formulary

1) phenobarbital 30mg 97.2mg 2) clonazepam (Klonopin) 0.5mg 1mg 3) carbamazepine (Tegretol) 200mg 4) primidone (Mysoline) 250mg 5) phenytoin ER (Dilantin) 30mg 100mg 50mg infatab 6) Depakote ER (divalproex) 250mg 500mg 7) valproic acid (Depakene) 250mg 8) gabapentin (Neurontin) 300mg 400mg 9) Lyrica (Pregabalin)

90 – 6.15 90 – 8.09 30 – 6.59 30 – 6.75 120 – 9.95 90 – 41.59 90 – 28.25 90 – 20.95 90 – 30.00 90 – 47.89 90 – 83.65 90– 27.99 90 – 14.55 90 – 12.95

Neurology

36 36

NEUROLOGY

NEUROLOGY COST TO PATIENT

SCHC

Formulary

ANTIPARKINSONIAN AGENTS 1) amantadine (Symmetrel) 100mg 50mg/5ml 2) Parlodel (bromocriptine) 5mg

MIGRAINE MEDICATIONS 1) butalbital/APAP/caffeine 50/325/40mg

60 – 12.35 120ml – 11.15 360 – 552.89 30 – 8.05

37 37

CONTRACEPTIVES

COST TO PATIENT

SCHC

Formulary

1) Alesse-28 2) Lo/Ovral 3) Nordette (Levlen) 4) Ortho-Cept (Desogen) 5) Ortho Evra Patch 6) Ortho Novum 35 7) Ortho-Novum 7/7/7 8) Ortho Tri-Cyclen 9) Triphasil

ESTROGENS 1) Premarin (conjugated estrogens) 0.3mg 0.625mg 0.9mg 1.25mg vaginal cream

PROGESTINS 1) medroxyprogesterone (Provera) 2.5mg 5mg 10mg

28 – 22.50 28 – 22.50 28 – 25.00 28 – 20.00 3 – 31.00 28 – 20.00 28 – 20.00 28 – 22.50 28 – 20.00 30 – 10.09 30 – 12.39 30 – 16.09 30 – 40.89 42.5gm – 28.35 30 – 6.25 30 – 6.25 10 – 5.85

OB/GYN

38 38

OPHTHALMOLOGY

OPHTHALMICS COST TO PATIENT

SCHC

Formulary

1) Artificial Tears 2) erythromycin oint 3) gentamicin (Garamycin) 3mg/ml soln 3mg oint 4) Naphcon-A (naphazoline) 5) Pred Forte (prednisolone) 1% soln 6) sulfacetamide opth (Sodium Sula-myd) 10% soln

15ml – 4.99 3.5gm – 8.00 5ml – 6.75 3.5mg – 18.75 15ml – 9.65 5ml – 16.39 15ml – 6.85

39 39

ANTIDEPRESSANTS

COST TO PATIENT

SCHC

Formulary

SSRIs 1) fluoxetine (Prozac) 10mg 20mg 3) Celexa (citalopram) 10mg 20mg 40mg 5) paroxetine (Paxil) 20mg 30mg 40mg 4) trazodone (Desyrel) 50,100mg 2) *Zoloft (sertraline) 50,100mg

TCAs 2) amitriptyline (Elavil) 10mg 25mg 50mg 75mg 100mg 3) imipramine (Tofranil) 50mg

S/NRIs 9) Effexor XR (venlafaxine) 75mg 150mg 2) Cymbalta (Duloxetine) 30mg 60mg

DRIs 1) Wellbutrin XL 150mg 300mg

30 – 5.95 30 – 6.85 30 – 10.05 30 – 7.95 30 - 6.95 30 – 10.49 30 – 14.19 30 – 17.89 30 – 6.85 30 – 70.95 / 90 – 6.00 30 – 6.15 30 – 6.19 30 – 6.55 30 – 6.85 30 – 6.88 30 – 12.35 30 – 71.95 30 – 78.29 30- 102.99 30- 102.95 30 – 76.39 / 90 – 6.00 30 – 99.29 / 90 – 6.00

Psychiatry

40 40

ANTIPSYCHOTICS COST TO PATIENT

SCHC

Formulary

1) lithium carbonate (Eskalith) 300mg 2) Risperdal (risperadone) 1mg 3mg

PSYCHOTHERAPEUTICS 1) Adderall (mixed salt amphetamines)

5mg 10mg Adderall XR 10mg 15mg 20mg 25mg 30mg 2) Metadate CD (methylphenidate) 20mg 3) methylphenidate (Ritalin) 5,10mg

90 – 7.75 30 – 70.15 30 – 145.59 30 – 18.05 30 – 21.35 30 – 77.55 30 – 79.95 30 – 77.75 30 – 78.59 30 – 77.75 30 – 24.69 30 – 6.79

Psychiatry

41 41

PSYCHIATRY

SEDATIVE/HYPNOTIC

AGENTS COST TO PATIENT

SCHC

Formulary

BENZODIAZEPINES 1) alprazolam (Xanax) 0.25mg 0.5mg 1mg 2) lorazepam (Ativan) 0.5mg 1mg 3) clonazepam (Klonopin) 0.5mg 1mg 4) diazepam (Valium) 5mg tabs

MISCELLANEOUS 5) buspirone (BuSpar) 5mg 15mg

NONBENZODIAZEPINE HYPNOTICS

6) Ambien (zolpidem) 5mg 10mg

30 – 5.95 30 – 5.95 30 – 6.95 30 – 6.19 30 – 6.79 30 – 6.59 30 – 6.75 30 – 6.59 30 – 6.75 30 – 8.29 30 – 46.99 30 – 57.29

42 42

COST TO PATIENT

SCHC Formulary

ANTIASTHMATICS 1) Singulair (montelukast) 5mg chew. 10mg

RESPIRATORY AGENTS 1) Aerochamber

INHALANTS

1) albuterol (Ventolin) MDI (200 doses) Syrup unitdose soln Soln 2) Advair Diskus (fluticasone/salmeterol) 100/50mcg 250/50mcg 500/50mcg 3) Atrovent (ipratropium) MDI (200 dose) 4) Combivent (ipratropium/albuterol) MDI (200 dose) 5) Flovent (fluticasone) 44mcg HFA MDI (120 dose) 110mcg HFA MDI (120 dose) 220mcg MDI (120 dose) 6) ipratropium bromide 2.5ml vial 7) Serevent (salmeterol) DISKUS (60 dose) 8) theophylline (Theo-Dur) 200mg 300mg

30 – 109.89 30 – 78.49 1 unit – 45.25 17 g – 14.75 120ml – 10.99 25x3ml – 9.75 20ml – 9.85 1 disk – 111.05 1 disk – 140.55 1 disk – 185.09 14.7g – 28.39 14.7 g – 41.25 10.6g – 71.55 12g – 93.05 13 gm – 72.99 25 vials – 15.75 1 Diskus – 69.55 90 – 13.85 90 – 22.39

PULMONARY

43 43

UROGENITAL

SYSTEM COST TO PATIENT

SCHC

Formulary

Incontinence/Enuresis 1) Desmopressin 1% (DDAVP nasal soln (50 doses) 2) *Detrol LA (tolterodine) 2mg 4mg 3) Ditropan XL (oxybutynin) 5mg 10mg 15mg 4) oxybutynin (Ditropan, Oxytrol) 5mg

Erectile Dysfunction

1) Levitra (vardenafil) 10mg 20mg 2) *Viagra (sildenafil) 50,100mg

5 ml – 85.29 30 – 103.75/90 – 6.00 30 – 63.95/90 – 6.00 30 – 69.45 30 – 78.19 30 – 85.29 100 – 10.89 10 – 85.65 10 – 89.55 10 – 97.69 / 6.00

UROLOGY

44 44

A A/B Otic 29 A&D ointment 22 Abacavir 34 Acetic Acid/HC 29 Accu-Check 25 Accupril 13 Acetaminophen 4 Acetaminophen/codeine 6 Actos 24 Acyclovir 9, 22 Adderall, Adderall XR 40 Advair 42 Aerochamber 42 Albuterol 42 Aldactone 14 Alendronate 26 Alesse-28 37 Alcohol preps 25 Allergen 29 Allopurinol 26 Alprazolam 41 Amantadine 9, 36 Ambien 41 Amitriptyline 39 Amoxicillin 11 Amoxicillin/clavulanate 11 Amoxil 11 Antivert 28, 32 Anucort HC 21 Aspirin 4 Artificial Tears 38 Atenolol 15 Ativan 41 Atrovent 42 Augmentin 11 Augmentin XR 11 Avandia 24 Aveeno 22 Azithromycin 10

B Bacitracin 20 Bactrim 12 Bactroban 20 Benadryl 28 Benicar 13 Benzamycin 20 Benzonatate 30 Benzoyl Peroxide 20 Betamethasone valerate 22 Bismuth subsalicylate 31, 33 Boniva 26 BuSpar 41 Buspirone 41 Butalbital/APAP/Caffeine 4, 36

C Caduet 18 Calcium carbonate 27 Carafate 33 Carbamazepine 35 Carbinoxamine/pseudo 29 Cardec DM 30 Cardura 15 Carisoprodol 7 Carvedilol 15 Catapres 15 Ceftin 9 Cefzil 9 Cephalexin 9 Celebrex 4 Celexa 39 Centrum 27 Certagen 27 Children’s chewable vitamins 27 Chlorhexidine 19 Chlorpheniramine 28 Chlorpheniramine/pseudo 29 Cholestyramine 18 Cipro 12, 29 Ciprofloxacin 12, 29

45 45

C Citalopram 39 Cleocin 10 Clindamycin 10, 20 Clobetasol 22 Clonazepam 35, 41 Clonidine 15 Clotrimazole 8, 21, 23 Colyte 32 Combivent 42 Combivir 34 Compazine 32 Condylox 23 Coreg 15 Cortisporin 29 Cozaar 13 Cyanocobalamin 27 Cyclobenzaprine 7 Cymbalta 39

D Darvocet-N 6 DDAVP 43 Deconamine 29 Deconsal II 30 Depakote ER 35 Desmopressin 43 Detrol LA 43 Diazepam 41 Dicloxacillin 10 Dicyclomine 33 Digitek 16 Digoxin 16 Dilacor 16 Diltiazem 16 Diphenhydramine 28 Diphenoxylate/atropine 31 Ditropan XL 43 Divalproex 35 Docusate 32 Doxazosin 15

D Doxycycline 12 Duloxetine 39 Duragesic 6 Dyazide 14

E Ear Wax Remover 29 Effexor XR 39 Enalapril 13 Epivir 34 Eplerenone 14 Ery-Tab 10 Erythromycin 10, 38 Erythromycin w/sulfisoxazole 10 Esgic 4, 36 Eskalith 40 Evista 26

F Ferrous gluconate 17 Ferrous sulfate 17 Flagyl 10 Flexeril 7 Flonase 26 Flovent 42 Fluconazole 8 Fluoxetine 39 Fluticasone 26 Folic Acid 27 Fosamax 26 Furosemide 14

G Gabapentin 35 Gemfibrozil 18 Gentamicin 38 Glipizide 24 Glucagon 25 Glucophage 24

46 46

G Glucovance 24 Glucotrol 24 Glyburide 24 Guaifenesin w/ codeine 30 Guaifenesin w/ DM 30 Guaifenesin w/ pseudo 30 Guiatuss DM 30 Grifulvin V 8

H Hydrocodone/APAP 6 Hydrochlorothiazide 14 Hydrocortisone 22 Hydroxyzine 28 Hytrin 15

I Ibandronate 26 Ibuprofen 5 Imitrex 7 Indomethacin 5 Imdur 16 Imipramine 39 Imodium 31 Inspra 14 Ipratropium 42 Iron 17 Isosorbide Dinitrate 16 Isosorbide Mononitrate 16

K Keflex 9 Kenalog 22 Ketoconazole 21

L Labetalol 15 Lamisil 8 Lanaphilic 22

L Lantus 25 Levaquin 12 Levitra 43 Levoxyl 26 Lexiva 34 Lidocaine 4 Lindane 23 Lipitor 18 Lisinopril 13 Lisinopril-HCTZ 14 Lithium 40 Lomotil 31 Lo/Ovral 37 Loperamide 31 Loprox 21 Lorazepam 41 Lorcet 6 Lotrisone 21 Lovastatin 18 Lyrica 35

M Macrodantin 10 Magnesium Citrate 32 Marinol 32, 34 Maxzide 14 Mebendazole 8 Meclizine 28, 32 Medrol 26 Medroxyprogesterone 37 Metadate 40 Methadone 6 Methocarbamol 7 Methotrexate 7 Methylin 40 Methylphenidate 40 Methylprednisolone 26 Metformin 24 Metoclopramide 33 Metoprolol 15 Metro-Gel 23

47 47

M Metronidazole 10 Mevacor 18 Miconazole 23 Miralax 32 Milk of Magnesia 32 Monoject syringes 25 Morphine 6 Mucinex 30 Multivitamins 27 Mycelex 8 Mycolog II 21 Mylanta 31

N Nabumetone 5 Nadolol 15 Naphcon-A 38 Naprosyn 5 Naproxen 5 NatalCare Plus 27 Neomycin/Polymyxin/HC 29 Niacin 27 Niaspan 18 Nifediac CC 16 Nitrostat SL 16 Nix 23 Nordette 37 Norvasc 16 Norvir 34 Novofine 25 Novolin 25 Novolog 25 Nystatin 8, 21 Nystatin/triamcinolone 21

O Olmesartan 13 Ortho-Cept 39 Ortho Evra 39 Ortho-Novum 39

O Ortho Tri-Cyclen 39 Oxybutynin 43 Oxycodone/APAP 6

P Parlodel 36 Paroxetine 39 Paxil 39 Pedialyte 31 Pediatric Electrolytes 31 Penicillin 10 Pentoxifylline 17 Percocet 6 Peridex 19 Permethrin 23 Phenazopyridine 7 Phenobarbital 35 Phenytoin 35 Pioglitazone 24 Piroxicam 5 Plavix 17 Polyvitamin 27 Potassium chloride 27 Pravachol 18 Primidone 35 Pred-Forte 38 Prednisone 26 Prednisolone 26 Pregabalin 35 Prelone 26 Premarin 23, 37 Prevacid 33 Prevident 19 Prilosec 33 Promethazine 28, 32 Promethazine w/codeine 30 Promethazine w/DM 30 Propranolol 15 Protonix 33 Provera 37

\

48 48

P Psyllium 32 Pyridium 7 Pyridoxine 27

Q Quinapril 13

R Raloxifene 26 Ranitidine 33 Relpax 7 Risperdal 40 Ritalin 40 Robitussin DM 30 Rocaltrol 27 Rondec DM 30 Rosiglitazone 24

S Salicylic Acid 23 Selenium 22 Selsun 22 Serevent 42 Silvadene 20 Silver sulfadiazine 20 Singulair 42 Sodium Sulamyd 38 Soma 7 Spironolactone 14 Sucralfate 33 Sulfacetamide 38 Sustiva 34 Symmetrel 36

T Terazosin 15 Tessalon 30 Tetracycline 12 Theophylline 42

T Thiamine 27 Tocopherol 27 Tofranil 39 Tramadol 4 Trazodone 39 Triamcinolone 19, 22 Triamterene/HCTZ 14 Triphasil 37 Triple antibiotic ointment 20 Trizivir 34

U Ultram 4

V Valium 41 Valproic Acid 35 Valtrex 9 Vasotec 13 Vegetable laxative powder 32 Vermox 8 Viagra 43 Vicodin 6 Videx EC 34 Viracept 34 Viramune 34 Vitalet Lancets 25 Vitamin E 27

W Warfarin 17 Wellbutrin XL 39

Z Zaroxolyn 14 Zerit 34 Zetia 18 Ziagen 34 Zithromax 10 Zocor 18 Zoloft 39 Zovirax 22 Zyrtec 28 Zyrtec D 29

49 49