texas health and human services · pdf filedisability services utilize a closed formulary...

TEXAS HEALTH AND HUMAN SERVICES COMMISSION

DEPARTMENT OF STATE HEALTH SERVICES DEPARTMENT OF AGING AND DISABILITY SERVICES

DRUG FORMULARY 2016

http://www.dshs.state.tx.us/mhprograms/Formulary.shtm

Approved October 2015

http://www.dshs.state.tx.us/mhprograms/Formulary.shtm

The Texas Department of State Health Services (DSHS)/Department of Aging and Disability Services (DADS) Drug Formulary is the publication that outlines the medications that have been approved for use in Community Mental Health Centers, Mental Health State Hospitals and the State Supported Living Centers. The formulary is published annually around the beginning of the calendar year. This document is divided into three sections (Alphabetical Listing, Therapeutic Classification/Cost Index, and Alphabetical Index) to facilitate usage. 1. ALPHABETICAL LISTING: This section lists all the medications alphabetically by generic (nonproprietary) name. Trade (proprietary) names and abbreviations are listed in parenthesis after the generic name. In this section, all approved dosage forms and strengths are also listed.

L o raz ep a m (A tiv a n ) C - IVIn je c tio n : 2 m g /m L , 4 m g /m LS o lu tio n , o ra l: 2 m g /m LT a b le t: 0 .5 m g , 1 m g , 2 m g

Generic Name Trade Name ScheduledDrug

{ }Dosage

Strengths &Concentrations

DosageForms

2. THERAPEUTIC CLASSIFICATION/COST INDEX: This section groups the medications by therapeutic usage and lists them alphabetically by generic (nonproprietary) name. Medications may be listed in multiple categories. For trade names, consult the alphabetical index. Also in this section is a relative cost index so that medications used in similar situations can be evaluated keeping cost of care in mind. Relative cost is based on cost per day of the average dose. The cost of bulk items is listed per unit (gram, ml).

Mood StabilizersCarbamazepine (Tegretol) $ - $$$Divalproex (Depakote) $$ - $$$Lithium Carbonate (Eskalith, Lithonate,

Lithobid)$

Lithium Citrate (Cibalith-S) $$ - $$Valproate (Depakene) $$ - $$

TherapeuticClass

RelativeCost

Index* * Index = $ < $$ < $ < $$ < $$$ < $$$$ < $$$$$ < $$$$$$ < $$$$$$$

Range is < $0.25 - ≤$20.00 + <<++ + < ++ < +++ < ++++ < +++++ < +++++ < ++++++

Range is > $20.00 > $2,000.00

3. ALPHABETICAL INDEX: This section lists all the medications alphabetically by trade name, generic name, and abbreviations. Page numbers for each of the listings is provided.

INTRODUCTION The purpose of the DSHS/DADS Executive Formulary Committee is to maintain and update the Formulary and to recommend standards for drug use within the Community Mental Health Centers, Mental Health State Hospital and the State Supported Living Centers. The Committee is concerned with maintaining the highest standards for drug use. To assist the clinician in prescribing the most cost effective agents a Therapeutic Classification with relative cost data is provided. Because of their frequency of use, the highest level of concern and vigilance centers on the psychotropic medications. For the clinician's reference, the Formulary provides tables summarizing the recommended dosage ranges for the psychotropic drugs; however, these guidelines are not intended to replace other references or the clinician's clinical judgment. The clinician is urged to check with other references, including the Department of State Health Services rule governing prescribing of psychoactive medications (Texas Administrative Code, Title 25, Part 1, Chapter 415, Subchapter A), The American Hospital Formulary Service Drug Information, Facts & Comparisons, and The AMA Drug Evaluations among other reliable sources. This Formulary, is not intended to be a reference for drug use. Rather it is to serve the clinician as a listing of drugs, which are approved for use within the Department. Approval of a drug entity for inclusion in the Formulary does not imply approval of all formulations containing that entity. The Executive Formulary Committee will decide which formulations are approved for use within the department. Not all drugs listed in the Formulary will be stocked at each facility's pharmacy. If a physician, dentist, nurse or pharmacist desires to have a drug added to the Formulary, he or she should complete and submit the appropriate form (New Drug Application, DF-1, see Appendix 1) to the facility’s Pharmacy and Therapeutics Committee. If it is approved at the facility level but is not included in the Departmental Formulary, the facility’s Director of Pharmacy must then forward the request to the DSHS/DADS Executive Formulary Committee in care of the Texas Department of State Health Services, State Hospital Section. Requests received at least 30 days prior to the quarterly meeting will be considered at that meeting. Requests received less than 30 days before the meeting will not be considered until the following meeting. Clinicians and facilities are encouraged to submit supporting documents with their formulary request. The Executive Formulary Committee will evaluate the submission's appropriateness based upon the efficacy and safety of the proposed drug compared with existing formulary items and cost effectiveness of the new agent. When appropriate, the Executive Formulary committee will add the new drug or replace old agents in the same pharmacological/therapeutic category with the new agent. The DSHS/DADS Formulary and Interim Formulary Updates are available at http://www.dshs.state.tx.us/mhprograms/Formulary.shtm The DSHS/DADS Formulary consists of routine and reserve drugs. Drugs in the reserve class have specific guidelines for use printed in the Formulary. These guidelines will be used to audit the appropriate use of reserve drugs. Based on the audit results, continuing education will be developed and targeted as needed. The purpose of reserve status is to stimulate thought and promote care in prescribing. Discussions about the use of reserve status drugs with peers are encouraged. Use of reserve status drugs requires documentation of justification in the patient’s progress notes.

As a means of preventing medication errors, the Formulary has incorporated TALL MAN characters to assist in distinguishing look-alike drug names. TALL MAN characters are being implemented in various parts of the pharmaceutical industry in order to prevent medication errors. Even though the Formulary may not play a major role in preventing medication errors, hopefully this change will stimulate the awareness of TALL MAN characters and assist in implementing this print style in other areas of our medication use process. The Texas Department of State Health Services and The Texas Department of Aging and Disability Services utilize a closed formulary system. Only drugs listed in the Formulary are to be stocked, prescribed and dispensed in DSHS/DADS facilities including pharmaceutical products recommended by consultants for specialized treatments. When a patient's condition requires a drug not listed in the Formulary, limited quantities can be obtained for use in that particular patient. However, documentation (Non-Formulary Drug Justification Form, DF-2, see Appendix 2) or other appropriate pharmacy software generated report should be submitted to the facility Clinical Director and the Office of the Medical Director where it will be reviewed by the Executive Formulary Committee to assure reasonable compliance with the Formulary. When requested by the Commissioner, the Executive Formulary Committee will make other recommendations regarding drug use. If facility clinicians have topics for committee consideration, these requests should be sent to the Chairperson, DSHS/DADS Executive Formulary Committee in care of the Texas Department of State Health Services, State Hospital Section (mail code 2023). The Committee also appreciates your comments concerning the printing of the Formulary and Committee deliberations and decisions. Please feel free to provide input.

Jennifer Wright, M.D. Chairperson Executive Formulary Committee October 30, 2015 Date

MEMBERS OF THE DSHS/DADS EXECUTIVE FORMULARY COMMITTEE Archie Smith, M.D. Austin State Supported Living Center

Vacant DADS Physician

Mary Bowers, RN, BSN Lufkin State Supported Living Center

Catherine S. Hall, Pharm.D., BCPP San Antonio State Hospital

Mark Messer, DO Terrell State Hospital

Connie Millhollon, RN Terrell State Hospital

Marla Knight, Pharm.D., CGP, FASCP Abilene State Supported Living Center

Nina Muse, M.D. Interim DSHS Medical Director

Jeanna Heidel, PharmD Rusk State Hospital

Ann L. Richards, PharmD, BCPP DSHS Pharmacy Services Director San Antonio State Hospital

Jennifer Wright, M.D., Chair Kerrville State Hospital

Kenda Pittman, Pharm.D. DADS Pharmacy Services Director State Supported Living Centers

Jeff Matthews, M.D. UT Health Northeast

Phillip Balfanz, M.D. Hill Country Community MHMR Center

Ex-Officio Members

Peggy Perry Director, State Mental Health Facilities (DSHS) Kerry Raymond Assistant Director, State Mental Health Facilities (DSHS) Scott Schalchlin Assistant Commissioner (DADS) Lauren Lacefield Lewis Deputy Commissioner MH/SA Program Services (DSHS) Lilani Muthali, MD Medical Director – State Supported Living Centers (DADS) Nina Jo Muse, MD Psychiatric Advisory for Mental Health, State Hospitals Section (DSHS) Vacant Nursing Director, State Hospitals Sections (DSHS) Valerie Kipfer, MSN, RN Nursing Services Coordinator, State Supported Living Centers (DADS)

DSHS/DADS DRUG FORMULARY EDITOR Debra Gregg, RPh, MBA

San Antonio State Hospital

DSHS/DADS Drug Formulary 2016 page 6 Procedure for Addition of Drugs to the Formulary

Table of Contents Texas Health and Human Services Commission .................................................... 1

Procedure for Addition of Drugs to the Formulary 10

Psychotropic Dosage Guidelines 11 Children and Adolescent Treatment of Behavioral Emergencies Intramuscular Short-Acting Agents ........................................................................................................ 12 Adult Treatment of Behavioral Emergencies Intramuscular Short-Acting Agents .. 13 Antipsychotics ....................................................................................................... 14 Antidepressants .................................................................................................... 16 Mood Stabilizers .................................................................................................... 17 Stimulants ............................................................................................................. 18 Miscellaneous Drugs Used for Psychotropic Purposes ......................................... 18 Anxiolytics ............................................................................................................. 20 Hypnotics .............................................................................................................. 21

Reserve Drugs 22

Therapeutic Serum Concentrations of Some Anticonvulsants 25

Alphabetical Listing 26

Therapeutic Classification/Cost Index 79

Antidiabetic Agents 79 Insulins, Human ........................................................................................ 79 Sulfonylureas ............................................................................................ 79 Miscellaneous Antidiabetics ...................................................................... 79 Glucose Elevating Agents ......................................................................... 79

Antidotes-Deterrents-Poison Control Agents 80

Antihistamines 80

Antineoplastic Agents 81

Blood Modifying Agents 81 Antiplatelet ................................................................................................ 81 Anticoagulant ............................................................................................ 81 Anticoagulation Antagonist ........................................................................ 81 Miscellaneous Blood Modifying Agents ..................................................... 81

Cardiovascular Agents 81 Diuretics .................................................................................................... 81 Cardiac Glycosides ................................................................................... 82 Antianginals ............................................................................................... 82


Antiarrhythmics ......................................................................................... 82 Calcium Channel Blockers ........................................................................ 82 Beta-Adrenergic Blockers .......................................................................... 83 Antihyperlipidemics ................................................................................... 83 Angiotensin Converting Enzyme Inhibitors ................................................ 83 Vasopressors ............................................................................................ 83 Miscellaneous Antihypertensives .............................................................. 83 Miscellaneous Cardiovasculars ................................................................. 84

Central Nervous System Agents 84 Analgesics ................................................................................................. 84 Antiemetic-Antivertigo Agents ................................................................... 86 Miscellaneous Agents ............................................................................... 86 Psychotropic Agents.................................................................................. 87 Anticonvulsants ......................................................................................... 95 Muscle Relaxants ...................................................................................... 97 AntiParkinson Agents ................................................................................ 97 Agents for Migraine ................................................................................... 98 Dementia Agents ....................................................................................... 98

Endocrine Agents 98 Estrogens .................................................................................................. 98 Progesterones ........................................................................................... 98 Combination Products ............................................................................... 98 Androgens ................................................................................................. 98 Adrenal Cortical Steroids ........................................................................... 99 Thyroid Agents .......................................................................................... 99 Miscellaneous Endocrine Agents .............................................................. 99

Gastrointestinal Agents 100 Antacids .................................................................................................... 100 Antispasmodics/Anticholinergic Agents ..................................................... 100 Histamine (H2) Antagonists ....................................................................... 101 Proton Pump Inhibitors .............................................................................. 101 Antiflatulents .............................................................................................. 101 Stimulants ................................................................................................. 101 Laxatives ................................................................................................... 102 Antidiarrheals ............................................................................................ 103 Rectal Agents^ .......................................................................................... 103 Miscellaneous Gastrointestinal Agents...................................................... 104

Genitourinary Agents 104 Interstitial Cystitis Agents .......................................................................... 104 Genitourinary Irrigants ............................................................................... 105 Medications for BPH.................................................................................. 105 Urinary Alkalinizers.................................................................................... 105 Urinary Anticholinergics ............................................................................. 105 Urinary Cholinergics .................................................................................. 105


Vaginal Antifungals.................................................................................... 105 Miscellaneous Genitourinary Agents ......................................................... 105

Immunological Agents 106 Immune Serums ........................................................................................ 106 Bacterial Vaccines ..................................................................................... 106 Viral Vaccines ........................................................................................... 106 Toxoids ...................................................................................................... 106 In-Vivo Diagnostic Biologicals ................................................................... 106

Infectious Disease Agents 107 Antibiotics .................................................................................................. 107 Antifungals ................................................................................................ 111 Antituberculars .......................................................................................... 111 Antivirals .................................................................................................... 112 Antihelmintics ............................................................................................ 112 Urinary Anti-Infectives ............................................................................... 112 Miscellaneous Anti-Infectives .................................................................... 112

Intravenous Solutions and Additives 113 Intravenous Solutions ................................................................................ 113 Electrolyte Replacement Additives ............................................................ 113

Nutritional Agents 114 Vitamins .................................................................................................... 114 Minerals, Trace Elements, and Electrolytes .............................................. 114 Combination Products ............................................................................... 114

Osteoporosis Agents 115

Respiratory Agents 115 Bronchodilators ......................................................................................... 115 Bronchodilators, Combination/Short Acting ............................................... 115 Bronchodilators, Combination Steroid + Long Acting Beta-2 agonists ...... 115 Cough, Cold and Decongestant Preparations ........................................... 116 Expectorants ............................................................................................. 116 Steroids ..................................................................................................... 116 Miscellaneous Respiratory Drugs .............................................................. 116

Topical Agents 117 Ophthalmics .............................................................................................. 117 Otics^ ........................................................................................................ 120 Mouth and Throat Agents .......................................................................... 120 Nasal Agents ............................................................................................. 121 Dermatologicals^ ....................................................................................... 122 Irrigation Solutions..................................................................................... 125


Nutritional Supplements* 127

Alphabetical Index 128

Appendix 1: New Drug Application Form 139

Appendix 2: Executive Formulary Committee Conflict of Interest Policy 141

Appendix 3: Non-Formulary Drug Justification Form 127

Appendix 4: Adverse Drug Reaction Reporting (MedWatch) Form 144

Appendix 5: Foods Containing Tyramine 146


PROCEDURE FOR ADDITION OF DRUGS TO THE FORMULARY

A physician, dentist, nurse or pharmacist desiring that a new drug be added to the Formulary should submit a new drug application (Form DF-1) to the facility's formulary committee. If approved, the new drug application should be forwarded to the Executive Formulary Committee. The following information should accompany the application:

(1) published articles in the biomedical literature that substantiate the efficacy and safety of the proposed new drug;

(2) advantages of the proposed new drug compared with similar therapeutic agents presently in the Formulary;

(3) drugs in the Formulary which the proposed agent will replace or supplement;

(4) cost effectiveness data.

New drug applications should be received by the secretary of the committee thirty days prior to the committee's scheduled meeting date. Applications received after this time will be considered at the next meeting.

The chairperson will assign a committee member to present an objective treatise and recommendations concerning the proposed to new drug to the Executive Formulary Committee. The committee may decide to approve or deny the drug's inclusion, approve the drug on a trial basis, or postpone a decision until the following meeting of the committee. The committee, at its discretion, may approve a drug's inclusion in the Formulary subject to specific limitations (e.g., recommendation by qualified specialists or consultants) or as a reserve drug.

The specific limitations or guidelines for use of a reserve drug are stated in the formulary. A credentialed clinician may prescribe reserve drugs outside Formulary guidelines; however, such exceptions must be justified in the patient record and must be reviewed in routine facility audits of reserve drug utilization.

Executive Formulary Committee DSHS – State Hospital Section P.O. Box 149347 Mail Code 2023 Austin, TX 78714-9347 Fax: 512-206-5297

DSHS/DADS Drug Formulary 2016 page 11 Psychotropic Dosage Guidelines

PSYCHOTROPIC DOSAGE GUIDELINES The following is a list of psychotropic drug dosages. These guidelines are not intended to establish rigid standards of treatment but to assist in monitoring the pharmacotherapy of the patient. Furthermore, guidelines for special patient populations are not intended to be absolute. For those medications that have a well-established therapeutic serum range, the dosage should be based upon the desired serum range and response rather than a specific maximum administered daily dosage. These guidelines should be used in conjunction with sound clinical judgment and the prescriber’s experience. In children and adolescents, metabolic and physiologic differences from adults should be considered when prescribing. Dosing based on body weight may be more accurate when treating these patients. Different dosage requirements are usually necessary in the geriatric population. Since there is no standard definition for “geriatric”, the arbitrary age of 65 has been chosen to identify geriatric patients. In general, geriatric patient dosing guidelines should reflect a “go low, go slow” approach. Standard reference books should be consulted if needed for appropriate dosages when treating this population. In general, when treating patients with intellectual disabilities, a “go low, go slow” approach is recommended when increasing or decreasing psychotropic medication. The use of psychotropic medication can be therapeutic and empowering for a person with both intellectual disabilities and mental illness. The primary goal is to obtain an accurate diagnosis of behavioral and psychiatric symptoms so that the patients’ treatment is appropriate. A functional analysis by a psychologist is vital prior to starting any psychotropic medication except in an emergency. Prescribing psychotropic medication should be based on the following resources:

The Department of State Health Services rule governing prescribing of psychoactive medications (Texas Administrative Code, Title 25, Part 1, Chapter 415, Subchapter A)

Other useful resources that reflect current Standards of Care for the mentally ill include but are not limited to the following:

APA Practice Guidelines

Texas Dept of Family and Protective Services: Psychotropic Medication Utilization Parameters for Foster Children

Reviewed 30 October 2015


CHILDREN AND ADOLESCENT TREATMENT OF BEHAVIORAL EMERGENCIES

INTRAMUSCULAR SHORT-ACTING AGENTS

The following doses are for recommendation only and were obtained from a survey of use that was completed by practitioners that treat this population within our agency. These doses are not based on any literature support unless otherwise indicated and are to be used for general guidelines.

Children (< 12 y/o)

Drug Maximum Single dose (mg)

Minimum Interval (hrs)

Maximum Total Dose per day

(mg) ARIPiprazole 4.875 - 9.75

(older) 4 to 8 19.5

chlorproMAZINE 25 – 50 6 to 8 75^ *diphenhydrAMINE 25 – 50 4 to 6 50-150 Haloperidol 2.5 – 5 4 to 6 10 hydrOXYzine 25 – 50 4 to 6 150 LORazepam 1 – 2 4 to 8 4 -6 OLANZapine 5 – 10 4 to 6 15 Ziprasidone 10 4 to 6 20

Adolescent (12 y/o to < 18 y/o)

Drug Maximum Single dose (mg)

Minimum Interval (hrs)

Maximum Total Dose per day

(mg) ARIPiprazole 9.75 4 to 8 19.5 chlorproMAZINE 25 – 50 4 to 6 150 *diphenhydrAMINE 50 – 100 4 to 6 200 fluPHENAZine 2 6 to 8 10 Haloperidol 5 4 to 6 20 hydrOXYzine 50 – 100 4 to 6 200 LORazepam 2 4 to 8 8 OLANZapine 10 4 to 6 20 Ziprasidone 10 – 20 4 to 6 40

^ Lexicomp® Online (cited 10-27-15) * diphenhydrAMINE use in behavioral emergencies is not supported in the literature

and there is a high rate of paradoxical reactions in this population

Tables added 5 February 2009 Reviewed 30 October 2015


ADULT TREATMENT OF BEHAVIORAL EMERGENCIES INTRAMUSCULAR SHORT-ACTING AGENTS

DRUG MAXIMUM

SINGLE DOSE (MG)

MINIMUM INTERVAL (HRS)

MAXIMUM TOTAL DOSE

PER DAY (MG) IM ARIPiprazole1 15 2 30 IM chlorproMAZINE2 100* 2 400 IM diphenhydrAMINE3-

4 100 1 400

IM fluPHENAZine4-5 10 1 10^ IM Haloperidol2 10 1 40 IM hydrOXYzine3,4 100 1 400 IM LORazepam2,6 4 1 12 IM OLANZapine7 10 2 30 IM Ziprasidone8 10 2 40

20 4 40 *Initial dose is not recommended to be greater than 50mg if tolerability is unknown

^ Use doses exceeding 10 mg daily with caution

1. Product Information: Abilify®, aripiprazole injection. Otsuka Pharmaceutical Co. Ltd., Tokyo, Japan, 2014.

2. Allen MH, Currier GW, Carpenter D, et al. Treatment of Behavioral Emergencies Expert Consensus Guideline Series. Journal of Psychiatric Practice 2005;11 [Suppl 1]:1-108.

3. Lexicomp® Online (cited 10-27-15) 4. Micromedex® 2.0 [electronic version]. Truven Health Analytics, Greenwood

Village, CO, USA (cited 10-27-15) 5. Product Information: Fluphenazine hydrochloride injection. App Pharmaceuticals

LCC, Schaumburg, IL, 2010. 6. Lukens TW, Wolf SJ, Edlow JA, et al. Clinical Policy: Critical Issues in the

Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med 2006;47:79-99.

7. Product Information: Zyprexa®, olanzapine intramuscular injection. Eli Lilly and Company, Indianapolis, IN, USA, 7-23-15.

8. Product Information: GEODON® ziprasidone mesylate IM injection. Pfizer,Inc, New York, NY, 8-20-15

Table updated 30 October 2015


ANTIPSYCHOTICS

Suggested Maximum Dose (mg/day)

Drug Adult Child (< 12 y/o)

Adolescent (12 y/o to < 18 y/o)

ARIPiprazole (Abilify)

ARIPiprazole Extended Release (Abilify Maintena)

ARIPiprazol lauroxil (Aristada) NON-FORMULARY

30

400 per 4 weeks

882 per 4 weeks

15

30

Asenapine (Saphris) 20 ID ID Brexpiprazole (Rexulti) NON-FORMULARY 4

Cariprazine (Vraylar) NON-FORMULARY 6

chlorproMAZINE (Thorazine) 2,000 500 (≤ 45.5 kg) 800 (>45.5kg)

cloZAPine (Clozaril, Fazaclo, Versacloz) - RESERVE USE 900 300 (Lit) 600 (Lit)

fluPHENAZine(oral) (Prolixin)

fluPHENAZine Decanoate (Prolixin Decanoate)

60

400 per 4 weeks

Haloperidol (oral) (Haldol)

Haloperidol Decanoate (Haldol Decanoate)

40

450 per month

0.15 mg/kg (Lit) 15 (Lit)

Iloperidone (Fanapt) RESERVE USE 24 ID ID Loxapine (Loxitane) 250 Lurasidone (Latuda) 160 ID ID OLANZapine (ZyPREXA, ZyPREXA Zydis) 30 12.5 (Lit) 20 (Lit)

OLANZapine pamoate (ZyPREXA Relprevv) RESERVE USE

300 per 2 weeks

405 per 4 weeks

Paliperidone (Invega)

Paliperidone palmitate (Invega Sustenna)

Paliperidone palmitate (Invega Trinza) NON-FORMULARY

12

234 per 4 weeks

819 per 3 months

ID

6 (<51kg) 12 (≥51kg)

(Lit)

Perphenazine (Trilafon) 64 ID 64 (Lit)

QUEtiapine (SEROquel) 800 400 (≤ 9 y/o) 800 (10-12)

(Lit) 800 (Lit)

risperiDONE (RisperDAL, RisperDAL M-Tab) RisperDAL Consta

82

50 per 2 weeks

3 (Lit) 6

Thioridazine (Mellaril)1- RESERVE USE (ABSOLUTE) 800


Suggested Maximum Dose (mg/day) Thiothixene (Navane) 60 Trifluoperazine (Stelazine) 40

Ziprasidone (Geodon) 240 803 (≤45kg)

404 (Lit)

1603 (>45kg) 404 (Lit)

1 A boxed warning has been added to advise clinicians of prolongation of the QTc interval 2 Risperidone doses >6 mg/day have increased risk of EPS

3Bipolar Disorder

4Tourette’s Disorder

ID – insufficient data Lit – Literature Support

T

Drug

Therapeutic reference range/ Recommended drug concentration

Clozapine 350 – 600 ng/mL Fluphenazine 1 – 10 ng/mL Haloperidol 1 – 10 ng/mL Olanzapine 20 – 80 ng/mL

Perphenazine 0.6 – 2.4 ng/mL Thioridazine 100 – 200 ng/mL

Revised 30 Oct 2015


ANTIDEPRESSANTS Suggested Maximum Dose (mg/day)

Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

Amitriptyline (Elavil) 3006 buPROPion (Wellbutrin) buPROPion SR (Wellbutrin SR) buPROPion XL (Wellbutrin XL)

450 (with no single dose > 150)

400

(with no single dose > 200)

450

Lesser of 6 mg/kg or 300 (Lit) 4

Lesser of 6 mg/kg or 300 (Lit) 4

400 (Lit) 4

450 (Lit) 4

Citalopram** (celeXA) 40 40 (Lit) 40 (Lit) clomiPRAMINE (Anafranil) 250 Desipramine (Norpramin) 300*1 Doxepin (SINEquan) 3007 DULoxetine (Cymbalta) 120 ID 60 (Lit) Escitalopram (Lexapro) 20 20 (Lit) 30 (Lit) FLUoxetine** (PROzac) 80 60 (Lit) 60 fluvoxaMINE (Luvox) 300 200 300 Imipramine (Tofranil) 300*2 Lesser of 4 mg/kg or

200 (Lit) 4 Lesser of 4 mg/kg or

200 (Lit) 4 Mirtazapine (Remeron) 45 Nortriptyline (Pamelor, Aventyl) 150*3 Lesser of 2 mg/kg or

100 (Lit) 4 Lesser of 2 mg/kg or

100 (Lit) 4 PARoxetine (Paxil) 60 Not recommended 40 (Lit) Phenelzine (Nardil) 90 Protriptyline (Vivactil) - Non-formulary 60 Sertraline** (Zoloft) 200 200 (Lit) 200 Tranylcypromine (Parnate) 60 traZODone (Desyrel) 600 ID 100 (Lit) 5 Venlafaxine (Effexor) Venlafaxine XR (Effexor XR)

375 225 (XR)

150 (Lit) 375 (Lit)

*Plasma concentration monitoring is recommended if these doses are exceeded. **Dose varies with diagnosis. 1Desipramine Therapeutic = 100-300 ng/mL 2Imipramine Therapeutic Concentration = 150-250 ng/mL 3Nortriptyline Therapeutic Concentration = 50-150 ng/mL

4

5 For sedative hypnotic 6Amitriptyline Therapeutic Conc. = 120-250 ng/mL 7Doxepin Therapeutic Concentration = 150 ng/mL Lit – Literature Support

For ADHD ID = Insufficient data to suggest support regarding its efficacy or to provide maximum dose guidelines in this patient group. Reviewed 30 October 2015


MOOD STABILIZERS Suggested Maximum Dose (mg/day)*

Drug Therapeutic Serum

Concentration

Child (< 12 y/o)

Adolescent (12y/o to < 18 y/o)

Adult

carBAMazepine (TEGretol, TEGretol XR, Carbatrol)

4 - 12 mcg/mL Adol – Max 12 mcg/ml

1,600

35 mg/kg (<6)

800 mg (6-12 mcg/ml)

# 1,000 (12-15) 1,200 (>15)

lamoTRIgine (LaMICtal) nd

• With VPA 100

• Mono-therapy 200

• With EIAED 400

• With VPA 1-3 mg/kg

• With VPA & EIAED 1-5 mg/kg

• Mono-therapy 4.5 – 7.5 mg/kg

• With EIAED 5 – 15 mg/kg

• With VPA 200 • With VPA &

EIAED 400 • Monotherapy

375 • With EIAED 500

Lithium (Lithobid, Eskalith)

Adult – 0.6-1.5 mEq/L

Elderly – 0.6-1.mEq/L

Child – 0.6 mEq/L

Adol – Max 1.2 mEq/L

0

3,600 (<65 years old)

1,800 (≥65 years old)

# (0.6–1.2 mEq/L)

(Lit)

# 1800

(0.6-1.2 mEq/L) (Lit)

OXcarbazepine (Trileptal) nd 2,400 60 mg/kg or

1500 (Lit)

60 mg/kg or 2100 (Lit)

Valproic Acid, Valproate, Divalproex (Depakene, Depakote, Depakote ER)

50 - 125 mcg/mL

Adol – Max 125mcg/ml (Lit)

Divalproex ER 85-125

60 mg/kg

20 mg/kg (<10 years

old)

60mg/kg (≥10 years

old) #

60mg/kg#

* Plasma concentration monitoring is recommended if these doses are exceeded nd = not yet determined # - Maximum daily dose typically determined by drug serum concentration and individual patient tolerability. Lit – Literature support EIAED – Enzyme inducing anti-epileptic drugs (e.g., carbamazepine, phenobarbital, phenytoin, primidone) VPA – valproic acid-valproate Reviewed 30 October 2015


STIMULANTS



Amphetamine Mixture (Adderall, Adderall XR) 60 40

30 (XR) 40

30 (XR) Dextroamphetamine (Dexedrine, Dexedrine spansules) 60 40 40

Lisdexamfetamine (Vyvnase) 70 70

(6-12 years old) 70

Methylphenidate, immediate release (Ritalin, Methylin, Metadate Methylphenidate, sustained release (Ritalin SR, Concerta, Metadate CD)

60

72 (Concerta)

60 Concerta – 2 mg/kg (not to

exceed 54 mg/day)

60 Concerta – 2 mg/kg (not to exceed 108

mg/day) (Lit)

Revised 30 October 2015

MISCELLANEOUS DRUGS USED FOR PSYCHOTROPIC PURPOSES



atoMOXetine (Strattera) 100 1.4mg/kg (≤70kg)

100 (>70kg)

1.4mg/kg (≤70kg)

100 (>70kg)

cloNIDine (Catapres) 0.4 0.2 (27-40.5kg) 0.3 (40.5-45kg)

# (Lit)

0.4 (>45kg) # (Lit)

cloNIDine Extended Release (Kapvay) NON-FORMULARY 0.4 0.4* 0.4

guanFACINE (Tenex) 4 2 (27-40.5kg) 3 (40.5-45kg)

# (Lit)

4 (>45kg) # (Lit)

guanFACINE Extended Release (Intuniv) NON-FORMULARY 4

4* 4 Naltrexone (ReVia) 200

Propranolol (Inderal) 160 (anxiety)***

*** Maximum dose has not been determined for aggression or self-injurious behavior (SIB).


# For ADHD * Not studied in children < 6 years old Lit – Literature support Reviewed 30 October 2015


ANXIOLYTICS Suggested Maximum Dose

(mg/day) Drug Under 65 years

(mg/day) Over 65 years

(mg/day)

)

ALPRAZolam (Xanax) (exception: for panic disorder)

4

10

2

N/A

busPIRone (BuSpar) 60 60

chlordiazePOXIDE (Librium 100* 40*

clonazePAM (KlonoPIN) 4^ 4^

Clorazepate1 (Tranxene) 60 30

Diazepam1 (Valium) 60 20

LORazepam (Ativan) 10* 3*

Oxazepam (Serax) 90 60 *Larger doses may be necessary in some cases of alcohol-substance withdrawal. 1 Long acting benzodiazepines are not recommended in the geriatric population. ^ doses up to 20 mg have been used to treat seizure disorders Reviewed 30 October 2015


HYPNOTICS


Drug Under 65 years

(mg/day)

Over 65 years

(mg/day)

Child (< 12 y/o) Adolescent (12 y/o to < 18

y/o)

diphenhydrAMINE (Benadryl) 300 300

1 mg/kg up to max of 50

50 mg per dose up to a max 300 mg/day

hydrOXYzine (Atarax, Vistaril) 400 300

25 (3-6 y/o) 50 (6-12 y/o)

(Lit)

100 (>12 y/o) (Lit)

Temazepam (Restoril) 30 15 traZODone (Desyrel) 200 150 ID 100 (Lit) Triazolam (Halcion) (Conscious sedation dosing)

0.25

(0.5)

0.125

(0.25)

Zaleplon (Sonata) 10 5 NR NR

Zolpidem (Ambien) 10 (Males)

5 (Females) 5

NR NR

NR – Not Recommended ID – Insufficient data to suggest support regarding its efficacy or to provide maximum dose

guidelines for this patient population.

Revised 30 October 2015

DSHS/DADS Drug Formulary 2016 page 22 Reserve Drugs

RESERVE DRUGS

The purpose of the reserve drug class is to stimulate thought and promote care in prescribing. Discussions and interaction with other prescribers is strongly encouraged. When reserve status drugs are utilized, documentation of justification in the patient’s progress notes is mandated. To assist the prescriber, specific guidelines have been developed by the Executive Formulary Committee for use of each drug so classified. The guidelines will be used to audit the appropriate use of reserve drugs. Based on the audit results, continuing education will be developed and targeted as needed.

Drug Guidelines for Use Adenosine (Adenocard) To be used in an ECT Suite or under the direction of an

anesthesiologist Atovaquone (Mepron) Patients needing PCP treatment-prophylaxis that cannot

tolerate cotrimoxazole or dapsone. Betamethasone dipropionate, augmented (Diprolene A/F)

To be used under the direction of a dermatologist

Clobetasol (Temovate) To be used under the direction of a dermatologist Clopidogrel (Plavix) Documented sensitivity to aspirin cloZAPine (Clozaril, Fazaclo, Versacloz)

1) For use in patients with refractory schizophrenia or schizoaffective disorder [defined as failure on two antipsychotics from two different chemical families given for sufficient time (6-12 weeks) at a sufficient dose (1,000 mg/day of chlorpromazine equivalents); or

2) For use in schizophrenic or schizoaffective patients who cannot tolerate other antipsychotics; or

3) Psychosis associated with other organic conditions who have failed two antipsychotics or who cannot tolerate otherantipsychotics; or

4) Manic disorders with psychosis in patients who have failed two antipsychotics

5) Reduction in the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective

cycloSERINE (Seromycin) When recommended by a consultant physician or prescribed by an infectious disease specialist at TCID.


Drug Guidelines for Use Drug Guidelines for Use

DOPamine (Intropin) To be used in an ECT Suite or under the direction of an anesthesiologist

Epoetin alfa (Epogen, Procrit) When recommended by a consultant physician or prescribed by an infectious disease specialist at TCID.

Esomeprazole (NexIUM) Patients who have Medicare Part D coverage for esomeprazole

Felbamate (Felbatol) Weekly progress note by physician monitoring for response and adverse effects for at least two weeks following initiation of therapy

Iloperidone (Fanapt) 1) For use in patients that have failed on two antipsychotics given for a sufficient time; or

2) For patients who cannot tolerate other antipsychotics due to akathisia

Insulin, Detemir (Levemir) For those who are unable to tolerate Insulin, glargine. Linezolid (Zyvox) Patients at TCID or in consultation with an expert in infectious

disease. Lisdexamfetamine dimesylate (Vyvanse)

1) Continued therapy on admission; or 2) Failed other stimulants.

Moxifloxacin (Moxeza, Vigamox)

For bacterial conjunctivitis where MRSA or gram negative microorganisms is identified or suspected.

Nabumetone (Relafen) For the treatment of chronic osteoarthritis or chronic rheumatoid arthritis

Norepinephrine or Levarterenol (Levophed)

To be used in an ECT Suite or under the direction of an anesthesiologist.

OLANZapine pamoate (ZyPREXA Relprevv)

1) Written approval by the Hospital Clinical Director and the local mental health authority clinical director prior to initiation of therapy with olanzapine pamoate 2) Compliance with the Risk Evaluation and Mitigation Strategy (REMS)

Olmesartan (Benicar) Prior failure to ACE inhibitor therapy due to intolerable side effects

Ophthalmic agents containing a steroid

Consultation with an Ophthalmologist or Therapeutic Optometrist prior to initiation.

Pentamidine (Pentam) 1) Prophylaxis post-treatment of documented Pneumocystis carinii pneumonia; or

2) Prophylaxis of Pneumocystis carinii in patients with CD 4 counts of less than 200

Thioridazine (Mellaril) 1) Indicated only for patients with refractory schizophrenia (failed other classes of antipsychotics)

2) EKG prior to initiating therapy: 7 – 14 days after dose change; 7 – 14 days after other medication changes that could significantly alter the cardiac effects of Thioridazine; every six months; and as clinically indicated

3) Potassium level prior to initiating therapy; every six months; and as clinically indicated

4) Magnesium level prior to initiating therapy; and as clinically indicated (especially if potassium level is low)

tiZANidine (Zanaflex) 1) Documented failure or intolerance to baclofen


Drug Guidelines for Use 2) Liver enzymes obtained at baseline, 1, 3, and 6 months

and at least annually 3) Documentation of efficacy after one month of therapy 4) The dose should be decreased in severe renal dysfunction

(CrCl <25 mL/min) Valsartan (Diovan) Prior failure to ACE inhibitor therapy due to intolerable side

effects

DSHS/DADS Drug Formulary 2016 page 25 Anticonvulsant Serum Concentrations

THERAPEUTIC SERUM CONCENTRATIONS OF SOME ANTICONVULSANTS

Drug (mcg/mL) carBAMazepine (TEGretol, TEGretol XR,

Carbatrol 4-12

Ethosuximide (Zarontin) 40-100 PHENobarbital (Luminal) 15-40

Phenytoin (Dilantin) 10-20

Valproic Acid, Valproate, Divalproex (Depakene, Depakote, Depakote ER)

Seizure Disorder: 50-100 Bipolar Disorder: 50-125

Aggression: not established

Depakote ER Seizure Disorder: 50-100 Bipolar Disorder: 85-125

Serum concentrations are useful in the evaluation of therapy. However, they should only be considered as a guide to treatment, not the sole criterion for determination of dosage regimens. The following anticonvulsants do not have an established therapeutic serum concentration range. Routine monitoring of these anticonvulsants is not warranted as serum concentrations cannot be correlated with clinical efficacy.

Benzodiazepines cloBAZam Gabapentin Lacosamide lamoTRIgine LevETIRAcetam

OXcarbazepine Pregabalin Rufinamide tiaGABine Topiramate Zonisamide

*Source: Lexicomp® Online (cited 10-28-15)

Reviewed 30 October 2015

DSHS/DADS Drug Formulary 2016 page 26 Alphabetical Listing

ALPHABETICAL LISTING

Abrasive Cleanser (Brasivol, Pernox, Salac, Seba-Nil) Cleanser: Lotion:

Acamprosate (Campral) Tablet, delayed release: 333 mg

Acetaminophen (Tylenol) Capsule: 500 mg Liquid: 160 mg/5 mL Suppository, rectal: 120 mg, 125 mg, 325 mg, 650 mg Tablet: 325 mg, 500 mg Tablet, chewable: 80 mg

Acetaminophen-Codeine C-III Liquid, oral: Acetaminophen 120 mg-Codeine 12 mg per 5 mL (C-V) Tablet: #2: Acetaminophen 300 mg-Codeine 15 mg #3: Acetaminophen 300 mg-Codeine 30 mg

Acetaminophen-HYDROcodone (Lortab, Vicodin, Vicodin ES) C-II Elixir: Acetaminophen 167 mg-HYDROcodone 2.5 mg per 5 mL with 7% alcohol Tablet: Acetaminophen 300 mg- HYDROcodone 5 mg Acetaminophen 300 mg- HYDROcodone 7.5 mg Acetaminophen 300 mg- HYDROcodone 10mg Acetaminophen 325 mg- HYDROcodone 5 mg Acetaminophen 325 mg- HYDROcodone 10 mg

acetaZOLAMIDE (Diamox) Capsule, sustained release: 500 mg Tablet: 125 mg, 250 mg

Acetic Acid (Acetasol, VoSol) Solution, otic: 2%

Acetic Acid-Aluminum Acetate (Domeboro Otic) Solution, otic: 2% acetic acid in aluminum acetate

Acetic Acid-Hydrocortisone-Propylene Glycol-Sodium Acetate-Benzethonium (VoSol HC)

Solution, otic: 1% Hydrocortisone, 2% Acetic Acid, 3% Propylene Glycol, 0.015% Sodium Acetate, and 0.02% Benzethonium


Acetylcysteine (Mucomyst) Solution, inhalation: 10% [100 mg/mL], 20% [200 mg/mL]

Activated Charcoal

Capsules: 260 mg Liquid, oral, activated, with sorbitol: 25 g, 50 g Oral suspension, activated: 15 g, 30 g, 40 g, 120 g, 240 g

Acyclovir (Zovirax)

Capsule: 200 mg Cream: 0.5% Powder for injection: 500 mg, 1000 mg Ointment, topical 5% [50 mg/g]: 3 gm, 15 gm Suspension, oral: 200 mg/5 mL Tablet: 400 mg, 800 mg

Adapalene (Differin)

Cream: 0.1% Gel, topical: 0.1%

Adenosine (Adenocard) RESERVE USE

Injection: 3 mg/mL Albuterol (Proventil, Ventolin, Vospire ER)

Aerosol, inhalation, chlorofluorocarbon free: 90 mcg/dose (17g) [200 doses] Solution, inhalation: 0.083% [2.5mg/3mL], 0.5% [5 mg/mL] Syrup: 2 mg/5 mL Tablet: 2 mg, 4 mg Tablet, extended release: 4 mg, 8 mg

Albuterol-Ipratropium (Combivent, DuoNeb)

Inhaler, oral: Albuterol 103 mcg-Ipratropium 18 mcg Solution, inhalation: Albuterol 2.5mg-Ipratropium 0.5mg/3ml

Alendronate (Fosamax)

Solution, oral: 70 mg/5 mL Tablet: 5 mg, 10 mg, 35 mg, 40 mg, 70 mg

Allopurinol (Zyloprim)

Tablet: 100 mg, 300 mg ALPRAZolam (Xanax, Xanax XR) C-IV

Tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg Tablet, sustained release: 0.5 mg, 1 mg, 2 mg, 3 mg


Aluminum Chloride Hexahydrate (Drysol) Liquid

Aluminum Hydroxide (Amphojel) Suspension, oral: 320 mg/5 mL, 600 mg/5 mL

Aluminum Hydroxide-Magnesium Trisilicate (Gaviscon) Tablet, chewable: each tablet contains Aluminum Hydroxide-Magnesium Trisilicate

Aluminum Hydroxide-Magnesium Hydroxide (Maalox) Suspension, oral: containing Aluminum Hydroxide-Magnesium Hydroxide

Aluminum Hydroxide-Magnesium Hydroxide-Simethicone (Mylanta, Aludrox) Liquid, oral: containing Aluminum Hydroxide-Magnesium Hydroxide-Simethicone Tablet: each tablet contains Aluminum Hydroxide-Magnesium Hydroxide-Simethicone

Amantadine (Symmetrel) Capsule: 100 mg Syrup: 50 mg/5 mL

Amikacin Injection: 50 mg/mL, 250 mg/mL

Amino Acid Injection (Aminosyn) Infusion: 3.5%, 5%, 7%, 8.5%, 10%, 15%

Amino Acid Injection-Dextrose-Electrolytes (Clinimix E) Infusion: 2.75%, 4.25%, 5%

Aminophylline (79% Theophylline) Injection: 25 mg/mL Suppository, rectal: 250 mg Tablet: 200 mg

Amiodarone (Pacerone, Cordarone) Tablet: 100 mg, 200 mg, 400 mg

Amitriptyline (Elavil) Tablet: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg

amLODIPine (Norvasc) Tablet, extended release: 2.5 mg, 5 mg, 10 mg


Amoxicillin (Amoxil, Polymox) Capsule: 250 mg, 500 mg Powder for oral suspension: 125 mg/5 mL, 250 mg/5 mL Tablet: 500 mg, 875 mg Tablet, chewable: 125 mg, 250 mg

Amoxicillin-Clavulanate (Augmentin) Suspension, oral: 400mg (contains Clavulanate 57 mg) per 5 ml

600mg (contains Clavulanate 42.9 mg) per 5 ml Tablet :250 mg (contains Clavulanate 125 mg)

500 mg (contains Clavulanate 125 mg) 875 mg (contains Clavulanate 125 mg)

Tablet, chewable: 125 mg (contains Clavulanate 31.25 mg) 250 mg (contains Clavulanate 62.5 mg)

Tablet, extended release: 1000 mg (contains Clavulanate 62.5 mg)

Amphetamine Mixture (Adderall, Adderall XR) CII Capsule, extended release: 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg Tablet: 2.5 mg, 5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg

Ampicillin (Polycillin, Omnipen) Capsule, as anhydrous: 250 mg, 500 mg Capsule, as trihydrate: 250 mg, 500 mg Powder for injection: 125 mg, 250 mg, 500 mg, 1 g, 2 g, 10 g Powder for oral suspension, as trihydrate: 125 mg/5 mL, 250 mg/5 mL

Antineoplastic Agents In consultation with the oncologist or field specialist

Antipyrine-Benzocaine (Allergen, Auralgan) Solution, otic

Antiviral Agents Used to treat AIDS/HIV

ARIPiprazole (Abilify, Abilify discmelt, Abilify Maintena) Injection: 9.75 mg Injection, extended release: 300 mg, 400 mg Solution, oral: 1 mg/mL Tablet: 2mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg Tablet, rapid dissolving: 10 mg, 15 mg

Ascorbic Acid (Vitamin C) Solution, oral: 100 mg/mL Tablet: 250 mg, 500 mg, 1000mg Tablet, chewable: 250 mg, 500 mg


Asenapine (Saphris) Tablet, sublingual: 5 mg, 10 mg

Aspirin Suppository, rectal: 300 mg, 600 mg Tablet: 325 mg Tablet, buffered: 325 mg with buffering agents Tablet, chewable: 81 mg Tablet, enteric coated: 81 mg, 162 mg, 325 mg, 500 mg, 650 mg

Aspirin-Acetaminophen-Caffeine (Excedrine Migraine) Tablet: Aspirin 250 mg-Acetaminophen 250 mg-Caffeine 65 mg

Atenolol (Tenormin) Tablet: 25 mg, 50 mg, 100 mg

atoMOXetine (Strattera) Capsule: 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg

atorvaSTATin (Lipitor) Tablet: 10 mg, 20 mg, 40 mg, 80 mg

Atropine Sulfate (Isopto Atropine) Ointment, ophthalmic: 1% Solution, ophthalmic: 1%

Atovaquone (Mepron) RESERVE USE Suspension: 750 mg/5 mL

Azelastine (Astelin) Nasal spray: 0.1% (137 mcg/spray)

Azithromycin (Zithromax) Powder for oral solution: 200 mg/5 mL Tablet: 250 mg, 500 mg, 600 mg

Bacitracin (Baciguent) Injection: 50,000 units Ointment, ophthalmic: 500 units/g Ointment, topical: 500 units/g

Bacitracin-Polymyxin B (Polysporin) Ointment, ophthalmic: Bacitracin 500 units-Polymyxin B 10,000 units/g Ointment, topical: Bacitracin 500 units-Polymyxin B 10,000 units/g Powder, topical: Bacitracin 500 units-Polymyxin B 10,000 units/g


Baclofen (Lioresal) Tablet: 10 mg, 20 mg

Beclomethasone, (Beconase, QVAR) Inhaler, oral: 40mcg [100 actuations], 80mcg [100 actuations] Spray, nasal: 0.084% (19 g) [120 metered doses] Spray, nasal: 40mcg/actuation Spray, nasal: aqueous: 42 mcg/inhalation (25 g) [≥200 metered doses], 84 mcg/inhalation

(25 g) [≥200 metered doses]

Benazepril (Lotensin) Tablet: 5 mg, 10 mg, 20 mg, 40 mg

Benzocaine (Lanacaine, Cepacol, Oragel) Topical, for mucous membranes:

Gel: 6%, 20% Liquid: 20%

Topical, dermatalogic: Cream, topical: 5%, 6% Ointment: 5% Spray: 5%, 20%

Mouth-Throat preparations: Gel: 6.3%, 7.5%, 10%, 15%, 20% Liquid: 5%, 6.3%, 10%, 20%

Benzoin, Compound Tincture Tincture, topical (also contains aloe, storax, tolu balsam, 74% to 80% alcohol): 30 mL, 60

mL, 120 mL, 480 mL, 4000 mL

Benzonatate (Tessalon Perle) Capsule: 100 mg, 200 mg

Benzoyl Peroxide Bar: 5% Cream, topical: 10% Gel, topical: 2.5%, 5%, 10% Liquid, topical: 5%, 10% Lotion: 10% Pads: 9% Wash, topical: 2.5%, 4%, 5%, 10%

Benzoyl Peroxide-Clindamycin (BenzaClin) Gel, topical: Benzoyl Peroxide 5%-Clindamycin 1%


Benztropine (Cogentin) Injection: 1 mg/mL Tablet: 0.5 mg, 1 mg, 2 mg

Betamethasone dipropionate (Diprolene) Cream: 0.05% Gel: 0.05% Lotion: 0.05% Ointment 0.05%

Betamethasone dipropionate, augmented (Diprolene A/F) RESERVE USE Cream: 0.05% Gel: 0.05% Lotion: 0.05% Ointment: 0.05%

Betamethasone Valerate (Valisone) Cream, topical: 0.01%, 0.1% Lotion: 0.1% Ointment, topical: 0.1%

Betaxolol (Betoptic S) Solution, ophthalmic: 0.5% Suspension, ophthalmic: 0.25%

Bethanechol (Urecholine) Injection: 5 mg/mL Tablet: 5 mg, 10 mg, 25 mg, 50 mg

Bimatoprost (Lumigan) Solution, ophthalmic: 0.01%, 0.03%

Birth Control Agents Any commercially available

Bisacodyl (Dulcolax) Suppository, rectal: 10 mg Tablet, enteric coated: 5 mg

Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate) Liquid, oral: 262 mg/15 mL Tablet, chewable: 262 mg

Brimonidine (Alphagan P) Solution, ophthalmic: 0.1% 0.15%, 0.2%


Bromocriptine (Parlodel) Capsule: 5 mg Tablet: 2.5 mg

Brompheniramine-Phenylephrine (Dimetapp Cold and Allergy) Liquid: Brompheniramine 1 mg-Phenylephrine 2.5 mg per 5mL

Brompheniramine-Pseudoephedrine (Bromfed) Capsule: Brompheniramine 12 mg-Pseudoephedrine 120 mg Elixir: Brompheniramine 4 mg-Pseudoephedrine 30 mg Liquid: Brompheniramine 15mg-Psuedoephedrine 1mg per 5mL, Brompheniramine 12mg-Psuedoephedrine 1mg per 5mL Syrup: Brompheniramine 2 mg-Pseudoephedrine 30 mg Tablet: Brompheniramine 4 mg Pseudoephedrine 60 mg Tablet, sustained release: Brompheniramine 8mg-Psuedoephedrine120mg

Budesonide (Pulmicort) Solution, inhalation: 0.25 mg, 0.5 mg, 1 mg

Budesonide-Formoterol (Symbicort) Aerosol, inhalation, oral: 160 mcg/4.5 mcg, 80 mcg/4.5 mcg

buPROPion (Budeprion, Wellbutrin, Zyban) Tablet: 75 mg, 100 mg Tablet, sustained release: 100 mg, 150 mg, 200 mg Tablet, extended release: 150 mg, 300 mg

busPIRone (BuSpar) Tablet: 5 mg, 10 mg, 15 mg, 30 mg

Calamine-Zinc Oxide-Glycerin (Calamine Lotion) Lotion, topical: 120 mL, 240 mL, 480 mL

Calamine-Pramoxine (Caladryl) Lotion, topical: 180 mL

Calcipotriene (Dovonex) Cream, topical: 0.005% Ointment, topical: 0.005% Solution, topical: 0.005%

Calcitonin-Salmon (Miacalcin) Nasal spray: 200 IU/activation


Calcium Carbonate (Os-Cal, Titralac) [40% elemental calcium] Liquid, oral: Tablet: Tablet, chewable:

Calcium Carbonate-Vitamin D (Os-Cal + D, Os-Cal chewable) Tablet: Calcium 250 mg-Vitamin D 125 units

Calcium 315 mg-Vitamin D 200 units Calcium 500 mg-Vitamin D 125 units Calcium 600 mg-Vitamin D 200 units

Tablet,chewable: Calcium 500 mg-Vitamin D 600 units

Calcium Citrate (Citracal) [21% elemental calcium] Tablet: 200 mg, 250 mg, 315 mg, 950 mg

Calcium Citrate-Vitamin D (Citrical+D) Tablet: Calcium 315 mg-Vitamin D 200 units

Calcium 600 mg-Vitamin D 200 units

Calcium Glubionate (Neo-Calglucon) [6% elemental calcium] Syrup: 1.8 g/5 mL

Calcium Gluconate [9% elemental calcium] Injection: 10% [100 mg/mL] Tablet: 500 mg, 650 mg, 975 mg, 1000 mg

Camphor-Phenol (Campho-Phenique) Liquid, topical: Camphor 10.8%-Phenol 4.7% [with eucalyptus oil and mineral oil]

Captopril (Capoten) Tablet: 12.5 mg, 25 mg, 50 mg, 100 mg

carBAMazepine (TEGretol, TEGretol XR, Carbatrol) Capsule, extended release: 100 mg, 200 mg, 300 mg Suspension, oral: 100 mg/5 mL Tablet: 200 mg Tablet, chewable: 100 mg Tablet, extended release: 100 mg, 200 mg, 400 mg

Carbamide Peroxide-Glycerin-Propylene Glycol-Sodium Stannate (Debrox, Gly-Oxide) Gel, oral: 10% Solution, oral: 10%, 15% Solution, otic: 6.5%


Carbidopa-Levodopa (Sinemet) Tablet: Carbidopa 10 mg-Levodopa 100 mg

Carbidopa 25 mg-Levodopa 100mg Carbidopa 25 mg-Levodopa 250 mg

Tablet, Sustained release: Carbidopa 25 mg-Levodopa 100 mg Carbidopa 50 mg-Levodopa 200 mg

Carvedilol (Coreg) Tablet: 3.125 mg, 6.25 mg, 12.5 mg, 25 mg

ceFAZolin (Kefzol) Injection: 500 mg, 1 g Powder for injection: 500 mg, 1 g, 5 g, 10 g, 20 g

Cefepime (Maxipime) Injection: 500 mg, 1 g, 2 g

cefTRIAxone (Rocephin) Infusion, premixed in dextrose: 1 g, 2 g Powder for injection: 250 mg, 500 mg, 1 g, 2 g, 10 g

Cefuroxime Axetil (Ceftin) - Oral form only - Powder for oral suspension: 125 mg/5 mL, 250 mg/5 mL Tablet: 125 mg, 250 mg, 500 mg

Cellulose (Unifiber) Powder, oral: 150 g, 270 g, 480 g

Cephalexin (Keflex) Capsule: 250 mg, 500 mg Powder for oral suspension: 125 mg/5 mL, 250 mg/5 mL Tablet: 250 mg, 500 mg

Cetirizine (ZyrTEC) Syrup: 1 mg/ml Tablet: 5 mg, 10 mg Tablet, chew: 5 mg, 10 mg

Cetirizine-Pseudoephedrine (ZyrTEC D) Tablet, 12hr: Cetirizine 5 mg-Pseudoephedrine 120 mg

chlordiazePOXIDE (Librium) - oral form only - C-IV Capsule: 5 mg, 10 mg, 25 mg


Chlorhexidine (Peridex, Hibiclens, Bactoshield ) Liquid, topical, with 4% isopropyl alcohol: 4% Rinse, oral, with 12% alcohol: 0.12%

Chlorpheniramine (Chlor-Trimeton, Teldrin) Capsule: 12 mg Syrup: 2 mg/5 mL Tablet: 4 mg, 8 mg, 12 mg Tablet, chewable: 2 mg Tablet, timed release: 8 mg, 12 mg

chlorproMAZINE (Thorazine) Injection: 25 mg/mL Tablet: 10 mg, 25 mg, 50 mg, 100 mg, 200 mg

Chlorthalidone (Hygroton) Tablet: 15 mg, 25 mg, 50 mg, 100 mg

Cholestyramine (Questran) Powder, oral: 4 gm resin/9 gm powder Powder for oral suspension (aspartame): 4 gm resin/5 gm powder Powder for oral suspension (phenyalanine): 4 gm resin/5.5 gm powder Tablet: 1 gm


Ciclopirox (Loprox, Penlac) Shampoo: 1% Solution, Topical: 8%

Ciprofloxacin (Cipro, Ciloxan) Injection: 200 mg, 400 mg Ointment, ophthalmic: 0.3% Solution, ophthalmic: 0.3% Suspension, oral: 250 mg/5 mL, 500 mg/5 mL Tablet: 100 mg, 250 mg, 500 mg, 750 mg

Ciprofloxacin-Hydrocortisone (Cipro Otic) Solution, otic: Ciprofloxacin 2 mg-Hydrocortisone 10 mg per mL

Citalopram (celeXA) Solution, oral: 10 mg/5 mL Tablet: 10 mg, 20 mg, 40 mg

Clarithromycin (Biaxin) Granules for oral suspension: 125 mg/5 mL, 250 mg/5 mL Tablet, film coated: 250 mg, 500 mg

Clindamycin (Cleocin, Cleocin T) Capsule: 75 mg, 150 mg, 300 mg Gel, topical: 1% [10 mg/g] Granules for oral solution: 75 mg/5 mL Injection: 150 mg/mL Lotion: 1% [10 mg/mL] Solution, topical: 1% [10 mg/mL]

cloBAZam (Onfi) C-IV Suspension: 2.5 mg/mL Tablet: 5 mg, 10 mg, 20 mg

Clobetasol (Temovate, Cormax, Clobex) - RESERVE USE Cream, topical: 0.05% Cream, topical, in emollient base: 0.05% Gel, topical: 0.05% Lotion, topical: 0.05% Ointment, topical: 0.05% Solution, topical scalp application: 0.05%

clomiPRAMINE (Anafranil) Capsule: 25 mg, 50 mg, 75 mg


clonazePAM (KlonoPIN) C-IV Tablet: 0.5 mg, 1 mg, 2 mg Tablet, oral disintegrating: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

cloNIDine (Catapres) Patch, transdermal: 1, 2, and 3 (0.1, 0.2, 0.3 mg/day, 7 day duration) Tablet: 0.1 mg, 0.2 mg, 0.3 mg

Clopidogrel (Plavix) - RESERVE USE Tablet: 75 mg

Clorazepate (Tranxene) C-IV Tablet: 3.75 mg, 7.5 mg, 15 mg

Clotrimazole (Lotrimin, Mycelex, Gyne-Lotrimin, Fungoid) Cream, topical: 1% Cream, vaginal: 1%, 2% Lotion: 1% Solution, topical: 1% Suppository, vaginal: 100 mg, 200 mg Tablet, vaginal: 100 mg, 500 mg Troche: 10 mg

cloZAPine (Clozaril, Fazaclo, Versacloz) - RESERVE USE Susp: 50 mg/mL Tablet: 25 mg, 50mg, 100 mg, 200mg Tablet, oral disintegrating: 12.5 mg, 25 mg, 100 mg, 150 mg, 200 mg

Coal Tar (Ionil-T, Tegrin, Pentrax, Polytar) Cream, topical: 2% Liquid, topical: 30% Shampoo: 1%, 2%, 2.5%, 5% Solution, topical: 120 mL, 480 mL

Cod Liver Oil-Zinc Oxide-Talc (Desitin) Ointment, topical: Zinc Oxide 40% [with Cod Liver Oil, Talc, Petrolatum, Lanolin, and

Methylparaben]

Colchicine Tablet: 0.5 mg, 0.6 mg

Collagenase (Santyl) Ointment, topical: 0.03%, 0.1%


Cromolyn (Intal) Solution, nebulizing: 10 mg/mL Solution, nasal: 40 mg/mL Solution, ophthalmic: 4%

Cyanocobalamin (Vitamin B12)

Injection: 1000 mcg/mL Tablet: 100 mcg, 250 mcg, 500 mcg, 1000 mcg

Cyclobenzaprine (Flexeril)

Tablet: 5 mg, 10 mg cycloSERINE `RESERVE USE

Capsule: 250mg Cyproheptadine (Periactin)

Syrup: 2 mg/5 mL with 5% alcohol Tablet: 4 mg

Dantrolene (Dantrium)

Capsule: 25 mg, 50 mg, 100 mg Powder for injection: 20 mg

Dapsone

Tablet: 25 mg, 100 mg Darifenacin (Enablex)

Tablet: 7.5 mg, 15mg Deferoxamine (Desferal)

Powder for injection: 500 mg Denosumab (Prolia)

Injection: 60mg Desipramine (Norpramin,)

Tablet: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg Desmopressin (DDAVP, Stimate)

Injection: 4mcg/ml Solution, nasal: 100 mcg/mL, 1.5 mg/mL Tablet: 0.1 mg, 0.2 mg


Desonide (Desowen, Lokara, Tridesilon) Cream: 0.05% Lotion: 0.05%` Ointment: 0.05%

Dexamethasone (Decadron)

Injection, as sodium phosphate: 4 mg/mL, 10 mg/mL, 20 mg/mL, 24 mg/mL Solution, oral: 0.5 mg/5 mL Suspension, ophthalmic: 0.1% with methylcellulose 0.5% - RESERVE USE Tablet: 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

Dextroamphetamine (Dexedrine, Dexedrine spansules, Dextrostat) C-II

Capsule, sustained release: 5 mg, 10 mg, 15 mg Tablet: 5 mg, 10 mg (5 mg tablet contain tartrazine)

Dextromethorphan

Capsule: 15 mg, 30 mg Liquid, oral: 3.5 mg/5 mL, 7.5 mg/5 mL, 10 mg/15 mL, 15 mg/5 mL Liquid, oral, sustained release: 30 mg/5 mL Lozenges: 2.5 mg, 5 mg, 7.5 mg

Dextrose 5%-Sodium Chloride Intravenous Solution

Infusion: Dextrose 5% in 0.2% Sodium Chloride Infusion: Dextrose 5% in 0.45% Sodium Chloride Infusion: Dextrose 5% in 0.9% Sodium Chloride

Dextrose 5%-Sodium Chloride-Potassium Chloride Intravenous Solution

Infusion: Dextrose 5%-Sodium Chloride 0.2% with Potassium Chloride: 10 mEq, 20 mEq Infusion: Dextrose 5%-Sodium Chloride 0.45% with Potassium Chloride: 10 mEq, 20 mEq, 40 mEq Infusion: Dextrose 5%-Sodium Chloride 0.9% with Potassium Chloride: 20 mEq, 40 mEq

Dextrose 5% in Water

Infusion Dextrose 5% in Ringer's Lactate

Infusion Dextrose 5% with Multiple Electrolytes (D5 E75, Baxter)

Infusion


Dextrose 50% in Water Infusion Syringe Vials

Diaper Rash Ointment (Desitin, Diaperene, Vitamin A&D) see Cod Liver Oil-Zinc Oxide-Talc (Desitin) see Vitamin A&D Topical see Zinc Oxide-Petrolatum-Imidazolidinyl Urea (Diaperene) Diaper Rash Powder (Mexsana)

Powder: contains kaolin, eucalyptus oil, camphor, corn starch, lemon oil, zinc oxide Diazepam (Valium, Diastat) C-IV

Gel, rectal: 2.5 mg, 10 mg, 20 mg Injection: 5 mg/mL Solution, oral: 1 mg/mL, 5 mg/mL Tablet: 2 mg, 5 mg, 10 mg

Dicyclomine (Bentyl)

Capsule: 10 mg Injection: 10 mg/mL Syrup: 10 mg/5 mL Tablet: 20 mg

Digoxin (Lanoxin)

Capsule: 50 mcg, 100 mcg, 200 mcg Elixir: 50 mcg/mL with 10% alcohol Injection: 100 mcg/mL, 250 mcg/mL Tablet: 125 mcg, 250 mcg, 500 mcg

Diltiazem (Cardizem)

Capsule, sustained release: Cardizem CD: 120 mg, 180 mg, 240 mg, 300 mg Cardizem SR: 60 mg, 90 mg, 120 mg Dilacor XR: 180 mg, 240 mg Tiazac: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg Tablet: 30 mg, 60 mg, 90 mg, 120 mg Tablet, sustained release: 120 mg, 180 mg, 240 mg

Dimercaprol (B.A.L.)

Injection: 100 mg/mL


diphenhydrAMINE (Benadryl) Capsule: 25 mg, 50 mg Cream, topical: 2% Injection: 50 mg/mL Liquid, oral: 12.5 mg/5 mL Lotion: 1% Tablet: 25 mg, 50 mg

Diphtheria-Tetanus Toxoids Adsorbed (DT)

Injection, single dose Diphtheria-Tetanus Toxoids Adsorbed for Adult Use (Td)

Injection, single dose Diphtheria-Tetanus-Acellular Pertussis (Tdap, Boostrix, Adacel)

Injection, single dose Disulfiram (Antabuse)

Tablet: 250 mg, 500 mg Divalproex (Depakote, Depakote ER)

Capsule, sprinkles: 125 mg Tablet, delayed release: 125 mg, 250 mg, 500 mg Tablet, extended release: 250 mg, 500 mg

Docusate Calcium (Surfak)

Capsule: 240 mg Docusate Sodium (Colace)

Capsule: 50 mg 100 mg, 250 mg Liquid, oral: 150 mg/15 mL Syrup: 60 mg/15 mL

Docusate Sodium-Sennosides (Peri-Colace)

Tablet: Docusate 50 mg-Sennosides 8.6 mg Donepezil (Aricept)

Tablet: 5 mg, 10 mg, 23 mg Tablet, oral disintegrating: 5 mg, 10 mg

DOPamine (Intropin) RESERVE USE

Infusion in D5W: 0.8 mg/mL, 1.6 mg/mL, 3.2 mg/mL Injection: 40 mg/mL, 80 mg/mL, 160 mg/mL


Doxepin (SINEquan, Zonalon) Capsule: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg Concentrate, oral: 10 mg/mL Cream: 5%

Doxycycline (Vibramycin, Periostat)

Capsule: 50 mg, 100 mg Powder for oral suspension: 25 mg/5 mL Tablet: 20 mg, 50 mg, 100 mg

DULoxetine (Cymbalta)

Capsule, delayed release: 20 mg, 30 mg, 60 mg Emollient Gel (Clinac O.C.)

Gel, topical Emollient Lotion-Cream (Lubriderm, Allercreme, Keri Lotion, Cetaphil, Lac-Hydrin, Eucerin, Nutraderm)

Cream, topical Lotion, topical

Emollient Ointment (Lanolin, Aquaphor)

Ointment, topical Enalapril (Vasotec)

Tablet: 2.5 mg, 5 mg, 10 mg, 20 mg Enoxaparin (Lovenox)

Injection: 30 mg, 40 mg, 60 mg, 80 mg, 100 mg, 120 mg, 150 mg Entacapone (Comtan)

Tablet: 200 mg EPINEPHrine (Adrenalin)

Auto-injector: 1:2000 [0.15 mg], 1:1000 [0.3 mg] Injection: 1:100,000 [0.01 mg/mL], 1:10,000 [0.1 mg/mL], 1:1000 [1 mg/mL]

Epoetin alfa (Epogen, Procrit)- RESERVE USE

Injection: 2,000 units/mL, 3,000 units/mL, 4,000 units/mL, 10,000 units/mL, 20,000 units/mL, 40,000 units/mL

Ergocalciferol (Calciferol, Drisdol) See Vitamin D


Erythromycin Erythromycin base(Eryc, Erythrocin): Capsule, delayed release: 250 mg Tablet, film coated: 250 mg, 500 mg Erythromycin Ethylsuccinate (EryPed, E.E.S.): Granules/Powder for oral suspension: 200 mg/5 mL, 400 mg/5 mL Suspension, oral: 200 mg/5 mL, 400 mg/5 mL Tablet: 400 mg Ointment, ophthalmic: 5%

Erythromycin-Benzoyl Peroxide (Benzamycin)

Gel, topical: Erythromycin 30 mg-Benzoyl Peroxide 50 mg per gram (with 16% alcohol) Escitalopram (Lexapro)

Solution: 5 mg/5 ml Tablet: 5 mg, 10 mg, 20 mg

Esomeprazole (NexIUM) RESERVE USE

Capsule: 20 mg, 40 mg Suspension packet: 10 mg, 20 mg, 40 mg

Estradiol (Estrace, Vivelle, Alora, Climara, Estraderm, Vagifem)

Cream, vaginal: 43 gm Systems, transdermal: 0.025 mg, 0.0375 mg, 0.05 mg, 0.075 mg, 0.1 mg per 24 hr Tablet: 0.5 mg, 1 mg, 2 mg Tablet, vaginal: 25 mg

Estrogen-medroxyPROGESTERone (PremPro, Premphase)

Tablet: Conjugated estrogen 0.3 mg-medroxyPROGESTERone 1.5 mg Tablet: Conjugated estrogen 0.45 mg-medroxyPROGESTERone 1.5 mg Tablet: Conjugated estrogen 0.625 mg-medroxyPROGESTERone 2.5 mg Tablet: Conjugated estrogen 0.625 mg-medroxyPROGESTERone 5 mg

Estrogens, Conjugated (Premarin)

Cream, vaginal: 0.625 mg/g Injection: 25 mg Tablet: 0.3 mg, 0.625 mg, 0.9 mg, 1.25 mg, 2.5 mg

Ethambutol (Myambutol)

Tablet: 100 mg, 400 mg


Ethinyl Estradiol-Norethindrone (Loestrin, , Ortho-Novum 777) Loestrin: 1/20: Ethinyl Estradiol 0.02 mg-Norethindrone 1 mg 1.5/30: Ethinyl Estradiol 0.03 mg-Norethindrone 1.5 mg Ortho-Novum 777 Phase 1(Ethinyl Estradiol 0.035 mg-Norethindrone 0.5 mg), Phase 2

(Ethinyl Estradiol 0.035 mg-Norethindrone 0.75 mg), Phase 3 (Ethinyl Estradiol 0.035 mg-Norethindrone 1 mg)

Ethinyl Estradiol-Norgestrel (Ovral, Lo-Ovral)

Lo-Ovral: Ethinyl Estradiol 0.03 mg-Norgestrel 0.3 mg Ovral: Ethinyl Estradiol 0.05 mg-Norgestrel 0.5 mg

Ethionamide (Trecator)

Tablet, sugar coated: 250 mg Ethosuximide (Zarontin)

Capsule: 250 mg Syrup: 250 mg/5 mL

Ethyl Chloride

Spray: 100 g, 105 mL, 120 mL, 270 mL Famotidine (Pepcid)

Injection: 10 mg/mL Powder for oral suspension: 40 mg/5 mL Tablet: 10 mg, 20 mg, 40 mg

Felbamate (Felbatol) - RESERVE USE

Suspension, oral: 600 mg/5 mL Tablet: 400 mg, 600 mg

Felodipine (Plendil)

Tablet, extended release: 2.5 mg, 5 mg, 10 mg Fenofibrate (Antara, Lofibra, Tricor, Triglide)

Capsule: 50 mg, 150 mg, 160 mg Capsule, micronized: 43 mg, 67 mg, 130 mg, 134 mg, 200 mg Tablet: 40 mg, 54 mg, 120 mg, 160 mg Tablet: nanocrystallized: 48 mg, 50 mg, 145 mg, 160 mg

fentaNYL (Duragesic) C-II

Lozenge: 200 mcg, 400 mcg, 600 mcg, 800 mcg Patch, transdermal: 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr


Ferrous Fumarate-Docusate Sodium (Ferro-Sequels)[contains 33% elemental iron]

Tablet, timed released: Ferrous fumarate 150 mg [50 mg]-Docusate Sodium 100 mg Ferrous Sulfate (Feosol, Fer-In-Sol) [contains 20% elemental iron]

Elixir with 5% alcohol: 220 mg/5 mL [18 mg/5 mL] Tablet: 160 mg [32mg], 300 mg [60 mg], 325 mg [65 mg]

Fexofenadine (Allegra)

Tablet: 30 mg, 60 mg, 180 mg Fexofenadine-Pseudoephedrine (Allegra-D)

Tablet, extended release: 60 mg Fexofenadine-120 mg Pseudoephedrine Finasteride (Proscar)

Tablet: 5 mg Fish Oil (Nature Made Fish Oil NUTRITIONAL SUPPLEMENT)

Capsules: 225 mg, 500 mg, 1000 mg 1200 mg, 1400 mg flavoxATE (Urispas)

Tablet, film coated: 100 mg Fluconazole (Diflucan)

Suspension: 40 mg/mL Tablet: 100 mg, 150 mg, 200 mg, 250 mg, 500 mg

Fludrocortisone (Florinef)

Tablet: 0.1 mg Fluocinolone (Capex, Derma-Smooth/FS, Synalar)

Cream, topical: 0.01%, 0.025% Oil: 0.01% Ointment, topical: 0.025% Shampoo: 0.01% Solution, topical: 0.01%

Fluocinonide (Lidex)

Cream, topical: 0.05% Gel, topical: 0.05% Ointment, topical: 0.05% Solution, topical: 0.05%

Fluorescein Sodium

Injection: 10% Strip, ophthalmic: 0.6 mg, 1 mg


FLUoxetine (PROzac) Capsule: 10 mg, 20 mg Liquid, oral: 20 mg/5 mL Tablet: 10 mg, 20 mg

fluPHENAZine (Prolixin)

Concentrate: 5 mg/mL with 14% alcohol Elixir: 2.5 mg/5 mL with 14% alcohol Injection, as decanoate: 25 mg/mL Injection, as hydrochloride: 2.5 mg/mL Tablet: 1 mg, 2.5 mg, 5 mg, 10 mg

Fluticasone (Flonase, Flovent)

Aerosol, inhalation, oral: 44 mcg/actuation, 110 mcg/actuation, 220 mcg/actuation Inhalation, nasal: 50 mcg/actuation

Fluticasone-Salmeterol (Advair)

Powder, inhalation: fluticasone 100 mcg/ salmeterol 50 mcg fluticasone 250 mcg /salmeterol 50 mcg fluticasone 500 mcg /salmeterol 50 mcg

Fluvastatin (Lescol)

Capsule: 20 mg, 40 mg fluvoxaMINE (Luvox)

Tablet: 25 mg, 50 mg, 100 mg Folic Acid (Folvite)

Tablet: 0.4 mg, 0.8 mg, 1 mg Fondaparinux (Arixtra)

Injection: 2.5 mg, 5 mg, 7.5 mg, 10 mg Fosphenytoin (Cerebyx)

Injection: 100 Phenytoin Equivalents [PE]/2 mL, 500 PE/10 mL Furosemide (Lasix)

Injection: 10 mg/mL Solution, oral: 10 mg/mL, 40 mg/5 mL Tablet: 20 mg, 40 mg, 80 mg

Gabapentin (Neurontin)

Capsule: 100 mg, 300 mg, 400 mg Solution, oral: 250 mg/5 mL Tablet: 400 mg, 600 mg, 800 mg


Galantamine (Razadyne) Capsule, 24hr: 8 mg, 16 mg, 24 mg Solution, oral: 4 mg/mL Tablet, film coated: 4 mg, 8 mg, 12 mg

Gemfibrozil (Lopid)

Tablet, film coated: 600 mg Gentamicin

Cream, topical: 0.1% Infusion, premixed in NS: 40 mg, 60 mg, 80 gm, 90 mg, 100 mg, 120 mg Injection: 10 mg/mL, 40 mg/mL Injection, intrathecal (preservative free): 2 mg/mL Ointment, ophthalmic: 0.3% [3 mg/g] Ointment, topical: 0.1% Solution, ophthalmic: 0.3% [3 mg/mL]

glipiZIDE (Glucotrol)

Tablet: 5 mg, 10 mg Tablet, extended release: 2.5 mg, 5 mg, 10 mg

Glucosamine NUTRITIONAL SUPPLEMENT

Capsule: 500 mg, 1000 mg Tablet: 500 mg, 1000 mg, 1500 mg

Glucagon

Powder for injection: 1 mg Glucose

Gel, oral Tablet

glyBURIDE (Micronase, DiaBeta)

Tablet: 1.25 mg, 2.5 mg, 5 mg Tablet, micronized: 1.5 mg, 3 mg, 6 mg

Glycerin (Sani-Supp)

Suppository, rectal Glycopyrrolate (Robinul)

Tablet: 1 mg


Griseofulvin (Fulvicin, Grifulvin V, Gris-Peg) Microsize: Suspension, oral: 125 mg/5 mL with 0.2% alcohol Tablet: 500 mg Ultramicrosize: Tablet: 125 mg, 250 mg

guaiFENesin (Robitussin Mucinex)

Caplet, sustained release: 600 mg Liquid, oral: 100 mg/5 mL, 200 mg/5 mL Tablet: 100 mg, 200 mg, 400mg Tablet, sustained release: 600 mg

guaiFENesin-Codeine (Robitussin AC) C-V

Syrup: guaiFENesin 100 mg-codeine 10 mg per 5mL guaiFENesin-Dextromethorphan (Robitussin DM)

Liquid, oral: guaiFENesin 100 mg-Dextromethorphan 10 mg per 5 mL, guaiFENesin 100 mg-Dextromethorphan 15 mg per 5 mL, guaiFENesin 66.7 mg-Dextromethorphan 6.7 mg per 5 mL

Tablet, sustained release: guaiFENesin 300 mg-Dextromethorphan 30 mg guaiFENesin-Pseudoephedrine (Mucinex D)

Tablet: guaiFENesin 600 mg-Pseudoephedrine 60 mg guanFACINE (Tenex)

Tablet: 1 mg, 2 mg Haloperidol (Haldol)

Concentrate, oral: 2 mg/mL Injection, as decanoate: 50 mg/mL, 100 mg/mL Injection, as lactate: 5 mg/mL Tablet: 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mg

Heparin

Injection: 10 units/mL, 100 units/mL, 1,000 units/mL, 5,000 units/mL, 10,000 units/mL, 20,000 units/mL

Hepatitis A Vaccine (Vaqta, Havrix)

Injection, single dose Hepatitis A-Hepatitis B Vaccine (Twinrix)

Injection, single dose Hepatitis B Immune Globulin (HBIG)

Injection, single dose


Hepatitis B Virus Vaccine, Recombinant (Recombivax HB, Engerix-B) Injection: 5 mcg/mL, 10 mcg/mL, 20 mcg/mL

Hexachlorophene (pHisoHex)

Liquid, topical: 3% Homatropine (Isopto Homatropine)

Solution, ophthalmic: 2%, 5% hydrALAZINE (Apresoline)

Tablet: 10 mg, 25 mg, 50 mg, 100 mg Hydrochlorothiazide (HydroDIURIL, Esidrix)

Capsule: 12.5 mg Solution, oral: 50 mg/5 mL Tablet: 12.5 mg, 25 mg, 50 mg, 100 mg

HYDROcodone-guaiFENesin (Hycotuss, Kwelcof) C-II

Liquid, oral: HYDROcodone 5 mg-guaiFENesin 100 mg per 5 mL Hydrocortisone

Injection, as sodium succinate: 100 mg, 250 mg, 500 mg, 1000 mg Suppositories, rectal, as acetate: 25 mg Suspension, oral, as cypionate: 10 mg/5 mL Hydrocortisone base: Cream, rectal: 1%, 2.5% Tablet, oral: 5 mg, 10 mg, 20 mg Hydrocortisone, topical (Lanacort, Corticaine): Cream, topical: 0.5%, 1%, 2.5% Lotion, topical: 0.5%, 1%, 2%, 2.5% Ointment, topical: 0.5%, 1%, 2.5%

Hydrogen Peroxide

Solution, topical: 3% hydrOXYzine (Atarax, Vistaril)

Capsule: 25 mg, 50 mg, 100 mg Injection, as hydrochloride: 25 mg/mL, 50 mg/mL Suspension: 25 mg/5 mL Syrup, as hydrochloride: 10 mg/5 mL Tablet: 10 mg, 25 mg, 50 mg

Ibandronate (Boniva)

Tab: 2.5 mg, 150 mg Injection: 3 mg/3 mL


Ibuprofen (Motrin) Suspension, oral: 40 mg/mL, 100 mg/5 mL Tablet: 200 mg, 400 mg, 600 mg, 800 mg Tablet, chewable: 100mg

Iloperidone (Fanapt) RESERVE USE

Tablet: 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg Imipramine (Tofranil)

Tablet: 10 mg, 25 mg, 50 mg Influenza Virus Vaccine (Fluzone, Fluviron)

Injection, single dose Insulin, Aspart (NovoLog)

Injection: 100 units/mL Insulin, Combination (70/30)

Injection: 100 units/mL Insulin, Detemir (Levemir) RESERVE USE

Injection: 100 units/mL Insulin, Glargine (Lantus)

Injection: 100 units/mL Insulin, Lispro (HumaLOG)

Injection: 100 units/mL Insulin, Lispro-Insulin, Lispro Protamine (HumaLOG Mix 75/25)

Injection: 100 units/mL Insulin, NPH

Injection: 100 units/mL Insulin, Regular

Injection: 100 units/mL Ipratropium (Atrovent)

Inhalation: 18 mcg/actuation Solution, nasal: 0.03%, 0.06% Solution, nebulizing: 0.02%


Iron salts with or without vitamins and/or minerals (Hemocyte Plus, Niferex, Niferex-150, Niferex-150 Forte)

Capsule Solution, oral Tablet

Isoniazid (INH)

Injection: 100 mg/mL Syrup: 50 mg/5 mL Tablet: 100 mg, 300 mg

Isosorbide Dinitrate (Isordil, Sorbitrate)

Capsule, sustained release: 40 mg Tablet, chewable: 5 mg, 10 mg Tablet, oral: 5 mg, 10 mg, 20 mg, 30 mg, 40 mg Tablet, sublingual: 2.5 mg, 5 mg, 10 mg Tablet, sustained release: 40 mg

Isosorbide Mononitrate (Imdur, ISMO, Monoket)

Tablet: 10 mg, 20 mg Tablet, extended release: 30 mg, 60 mg, 120 mg

Ivermectin (Stromectol)

Tablet: 3 mg Kaolin-Pectin

Suspension: 30 mL, 120 mL, 180 mL, 240 mL Ketoconazole (Nizoral)

Cream, topical: 2% Shampoo: 2% Tablet: 200 mg

Ketorolac (Toradol)

Injection: 15 mg/mL, 30 mg/mL Ketotifen (Zaditor)

Solution, ophthalmic: 0.025% Labetalol (Normodyne)

Tablet: 100 mg, 200 mg, 300 mg Lacosamide (Vimpat) C-V

Oral Solution: 10 mg/mL Injection: 10 mg/mL Tablet: 50 mg, 100 mg, 150 mg, 200 mg


Lactobacillus Acidophilus (Lactinex, Bacid) Capsule Granules: 1 g/packet Tablet, chewable

Lactulose (Enulose)

Syrup: 10 g/15 mL lamoTRIgine (LaMICtal)

Tablet: 25 mg, 100 mg, 150 mg, 200 mg Tablet, dispersible/chewable: 2 mg, 5 mg, 25 mg

Lansoprazole (Prevacid)

Capsule, enteric coated granules: 15 mg, 30 mg Latanoprost (Xalatan)

Solution, ophthalmic: 0.005% Leucovorin (Wellcovorin)

Injection: 3 mg/mL Powder for injection: 25 mg, 50 mg, 100 mg, 350 mg Tablet: 5 mg, 10 mg, 15 mg, 25 mg

Levarterenol (Levophed) RESERVE USE see Norepinephrine LevETIRAcetam (Keppra)

Solution, oral: 100 mg/mL Tablet: 100 mg, 250 mg, 500 mg, 750 mg, 1,000 mg

Levofloxacin (Levaquin)

Infusion: 250 mg, 500 mg, 750 mg Solution: 250 mg/10 mL Tablet: 250 mg, 500 mg, 750 mg

Levonorgestrel-Ethinyl Estradiol (Tri-Levlen, Triphasil)

Tablet: Phase I (Levonorgestrel 0.05 mg-Ethinyl Estradiol 30 mcg), Phase 2 (Levonorgestrel 0.075 mg-Ethinyl Estradiol 40 mg), Phase 3 (Levonorgestrel 0.125 mg-Ethinyl Estradiol 30 mg)

Levothyroxine (Synthroid, Levoxyl)

Powder for injection: 200 mcg/mL, 500 mcg/mL Tablet: 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 150 mcg

175 mcg, 200 mcg, 300 mcg


Lidocaine (Lidoderm, Xylocaine) Injection: 0.4%, 1%, 2%, 4%, 10% Gel, topical: 2%, 2.5% Liquid, topical: 2.5%, 4% Liquid, viscous: 2% Ointment, topical: 2.5%, 5% Patch: 5% Solution, topical: 2%, 4%

Lidocaine-Prilocaine (EMLA)

Cream: Lidocaine 2.5%-Prilocaine 2.5% Linezolid (Zyvox) RESERVE USE

Suspension, oral: 100 mg/5 mL Tablet: 600 mg

Lisdexamfetamine dimesylate (Vyvanse) C-II RESERVE USE

Capsule: 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg Lisinopril (Prinivil, Zestril)

Tablet: 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40 mg Lithium Carbonate (Eskalith, Lithonate, Lithobid)

Capsule: 150 mg, 300 mg, 600 mg Tablet: 300 mg Tablet, controlled release: 450 mg Tablet, slow release: 300 mg

Lithium Citrate

Syrup: 300 mg/5 mL Loperamide (Imodium)

Capsule: 2 mg Liquid, oral: 1 mg/5 mL Tablet: 2 mg

Loratadine (Claritin)

Liquid, oral: 5 mg/5 mL Tablet: 10 mg

Loratadine-Pseudoephedrine (Claritin D)

Tablet, sustained release: loratadine 5mg - pseudoephedrine 120 mg (12hr), loratadine 10mg – pseudoephedrine 240 mg (24hr)


LORazepam (Ativan) C-IV Injection: 2 mg/mL, 4 mg/mL Solution, oral: 2 mg/mL Tablet: 0.5 mg, 1 mg, 2 mg

Loxapine (Loxitane)

Capsule: 5 mg, 10 mg, 25 mg, 50 mg Lurasidone (Latuda)

Tablet: 20 mg 40 mg, 60 mg, 80 mg, 120 mg Lubiprostone (Amitiza)

Capsule: 8mcg, 24mcg Magnesium Citrate

Solution, oral: 300 mL Magnesium Hydroxide (Milk of Magnesia)

Liquid, oral: 400 mg/5 mL Liquid, oral, concentrate: 1200 mg/5 mL Tablet, chewable: 311 mg

Magnesium L-lactate dihydrate (Mag-Tab SR) NUTRITIONAL SUPPLEMENT

Tablet Magnesium Sulfate (Epsom Salt)

Granules: ~40 mEq magnesium/5 g Injection: 100 mg/mL, 125 mg/mL, 250 mg/mL, 500 mg/mL

Measles-Mumps-Rubella Virus Vaccine, Live (MMR II)

Injection, single dose Meclizine (Antivert, Bonine)

Tablet: 12.5 mg, 25 mg, 50 mg medroxyPROGESTERone (Provera)

Injection, suspension: 100 mg/mL, 150 mg/mL, 400 mg/mL Tablet: 2.5 mg, 5 mg, 10 mg

Megestrol (Megace, Megace ES)

Suspension: 200 mg/5 ml, 625 mg/5 ml Tablet: 20mg, 40mg


Melatonin NUTRITIONAL SUPPLEMENT Capsule: 10 mg Tablet: 1 mg, 3 mg, 5 mg, 10 mg Tablet, sublingual: 5 mg Tablet, sustained release: 3 mg

Meloxicam (Mobic)

Tablet: 7.5 mg, 15 mg Memantine (Namenda)

Tablet: 5 mg, 10 mg Menthol

Cream Liquid Ointment Patch Spray

Menthol-Methyl Salicylate (Ben-Gay)

Cream, topical: 30% Menthol-Zinc Oxide (Calmoseptine, Risamine)

Ointment Mesalamine (Asacol HD, Pentasa, Rowasa)

Capsule, extended release: 250 mg Suppository: 1,000 mg Suspension, rectal: 4 gm/60 mL Tablet, delayed release: 800 mg

metFORMIN (Glucophage, Glucophage XR)

Tablet: 500 mg, 850 mg, 1000 mg Tablet, extended release: 500 mg, 750 mg

Methadone (Dolophine) C-II

Solution, oral: 1 mg/mL Tablet: 5 mg, 10 mg, 40 mg

Methimazole (Tapazole)

Tablet: 5 mg, 10 mg Methocarbamol (Robaxin)



Methylcellulose (Citrucel) Powder: Methylcellulose 2 g per tbsp [with sucrose] Powder, sugar free: Methylcellulose 2 g per tbsp [with phylalanine]

Methyldopa (Aldomet)

Injection: 50 mg/mL Suspension, oral: 250 mg/5 mL Tablet: 125 mg, 250 mg, 500 mg

Methylphenidate, immediate release (Ritalin, Methylin, Metadate) C-II

Tablet: 5 mg, 10 mg, 20 mg Methylphenidate, sustained release (Ritalin SR, Concerta, Metadate CD) C-II

Tablet, extended release: 18 mg, 36 mg, 27 mg, 54 mg Tablet, sustained release: 20 mg

methylPREDNISolone (Medrol, Depo-Medrol)

Injection, as acetate: 20 mg/mL, 40 mg/mL, 80 mg/mL Injection, as sodium succinate: 40 mg, 125 mg, 500 mg, 1000 mg, 2000 mg Tablet: 2 mg, 4 mg, 8 mg, 16 mg, 24 mg, 32 mg

Metoclopramide (Reglan)

Injection: 5 mg/mL Liquid, oral, sugar free: 5 mg/5 mL Tablet: 5 mg, 10 mg

Metoprolol (Lopressor, Toprol XL)

Tablet: 25 mg, 50 mg, 100 mg Tablet, extended release: 25 mg, 50 mg, 100 mg, 200 mg

metroNIDAZOLE (Flagyl, Noritate, MetroGel)

Capsule: 375 mg Cream, topical: 0.75%, 1% Gel, topical: 0.75% [7.5 mg/mL] Gel, vaginal: 0.75% Injection: 5 mg/mL Powder for injection: 500 mg Tablet: 250 mg, 500 mg


Miconazole (Monistat) Cream, topical: 2% Cream, vaginal: 2% Injection: 10 mg/mL Lotion: 2% Powder, topical: 2% Spray, topical: 2% Suppository, vaginal: 100 mg, 200 mg

Midazolam (Versed) C-IV

Injection: 1 mg/mL, 5 mg/mL Mineral Oil - for topical use only

Oil Minocycline

Capsule: 50 mg, 75 mg, 100 mg Capsule, pellet filled: 50 mg, 100 mg

Mirtazapine (Remeron, Remeron SolTab)

Tablet: 7.5 mg, 15 mg, 30 mg, 45 mg Tablet, rapid dissolving: 15 mg, 30 mg, 45 mg

Misoprostol (Cytotec)

Tablet: 100 mcg, 200 mcg Mometasone (Nasonex)

Inhalation, nasal: 50 mcg/actuation Montelukast (Singulair)

Tablet, chewable: 4 mg, 5 mg Tablet: 10 mg

Morphine C-II

Injection: 1 mg/mL, 2 mg/mL, 4 mg/mL, 10 mg/mL Solution, oral: 20 mg/mL Suppository, rectal: 20 mg, 30 mg Tablet, controlled release: 15 mg, 30 mg, 60 mg Tablet, sublingual: 10 mg

Moxifloxacin (Avelox, Moxeza, Vigamox)

Infusion: 400 mg/250 mL Ophthalmic drops: 0.5% RESERVE USE Tablet: 400 mg


Multivitamin (Unicap, Hexavitamins) Liquid, oral: each solution contains a minimum of USDA requirements Tablet: each tablet contains a minimum of USDA requirements Tablet, chew: each tablet contains a minimum of USDA requirements

Multivitamin-Minerals

Liquid, oral: each solution contains a minimum of USDA requirements Tablet: each tablet contains a minimum of USDA requirements Tablet, chew: each tablet contains a minimum of USDA requirements

Multivitamins, Pediatric (Poly-Vi-Sol)

Liquid, oral: each solution contains a minimum of USDA requirements Multivitamin, Prenatal (Filibon)

Tablet: each tablet contains a minimum of USDA requirements Mupirocin (Bactroban)

Cream, topical: 2% Ointment, intranasal: 2% Ointment, topical: 2%

Nabumetone (Relafen) - RESERVE USE

Tablet: 500 mg, 750 mg Nafcillin

Powder for injection: 500 mg, 1 g, 2 g, 10 g Naloxone (Narcan)

Injection: 0.4 mg/mL, 1 mg/mL Naltrexone (Trexan, ReVia)

Tablet: 50 mg Naphazoline (Naphcon, AK-Con)

Solution, ophthalmic: 0.012%, 0.1% Naproxen (Naprosyn)

Tablet: 220 mg, 250 mg, 275 mg, 375 mg, 500 mg, 550 mg Tablet, delayed release: 500 mg

Neomycin

Tablet: 500 mg Neomycin-Polymyxin B-Bacitracin (Triple Antibiotic Ointment)

Ointment, topical: Neomycin 3.5 mg-Polymyxin B 5000 units-Bacitracin 400 units


Neomycin-Polymyxin B-Hydrocortisone (Cortisporin) Solution, otic: Neomycin-Polymyxin B-Hydrocortisone Suspension, otic: Neomycin-Polymyxin B-Hydrocortisone

Niacin-Nicotinamide (Nicobid)

Capsule, extended release: 250 mg, 500 mg Tablet: 50 mg, 100 mg, 250 mg, 500 mg Tablet, extended release: 250 mg, 500 mg, 750 mg, 1000 mg

Nicotine (Nicoderm, Habitrol, ProStep, Nicotrol, Nicorette)

Patch, transdermal: Habitrol: 21 mg/day, 14 mg/day, 7 mg/day Nicoderm: 21 mg/day, 14 mg/day, 7 mg/day Nicotrol: 15 mg/day (gradual release over 16 hours) Pieces, chewing gum, as polacrilex: 2 mg/square, 4 mg/square

NIFEdipine (Procardia, Procardia XL, Adalet CC)

Capsule, liquid-filled: 10 mg, 20 mg Tablet, sustained release: 30 mg, 60 mg, 90 mg

Nitrofurantoin (Macrodantin)

Capsule, macrocrystal: 25 mg, 50 mg, 100 mg Capsule, macrocrystal/monohydrate: 100 mg Suspension, oral: 25 mg/5 mL

Nitroglycerin

Capsule, sustained release: 2.5 mg, 6.5 mg, 9 mg, 13 mg Ointment, topical 2%: 30 gm, 60 gm Patch, transdermal, topical: systems designed to deliver 2.5 mg, 5 mg, 7.5 mg,

10 mg, or 15 mg over 24 hours Spray, translinqual: 0.4 mg/metered spray Tablet, buccal, controlled release: 2 mg, 3 mg Tablet, sublingual: 0.3 mg, 0.4 mg, 0.6 mg Tablet, sustained release: 2.6 mg, 6.5 mg, 9 mg

Non-Soap Cleanser (Cetaphil)

Bar Lotion

Norepinephrine or Levarterenol (Levophed) RESERVE USE

Injection: 1 mg/mL Norgestimate-Ethinyl Estradiol (Ortho Tri-Cyclen)

Tablet: 21 day, 28 day


Nortriptyline (Aventyl, Pamelor) Capsule: 10 mg, 25 mg, 50 mg, 75 mg Solution: 10 mg/5 mL

Nystatin (Mycostatin)

Cream, topical: 100,000 units/g Ointment, topical: 100,000 units/g Powder, topical: 100,000 units/g Suspension, oral: 100,000 units/mL Tablet, oral: 500,000 units

OLANZapine (ZyPREXA, ZyPREXA Zydis ZyPREXA Relprevv)

Injection: 10 mg/2 mL Injection as pamoate: 210 mg, 300 mg, 405 mg RESERVE USE Tablet: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg Tablet, rapid dissolving: 5 mg, 10 mg, 15 mg, 20 mg

Olmesartan (Benicar) - RESERVE USE

Tablet: 5 mg, 20 mg, 40 mg Olopatadine (Patanol)

Solution, ophthalmic: 0.1% Omeprazole (PriLOSEC)

Capsule, delayed release: 10 mg, 20 mg, 40 mg Ondansetron (Zofran, Zofran ODT)

Tablet: 4mg, 8mg Tablet, oral disintegrating: 4mg, 8mg

Ophthalmic Irrigating Solution (BSS, Eye Stream, AK-Rinse)

Solution, ophthalmic Ophthalmic Lubricant (HypoTears, HypoTears PF Artifical Tears, Liquitears)

Ointment, ophthalmic Solution, ophthalmic Solution, ophthalmic 1.4%

Oseltamivir (Tamiflu)

Capsule: 75 mg Oxazepam (Serax) C-IV

Capsule: 10 mg, 15 mg, 30 mg Tablet: 15 mg


OXcarbazepine (Trileptal) Suspension, oral: 300 mg/5 mL Tablet: 150 mg, 300 mg, 600 mg

Oxybenzone-PDO-Pet Hy-Phl (Vaseline Lip Therapy)

Ointment Oxybutynin (Ditropan, Ditropan XL)

Syrup: 5 mg/5 mL Tablet: 5 mg Tablet, extended release: 5 mg, 10 mg, 15 mg

oxyCODONE (OxyCONTIN) C-II

Tablet: 15mg, 30mg Tablet, controlled release: 5 mg,10 mg, 15 mg, 20 mg, 40 mg, 80 mg, 160 mg

Oxymetazoline (Afrin)

Solution, nasal, drops: 0.025%, 0.05% Solution, nasal, spray: 0.05%

Paliperidone (Invega, Invega Sustenna)

Injection, long acting: 39 mg, 78 mg, 117 mg, 156 mg, 234 mg Tablet, extended release: 1.5 mg 3 mg, 6 mg, 9 mg

Pancrelipase (Pancrease, Creon)

Capsule: contains lipase, protease and amylase Tablet: contains lipase, protease and amylase

Pantoprazole (Protonix)

Suspension Packets; 40mg Tablet: 20 mg, 40 mg

PARoxetine (Paxil)

Suspension, 10 mg/5 ml Tablet: 10 mg, 20 mg, 30 mg, 40 mg Tablet: controlled release: 12.5 mg, 25 mg, 37.5 mg

penicillAMINE (Cuprimine)

Capsule: 125 mg, 250 mg Tablet: 250 mg

Penicillin G Benzathine (Bicillin LA)

Injection: 600,000 units/mL


Penicillin G Benzathine-Penicillin G Procaine (Bicillin C-R) Injection:

Penicillin G Benzathine 600,000 units-Penicillin G Procaine 600,000 units/2 mL, Penicillin G Benzathine 900,000 units-Penicillin G Procaine 300,000 units

Penicillin G Procaine (Wycillin)

Injection (suspension): 600,000 units/mL Penicillin G Sodium

Injection: 5 million units Penicillin V Potassium (Pen-Vee K, V-Cillin K)

Powder for oral solution: 125 mg/5 mL, 250 mg/5 mL Tablet: 250 mg, 500 mg

Pentamidine (Pentam) - RESERVE USE

Inhalation: 300 mg Powder for injection: 300 mg

Permethrin (Acticin, Elimite, NIX)

Cream, topical: 5% Lotion: 1% Shampoo: 1%

Perphenazine (Trilafon)

Tablet: 2 mg, 4 mg, 8 mg, 16 mg Petrolatum, White (Vaseline)

Ointment, topical: 430 g Phenazopyridine (Pyridium)

Tablet: 95 mg, 100 mg, 200 mg Phenelzine (Nardil)

Tablet: 15 mg PHENobarbital (Luminal) C-IV

Elixir: 20 mg/5 mL Injection: 65 mg/mL, 130 mg/mL Tablet: 8 mg, 15 mg, 16 mg, 30 mg, 32 mg, 60 mg, 65 mg, 100 mg

Phenol (Chloraseptic)

Mouthwash/Gargle Throat Spray


Phenylephrine (Neo-Synephrine) Solution, nasal, drops: 0.125%, 0.25%, 0.5% Solution, nasal, spray: 0.25%, 0.5%, 1% Solution, ophthalmic: 2.5%, 10%

Phenytoin (Dilantin)

Capsule, extended release: 30 mg, 100 mg Capsule, immediate release: 100 mg, 200 mg, 300 mg Injection: 50 mg/mL Suspension, oral: 125 mg/5 mL Tablet, chewable: 50 mg

Physostigmine (Antilirium)

Injection: 1 mg/mL Phytonadione (Vitamin K1, Mephyton, Konakion)

Injection, aqueous colloidal: 2 mg/mL, 10 mg/mL Injection, aqueous (IM only): 2 mg/mL, 10 mg/mL Tablet: 5 mg

Pilocarpine (Isopto Carpine)

Solution, ophthalmic, as hydrochloride: 1%, 2%, 4% Pimecrolimus (Elidel)

Cream: 1% Pioglitazone (Actos)

Tablet: 15 mg, 30 mg, 45 mg Piperacillin-Tazobactam (Zosyn)

Injection: 2.25 g, 3.375 g and 4.5 g Pneumococcal Vaccine, Polyvalent (Pneumovax)

Injection, single dose Podophyllum Resin (Podocon-25)

Liquid, topical: 25% in benzoin Polycarbophil (Fibercon, Fiber-Lax)

Tablet: 500 mg, 625 mg Polyethylene Glycol (MiraLax)

Powder for oral solution Polyethylene Glycol Electrolyte Solution (PEG, Co-Lyte, GoLYTELY)

Powder for oral solution: 2000 mL, 4000 mL, 4800 mL, 6000 mL


Polymyxin B-Bacitracin (Polysporin) Ointment, ophthalmic: Polymyxin B 10,000 units-Bacitracin 500 units Ointment, topical: Polymyxin B 10,000 units-Bacitracin 500 units Powder, topical: Polymyxin B 10,000 units-Bacitracin 500 units

Polymyxin B-Neomycin (Neosporin)

Cream: Polymyxin B 10,000 units-Neomycin 3.5 mg Polymyxin B-Trimethoprim (Polytrim)

Solution, ophthalmic: Polymyxin B 10,000 units-Trimethoprim 1 mg/mL Potassium Chloride

Capsule: 8 mEq, 10 mEq Capsule, sustained release: 10 mEq Crystals for oral suspension, extended release: 20 mEq/packet Liquid, oral: 10% [20 mEq/15 mL], 15% [30 mEq/15 mL], 20% [40 mEq/15 mL] Powder for oral suspension(per packet): 15 mEq, 20 mEq, 25 mEq Injection, concentrate: 2 mEq/mL Tablet, controlled release (microencapsulated): 750 mg [10 mEq], 1500 mg [20 mEq] Tablet, controlled release (wax matrix): 500 mg [6.7 mEq], 600 mg [8 mEq], 750 mg [10

mEq] Potassium Citrate (Urocit K)

Tablet: 5 mEq, 10 mEq Potassium Citrate Combinations (Polycitra, Polycitra-LC, Polycitra K, Citrolith)

Solution, oral: containing Sodium Citrate-Potassium Citrate-Citric Acid Solution, oral: containing Sodium Citrate-Potassium Citrate

Potassium Iodide (SSKI)

Solution, oral: 100 mg/mL,1 g/mL Potassium Phosphate (Neutra-Phos-K)

Powder for oral solution: 250 mg elemental phosphours/14.2 mEq potassium per packet Povidone-Iodine (Betadine)

Cleanser, topical: 60 mL, 240 mL Ointment, topical: 10% Solution, prep: 30 mL, 60 mL, 240 mL, 473 mL, 1000 mL, 4000 mL Solution, topical: 10%

Pramipexole (Mirapex)

Tablet: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1.5 mg


Pramoxine (Tronothane) Cream, topical: 1% Gel, topical: 1% Lotion: 1% Spray: 1%

Pramoxine – Hydrocortisone (Analpram HC)

Cream, Rectal: Pramoxine 1% - Hydrocortisone 2.5% Pramoxine-Zinc (Caladryl Clear)

Lotion, topical: pramoxine 1%-zinc acetate 0.1% Pravastatin (Pravachol)

Tablet: 10 mg, 20 mg, 40 mg, 80 mg Prazosin (Minipress)

Capsule: 1 mg, 2 mg, 5 mg prednisoLONE (Delta-Cortef, Pred Mild, Pred Forte)

Solution, oral: 5 mg/5 mL Syrup: 15 mg/5 mL Tablet: 5 mg Solution, ophthalmic: 0.12%, 1% RESERVE USE

predniSONE (Meticorten, Deltasone) Syrup: 5 mg/5 mL Tablet: 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg

Pregabalin (Lyrica) C-V

Capsule: 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg, 300 mg Primidone (Mysoline)

Tablet: 50 mg, 250 mg Prochlorperazine (Compazine)

Injection: 5 mg/mL Suppository, rectal: 25 mg Tablet: 5 mg, 10 mg, 25 mg

Promethazine (Phenergan)

Injection: 25 mg/mL, 50 mg/mL Suppository, rectal: 12.5 mg, 25 mg, 50 mg Syrup: 6.25 mg/5 mL Tablet: 12.5 mg, 25 mg, 50 mg


Propantheline (Pro-Banthine) Tablet: 15 mg

Proparacaine (Alcaine)

Solution, ophthalmic: 0.5% Propranolol (Inderal)

Capsule, sustained release: 60 mg, 80 mg, 120 mg, 160 mg Injection: 1 mg/mL Solution, oral: 4 mg/mL, 8 mg/mL, 80 mg/mL Tablet: 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

Propylthiouracil

Tablet: 50 mg Protamine

Injection: 10 mg/mL Pseudoephedrine (Sudafed)

Liquid, oral: 15 mg/5 mL, 30 mg/mL Tablet, immediate release: 30 mg, 60 mg Tablet, timed release: 120 mg Tablet, extended release: 120 mg, 240 mg

Pyrazinamide

Tablet: 500 mg Pyrethins 0.33%-Piperonyl Butoxide 4% (Pronto, RID)

Liquid, topical: 0.18%, 0.3% Shampoo: 0.3%, 0.33%

Pyridoxine (Vitamin B6)

Injection: 100 mg/mL Tablet: 25 mg, 50 mg, 100 mg

QUEtiapine (SEROquel)

Tablet: 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg Raloxifene (Evista)

Tablet: 60 mg Ranitidine (Zantac)

Injection: 25 mg/mL Syrup: 15 mg/mL Tablet: 75 mg, 150 mg, 300 mg Tablet, effervescent: 25 mg


Rasagiline (Azilect) Tablet: 0.5 mg, 1 mg

Rectal Hemorrhoidal Cream-Hydrocortisone

Cream: see Hydrocortisone Rectal Hemorrhoidal Ointment (Anusol)

Ointment Rectal Hemorrhoidal Suppositories (Wyanoids, Anusol)

Suppository, rectal: Rectal Hemorrhoidal Suppositories-Hydrocortisone (Anusol-HC)

Suppository, rectal: see Hydrocortisone Repaglinide (Prandin)

Tablet: 0.5 mg, 1 mg, 2 mg Rifabutin (Mycobutin)

Capsule: 150 mg Rifampin (Rifadin)

Capsule: 150 mg, 300 mg Injection: 600 mg

Rifampin-Isoniazid (Rifamate)

Capsule: Rifampin 300 mg-Isoniazid 150 mg Ringer’s Lactate Solution (Hartmann's Solution)

Infusion Risedronate (Actonel)

Tablet: 5 mg, 30 mg, 35 mg risperiDONE (RisperDAL, RisperDAL M-Tab, RisperDAL Consta)

Injection, long acting: 12.5 mg/2 mL, 25 mg/2 mL, 37.5 mg/2 mL, 50 mg/2 mL Solution, oral: 1 mg/mL Tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg Tablet, orally disintegrating: 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Rivastigmine (Exelon, Exelon Patches)

Capsule: 1.5 mg, 3 mg, 4.5 mg, 6 mg Patch, transdermal: 4.6 mg/24 hours, 9.5 mg/24 hours

Rosuvastatin (Crestor) RESERVE USE

Tablet: 5 mg, 10 mg, 20 mg, 40 mg


Rufinamide (Banzel) Tablet: 200 mg, 400 mg

Salicylic Acid (Compound W, DuoFilm, Mediplast, Salex, Neutrogena)

Cleaning Pads Cleanser Gel, topical: 6%, 17% Liquid, topical: 17% Lotion: 3% Plaster: 40% Shampoo Soap: 2% Wash

Salicylic Acid-Sulfur

Bar Cleanser Cream Gel Lotion Shampoo

Saliva Substitute

Gel Mouthwash Spray Toothpaste

Salmeterol (Serevent)

Aerosol, inhalation: 25 mcg/dose Powder, inhalation: 50 mcg

Scopolamine (Isopto Hyoscine)

Solution, ophthalmic: 0.25% Selenium Sulfide (Selsun)

Shampoo: 1%, 2.5% Senna (Senokot)

Tablet: 8.6 mg Sertraline (Zoloft)

Concentrate, oral: 20 mg/mL Tablet: 25 mg, 50 mg, 100 mg


Sevelamer (Renagel) Tablet: 400 mg, 800 mg

Silver Nitrate

Applicator sticks Silver Sulfadiazine (Silvadene)

Cream, topical: 1% Simethicone (Mylicon)

Drops, oral: 40 mg/0.6 mL Tablet, chewable: 80 mg, 125 mg

Simvastatin (Zocor)

Tablet: 5 mg, 10 mg, 20 mg, 40 mg, 80 mg Sodium Bicarbonate

Injection: 4.2% [5 mEq/10 mL], 8.4% [10 mEq/10 mL] Sodium Chloride

Drops, nasal: 0.9% Infusion: 0.2%, 0.45%, 0.9%, 3%, 5%, 20%, 23.4% Injection, bacteriostatic: 0.9% Injection, for admixtures: 50 mEq, 100 mEq, 635 mEq Ointment, ophthalmic: 5% Solution, irrigation: 0.45%, 0.9% Solution, nasal: 0.4%, 0.6%, 0.65% Solution, nebulizing: 0.9% Solution, ophthalmic: 2%, 5% Tablet: 650 mg, 1 g Tablet, enteric coated: 1 g Tablet, slow release: 600 mg

Sodium Chloride Intravenous Solution

Infusion: 0.2%, 0.45%, 0.9% Sodium Citrate-Citric Acid (Bicitra, Oracit)

Solution, oral: Bicitra: Sodium Citrate 500 mg-Citric Acid 334 mg per 5 mL Oracit: Sodium Citrate 400 mg-Citric Acid 640 mg per 5 mL

Sodium Fluoride

Liquid, oral: 360 mL, 480 mL, 540 mL Tablet, chewable: 0.25 mg, 0.5 mg, 1 mg, 1.1 mg, 2.2 mg


Sodium Lactate Injection: 167 mEq per liter

Sodium Polystyrene Sulfonate (Kayexalate)

Powder for suspension: 454 gm Suspension, oral: 1.25 gm/5 mL (with sorbitol and alcohol)

Sorbitol

Solution, oral: 70% Spironolactone (Aldactone)

Tablet: 25 mg, 50 mg, 100 mg Spironolactone-Hydrochlorothiazide (Aldactazide)

Tablet: Spironolactone 25 mg-Hydrochlorothiazide 25 mg Spironolactone 50 mg-Hydrochlorothiazide 50 mg

Stannous Fluoride (OmniMed, PerioMed)

Solution, oral: 0.4%, 0.63% Sucralfate (Carafate)

Suspension, oral: 1 g/10 mL Tablet: 1 g

Sulfacetamide Sodium (Sulamyd, Sebizon)

Gel: 10% Lotion: 10% Ointment, ophthalmic: 10% Solution, ophthalmic: 10%

Sulfamethoxazole-Trimethoprim (Bactrim) The 5:1 ratio of Sulfamethoxazole to Trimethoprim is constant in all dosage forms

Injection: Sulfamethoxazole 80 mg-Trimethoprim 16 mg per mL Suspension, oral: Sulfamethoxazole 200 mg-Trimethoprim 40 mg per 5 mL Tablet: Sulfamethoxazole 400 mg-Trimethoprim 80 mg

Sulfamethoxazole 800 mg-Trimethoprim 160 mg sulfaSALAzine (Azulfidine)

Tablet: 500 mg Tablet, delayed release: 500 mg

Sulindac (Clinoril)



SUMAtriptan (Imitrex) Injection: 12 mg/mL Nasal Spray: 5 mg, 20 mg Tablet: 25 mg, 50 mg, 100 mg

Sunscreen-Block

Cream-Lotion: contains a minimum SPF of 15 Tacrolimus (Protopic)

Ointment: 0.03%, 0.1% Tamoxifen

Tablet: 10 mg, 20 mg Tamsulosin (Flomax)

Capsule, sustained release: 0.4 mg Tazarotene (Tazorac, Avage)

Cream, topical: 0.05%, 0.1% Gel, topical: 0.05%, 0.1%

Temazepam (Restoril) C-IV

Capsule: 7.5 mg, 15 mg, 30 mg Terbinafine (LamISIL)

Cream, topical: 1% Tablet: 250 mg

Terbutaline (Brethine)

Aerosol, oral: 0.2 mg/actuation Injection: 1 mg/mL Tablet: 2.5 mg, 5 mg

Testosterone (Androlan) C-IV

Injection, in oil, as cypionate: 100 mg/mL, 200 mg/mL Tetracycline

Capsule: 250 mg, 500 mg Tetrahydrozoline (Visine Allergy Relief, Visine Moisturizing)

Solution, ophthalmic: 0.05%


Theophylline (Elixophyllin) Capsule, timed release (12 hour): 130 mg, 260 mg Capsule, timed release (24 hour): 100 mg, 200 mg, 300 mg Solution, oral: 80 mg/15 mL, 150 mg/15 mL Tablet, immediate release [Slo-phyllin]: 100 mg, 125 mg, 200 mg, 250 mg, 300 mg Tablet, timed release: Theolair SR (8-12 hour): 100 mg, 200 mg, 250 mg, 300 mg, 500 mg Theo-Dur (8-24 hour): 100 mg, 200 mg, 300 mg, 450 mg Theophylline SR (12-24 hour): 100 mg, 200 mg, 300 mg Uniphyl (24 hour): 400 mg Tablet, timed release (12 hour): 100 mg, 200 mg, 300 mg

Thiamine (Vitamin B1)

Injection: 100 mg/mL, 200 mg/mL Tablet: 50 mg, 100 mg, 250 mg, 500 mg

Thioridazine (Mellaril) - RESERVE USE

Tablet: 10 mg, 25 mg, 50 mg, 100 mg Thiothixene (Navane)

Capsule: 1 mg, 2 mg, 5 mg, 10 mg tiaGABine (Gabatril)

Tablet: 2 mg, 4 mg, 12 mg, 16 mg, 20 mg Timolol (Timoptic, Timoptic XE)

Gel, ophthalmic: 0.25%, 0.5% Solution, as maleate, ophthalmic: 0.25%, 0.5% Solution, as maleate, ophthalmic, preservative free, single use: 0.25%, 0.5%

Timolol-Dorzolamide (Cosopt)

Solution, ophthalmic: Timolol 0.5%-Dorzolamide 2% Tioconazole (Vagistat-1)

Ointment, vaginal: 6.5% Tiotropium (Spriva)

Cap: 18 mcg (with device) tiZANidine (Zanaflex) - RESERVE USE

Capsule: 2 mg, 4 mg, 6 mg Tablet: 2 mg, 4 mg


Tobramycin (Tobrex) Injection: 10 mg/mL, 40 mg/mL Ointment, ophthalmic: 0.3% Powder for injection: 40 mg/mL Solution, ophthalmic: 0.3%

Tobramycin-Dexamethasone (TobraDex) [contains Benzalkonium] - RESERVE USE

Ointment, ophthalmic: Tobramycin 0.3%-Dexamethasone 0.1% Suspension, ophthalmic: Tobramycin 0.3%-Dexamethasone 0.1%

Tolnaftate (Tinactin)

Aerosol, topical, liquid: 1% Aerosol, topical, powder: 1% Cream, topical: 1% Powder, topical: 1% Solution, topical: 1%

Tolterodine (Detrol, Detrol LA)

Capsule, extended release: 2 mg, 4 mg Tablet: 1 mg, 2 mg

Topiramate (Topamax)

Capsule, sprinkle: 15 mg, 25 mg Tablet: 25 mg, 50 mg, 100 mg, 200 mg

traMADol (Ultram) C-IV

Tablet: 50 mg Tranylcypromine (Parnate)

Tablet: 10 mg Travoprost (Travatan, Travatan Z)

Solution, ophthalmic: 0.004% traZODone (Desyrel)

Tablet: 50 mg, 100 mg, 150 mg, 300 mg Tretinoin Gel (Retin-A)

Cream, topical: 0.025%, 0.05%, 0.1% Gel, topical: 0.01%, 0.025%, 0.1% Liquid, topical: 0.05%


Triamcinolone (Aristocort, Kenacort, Azmacort, Nasacort) Aerosol, oral, inhalation: 100 mcg/metered spray Aerosol, topical: 0.2 mg/2 second spray Cream, topical: 0.025%, 0.1%, 0.5% Lotion, topical: 0.025%, 0.1% Ointment, topical: 0.025%, 0.1%, 0.5% Spray, intranasal: 55 mcg/actuation [100 sprays/canister]

Triamterene (Dyrenium)

Capsule: 50 mg, 100 mg Triamterene-Hydrochlorothiazide (Dyazide, Maxzide)

Capsule (Dyazide): Triamterene 37.5 mg-Hydrochlorothiazide 25 mg Triamterene 50 mg-Hydrochlorothiazide 25 mg Tablet (Maxzide): Triamterene 37.5 mg-Hydrochlorothiazide 25 mg

Triamterene 75 mg-Hydrochlorothiazide 50 mg Triazolam (Halcion) C-IV

Tablet: 0.125 mg, 0.25 mg Trifluoperazine (Stelazine)

Tablet: 1 mg, 2 mg, 5 mg, 10 mg Trihexyphenidyl (Artane)

Elixir: 2 mg/5 mL Tablet: 2 mg, 5 mg

Trimethobenzamide (Tigan)

Capsule: 250 mg, 300 mg Injection: 100 mg/mL Suppository, rectal: 200 mg

Triprolidine-Pseudoephedrine (Actifed)

Capsule, extended release: Triprolidine 5 mg-Pseudoephedrine 120 mg Syrup: Triprolidine 1.25 mg-Pseudoephedrine 30 mg per 10 mL Tablet: Triprolidine 2.5 mg-Pseudoephedrine 60 mg

Tropicamide (Mydriacyl)

Solution, ophthalmic: 0.5%, 1% Trospium (Sanctura)

Tablet: 20 mg


Trypsin-Balsam Peru-Castor Oil (Granulex GranuloDerm, Revina, TBC,, Xenaderm, Vasolex)

Aerosol: Trypsin 0.1 mg-Balsam Peru 72.5 mg-Castor Oil 650 mg per 0.82 mL Ointment: Trypsin 90 units-Balsam Peru 87 mg-Castor Oil 788 mg per gram

Tuberculin, Purified Protein Derivative (P.P.D.)

Intermediate test strength: 5 TU/0.1 mL Urea

Cream: 10%, 20, 40% Lotion: 10%, 40% Shampoo: 10%

valACYclovir (Valtrex)

Caplets: 500 mg, 1 g Valproic Acid/Valproate (Depakene)

Capsule: 250 mg Syrup: 250 mg/5 mL

Valsartan (Diovan) RESERVE USE

Tablet: 40 mg, 80 mg, 160 mg, 320 mg

Vancomycin (Vancocin)

Capsule: 125 mg, 250 mg Powder for injection: 500 mg, 1g, 5g, 10 g

Varicella Virus Vaccine, Live (Varivax)

Injection, single dose Venlafaxine (Effexor)

Capsule, sustained release: 37.5 mg, 75 mg, 150 mg Tablet: 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg Tablet, extended release: 37.5 mg, 75 mg, 150 mg, 225 mg

Verapamil (Calan, Isoptin)

Capsule, sustained release: 100mg, 120 mg, 180 mg, 240 mg, 360 mg Injection: 2.5 mg/mL Tablet: 40 mg, 80 mg, 120 mg Tablet, sustained release: 120 mg, 180 mg, 240 mg

Vitamin A (Aquasol A)

Capsule: 8,000 units, 10,000 units, 25,000 units, 50,000 units Injection: 50,000 units/mL Tablet: 5000 units


Vitamin A&D Topical Cream Ointment

Vitamin B Complex

Tablet: each tablet contains a minimum of USDA requirements Vitamin B Complex-Vitamin C (Stresscaps, Allbee with C, Nephrocaps, Nephro-vite)

Capsule: each capsule contains a minimum of USDA requirements Tablet: each tablet contains a minimum of USDA requirements

Vitamin B Complex-Vitamin C-Zinc

Tablet: each tablet contains a minimum of USDA requirements Vitamin D (Ergocalciferol, Calciferol, Drisdol)

Capsule: 0.25 mcg, 0.5 mcg, 400 units, 2,000 units, 10,000 units, 50,000 units Drops, oral: 200 units/drop Tablet: 400 units, 2,000 units

Vitamin E (Aquasol E)

Capsule: 100 units, 200 units, 400 units, 1,000 units Tablet: 200 units, 400 units, 2,000 units

Warfarin (Coumadin)

Tablet: 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, 10 mg Water for Injection

Infusion Water for Irrigation

Solution, irrigation Wound Cleanser (CarraKlenz)

Topical, spray Zafirlukast (Accolate)

Tablet: 10 mg, 20 mg Zaleplon (Sonata) C-IV

Capsule: 5 mg, 10 mg Zanamivir (Relenza)

Powder for Inhalation: 5 mg


Zinc Oxide Ointment, topical: 20% in white ointment Paste, topical: 25% in white petrolatum

Zinc Oxide-Petrolatum-Imidazolidinyl Urea (Diaperene)

Ointment, topical Zinc Sulfate

Capsule: 220 mg [50 mg zinc] Injection: 1 mg/mL, 5 mg/mL Tablet: 220 mg

Ziprasidone (Geodon)

Capsule: 20 mg, 40 mg, 60 mg, 80 mg Injection: 20 mg

Zoledronic Acid (Reclast, Zometa)

Injection: 5 mg/100 mL Zolpidem (Ambien) C-IV

Tablet: 5 mg, 10 mg Zonisamide (Zonegran)

Capsule: 25 mg, 50 mg, 100 mg

DSHS/DADS Drug Formulary 2016 page 79 Therapeutic Classification/Cost Index

THERAPEUTIC CLASSIFICATION/COST INDEX

ANTIDIABETIC AGENTS

INSULINS, HUMAN Insulin, Aspart (NovoLog) $$$$$$$ Insulin, Combination (70/30) $$$$ Insulin, Detemir (Levemir) RESERVE USE $$$$$$$ Insulin, Glargine (Lantus) $$$$$$$ Insulin, Lispro (HumaLOG) $$$$$$$ Insulin, Lispro-Insulin, Lispro Protamine (HumaLOG Mix 75/25) $$$$$$$ Insulin, NPH $$$$ Insulin, Regular $$$$

SULFONYLUREAS glipiZIDE (Glucotrol) $

glyBURIDE (Micronase, DiaBeta) $$

MISCELLANEOUS ANTIDIABETICS metFORMIN (Glucophage, Glucophage XR) $ Pioglitazone (Actos) $$-$$$ Repaglinide (Prandin) $$ - $$$$

GLUCOSE ELEVATING AGENTS Dextrose 50% in Water $$ Glucagon $$$$$$$ Glucose $ - $$$


ANTIDOTES-DETERRENTS-POISON CONTROL AGENTS Acetylcysteine (Mucomyst) Activated Charcoal Deferoxamine (Desferal) Dimercaprol (B.A.L.) Disulfiram (Antabuse) Glucagon Glucose, oral Leucovorin (Wellcovorin) Naloxone (Narcan) $$ - $$ Naltrexone (Trexan, ReVia) $$$ Nicotine (Nicoderm, Habitrol, ProStep, Nicotrol, Nicorette) $$$ penicillAMINE (Cuprimine) Physostigmine (Antilirium) Phytonadione (Vitamin K1, Mephyton) $$ - $$$ Protamine $

ANTIHISTAMINES Cetirizine (ZyrTEC) $

Chlorpheniramine (Chlor-Trimeton, Teldrin) $ - $ Cyproheptadine (Periactin) $ diphenhydrAMINE (Benadryl) $ Fexofenadine (Allegra) $$ hydrOXYzine (Atarax, Vistaril) $ - $$ Loratadine (Claritin) $$


ANTINEOPLASTIC AGENTS All commercially available oncologic agents used in the treatment of cancer are considered to be formulary agents, if prescribed by an oncologist for the active treatment of cancer. . All commercially available oncologic agents prescribed by field specialists are considered to be on formulary Tamoxifen $$

BLOOD MODIFYING AGENTS

ANTIPLATELET Aspirin $ Clopidogrel (Plavix) – RESERVE USE $$$

ANTICOAGULANT Fondaparinux (Arixtra) $$$$$$$ Heparin $$ Enoxaparin (Lovenox) $$$$$$$ Warfarin (Coumadin) $

ANTICOAGULATION ANTAGONIST Phytonadione (Vitamin K1, Mephyton) $$ - $$$ Protamine $

MISCELLANEOUS BLOOD MODIFYING AGENTS Epoetin alfa (Epogen, Procrit) RESERVE USE $$$$$$$

Ferrous Fumarate-Docusate Sodium (Ferro-Sequels) [33% elemental iron]

$$

Ferrous Sulfate (Feosol, Fer-In-Sol) [20% elemental iron] $

CARDIOVASCULAR AGENTS

DIURETICS Thiazides & Related Diuretics

Chlorthalidone (Hygroton) $

Hydrochlorothiazide (HydroDIURIL, Esidrix) $


Loop Diuretics Furosemide (Lasix) $

Potassium-Sparing Diuretics Spironolactone (Aldactone) $

Triamterene (Dyrenium) $ - $

Carbonic Anhydrase Inhibitors acetaZOLAMIDE (Diamox) $

Combination Diuretics Spironolactone-Hydrochlorothiazide (Aldactazide) $ - $$

Triamterene-Hydrochlorothiazide (Dyazide, Maxzide) $ - $

CARDIAC GLYCOSIDES Digoxin (Lanoxin) $

ANTIANGINALS Isosorbide Dinitrate (Isordil, Sorbitrate) $ Isosorbide Mononitrate (Imdur, ISMO, Monoket) $ Nitroglycerin $ - $

ANTIARRHYTHMICS Adenosine (Adenocard) RESERVE USE $$$$$$$ Amiodarone (Pacerone, Cordarone) $ - $

CALCIUM CHANNEL BLOCKERS amLODIPine (Norvasc) $$ Diltiazem (Cardizem) $ - $$ Felodipine (Plendil) $ - $$ NIFEdipine (Procardia, Procardia XL, Adalet CC) $ - $$$ Verapamil (Calan, Isoptin)


BETA-ADRENERGIC BLOCKERS Atenolol (Tenormin) $ Carvedilol (Coreg) $-$$ Labetalol (Normodyne) $ - $$ Metoprolol (Lopressor, Toprol XL) $ - $$ Propranolol (Inderal) $ - $$$

ANTIHYPERLIPIDEMICS atorvaSTATin (Lipitor) $-$$$$ Cholestyramine (Questran) $ - $$$ Fenofibrate (Antara, Lofibra, Tricor, Triglide) $-$$$$ Fluvastatin (Lescol) $$ Gemfibrozil (Lopid) $ Niacin-Nicotinamide (Nicobid) $ - $ Pravastatin (Pravachol) $$ Rosuvastatin (Crestor) RESERVE USE $$$$ Simvastatin (Zocor) $

ANGIOTENSIN CONVERTING ENZYME INHIBITORS Benazepril (Lotensin) $

Captopril (Capoten) $

Enalapril (Vasotec) $ Lisinopril (Prinivil, Zestril) $

VASOPRESSORS DOPamine (Intropin) RESERVE USE $$$ - $$$$ EPINEPHrine (Adrenalin) $ - $$$$$$$ Norepinephrine or Levarterenol (Levophed) RESERVE USE $$$ - $$$$$$$

MISCELLANEOUS ANTIHYPERTENSIVES cloNIDine (Catapres) $ - $$$$$$ hydrALAZINE (Apresoline) $ Methyldopa (Aldomet) $ - $$$$$$$ Olmesartan (Benicar RESERVE USE $$

Valsartan (Diovan) RESERVE USE $$


MISCELLANEOUS CARDIOVASCULARS Sodium Polystyrene Sulfonate (Kayexalate) $$ - $$$$

CENTRAL NERVOUS SYSTEM AGENTS

ANALGESICS Nonsteroidal Anti-Inflammatory Agents

Aspirin Suppository, rectal: 300 mg, 600 mg $$ - $$$$ Tablet: 325 mg $

Tablet, buffered: 325 mg with buffering agents $

Tablet, chewable: 81 mg $

Tablet, enteric coated: 81 mg, 162 mg, 325 mg, 500 mg, 650 mg

$

Ibuprofen (Motrin) Suspension, oral: 40 mg/mL, 100 mg/5 mL $ - $$$$

Tablet: 200 mg, 400 mg, 600 mg, 800 mg $

Tablet, chewable: 100mg $ - $$$ Ketorolac (Toradol)

Injection: 15 mg/mL, 30 mg/mL $ - $$$ Meloxicam (Mobic)

Tablet: 7.5 mg, 15 mg $

Nabumetone (Relafen) - RESERVE USE Tablet: 500 mg, 750 mg $$ - $

Naproxen (Naprosyn)

Tablet: 220 mg, 250 mg, 275 mg, 375 mg, 500 mg, 550 mg

$

Tablet, delayed release: 500 mg $$

Sulindac (Clinoril) Tablet: 150 mg, 200 mg $$ - $


Opiate Agonists fentaNYL (Duragesic) C-II *

Lozenge: 200 mcg, 400 mcg, 600 mcg, 800 mcg Patch, transdermal: 12 mcg/hr, 25 mcg/hr, 50 mcg/hr,

75 mcg/hr, 100 mcg/hr

Methadone (Dolophine) C-II * Solution, oral: 1 mg/mL Tablet: 5 mg, 10 mg, 40 mg

Morphine C-II * Injection: 1 mg/mL, 2 mg/mL, 4 mg/mL, 10 mg/mL Solution, oral: 20 mg/mL Suppository, rectal: 20 mg, 30 mg Tablet, controlled release: 15 mg, 30 mg, 60 mg Tablet, sublingual: 10 mg

oxyCODONE (OxyCONTIN) C-II * Tablet: 15mg, 30mg Tablet, controlled release: 5 mg,10 mg, 15 mg, 20 mg, 40 mg,

80 mg, 160 mg

*Opiate agonists include a range of dosage forms and strengths. Dosing of each is dependent on the individual patient and condition(s) treated.

Miscellaneous Analgesics & Antipyretics Acetaminophen (Tylenol)

Capsule: 500 mg $

Liquid: 160 mg/5 mL $ - $ Suppository, rectal: 120 mg, 125 mg, 325 mg, 650 mg $ Tablet: 325 mg, 500 mg $ Tablet, chewable: 80 mg $ - $$

Acetaminophen-Codeine C-III Liquid, oral: Acetaminophen 120 mg-Codeine 12 mg per 5 mL C-V $ - $$ Tablet: #2: Acetaminophen 300 mg-Codeine 15 mg $ - $ #3: Acetaminophen 300 mg-Codeine 30 mg $ - $

Acetaminophen-HYDROcodone (Lortab, Vicodin, Vicodin ES) C-II Elixir: Acetaminophen 167 mg-HYDROcodone 2.5 mg per 5

mL with 7% alcohol $$ - $$$$$

Tablet: Acetaminophen 300 mg- HYDROcodone 5 mg $$

Acetaminophen 300 mg- HYDROcodone 7.5 mg $$

Acetaminophen 300 mg- HYDROcodone 10mg $$

Acetaminophen 325 mg- HYDROcodone 5 mg $$

Acetaminophen 325 mg- HYDROcodone 10 mg $$

traMADol (Ultram) C-IV Tablet: 50 mg $


ANTIEMETIC-ANTIVERTIGO AGENTS diphenhydrAMINE (Benadryl) $

hydrOXYzine (Atarax, Vistaril) $ - $$

Meclizine (Antivert, Bonine) $

Metoclopramide (Reglan) $ - $$$ Ondansetron (Zofran, Zofran ODT) $ - $$$ Prochlorperazine (Compazine)

Promethazine (Phenergan) $ - $$$$$ Trimethobenzamide (Tigan) $$

MISCELLANEOUS AGENTS Megestrol (Megace, Megace ES) $ - $$$$$$$


PSYCHOTROPIC AGENTS Benzodiazepine Anxiolytics and Hypnotics

ALPRAZolam (Xanax, Xanax XR) C-IV

Tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg $

Tablet, sustained release: 0.5 mg, 1 mg, 2 mg, 3 mg $$ - $ chlordiazePOXIDE (Librium) oral only C-IV

Capsule: 5 mg, 10 mg, 25 mg $ clonazePAM (KlonoPIN) C-IV

Tablet: 0.5 mg, 1 mg, 2 mg $

Tablet, oral disintegrating: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

$$

Clorazepate (Tranxene) C-IV

Tablet: 3.75 mg, 7.5 mg, 15 mg $$

Diazepam (Valium) C-IV Injection: 5 mg/mL $$ - $$$$$ Solution, oral: 1 mg/mL, 5 mg/mL $$ - $$$$ Tablet: 2 mg, 5 mg, 10 mg $

LORazepam (Ativan) C-IV Injection: 2 mg/mL, 4 mg/mL $ - $$^ Solution, oral: 2 mg/mL $ - $$ Tablet: 0.5 mg, 1 mg, 2 mg $

Midazolam (Versed) C-IV

Injection: 1 mg/mL, 5 mg/mL $ - $$ Oxazepam (Serax) C-IV

Capsule: 10 mg, 15 mg, 30 mg $$ - $$$$ Tablet: 15 mg

Temazepam (Restoril) C-IV Capsule: 7.5 mg, 15 mg, 30 mg $

Triazolam (Halcion) C-IV Tablet: 0.125 mg, 0.25 mg $

^ per dose


Miscellaneous Anxiolytics and Hypnotics busPIRone (BuSpar)

Tablet: 5 mg, 10 mg, 15 mg, 30 mg $ - $$ diphenhydrAMINE (Benadryl)

Capsule: 25 mg, 50 mg $

Injection: 50 mg/mL $ - $$^ Liquid, oral: 12.5 mg/5 mL $ - $$

Tablet: 25 mg, 50 mg $

hydrOXYzine (Atarax, Vistaril) Cap Capsule: 25 mg, 50 mg, 100 mg $ - $$ Injection, as hydrochloride: 25 mg/mL, 50 mg/mL $$ ^ Suspension: 25 mg/5 mL Syrup, as hydrochloride: 10 mg/5 mL $$$$ - ++

Tablet: 10 mg, 25 mg, 50 mg $ - $ Prazosin (Minipress)

Capsule: 1 mg, 2 mg, 5 mg $ - $$ traZODone (Desyrel)

Tablet: 50 mg, 100 mg, 150 mg, 300 mg $

Zaleplon (Sonata) C-IV

Capsule: 5 mg, 10 mg $$ - $

Zolpidem (Ambien) C-IV


^ per dose

Antidepressants Monoamine Oxidase Inhibitors

Phenelzine (Nardil) Tablet: 15 mg $ - $

Tranylcypromine (Parnate) Tablet: 10 mg $$$ - $$$$


Serotonin Selective Reuptake Inhibitors (SSRIs) Citalopram (celeXA)

Solution, oral: 10 mg/5 mL $$ - $$$ Tablet: 10 mg, 20 mg, 40 mg $

Escitalopram (Lexapro) Solution: 5 mg/5 ml $$$$ - $$$$$ Tablet: 5 mg, 10 mg, 20 mg $

FLUoxetine (PROzac) Capsule: 10 mg, 20 mg $

Liquid, oral: 20 mg/5 mL $

Tablet: 10 mg, 20 mg $$ - $$$ fluvoxaMINE (Luvox)

Tablet: 25 mg, 50 mg, 100 mg $ - $$

PARoxetine (Paxil)

Suspension, 10 mg/5 ml $$$$ - $$$$$$$ Tablet: 10 mg, 20 mg, 30 mg, 40 mg $

Tablet: controlled release: 12.5 mg, 25 mg, 37.5 mg $$$ - $$$$ Sertraline (Zoloft)

Concentrate, oral: 20 mg/mL $$ - $$$$ Tablet: 25 mg, 50 mg, 100 mg $

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) DULoxetine (Cymbalta)

Capsule, delayed release: 20 mg, 30 mg, 60 mg $ - $$ Venlafaxine (Effexor)

Capsule, sustained release: 37.5 mg, 75 mg, 150 mg $ - $ Tablet: 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg $ Tablet, extended release: 37.5 mg, 75 mg, 150 mg, 225 mg $$$ - $$$$

Tricyclic Agents Amitriptyline (Elavil)

Tablet: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg $$ - $$ clomiPRAMINE (Anafranil) - for OCD

Capsule: 25 mg, 50 mg, 75 mg $$$$ - $$$$$$$ Desipramine (Norpramin)

Tablet: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg $$$ - $$$$ Doxepin (SINEquan)

Capsule: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg $ Concentrate, oral: 10 mg/mL $

Imipramine (Tofranil) Tablet: 10 mg, 25 mg, 50 mg $ - $

Nortriptyline (Aventyl, Pamelor)

Capsule: 10 mg, 25 mg, 50 mg, 75 mg $

Solution: 10 mg/5 mL $$$$


Miscellaneous Antidepressant Agents

buPROPion (Budeprion, Wellbutrin, Zyban) Tablet: 75 mg, 100 mg $ - $$ Tablet, sustained release: 100 mg, 150 mg, 200 mg $ - $$

Tablet, extended release: 150 mg, 300 mg $ - $$ Mirtazapine (Remeron, Remeron SolTab)

Tablet: 7.5 mg, 15 mg, 30 mg, 45 mg $

Tablet, rapid dissolving: 15 mg, 30 mg, 45 mg $$ traZODone (Desyrel)

Tablet: 50 mg, 100 mg, 150 mg, 300 mg $ - $$$$


Antipsychotics ARIPiprazole (Abilify, Abilify discmelt)

Injection: 9.75 mg + ^

Injection, extended release: 300 mg, 400 mg + - ++

Solution, oral: 1 mg/mL ++ - + Tablet: 2mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg $$$$$$$ - +

Tablet, rapid dissolving: 10 mg, 15 mg $$$$$$$ - ++ Asenapine (Saphris)

Tablet, sublingual: 5 mg, 10 mg $$$$$$ chlorproMAZINE (Thorazine)

Injection: 25 mg/mL +++ Tablet: 10 mg, 25 mg, 50 mg, 100 mg, 200 mg $$ - $$$$

cloZAPine (Clozaril)- RESERVE USE Susp: 50 mg/mL + ++

Tablet: 25 mg, 50mg, 100 mg, 200mg $$ - $$$ Tablet, oral disintegrating: 12.5 mg, 25 mg, 100 mg, 150 mg,

200 mg +

fluPHENAZine (Prolixin) Concentrate: 5 mg/mL with 14% alcohol $$ - $

Elixir: 2.5 mg/5 mL with 14% alcohol $$$$ - $$$$$ Injection, as decanoate: 25 mg/mL $ - $$ Injection, as hydrochloride: 2.5 mg/mL $$$$$ - +

Tablet: 1 mg, 2.5 mg, 5 mg, 10 mg $$ - $ Haloperidol (Haldol)

Concentrate, oral: 2 mg/mL $ - $$

Injection, as decanoate: 50 mg/mL, 100 mg/mL $$$$$$ - + ^ Injection, as lactate: 5 mg/mL $$$$ ^ Tablet: 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mg $ - $$

Iloperidone (Fanapt) RESERVE USE

Tablet: 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg + Loxapine (Loxitane)

Capsule: 5 mg, 10 mg, 25 mg, 50 mg $ - $$ Lurasidone (Latuda)

Tablet: 20 mg, 40 mg, 60 mg, 80 mg, 120 mg $$$$$$ - +

OLANZapine (ZyPREXA) Injection: 10 mg/2 mL $$$$$$$ - + ^ Injection as pamoate: 210 mg, 300 mg, 405 mg RESERVE USE ++++ - +++++ Tablet: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg $ - $$ Tablet, rapid dissolving: 5 mg, 10 mg, 15 mg, 20 mg $ - $$

Paliperidone (Invega)

Injection, long acting: 39 mg, 78 mg, 117 mg, 156 mg, 234 mg + - ++

Tablet, extended release: 1.5 mg 3 mg, 6 mg, 9 mg $$$$$$$ - +


Perphenazine (Trilafon) Tablet: 2 mg, 4 mg, 8 mg, 16 mg $$ - $$$$$

QUEtiapine (SEROquel) Tablet: 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg $$ - $

risperiDONE (RisperDAL) Injection, long acting: 12.5 mg/2 mL, 25 mg/2 mL,

37.5 mg/2 mL, 50 mg/2 mL $$$$$$$ - +

Solution, oral: 1 mg/mL $ - $$

Tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg $

Tablet, orally disintegrating: 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg $$ - $$$$$ Thioridazine (Mellaril) - RESERVE USE

Tablet: 10 mg, 25 mg, 50 mg, 100 mg $$ - $$$ Thiothixene (Navane)

Capsule: 1 mg, 2 mg, 5 mg, 10 mg $$ - $$$ Trifluoperazine (Stelazine)

Tablet: 1 mg, 2 mg, 5 mg, 10 mg $$ - $$$ Ziprasidone (Geodon)

Capsule: 20 mg, 40 mg, 60 mg, 80 mg $ Injection: 20 mg $$$$$$$ ^

^Per Dose


Mood Stabilizers

carBAMazepine (TEGretol) Capsule, extended release: 100 mg, 200 mg, 300 mg $$ - $$$$ Suspension, oral: 100 mg/5 mL $$ - $$$$ Tablet: 200 mg $$ - $$$ Tablet, chewable: 100 mg $$ - $$$ Tablet, extended release: 100 mg, 200 mg, 400 mg $$$ - $$$$

Divalproex (Depakote) Capsule, sprinkles: 125 mg $$$ - +

Tablet, delayed release: 125 mg, 250 mg, 500 mg $$ - $ Tablet, extended release: 250 mg, 500 mg $$$ - $$$$$$$

lamoTRIgine (LaMICtal)

Tablet: 25 mg, 100 mg, 150 mg, 200 mg $ - $$

Tablet, dispersible/chewable: 2 mg, 5 mg, 25 mg $$$$$$ - $$$$$$$

Lithium Carbonate (Eskalith, Lithonate) Capsule: 150 mg, 300 mg, 600 mg $

Tablet: 300 mg $$ - $ Tablet, controlled release: 450 mg $ Tablet, slow release: 300 mg $

Lithium Citrate Syrup: 300 mg/5 mL $$ - $

OXcarbazepine (Trileptal) Suspension, oral: 300 mg/5 mL $$$$ - +

Tablet: 150 mg, 300 mg, 600 mg $$ - $$ Topiramate (Topamax)

Capsule, sprinkle: 15 mg, 25 mg $$ - $$$$ Tablet: 25 mg, 50 mg, 100 mg, 200 mg $ - $$

Valproic Acid (Depakene) Capsule: 250 mg $$ - $$ Syrup: 250 mg/5 mL $$ - $$$$


Stimulants Amphetamine Mixture (Adderall) CII

Capsule, extended release: 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg

$$$ - $$$$

Tablet: 2.5 mg, 5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg $

atoMOXetine (Strattera) Capsule: 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg $$$$ - $$$$$

Dextroamphetamine (Dexedrine, Dextrostat) C-II (Rarely used in adults)

Capsule, sustained release: 5 mg, 10 mg, 15 mg $$$ Tablet: 5 mg, 10 mg (5 mg tablet contain tartrazine) $$ - $

Lisdexamfetamine dimesylate (Vyvanse) C-II RESERVE USE Capsule: 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg $$$$

Rarely used in adults Methylphenidate, immediate release (Ritalin, Methylin, Metadate)

C-II

Tablet: 5 mg, 10 mg, 20 mg $ - $$

Rarely used in adults Methylphenidate, sustained release (Ritalin SR, Metadate CD

Concerta) C-II

Tablet, extended release: 18 mg, 36 mg, 27 mg, 54 mg $$$$ - $$$$$$

Other ADHD Agents cloNIDine (Catapres)

Patch, transdermal: 1, 2, and 3 (0.1, 0.2, 0.3 mg/day, 7 day duration)

$$ - $$$$

Tablet: 0.1 mg, 0.2 mg, 0.3 mg $

guanFACINE (Tenex) Tablet: 1 mg, 2 mg $$$$

Chemical Dependency Adjuncts Acamprosate (Campral)

Tablet, delayed release: 333 mg $$$ Disulfuram (Antabuse)

Tablet: 250 mg, 500 mg $$ - $$$$ Naltrexone (Trexan, ReVia)

Tablet: 50 mg $ - $$ Topiramate (Topamax)

Capsule, sprinkle: 15 mg, 25 mg $$ - $$$$ Tablet: 25 mg, 50 mg, 100 mg, 200 mg $ - $$


ANTICONVULSANTS Barbiturates

PHENobarbital (Luminal) C-IV Elixir: 20 mg/5 mL $$ - $$$$ Injection: 65 mg/mL, 130 mg/mL $$$$ - + Tablet: 8 mg, 15 mg, 16 mg, 30 mg, 32 mg, 60 mg, 65 mg, 100 mg $ - $$

Primidone (Mysoline)


Benzodiazepines cloBAZam (Onfi) C-IV

Suspension: 2.5 mg/mL $$$$$$ - ++

Tablet: 5 mg, 10 mg, 20 mg $$$$$$ - +

clonazePAM (KlonoPIN) C-IV Tablet: 0.5 mg, 1 mg, 2 mg $ - $ Tablet, oral disintegrating: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg $$ - $$$$

Clorazepate (Tranxene) C-IV Tablet: 3.75 mg, 7.5 mg, 15 mg $$ - $$

Diazepam (Valium, Diastat) C-IV Gel, rectal: 2.5 mg, 10 mg, 20 mg ++

Injection: 5 mg/mL $$$$ - +

Solution, oral: 1 mg/mL, 5 mg/mL $$ - $$$$ Tablet: 2 mg, 5 mg, 10 mg $ - $$

LORazepam (Ativan) Inj C-IV Injection: 2 mg/mL, 4 mg/mL $$ Solution, oral: 2 mg/mL $$ - $$ Tablet: 0.5 mg, 1 mg, 2 mg $

Hydantoins Fosphenytoin (Cerebyx)

Injection: 100 Phenytoin Equivalents [PE]/2 mL, 500 PE/10 mL $$$$ - $$$$$ Phenytoin (Dilantin)

Capsule, extended release: 30 mg, 100 mg $$ Capsule, immediate release: 100 mg, 200 mg, 300 mg $$ Injection: 50 mg/mL Suspension, oral: 125 mg/5 mL $$$ - $$$$ Tablet, chewable: 50 mg $$

Succinimides Ethosuximide (Zarontin)

Capsule: 250 mg $ - $$$$ Syrup: 250 mg/5 mL $$ - $$$$


Miscellaneous Anticonvulsants carBAMazepine (TEGretol)

Capsule, extended release: 100 mg, 200 mg, 300 mg $$ - $$$$$ Suspension, oral: 100 mg/5 mL $$ - $$$$Tablet: 200 mg $$ - $$$Tablet, chewable: 100 mg $$ - $$$ Tablet, extended release: 100 mg, 200 mg, 400 mg $$ - $$$$

Divalproex (Depakote) Tablet, delayed release: 125 mg, 250 mg, 500 mg $$ - $$ Tablet, extended release: 250 mg, 500 mg $$$ - $$$$$$$ Tablet, delayed release: 125 mg, 250 mg, 500 mg $$ - $$

Felbamate (Felbatol) - RESERVE USE Suspension, oral: 600 mg/5 mL $$$$ - Tablet: 400 mg, 600 mg $$$$$$ - ++

Gabapentin (Neurontin) Capsule: 100 mg, 300 mg, 400 mg $ - $ Solution, oral: 250 mg/5 mL $$ - $$$ Tablet: 400 mg, 600 mg, 800 mg $$

Lacosamide (Vimpat) C-V Oral Solution: 10 mg/mL $$$$ - +

Injection: 10 mg/mL $$$$$ - ++

Tablet: 50 mg, 100 mg, 150 mg, 200 mg $$$$$ - $$$$$$ lamoTRIgine (LaMICtal)

Tablet: 25 mg, 100 mg, 150 mg, 200 mg $

Tablet, dispersible/chewable: 2 mg, 5 mg, 25 mg $$$$$ - ++

LevETIRAcetam (Keppra) Solution, oral: 100 mg/mL $$ - $$$ Tablet: 100 mg, 250 mg, 500 mg, 750 mg, 1,000 mg $ - $

OXcarbazepine (Trileptal) Suspension, oral: 300 mg/5 mL $$$$ - +

Tablet: 150 mg, 300 mg, 600 mg $$ - $$ Pregabalin (Lyrica) C-V

Capsule: 25 mg, 50 mg, 75 mg, 300 mg

100 mg, 150 mg, 200 mg, 225 mg, $$$$$

Rufinamide (Banzel) Tablet: 200 mg, 400 mg $$$$$ - ++

tiaGABine (Gabatril) Tablet: 2 mg, 4 mg, 12 mg, 16 mg, 20 mg $$$$$ - +

Topiramate (Topamax) Capsule, sprinkle: 15 mg, 25 mg $$$ - $$$$ Tablet: 25 mg, 50 mg, 100 mg, 200 mg $ - $$

Valproic Acid (Depakene) Capsule: 250 mg $$ - $$ Syrup: 250 mg/5 mL $$ - $$$$

Zonisamide (Zonegran) Capsule: 25 mg, 50 mg, 100 mg $ - $


MUSCLE RELAXANTS Antispasticity Agents

Baclofen (Lioresal) Tablet: 10 mg, 20 mg $ - $$

Dantrolene (Dantrium) Capsule: 25 mg, 50 mg, 100 mg $$ - $$$$

Diazepam (Valium) C-IV Injection: 5 mg/mL $$

Solution, oral: 1 mg/mL, 5 mg/mL $ - $ Tablet: 2 mg, 5 mg, 10 mg $$

tiZANidine (Zanaflex) - RESERVE USE Capsule: 2 mg, 4 mg, 6 mg $$$ - $$$$$ Tablet: 2 mg, 4 mg $ - $$

Muscle Relaxant Agents Cyclobenzaprine (Flexeril)


Diazepam (Valium) C-IV

Injection: 5 mg/mL $$ Solution, oral: 1 mg/mL, 5 mg/mL $ - $ Tablet: 2 mg, 5 mg, 10 mg $$

Methocarbamol (Robaxin) Tablet: 500 mg, 750 mg $ - $

ANTIPARKINSON AGENTS Amantadine (Symmetrel) $$ Benztropine (Cogentin) $ - $$$$ Bromocriptine (Parlodel) $$ - $$$$$$$ Entacapone (Comtan) $$$ - + Carbidopa-Levodopa (Sinemet) $$ - $$$$ Pramipexole (Mirapex) $$ - $$$ Rasagiline (Azilect) $$$$$

Trihexyphenidyl (Artane) $ - $$


AGENTS FOR MIGRAINE Aspirin-Acetaminophen-Caffeine (Excedrine Migraine) $ Atenolol (Tenormin) $ Divalproex (Depakote, Depakote ER) $$ - $$$$ FLUoxetine (PROzac) $ Metoprolol (Lopressor, Toprol XL) $ - $$ Naproxen (Naprosyn) $$

Propranolol (Inderal) $ - $$$ SUMAtriptan (Imitrex) $$$$$ - $$$$$$$ Topiramate (Topamax) $ Valproate (Depakene) $ - $$$$ Verapamil (Calan, Isoptin) $ - $$

DEMENTIA AGENTS Donepezil (Aricept) $$$-$$$$ Galantamine (Razadyne) $$ - $$$ Memantine (Namenda) $$ - $$$ Rivastigmine (Exelon, Exelon Patches) $$$-$$$$

ENDOCRINE AGENTS

ESTROGENS Estradiol (Estrace, Vivelle, Alora, Climara, Estraderm) $ - $$$$$$$ Estrogens, Conjugated (Premarin) $$

PROGESTERONES medroxyPROGESTERone (Provera) $ - $$

COMBINATION PRODUCTS All commercially available Birth Control Agents are considered to be formulary agents

Estrogen-medroxyPROGESTERone (PremPro, Premphase) $$ -$$Ethinyl Estradiol-Norethindrone (Loestrin, , Ortho-Novum 777) $$$$$$$ Ethinyl Estradiol-Norgestrel (Ovral, Lo-Ovral) $$$$$$$ Levonorgestrel-Ethinyl Estradiol (Tri-Levlen, Triphasil) $$$$$$$ Norgestimate-Ethinyl Estradiol (Ortho Tri-Cyclen) $$$$$$$

ANDROGENS Testosterone (Androlan) C-IV $$ - $$$


ADRENAL CORTICAL STEROIDS Dexamethasone (Decadron) $ - $$ Fludrocortisone (Florinef) $ -$$ Hydrocortisone $$ - $$$$$ methylPREDNISolone (Medrol, Depo-Medrol) $ - $$$$ prednisoLONE (Delta-Cortef) $ - $$ predniSONE (Meticorten, Deltasone) $ - $$$$ Triamcinolone (Aristocort, Kenacort) $ - $$$$$

THYROID AGENTS Levothyroxine (Synthroid, Levoxyl) $ Methimazole (Tapazole) $$ - $$ Propylthiouracil $

MISCELLANEOUS ENDOCRINE AGENTS Allopurinol (Zyloprim) $ Colchicine $ Desmopressin (DDAVP, Stimate) $$$ - $$$$


GASTROINTESTINAL AGENTS

ANTACIDS

Capsule: 10 mg $$ - $$$$

Suspension, oral: 320 mg/5 mL, 600 mg/5 mL $ - $$ Aluminum Hydroxide (Amphojel)

Aluminum Hydroxide-Magnesium Trisilicate (Gaviscon)

$

Aluminum Hydroxide-Magnesium Hydroxide (Maalox) Suspension, oral: containing Aluminum Hydroxide-Magnesium

Hydroxide $$

Aluminum Hydroxide-Magnesium Hydroxide-Simethicone (Mylanta, Aludrox)

Liquid, oral: containing Aluminum Hydroxide-Magnesium Hydroxide-Simethicone

$

Tablet: each tablet contains Aluminum Hydroxide-Magnesium Hydroxide-Simethicone

Calcium Carbonate (Os-Cal, Os-Cal chewable, Titralac) - 40% elemental calcium

Liquid, oral: $

Tablet: $

Tablet, chewable: $$

Tablet, chewable: each tablet contains Aluminum Hydroxide-Magnesium Trisilicate

ANTISPASMODICS/ANTICHOLINERGIC AGENTS Dicyclomine (Bentyl)

Injection: 10 mg/mL ++ - + Syrup: 10 mg/5 mL $$$$ - $$$$$$ Tablet: 20 mg $$ - $

Glycopyrrolate (Robinul) Tablet: 1 mg $$

Propantheline (Pro-Banthine) Tablet: 15 mg $$


HISTAMINE (H2) ANTAGONISTS Preferred Agent:

Famotidine (Pepcid)

Injection: 10 mg/mL $ Powder for oral suspension: 40 mg/5 mL $$ - $$$$ Tablet: 10 mg, 20 mg, 40 mg $

Others:

Ranitidine (Zantac) Injection: 25 mg/mL $$$$ - $$$$$ Syrup: 15 mg/mL $$ Tablet: 75 mg, 150 mg, 300 mg $ - $$ Tablet, effervescent: 25 mg

PROTON PUMP INHIBITORS Preferred Agent:

Lansoprazole (Prevacid) Capsule, enteric coated granules: 15 mg, 30 mg $ - $

Pantoprazole (Protonix) Suspension Packets; 40mg $$ Tablet: 20 mg, 40 mg $

Others: Esomeprazole (NexIUM) RESERVE USE

Capsule: 20 mg, 40 mg $$$$ Suspension packet: 10 mg, 20 mg, 40 mg $$$$

Omeprazole (PriLOSEC)

Capsule, delayed release: 10 mg, 20 mg, 40 mg $- -$$

ANTIFLATULENTS Simethicone (Mylicon)

Drops, oral: 40 mg/0.6 mL $ - $$ Tablet, chewable: 80 mg, 125 mg $

STIMULANTS Metoclopramide (Reglan)

Injection: 5 mg/mL $$$ Liquid, oral, sugar free: 5 mg/5 mL $



LAXATIVES Saline Laxatives

Magnesium Citrate Solution, oral: 300 mL $

Magnesium Hydroxide (Milk of Magnesia) Liquid, oral: 400 mg/5 mL $

Liquid, oral, concentrate: 1,200 mg/5 mL $ - $$

Tablet, chewable: 311 mg $$- $ Magnesium Sulfate (Epsom Salt)

Granules: ~40 mEq magnesium/5 g $ ^ Per Dose

Irritant/Stimulant Laxatives Bisacodyl (Dulcolax)^

Suppository, rectal: 10 mg $ Tablet, enteric coated: 5 mg $

Senna (Senokot) Tablet: 8.6 mg $

^ Per Dose

Bulk Laxatives Cellulose (Unifiber)

Powder, oral: 150 g, 270 g, 480 g $ Methylcellulose (Citrucel)

Powder: Methylcellulose 2 g per tbsp [with sucrose] $$ - $ Powder, sugar free: Methylcellulose 2 g per tbsp [with phylalanine] $$ - $

Polycarbophil (Fibercon, Fiber-Lax) Tablet: 500 mg, 625 mg $ - $

Osmotic Laxatives Lactulose (Enulose)

Syrup: 10 g/15 mL $ - $$

Polyethylene Glycol (MiraLax) Powder for oral solution $$

Polyethylene Glycol Electrolyte Solution (PEG, Co-Lyte, GoLYTELY, ) Powder for oral solution: 2000 mL, 4000 mL, 4800 mL,

6000 mL $$$$^

Sorbitol Solution, oral: 70% $ - $

^ Per Dose


Combination Laxatives Docusate Sodium-Sennosides (Peri-Colace)

Tablet: Docusate 50 mg-Sennosides 8.6 mg $

Surfactants Docusate Calcium (Surfak)

Capsule: 240 mg $

Docusate Sodium (Colace) Capsule: 50 mg, 100 mg, 250 mg $

Liquid, oral: 150 mg/15 mL $

Syrup: 60 mg/15 mL $

Miscellaneous Laxatives Glycerin Suppository (Sani-Supp)

Suppository, rectal $

^ Per Dose

ANTIDIARRHEALS Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate)

Liquid, oral: 262 mg/15 mL $ - $$ Tablet, chewable: 262 mg $ - $$

Kaolin-Pectin Suspension: 30 mL, 120 mL, 180 mL, 240 mL $ - $$

Lactobacillus Acidophilus (Lactinex, Bacid) Capsule $$ Granules: 1 g/packet $$ Tablet, chewable $$

Loperamide (Imodium)

Capsule: 2 mg $$

Liquid, oral: 1 mg/5 mL $$ - $$ Tablet: 2 mg $

^ Pricing per Gram/supp

RECTAL AGENTS^ Pramoxine (Tronothane)^

Cream, topical: 1%

Gel, topical: 1% $

Lotion: 1% $

Spray: 1% $

Pramoxine – Hydrocortisone (Analpram HC)^

Cream, rectal: Pramoxine 1% - Hydrocortisone 2.5% $$$$$ - $$$$$$$

Rectal Hemorrhoidal Cream-Hydrocortisone^ Cream, rectal: 1%, 2.5% $$


Pramoxine (Tronothane)^

Rectal Hemorrhoidal Ointment (Anusol)^ Ointment $

Rectal Hemorrhoidal Suppositories (Wyanoids, Anusol)

Suppository, rectal: $$

Rectal Hemorrhoidal Suppositories-Hydrocortisone (Anusol-HC) Suppositories, rectal, as acetate: 25 mg $$$$

^ Pricing per Gram

MISCELLANEOUS GASTROINTESTINAL AGENTS Activated Charcoal

Capsules: 260 mg $ - $$ Liquid, oral, activated, with sorbitol: 25 g, 50 g $$$$ - $$$$$$$ Oral suspension, activated: 15 g, 30 g,

40 g, 120 g, 240 g $$$$$ - +

Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate) Liquid, oral: 262 mg/15 mL $ - $$ Tablet, chewable: 262 mg $ - $$

Lubiprostone (Amitiza) Capsule: 8 mcg, 24 mcg $$$$$

Mesalamine (Asacol HD, Pentasa, Rowasa) Capsule, extended release: 250 mg $$$$ Suppository: 1,000 mg $$$$$$$ Suspension, rectal: 4 gm/60 mL $$$$$ Tablet, delayed release: 800 mg +

Misoprostol (Cytotec) Tablet: 100 mcg, 200 mcg $$$

Pancrelipase (Pancrease, Creon) Capsule: contains lipase, protease and amylase $$$$ - + Tablet: contains lipase, protease and amylase

Sucralfate (Carafate) Suspension, oral: 1 g/10 mL $$$$ - $$$$$ Tablet: 1 g $$ - $

sulfaSALAzine (Azulfidine) Tablet: 500 mg $ Tablet, delayed release: 500 mg $

GENITOURINARY AGENTS

INTERSTITIAL CYSTITIS AGENTS Phenazopyridine (Pyridium) $ - $$


GENITOURINARY IRRIGANTS Sodium Chloride $$$ Water for Irrigation $ - $$

MEDICATIONS FOR BPH Finasteride (Proscar) $$ Tamsulosin (Flomax) $$

URINARY ALKALINIZERS Potassium Citrate (Urocit K) $ - $$$$ Potassium Citrate Combinations (Polycitra, Polycitra-LC, Polycitra K, Citrolith)

$$ - $$

Sodium Bicarbonate $ - $$ Sodium Citrate-Citric Acid (Bicitra, Oracit) $$ - $$$

URINARY ANTICHOLINERGICS Darifenacin (Enablex) $$$ flavoxATE (Urispas) $$$ Oxybutynin (Ditropan, Ditropan XL) $$ - $$ Trospium (Sanctura) $$$ Tolterodine (Detrol, Detrol LA) $$ - $$$

URINARY CHOLINERGICS Bethanechol (Urecholine) $ - $$$

VAGINAL ANTIFUNGALS Clotrimazole (Gyne-Lotrimin, Mycelex) $$$$ - $$$$$ Miconazole (Monistat) $$$$ - $$$$$ Tioconazole (Vagistat-1) $$$$

MISCELLANEOUS GENITOURINARY AGENTS Estradiol (Estrace) $$ - $$$$$$$ Estrogens, Conjugated (Premarin) $$$$$$$ Nitrofurantoin (Macrodantin) $$ - $$$$ Sevelamer (Renagel) $$$ - $$$$


IMMUNOLOGICAL AGENTS

IMMUNE SERUMS Hepatitis B Immune Globulin (HBIG) $$$$$$$

BACTERIAL VACCINES Pneumococcal Vaccine, Polyvalent (Pneumovax) $$$$$

VIRAL VACCINES Hepatitis A Vaccine (Vaqta, Havrix) $$$$$$$ Hepatitis A-Hepatitis B Vaccine (Twinrix) $$$$$$$ Hepatitis B Virus Vaccine, Recombinant (Recombivax HB, Engerix-B ) $$$$$$$ Influenza Virus Vaccine (Fluzone, Fluviron) $$ Measles-Mumps-Rubella Virus Vaccine, Live (MMR II) $$$$$$$ Varicella Virus Vaccine, Live (Varivax) $$$$$$$

TOXOIDS Diphtheria-Tetanus Toxoids Adsorbed (DT) $$$$ Diphtheria-Tetanus Toxoids Adsorbed for Adult Use (Td) $$$ Diphtheria-Tetanus-Acellular Pertussis (Tdap) (Boostrix, Adacel) $$$$$$$

IN-VIVO DIAGNOSTIC BIOLOGICALS Tuberculin, Purified Protein Derivative (P.P.D.) $$ - $$$$$$$


INFECTIOUS DISEASE AGENTS

ANTIBIOTICS Penicillins

Amoxicillin (Amoxil, Polymox) Capsule: 250 mg, 500 mg $

Powder for oral suspension: 125 mg/5 mL, 250 mg/5 mL $$ - $ Tablet: 500 mg, 875 mg $

Tablet, chewable: 125 mg, 250 mg $$ - $ Amoxicillin-Clavulanate (Augmentin)

Suspension, oral: 400mg (contains Clavulanate 57 mg) per 5 ml $ - $ 600mg (contains Clavulanate 42.9 mg) per 5 ml $ - $

Tablet: 250 mg (contains Clavulanate 125 mg) $$$$$ 500 mg (contains Clavulanate 125 mg) $$ 875 mg (contains Clavulanate 125 mg) $$

Tablet, chewable: 125 mg (contains Clavulanate 31.25 mg) 250 mg (contains Clavulanate 62.5 mg)

Tablet, extended release: 1,000 mg (contains Clavulanate 62.5 mg) $$$$$$ Ampicillin (Polycillin, Omnipen)

Capsule, as anhydrous: 250 mg, 500 mg Capsule, as trihydrate: 250 mg, 500 mg $ - $$

Powder for injection: 125 mg, 250 mg, 500 mg, 1 g, 2 g, 10 g $$$$ - $$$$$ Powder for oral suspension, as trihydrate: 125 mg/5 mL, 250 mg/5 mL $$

Nafcillin

Powder for injection: 500 mg, 1 g, 2 g 10 g $$$$$$$ - ++

Penicillin G Benzathine (Bicillin LA)

Injection: 600,000 units/mL ++ - + Penicillin G Benzathine-Penicillin G Procaine (Bicillin C-R)

Injection: + Penicillin G Benzathine 600,000 units-Penicillin G Procaine

600,000 units/2 mL

Penicillin G Benzathine 900,000 units-Penicillin G Procaine 300,000 units

Penicillin G Procaine (Wycillin)

Injection (suspension): 600,000 units/mL $$$$$$$ - +

Penicillin G Sodium

Injection: 5 million units $$$$ - + Penicillin V Potassium (Pen-Vee K, V-Cillin K)

Powder for oral solution: 125 mg/5 mL, 250 mg/5 mL

$ - $$

Tablet: 250 mg, 500 mg $ - $$

Piperacillin-Tazobactam (Zosyn)

Injection: 2.25 g, 3.375 g and 4.5 g $$$$$$ - $$$$$$$


Cephalosporins ceFAZolin (Kefzol)

Injection: 500 mg, 1 g $ - $$ Powder for injection: 500 mg, 1 g, 5 g, 10 g, 20 g

Cefepime (Maxipime) Injection: 500 mg, 1 g, 2 g $$$$$-$$$$$$

cefTRIAxone (Rocephin) Infusion, premixed in dextrose: 1 g, 2 g $$$ - $$$$ Powder for injection: 250 mg, 500 mg, 1 g, 2 g, 10 g $$

Cefuroxime Axetil (Ceftin) - Oral form only Powder for oral suspension: 125 mg/5 mL,

250 mg/5 mL $$$$$$ - +

Tablet: 125 mg, 250 mg, 500 mg $$$ - $$$$ Cephalexin (Keflex)

Capsule: 250 mg, 500 mg $ - $$

Powder for oral suspension: 125 mg/5 mL, 250 mg/5 mL

$$ - $$$$


Macrolides Azithromycin (Zithromax)

Powder for oral solution: 200 mg/5 mL, $$ - $$$$ Tablet: 250 mg, 500 mg, 600 mg $$

Clarithromycin (Biaxin) Granules for oral suspension: 125 mg/5 mL, 250 mg/5 mL $$$$ - $$$$$ Tablet, film coated: 250 mg, 500 mg $$$$

Tetracyclines Doxycycline (Vibramycin)

Capsule: 50 mg, 100 mg $$ - $$$ Powder for oral suspension: 25 mg/5 mL $$$$ - $$$$$ Tablet: 20 mg, 50 mg, 100 mg $$

Minocycline Capsule: 50 mg, 75 mg, 100 mg $$ - $ Capsule, pellet filled: 50 mg, 100 mg +

Tetracycline Capsule: 250 mg, 500 mg


Quinolones Ciprofloxacin (Cipro)

Injection: 200 mg, 400 mg $$ - $$$$ Suspension, oral: 250 mg/5 mL, 500 mg/5 mL $$$$ - $$$$$$ Tablet: 100 mg, 250 mg, 500 mg, 750 mg $ - $$

Levofloxacin (Levaquin) Infusion: 250 mg, 500 mg, 750 mg $$$ Solution: 250 mg/10 mL $$$$ - $$$$$$$ Tablet: 250 mg, 500 mg, 750 mg $ - $$

Moxifloxacin (Avelox) Infusion: 400 mg/250 mL +

Tablet: 400 mg $$$$

Aminoglycosides Amikacin

Injection: 50 mg/mL, 250 mg/mL $$$$ - $$$$$ Gentamicin

Infusion, premixed in NS: 40 mg, 60 mg, 80 gm, 90 mg, 100 mg, 120 mg

$$$$$

Injection: 10 mg/mL, 40 mg/mL $$ Injection, intrathecal (preservative free):

2 mg/mL

Neomycin Tablet: 500 mg $$$$ - $$$$$$

Tobramycin Injection: 10 mg/mL, 40 mg/mL $$ Powder for injection: 40 mg/mL


Miscellaneous Antibiotics Clindamycin (Cleocin)

Capsule: 75 mg, 150 mg, 300 mg $ - $$ Granules for oral solution: 75 mg/5 mL $$$$$ - +

Injection: 150 mg/mL $$$$$ cycloSERINE RESERVE USE

Capsule: 250mg + - ++

Linezolid (Zyvox) RESERVE USE

Suspension, Oral: 100 mg/5 mL + Tablet: 600 mg +

metroNIDAZOLE (Flagyl) Capsule: 375 mg $$$$$ Injection: 5 mg/mL $$$$ Powder for injection: 500 mg Tablet: 250 mg, 500 mg $ - $$

Sulfamethoxazole-Trimethoprim (Bactrim) The 5:1 ratio of Sulfamethoxazole to Trimethoprim is constant in all dosage forms

Injection: Sulfamethoxazole 80 mg Trimethoprim 16 mg per mL

+ - ++

Suspension, oral: Sulfamethoxazole 200 mg Trimethoprim 40 mg per 5mL

$$$$

Tablet: Sulfamethoxazole 400 mg Trimethoprim 80 mg

$

Sulfamethoxazole 800 mg Trimethoprim 160 mg

$$

Vancomycin (Vancocin) Capsule: 125 mg, 250 mg + - + Powder for injection: 500 mg, 1 g, 5 g, 10 g +


ANTIFUNGALS Fluconazole (Diflucan)

Suspension: 40 mg/mL $ - $$$$ Tablet: 100 mg, 150 mg, 200 mg, 250 mg,

500 mg $$ - $$$

Griseofulvin (Fulvicin, Grifulvin V, Gris-Peg) Microsize: Suspension, oral: 125 mg/5 mL with 0.2% alcohol $$$ - $$$$ Tablet: 500 mg $$$$ - $$$$$ Ultramicrosize: Tablet: 125 mg, 250 mg $$$$ - $$$$$

Ketoconazole (Nizoral) Tablet: 200 mg $

Nystatin (Mycostatin) Suspension, oral: 100,000 units/mL $$ Tablet, oral: 500,000 units $$ - $$$

Terbinafine (LamISIL) Tablet: 250 mg $ - $$

ANTITUBERCULARS cycloSERINE (Seromycin)

Capsule: 250mg + - ++ Ethambutol (Myambutol)

Tablet: 100 mg, 400 mg $$ Ethionamide (Trecator)

Tablet, sugar coated: 250 mg $$$ - $$$$$ Isoniazid (INH)

Injection: 100 mg/mL + Syrup: 50 mg/5 mL $$ Tablet: 100 mg, 300 mg $

Pyrazinamide Tablet: 500 mg $$$ - $$$$

Rifabutin (Mycobutin) Capsule: 150 mg $$$$$ - $$$$$$$

Rifampin (Rifadin) Capsule: 150 mg, 300 mg $ Injection: 600 mg +

Rifampin-Isoniazid (Rifamate) $$$$$ Capsule: Rifampin 300 mg-Isoniazid 150 mg


ANTIVIRALS All commercially available Antiviral Agents used in the treatment of AIDS/HIV are

considered to be formulary agents Acyclovir (Zovirax)

Capsule: 200 mg $$ - $$ Powder for injection: 500 mg, 1000 mg $$$$$ - + Suspension, oral: 200 mg/5 mL $$$$$$ - ++

Tablet: 400 mg, 800 mg $$ - $ Oseltamivir (Tamiflu)

Capsule: 75 mg $$$$$$$ valACYclovir (Valtrex)

Caplets: 500 mg, 1 g $ - $$ Zanamivir (Relenza)

Powder for Inhalation: 5 mg $$$$ - $$$$$

ANTIHELMINTICS Ivermectin (Stromectol)

Tablet: 3 mg $$$$$ - +

URINARY ANTI-INFECTIVES Nitrofurantoin (Macrodantin)

Capsule, macrocrystal: 25 mg, 50 mg, 100 mg $$ - $$$ Capsule, macrocrystal/monohydrate: 100 mg $$$ Suspension, oral: 25 mg/5 mL $$$$$$ - +

MISCELLANEOUS ANTI-INFECTIVES Atovaquone (Mepron) - RESERVE USE

Suspension: 750 mg/5 mL ++

Dapsone Tablet: 25 mg, 100 mg $$

Pentamidine (Pentam) - RESERVE USE Inhalation: 300 mg +

Powder for injection: 300 mg +


INTRAVENOUS SOLUTIONS AND ADDITIVES

INTRAVENOUS SOLUTIONS Amino Acid Injection (Aminosyn) $$$$ - $$$$$$$ Amino Acid Injection-Dextrose-Electrolytes (Clinimix E) $$$$$$$ Dextrose 5%-Sodium Chloride Intravenous Solution $$$$

Dextrose 5% in 0.2% Sodium Chloride Dextrose 5% in 0.45% Sodium Chloride Dextrose 5% in 0.9% Sodium Chloride

Dextrose 5% in Water $ - $$ Dextrose 5% in Ringer's Lactate $ Dextrose 5% with Multiple Electrolytes (D5 E75, Baxter) $$$ Dextrose 5%-Sodium Chloride-Potassium Chloride Intravenous Solution $$$$$$ -

$$$$$$$ Dextrose 5% in 0.2% Sodium Chloride with Potassium Chloride Dextrose 5% in 0.45% Sodium Chloride with Potassium Chloride Dextrose 5% in 0.9% Sodium Chloride with Potassium Chloride

Dextrose 50% in Water $$$$ - $$$$$ Ringer’s Lactate Solution (Hartmann's Solution) $$ Sodium Chloride Intravenous Solution $$$$ - $$$$$

0.2% Sodium Chloride 0.45% Sodium Chloride 0.9% Sodium Chloride

$ - $$$

Water for Injection $$ - $$$$

ELECTROLYTE REPLACEMENT ADDITIVES Calcium Gluconate $$ Magnesium Sulfate $ - $ Potassium Chloride $ - $$ Sodium Bicarbonate $ - $$ Sodium Chloride $ - $$ Sodium Lactate $$$$ Zinc Sulfate $ - $$


NUTRITIONAL AGENTS

VITAMINS Ascorbic Acid (Vitamin C) $ - $ Cyanocobalamin ( Vitamin B12) $ - $$$$$$$ Folic Acid (Folvite) $ - $$$$ Leucovorin (Wellcovorin) $$ - $$$$ Niacin-Nicotinamide (Nicobid) $ Phytonadione (Vitamin K1, Mephyton, Konakion) $$ - $$$ Pyridoxine (Vitamin B6) $ - $$ Thiamine (Vitamin B1) $ - $ Vitamin A (Aquasol A) $ - $$$$$$$ Vitamin D (Ergocalciferol, Calciferol, Drisdol) $-$

Vitamin E (Aquasol E) $ - $$$$$$$

MINERALS, TRACE ELEMENTS, AND ELECTROLYTES Calcium Carbonate (Os-Cal, Os-Cal chewable, Titralac) - 40% elemental

calcium $

Calcium (Citracal) $

Calcium Glubionate (Neo-Calglucon) - 6% elemental calcium $ - $$ Calcium Gluconate - 9% elemental calcium $$ Ferrous Fumarate-Docusate Sodium (Ferro-Sequels) - 33% elemental iron $$ Ferrous Sulfate (Feosol, Fer-In-Sol) -20% elemental iron $ Potassium Chloride $$ Potassium Phosphate (Neutra-Phos-K) $$ - $$$

Zinc Sulfate $ - $$

COMBINATION PRODUCTS Calcium Carbonate-Vitamin D (Os-Cal + D) $ Calcium Citrate-Vitamin D (Citrical+D) $

Iron salts with or without vitamins and/or minerals (Hemocyte Plus, Niferex, Niferex-150, Niferex-150 Forte)

$ - $$$$

Multivitamin (Unicap, Hexavitamins) $ - $ Multivitamin-Minerals $ - $ Multivitamins, Pediatric (Poly-Vi-Sol) $$ Multivitamins, Prenatal (Filibon) $ Vitamin B Complex

Vitamin B Complex-Vitamin C (Stresscaps, Allbee with C Nephrocaps, Nephro-vite)

$ -$$

Vitamin B Complex-Vitamin C-Zinc $


OSTEOPOROSIS AGENTS

Alendronate (Fosamax) $ - $$ Calcitonin-Salmon (Miacalcin) $$$ Denosumab (Prolia) $$$$$$$ Ibandronate (Boniva) $$$$$$$ Raloxifene (Evista) $$ Risedronate (Actonel) $$$$$ Zoledronic Acid (Reclast, Zometa) $$$$$$$

RESPIRATORY AGENTS

BRONCHODILATORS Albuterol (Proventil, Ventolin Vospire ER) $ - $$$

Aminophylline $$ - $$ Ipratropium (Atrovent Inhaler) $$$$$$$ Salmeterol (Serevent) $$$$$$$ Terbutaline (Brethine) $ - $$$$$$ Theophylline (Elixophyllin) $ - $$ Tiotropium (Spriva) $$$$$$$

BRONCHODILATORS, COMBINATION/SHORT ACTING Albuterol-Ipratropium (Combivent, DuoNeb) $$ - $$$$$$$

BRONCHODILATORS, COMBINATION STEROID + LONG ACTING BETA-2 AGONISTS

Budesonide-Formoterol (Symbicort) $$$$$$$ Fluticasone-Salmeterol (Advair) $$$ - $$$$$


COUGH, COLD AND DECONGESTANT PREPARATIONS Benzonatate (Tessalon Perle) Antitussive $$$

Brompheniramine-Phenylephrine (Dimetapp Cold and Allergy) $

Brompheniramine-Pseudoephedrine (Bromfed) $$ Cetirizine-Pseudoephedrine (ZyrTEC D) $

Chlorpheniramine (Chlor-Trimeton, Teldrin) $ - $$ DextromethorphanAntitussive $ - $$ diphenhydrAMINE (Benadryl) $ Fexofenadine (Allegra) $ - $$ Fexofenadine-Pseudoephedrine (Allegra-D) $$ guaiFENesin-Codeine (Robitussin AC) C-V $$

guaiFENesin-Dextromethorphan (Robitussin DM) $ - $$ guaiFENesin-Pseudoephedrine (Mucinex D) $$ HYDROcodone-guaiFENesin (Hycotuss, Kwelcof) C-II $$ Loratadine (Claritin) $$

Loratadine-Pseudoephedrine (Claritin D) $$ - $$

Phenylephrine (Neo-Synephrine) Decongestant $$$

Pseudoephedrine (Sudafed) Decongestant $ - $$

Triprolidine-Pseudoephedrine (Actifed) $

EXPECTORANTS guaiFENesin (Robitussin, Mucinex) $ - $$ Potassium Iodide (SSKI) $ - $

STEROIDS Beclomethasone (Beconase QVAR) $$$$$$$ Budesonide (Pulmicort) $$$$ - $$$$$

Fluticasone (Flovent) $$$$$$$ Fluticasone-Salmeterol (Advair) $$$ - $$$$$

Mometasone (Nasonex) $$$$$$$ Triamcinolone (Azmacort, Nasacort) $$$$$$$

MISCELLANEOUS RESPIRATORY DRUGS Acetylcysteine (Mucomyst) $$$$ - $$$$$$ Cromolyn (Intal) $$$$$$$ Montelukast (Singulair) $$ Sodium Chloride $ - $ Zafirlukast (Accolate) $$


TOPICAL AGENTS

OPHTHALMICS Agents for Glaucoma

Betaxolol (Betoptic S) Solution, ophthalmic: 0.5% $$ - $ Suspension, ophthalmic: 0.25% $$

Bimatoprost (Lumigan)

Solution, ophthalmic: 0.01%, 0.03% $$$$$$$ - +

Brimonidine (Alphagan P) Solution, ophthalmic: 0.1% 0.15%, 0.2% $ - $$$$

Latanoprost (Xalatan)

Solution, ophthalmic: 0.005% $

Pilocarpine (Isopto Carpine) Solution, ophthalmic, as hydrochloride: 1%, 2%, 4% $ - $$

Timolol (Timoptic, Timoptic XE)

Gel, ophthalmic: 0.25%, 0.5% $ - $$ Solution, as maleate, ophthalmic: 0.25%, 0.5% $

Solution, as maleate, ophthalmic, preservative free, single use: 0.25%, 0.5%

$$$$$ - $$$$$$$

Timolol-Dorzolamide (Cosopt)

Solution, ophthalmic: Timolol 0.5%-Dorzolamide 2% $ - $$

Travoprost (Travatan, Travatan Z) Solution, ophthalmic: 0.004% $$ - $$$


Antibiotics Bacitracin (Baciguent)

Ointment, ophthalmic: 500 units/g $$$$ Ciprofloxacin (Ciloxan)

Ointment, ophthalmic: 0.3% $$$$$$ Solution, ophthalmic: 0.3% $

Erythromycin Ointment, ophthalmic: 5% $

Gentamicin (Garamycin) Ointment, ophthalmic: 0.3% [3 mg/g] $ Solution, ophthalmic: 0.3% [3 mg/mL] $$

Moxifloxacin (Moxeza, Vigamox) RESERVE USE

Solution, ophthalmic: 0.5% [5 mg/mL] + Polymyxin B-Bacitracin (Polysporin)

Ointment, ophthalmic: Polymyxin B 10,000 units-Bacitracin 500 units Polymyxin B-Trimethoprim (Polytrim)

Solution, ophthalmic: Polymyxin B 10,000 units -Trimethoprim 1 mg/mL

$$

Sulfacetamide Sodium (Sulamyd) Ointment, ophthalmic: 10% $$$ Solution, ophthalmic: 10% $$$

Tobramycin (Tobrex) Ointment, ophthalmic: 0.3% $$$$$ Solution, ophthalmic: 0.3% $

Mydriatics^

Atropine Sulfate (Isopto Atropine) Ointment, ophthalmic: 1% $$$ Solution, ophthalmic: 1% $$

Homatropine (Isopto Homatropine) Solution, ophthalmic: 2%, 5% $$$

Phenylephrine (Neo-Synephrine) Solution, ophthalmic: 2.5%, 10% $$$$

Scopolamine (Isopto Hyoscine) Solution, ophthalmic: 0.25%

Tropicamide (Mydriacyl)

Solution, ophthalmic: 0.5%, 1% $$

^Pricing per ml or per gram


Decongestant/Antiallergy^ Ketotifen (Zaditor)

Solution, ophthalmic: 0.025% $ Naphazoline (Naphcon, AK-Con)

Solution, ophthalmic: 0.012%, 0.1% $

Olopatadine (Patanol)

Solution, ophthalmic: 0.012%, 0.1% +

Tetrahydrozoline (Visine Allergy Relief, Visine Moisturizing)

Solution, ophthalmic: 0.05% $

^Pricing per ml or per gram

Miscellaneous Opthalmics^ Cromolyn (Intal)

Solution, ophthalmic: 4% $$

Dexamethasone (Decadron) - RESERVE USE Suspension, ophthalmic: 0.1% with methylcellulose 0.5% - RESERVE USE

$$$$$

Fluorescein Sodium Injection: 10% $$$$ Strip, ophthalmic: 0.6 mg, 1 mg $

Ophthalmic Irrigating Solution (BSS, Eye Stream, AK-Rinse)

Solution, ophthalmic $

Ophthalmic Lubricant (Artifical Tears, Liquitears, HypoTears, HypoTears PF)

Ointment, ophthalmic $

Solution, ophthalmic $ Solution, ophthalmic 1.4%

prednisolone (Pred Mild, Pred Forte) Reserve Use Solution, ophthalmic: 0.12%, 1% RESERVE USE $$$$$$$

Proparacaine (Alcaine) Solution, ophthalmic: 0.5% $$

Sodium Chloride Ointment, ophthalmic: 5% $$ Solution, ophthalmic: 2%, 5% $ - $$

Tobramycin-Dexamethasone (TobraDex)- RESERVE USE

Ointment, ophthalmic: Tobramycin 0.3%-Dexamethasone 0.1% ++

Suspension, ophthalmic: Tobramycin 0.3%-Dexamethasone 0.1% $$$$$ ^Pricing per ml or per gram


OTICS^ Acetic Acid (Acetasol, VoSol)

Solution, otic: 2% Solution, $$ Acetic Acid-Aluminum Acetate (Domeboro Otic)

Solution, otic: 2% acetic acid in aluminum acetate $ Acetic Acid-Hydrocortisone-Propylene Glycol-Sodium Acetate-

Benzethonium (VoSol HC)

Solution, otic: 1% Hydrocortisone, 2% Acetic Acid, 3% Propylene Glycol, 0.015% Sodium Acetate, and 0.02% Benzethonium

$$$$

Antipyrine-Benzocaine (Allergen, Auralgan) Solution, otic $

Carbamide Peroxide-Glycerin-Propylene Glycol-Sodium Stannate (Debrox)

Solution, otic: 6.5% $

Ciprofloxacin-Hydrocortisone (Cipro HC Otic) Solution, otic: Ciprofloxacin 2 mg-Hydrocortisone 10 mg per mL +/day

Hydrogen Peroxide Solution, topical: 3% $

Mineral Oil

Oil $

Neomycin-Polymyxin B-Hydrocortisone (Cortisporin) Solution, otic: Neomycin-Polymyxin B-Hydrocortisone $$/day Suspension, otic: Neomycin-Polymyxin B-Hydrocortisone $$/day

MOUTH AND THROAT AGENTS Benzocaine (Oragel Cepacol) $$ - $$$

Gel: 6.3%, 6%, 7.5%, 10%, 15%, 20% Liquid: 5%, 6.3%, 10%, 20%

Carbamide Peroxide-Glycerin-Propylene Glycol-Sodium Stannate (Gly-Oxide)

$$$

Gel, oral: 10% Solution, oral: 10%, 15%

Chlorhexidine (Peridex) Rinse, oral, with 12% alcohol: 0.12% $$

Clotrimazole (Mycelex, Fungoid) Troche: 10 mg $$

Doxycycline (Periostat) Tablet: 20 mg $$$

Nystatin (Mycostatin) $$ - $$$ Suspension, oral: 100,000 units/mL Troche: 200,000 units


Benzocaine (Oragel Cepacol) $$ - $$$ Phenol (Chloraseptic) $$

Mouthwash/Gargle Throat Spray

Saliva Substitute OTC $$$ Gel

Mouthwash Spray Toothpaste

Saliva Substitute Rx ++ - + Mouthwash

Spray Sodium Chloride $$

Ointment, ophthalmic: 5%

Solution, ophthalmic: 2%, 5% Sodium Fluoride $

Liquid, oral: 360 mL, 480 mL, 540 mL Tablet, chewable: 0.25 mg, 0.5 mg, 1 mg, 1.1 mg, 2.2 mg

Stannous Fluoride (OmniMed, PerioMed) Solution, oral: 0.4%, 0.63% $$$$

NASAL AGENTS Azelastine (Astelin) 0.1% nasal spray 137 mcg/spray

Nasal spray: 0.1% (137 mcg/spray) $$$$$$$ Fluticasone (Flonase)

Inhalation, nasal: 50 mcg/actuation $$$$ - $$$$$$$ Oxymetazoline (Afrin) $

Solution, nasal, drops: 0.025%, 0.05% Solution, nasal, spray: 0.05%

Phenylephrine (Neo-Synephrine) $$ Solution, nasal, drops: 0.125%, 0.25%, 0.5%

Solution, nasal, spray: 0.25%, 0.5%, 1%


DERMATOLOGICALS^ Acne Agents

Adapalene (Differin) $$ Benzoyl Peroxide $ - $$ Benzoyl Peroxide-Clindamycin (BenzaClin) $$$$$ Clindamycin (Cleocin T) $ - $$ Erythromycin-Benzoyl Peroxide (Benzamycin) $ metroNIDAZOLE (Noritate, MetroGel) $$ - $$$$$$ Salicylic Acid-Sulfur Sulfacetamide Sodium (Sebizon) $ Tazarotene (Tazorac, Avage) $$$$ Tretinoin Gel (Retin-A) $$$ - $$$$$

Anesthetics, Local Benzocaine (Lanacaine) Ethyl Chloride $$

Lidocaine (Xylocaine) $ - $$$$ Lidocaine-Prilocaine (EMLA, Lidoderm) $$ Pramoxine (Tronothane) $

Anti-Histamine Agents Calamine-Zinc Oxide-Glycerin (Calamine Lotion) $ Calamine-Pramoxine (Caladryl) $ diphenhydrAMINE (Benadryl) $ Doxepin (Zonalon) $$$ Pramoxine-Zinc (Caladryl Clear) $

Anti-Infectives Antibiotics

Bacitracin (Baciguent) $ Bacitracin-Polymyxin B (Polysporin) $ Clindamycin (Cleocin T) $ - $$ Gentamicin (Garamycin) $$ metroNIDAZOLE (Noritate, MetroGel) $$ - $$$$$$ Mupirocin (Bactroban) $$ - $$$ Neomycin-Polymyxin B-Bacitracin (Triple Antibiotic Ointment) $

Polymyxin B-Neomycin (Neosporin)

Antiviral Acyclovir (Zovirax) $$$$$$ - +


Antifungals Ciclopirox (Loprox, Penlac) $$-$$$ Clotrimazole (Lotrimin, Fungoid) $ - $ Ketoconazole (Nizoral) $ - $ Miconazole (Monistat) $ Nystatin (Mycostatin) $$ - $ Terbinafine (LamISIL) $ Tolnaftate (Tinactin) $

Antipsoriatics Calcipotriene (Dovonex) $$$ Coal Tar (Ionil-T, Tegrin, Pentrax, Polytar) $

Selenium Sulfide (Selsun) $ Tazarotene (Tazorac, Avage) $$$$

Antiseborrheic Agents Coal Tar (Ionil-T, Tegrin, Pentrax, Polytar) $ Salicylic Acid-Sulfur $ Selenium Sulfide (Selsun) $ Sulfacetamide Sodium (Sebizon) $

Antiseptics & Germacides Chlorhexidine (Hibiclens, Bactoshield) $

Hexachlorophene (pHisoHex) Povidone-Iodine (Betadine) $

Burn Agents Bacitracin (Baciguent) $ Silver Sulfadiazine (Silvadene) $


Corticosteroids Ultra High Potency

Betamethasone dipropionate, augmented (Diprolene A/F) - RESERVE USE $$ Clobetasol (Clobex, Cormax,Temovate) - RESERVE USE $$ - $$$

High Potency

Betamethasone dipropionate (Diprolene) $ - $$ Fluocinonide (Lidex) $$

Medium Potency

Betamethasone Valerate (Valisone) $ Fluocinolone (Capex, Derma-Smooth/FS, Synalar) $$ Triamcinolone (Aristocort, Kenacort) $ - $$$

Low Potency

Desonide (Desowen, Lokara, Tridesilon) $ - $$$ Hydrocortisone (Lanacort, Corticaine) $

Diaper Rash Agents Diaper Rash Ointment (Desitin, Vitamin A&D Topical, Diaperene ) $

Diaper Rash Powder (Mexsana) $ Zinc Oxide $

Emollients Emollient Gel (Clinac O.C.) $ Emollient Lotion-Cream (Lubriderm, Allercreme, Keri Lotion, Cetaphil, Lac-

Hydrin, Eucerin, Nutraderm) $

Emollient Ointment (Lanolin, Aquaphor) $

Keratolytics Podophyllum Resin (Podocon-25) $ Salicylic Acid (Compound W, DuoFilm, Mediplast, Salex, Neutrogena) Urea $

Ointment & Lotion Bases Petrolatum, White (Vaseline) $ Oxybenzone-PDO-Pet Hy-Phl (Vaseline Lip Therapy) $

Rubs and Liniments Menthol Menthol-Methyl Salicylate (Ben-Gay) $


Skin Cleansers Abrasive Cleanser (Brasivol, Pernox, Salac, Seba-Nil) Non-Soap Cleanser (Cetaphil) $ Salicylic Acid-Sulfur

Scabicides & Pediculicides Permethrin 1% Liquid (NIX) $ Permethrin 5% Cream (Acticin), Elimite) $ Pyrethins 0.33%-Piperonyl Butoxide 4% (Pronto, RID)

Skin Protectants Benzoin, Compound Tincture $ Menthol-Zinc Oxide (Calmoseptine, Risamine) $ Silver Sulfadiazine (Silvadene) $ Zinc Oxide $

Sunscreens Sunscreen-Block Cream-Lotion: contains a minimum SPF of 15 $

Tar-Containing Agents Coal Tar (Ionil-T, Tegrin, Pentrax, Polytar) $

Wound Agents Collagenase (Santyl) $$$$ Trypsin-Balsam Peru-Castor Oil (Granulex, GranuloDerm, Revina, TBC, Vasolex, Xenaderm)

$ - $

Wound Cleanser (CarraKlenz)

Miscellaneous Dermatologicals Aluminum Chloride Hexahydrate (Drysol) $ Camphor-Phenol (Campho-Phenique) $ Hydrogen Peroxide $ Pimecrolimus (Elidel) $$$$ Silver Nitrate $$ Tacrolimus (Protopic) $$$$ Trypsin-Balsam Peru-Castor Oil (Granulex) $ - $

IRRIGATION SOLUTIONS Sodium Chloride $$$ Water for Injection $$ - $$$$


NUTRITIONAL SUPPLEMENTS* Fish Oil (Nature Made Fish Oil) $ Glucosamine $$ Magnesium L-lactate dihydrate (Mag-Tab SR) $

Melatonin $

*The following certification processes and product lines certified Good Manufacturer Practices (GMP) Nature’s Way

Country Life Twin

Consumer Labs (CL) Good Neighbor Pharmacy Sundown United States Pharmacopoeia (USP) Nature Made National Sanitation Foundation (NSF) GNC Nutritional Supplements


APPENDIX 3: NON-FORMULARY DRUG JUSTIFICATION FORM DSHS/DADS

NON-FORMULARY DRUG JUSTIFICATION Facility/Component Drug Name

(Generic) (Trade) (Strength) (AHFS Therapeutic Class) The purpose of the Formulary is to ensure that the treatments available to THHSC consumers are consistent with need, effectiveness, risk, and cost. Exceptions to the Formulary are limited to the three categories listed below. This request is for:

an individual patient treatment course. Is this _________

chronic or acute therapy? more than one patient/course of therapy. It is estimated that patients will be treated with this drug. Is this chronic or acute therapy?

Reason for request:

An illness for which no Formulary drug is as safe or effective. A trial supply in anticipation of application to Formulary. To prevent interruption of course of therapy established prior to admission.

Quantity Ordered

Cost/ Unit

Total Purchase Cost

*Estimate Course Chronic Cost Per Month

*Estimate Course Acute Cost

Alternative drugs are available on the DSHS/DADS Formulary.

Attending Physician (signature) Date Was the drug ordered yes or no?

AGREE DISAGREE

Pharmacy Director or designee (signature) Date

APPROVED DISAPPROVED EMERGENCY Facility clinical/medical director’s approval must be obtained within three working days.

Facility clinical/medical director or designee (signature) Date

ALPHABETICAL INDEX

Abilify ................................................................. 14, 29, 89 Abilify discmelt......................................................... 29, 89 Abilify Maintena ....................................................... 14, 29 Abrasive Cleanser ................................................. 26, 123 Acamprosate ........................................................... 26, 92 Accolate ................................................................. 77, 114 Acetaminophen ....................................................... 26, 84 Acetaminophen-Codeine ......................................... 26, 84 Acetaminophen-HYDROcodone ............................. 26, 84 Acetasol ................................................................. 26, 118 acetaZOLAMIDE ..................................................... 26, 81 Acetic Acid ............................................................. 26, 118 Acetic Acid-Aluminum Acetate .............................. 26, 118 Acetic Acid-Hydrocortisone-Propylene Glycol-Sodium

Acetate-Benzethonium ...................................... 26, 118 Acetylcysteine ................................................. 27, 79, 114 Acticin .................................................................... 62, 123 Actifed ................................................................... 75, 114 Activated Charcoal .................................................. 27, 79 Actonel .................................................................. 68, 113 Actos ....................................................................... 63, 78 Acyclovir ........................................................ 27, 110, 121 Adacel ................................................................... 41, 104 Adalet CC ................................................................ 59, 81 Adapalene ............................................................. 27, 120 Adderall ............................................................. 18, 29, 92 Adderall XR ............................................................. 18, 29 Adenocard ......................................................... 22, 27, 81 Adenosine ......................................................... 22, 27, 81 Adrenalin ................................................................. 43, 82 Advair ............................................................ 46, 113, 114 Afrin ....................................................................... 61, 120 AK-Con .................................................................. 59, 117 AK-Rinse ............................................................... 61, 118 Albuterol ................................................................ 27, 113 Albuterol-Ipratropium ............................................. 27, 113 Alcaine ................................................................... 66, 118 Aldactazide .............................................................. 70, 81 Aldactone ................................................................ 70, 81 Aldomet ................................................................... 56, 82 Alendronate ........................................................... 27, 113 Allbee with C ......................................................... 76, 112 Allegra ............................................................. 45, 79, 114 Allegra-D ............................................................... 45, 114 Allercreme ............................................................. 42, 122 Allergen ................................................................. 29, 118 Allopurinol ................................................................ 27, 97 Alora ........................................................................ 43, 96 Alphagan P ............................................................ 32, 115 ALPRAZolam..................................................... 20, 27, 86 Aludrox .................................................................... 28, 98 Aluminum Chloride Hexahydrate .......................... 28, 123 Aluminum Hydroxide ............................................... 28, 98 Aluminum Hydroxide-Magnesium Hydroxide .......... 28, 98

Aluminum Hydroxide-Magnesium Hydroxide-Simethicone......................................................... 28, 98

Aluminum Hydroxide-Magnesium Trisilicate .......... 28, 98 Amantadine ............................................................. 28, 95 Ambien .............................................................. 21, 77, 87 Amikacin ............................................................... 28, 107 Amino Acid Injection ............................................. 28, 111 Amino Acid Injection-Dextrose-Electrolytes .......... 28, 111 Aminophylline ........................................................ 28, 113 Aminosyn .............................................................. 28, 111 Amiodarone ............................................................. 28, 81 Amitiza .................................................................. 54, 102 Amitriptyline ...................................................... 16, 28, 88 amLODIPine ........................................................... 28, 81 Amoxicillin ............................................................. 29, 105 Amoxicillin-Clavulanate ......................................... 29, 105 Amoxil ................................................................... 29, 105 Amphetamine Mixture ....................................... 18, 29, 92 Amphojel ................................................................. 28, 98 Ampicillin ............................................................... 29, 105 Anafranil ............................................................ 16, 37, 88 Analpram HC ........................................................ 65, 101 Androlan .................................................................. 72, 96 Antabuse ................................................................. 41, 79 Antara ..................................................................... 45, 82 Antilirium ................................................................. 63, 79 Antipyrine-Benzocaine .......................................... 29, 118 Antivert .................................................................... 55, 85 Antiviral Agents ..................................................... 29, 110 Anusol ................................................................... 67, 102 Anusol-HC ............................................................. 67, 102 Apresoline ............................................................... 49, 82 Aquaphor .............................................................. 42, 122 Aquasol A .............................................................. 76, 112 Aquasol E .............................................................. 76, 112 Aricept ..................................................................... 42, 96 ARIPiprazol lauroxil....................................................... 14 ARIPiprazole ......................................... 12, 13, 14, 29, 89 ARIPiprazole Extended Release .................................. 14 Aristada ......................................................................... 14 Aristocort ......................................................... 74, 97, 122 Arixtra ...................................................................... 47, 80 Artane ..................................................................... 74, 95 Artifical Tears ........................................................ 61, 118 Asacol HD ............................................................. 56, 102 Ascorbic Acid ........................................................ 29, 112 Asenapine ......................................................... 14, 30, 89 Aspirin ............................................................... 30, 80, 83 Aspirin-Acetaminophen-Caffeine ............................ 30, 96 Astelin ................................................................... 30, 120 Atarax .................................................... 21, 50, 79, 85, 86 Atenolol ............................................................. 30, 82, 96 Ativan .......................................................... 20, 54, 86, 93 atoMOXetine ..................................................... 18, 30, 92 atorvaSTATin .......................................................... 30, 82

Atovaquone ..................................................... 22, 30, 110 Atropine Sulfate ..................................................... 30, 116 Atrovent ................................................................. 51, 113 Augmentin ............................................................. 29, 105 Auralgan ................................................................ 29, 118 Avage ............................................................ 71, 120, 121 Avelox .................................................................... 58, 107 Aventyl ............................................................... 16, 60, 88 Azelastine .............................................................. 30, 120 Azilect ...................................................................... 67, 95 Azithromycin .......................................................... 30, 106 Azmacort ............................................................... 74, 114 Azulfidine ............................................................... 71, 102 B.A.L. ....................................................................... 41, 79 Bacid ..................................................................... 52, 101 Baciguent ...................................................... 30, 116, 121 Bacitracin ....................................................... 30, 116, 121 Bacitracin-Polymyxin B ......................................... 30, 121 Baclofen .................................................................. 31, 95 Bactoshield ............................................................ 36, 121 Bactrim .................................................................. 71, 108 Bactroban .............................................................. 58, 121 Banzel ..................................................................... 68, 94 Beclomethasone ................................................... 31, 114 Beconase .............................................................. 31, 114 Benadryl ............................... 21, 41, 79, 85, 86, 114, 120 Benazepril ............................................................... 31, 82 Ben-Gay ................................................................ 55, 122 Benicar .............................................................. 23, 60, 82 Bentyl ...................................................................... 40, 98 BenzaClin .............................................................. 31, 120 Benzamycin ........................................................... 43, 120 Benzocaine.................................................... 31, 119, 120 Benzodiazepines ........................................................... 25 Benzoin, Compound Tincture ................................ 31, 123 Benzonatate .......................................................... 31, 114 Benzoyl Peroxide .................................................. 31, 120 Benzoyl Peroxide-Clindamycin ............................. 31, 120 Benztropine ............................................................. 32, 95 Betadine ................................................................ 65, 121 Betamethasone dipropionate ................................ 32, 122 Betamethasone dipropionate, augmented .............. 22, 32 Betamethasone Valerate ....................................... 32, 122 Betaxolol ................................................................ 32, 115 Bethanechol .......................................................... 32, 103 Betoptic S .............................................................. 32, 115 Biaxin ..................................................................... 36, 106 Bicillin C-R ............................................................. 62, 105 Bicillin LA ............................................................... 62, 105 Bicitra .................................................................... 70, 103 Bimatoprost ........................................................... 32, 115 Birth Control Agents ................................................ 32, 96 Bisacodyl ............................................................... 32, 100 Bismatrol ....................................................... 32, 101, 102 Bismuth Subsalicylate ................................... 32, 101, 102 Bonine ..................................................................... 55, 85 Boniva ................................................................... 50, 113 Boostrix ................................................................. 41, 104

Brasivol ................................................................. 26, 123 Brethine ................................................................. 72, 113 Brexpiprazole ................................................................ 14 Brimonidine ........................................................... 32, 115 Bromfed ................................................................ 33, 114 Bromocriptine .......................................................... 33, 95 Brompheniramine-Phenylephrine ......................... 33, 114 Brompheniramine-Pseudoephedrine .................... 33, 114 BSS ....................................................................... 61, 118 Budeprion ................................................................ 33, 88 Budesonide ........................................................... 33, 114 Budesonide-Formoterol ........................................ 33, 113 buPROPion ....................................................... 16, 33, 88 buPROPion SR ............................................................. 16 buPROPion XL .............................................................. 16 BuSpar .............................................................. 20, 33, 86 busPIRone ........................................................ 20, 33, 86 Caladryl ................................................................. 33, 120 Caladryl Clear ....................................................... 65, 120 Calamine Lotion .................................................... 33, 120 Calamine-Pramoxine ............................................ 33, 120 Calamine-Zinc Oxide-Glycerin .............................. 33, 120 Calan ................................................................. 76, 81, 96 Calciferol ......................................................... 43, 76, 112 Calcipotriene ......................................................... 33, 121 Calcitonin-Salmon ................................................. 33, 113 Calcium Carbonate ......................................... 34, 98, 112 Calcium Carbonate-Vitamin D .............................. 34, 112 Calcium Citrate ..................................................... 34, 112 Calcium Citrate-Vitamin D .................................... 34, 112 Calcium Glubionate............................................... 34, 112 Calcium Gluconate........................................ 34, 111, 112 Calmoseptine ........................................................ 55, 123 Campho-Phenique ................................................ 34, 123 Camphor-Phenol ................................................... 34, 123 Campral .................................................................. 26, 92 Capex .................................................................... 46, 122 Capoten .................................................................. 34, 82 Captopril .................................................................. 34, 82 Carafate ................................................................ 71, 102 carBAMazepine ..................................... 17, 25, 34, 91, 94 Carbamide Peroxide-Glycerin-Propylene Glycol-Sodium

Stannate .................................................... 34, 118, 119 Carbatrol ........................................................... 17, 25, 34 Carbidopa-Levodopa .............................................. 35, 95 Cardizem ................................................................. 41, 81 Cariprazine .................................................................... 14 CarraKlenz ............................................................ 76, 123 Carvedilol ................................................................ 35, 82 Catapres ..................................................... 18, 37, 82, 92 ceFAZolin .............................................................. 35, 106 Cefepime ............................................................... 35, 106 Ceftin ..................................................................... 35, 106 cefTRIAxone ......................................................... 35, 106 Cefuroxime Axetil .................................................. 35, 106 celeXA ............................................................... 16, 36, 87 Cellulose ............................................................... 35, 100 Cepacol ................................................................. 31, 119

Cephalexin ............................................................ 35, 106 Cerebyx ................................................................... 47, 93 Cetaphil ...................................................42, 60, 122, 123 Cetirizine ................................................................. 35, 79 Cetirizine-Pseudoephedrine .................................. 35, 114 Chloraseptic .......................................................... 63, 119 chlordiazePOXIDE ............................................ 20, 35, 86 Chlorhexidine ................................................ 36, 119, 121 Chlorpheniramine ............................................ 36, 79, 114 chlorproMAZINE ................................... 12, 13, 14, 36, 89 Chlorthalidone ......................................................... 36, 80 Chlor-Trimeton ................................................ 36, 79, 114 Cholestyramine ....................................................... 36, 82 Ciclopirox ............................................................... 36, 121 Ciloxan .................................................................. 36, 116 Cipro ...................................................................... 36, 107 Cipro HC Otic ........................................................ 36, 118 Ciprofloxacin.................................................. 36, 107, 116 Ciprofloxacin-Hydrocortisone ................................ 36, 118 Citalopram ......................................................... 16, 36, 87 Citracal .................................................................. 34, 112 Citrical+D ............................................................... 34, 112 Citrolith .................................................................. 64, 103 Citrucel .................................................................. 56, 100 Clarithromycin ....................................................... 36, 106 Claritin ............................................................. 54, 79, 114 Claritin D ................................................................ 54, 114 Cleocin .................................................................. 37, 108 Cleocin T ....................................................... 37, 120, 121 Climara .................................................................... 43, 96 Clinac O.C. ............................................................ 42, 122 Clindamycin .......................................... 37, 108, 120, 121 Clinimix E .............................................................. 28, 111 Clinoril ..................................................................... 71, 83 cloBAZam .......................................................... 25, 37, 93 Clobetasol ....................................................... 22, 37, 122 Clobex ................................................................... 37, 122 clomiPRAMINE.................................................. 16, 37, 88 clonazePAM ................................................20, 37, 86, 93 cloNIDine .....................................................18, 37, 82, 92 cloNIDine Extended Release ........................................ 18 Clopidogrel ........................................................ 22, 37, 80 Clorazepate .................................................20, 37, 86, 93 Clotrimazole ......................................... 37, 103, 119, 121 cloZAPine ....................................................14, 22, 38, 89 Clozapine ...................................................................... 15 Clozaril ........................................................14, 22, 38, 89 Coal Tar ......................................................... 38, 121, 123 Cod Liver Oil-Zinc Oxide-Talc ................................. 38, 40 Cogentin .................................................................. 32, 95 Colace ................................................................... 42, 101 Colchicine ................................................................ 38, 97 Collagenase .......................................................... 38, 123 Co-Lyte .................................................................. 64, 100 Combivent ............................................................. 27, 113 Compazine .............................................................. 66, 85 Compound W ........................................................ 68, 122 Comtan .................................................................... 43, 95

Concerta ........................................................... 18, 56, 92 Cordarone ............................................................... 28, 81 Coreg ...................................................................... 35, 82 Cormax ................................................................. 37, 122 Corticaine .............................................................. 50, 122 Cortisporin ............................................................. 59, 119 Cosopt ................................................................... 73, 115 Coumadin ................................................................ 76, 80 Creon .................................................................... 61, 102 Crestor .................................................................... 68, 82 Cromolyn ....................................................... 38, 114, 118 Cuprimine ................................................................ 62, 79 Cyanocobalamin ................................................... 38, 112 Cyclobenzaprine ..................................................... 38, 95 cycloSERINE .......................................... 22, 38, 108, 109 Cymbalta ........................................................... 16, 42, 88 Cyproheptadine ....................................................... 38, 79 Cytotec .................................................................. 57, 102 D5 E75 .................................................................. 40, 111 Dantrium ................................................................. 38, 95 Dantrolene .............................................................. 38, 95 Dapsone ................................................................ 38, 110 Darifenacin ............................................................ 39, 103 DDAVP .................................................................... 39, 97 Debrox .................................................................. 34, 118 Decadron ........................................................ 39, 97, 118 Deferoxamine .......................................................... 39, 79 Delta-Cortef ............................................................. 65, 97 Deltasone ................................................................ 65, 97 Denosumab ........................................................... 39, 113 Depakene ........................................ 17, 25, 75, 91, 94, 96 Depakote ......................................... 17, 25, 41, 91, 94, 96 Depakote ER ............................................... 17, 25, 41, 96 Depo-Medrol ........................................................... 56, 97 Derma-Smooth/FS ................................................ 46, 122 Desferal ................................................................... 39, 79 Desipramine ...................................................... 16, 39, 88 Desitin ............................................................. 38, 40, 122 Desmopressin ......................................................... 39, 97 Desonide ............................................................... 39, 122 Desowen ............................................................... 39, 122 Desyrel .................................................. 16, 21, 74, 87, 88 Detrol .................................................................... 73, 103 Detrol LA ............................................................... 73, 103 Dexamethasone .............................................. 39, 97, 118 Dexedrine .......................................................... 18, 39, 92 Dexedrine spansules .............................................. 18, 39 Dextroamphetamine.......................................... 18, 39, 92 Dextromethorphan ................................................ 39, 114 Dextrose 5% in Ringer's Lactate .......................... 40, 111 Dextrose 5% in Water ........................................... 40, 111 Dextrose 5% with Multiple Electrolytes ................. 40, 111 Dextrose 5%-Sodium Chloride Intravenous Solution .. 39,

111 Dextrose 5%-Sodium Chloride-Potassium Chloride

Intravenous Solution ......................................... 40, 111 Dextrose 50% in Water ................................... 40, 78, 111 Dextrostat ................................................................ 39, 92

DiaBeta .................................................................... 48, 78 Diamox .................................................................... 26, 81 Diaper Rash Powder ............................................. 40, 122 Diaperene ........................................................ 40, 77, 122 Diastat ..................................................................... 40, 93 Diazepam ............................................. 20, 40, 86, 93, 95 Dicyclomine ............................................................. 40, 98 Differin ................................................................... 27, 120 Diflucan ................................................................. 45, 109 Digoxin .................................................................... 41, 81 Dilantin .............................................................. 25, 63, 93 Diltiazem .................................................................. 41, 81 Dimercaprol ............................................................. 41, 79 Dimetapp Cold and Allergy ................................... 33, 114 Diovan ............................................................... 24, 75, 82 diphenhydrAMINE .... 12, 13, 21, 41, 79, 85, 86, 114, 120 Diphtheria-Tetanus Toxoids Adsorbed ................. 41, 104 Diphtheria-Tetanus Toxoids Adsorbed for Adult Use... 41,

104 Diphtheria-Tetanus-Acellular Pertussis ................. 41, 104 Diprolene ............................................................... 32, 122 Diprolene A/F .................................................. 22, 32, 122 Disulfiram ................................................................ 41, 79 Ditropan ................................................................. 61, 103 Ditropan XL ........................................................... 61, 103 Divalproex ...................................... 17, 25, 41, 91, 94, 96 Docusate Calcium ................................................. 41, 101 Docusate Sodium .................................................. 42, 101 Docusate Sodium-Sennosides .............................. 42, 101 Dolophine ................................................................ 56, 84 Domeboro Otic ...................................................... 26, 118 Donepezil ................................................................ 42, 96 DOPamine ......................................................... 23, 42, 82 Dovonex ................................................................ 33, 121 Doxepin .....................................................16, 42, 88, 120 Doxycycline ................................................... 42, 106, 119 Drisdol ............................................................. 43, 76, 112 Drysol .................................................................... 28, 123 DT .......................................................................... 41, 104 Dulcolax ................................................................. 32, 100 DULoxetine ........................................................ 16, 42, 88 DuoFilm ................................................................. 68, 122 DuoNeb ................................................................. 27, 113 Duragesic ................................................................ 45, 84 Dyazide ................................................................... 74, 81 Dyrenium ................................................................. 74, 81 Effexor ............................................................... 16, 75, 88 Elavil .................................................................. 16, 28, 88 Elidel ...................................................................... 63, 123 Elimite .................................................................... 62, 123 Elixophyllin ............................................................ 72, 113 EMLA ..................................................................... 53, 120 Emollient Gel ......................................................... 42, 122 Emollient Lotion-Cream ......................................... 42, 122 Emollient Ointment ................................................ 42, 122 Enablex ................................................................. 39, 103 Enalapril .................................................................. 42, 82 Engerix-B ............................................................... 49, 104

Enoxaparin .............................................................. 42, 80 Entacapone ............................................................. 43, 95 Enulose ................................................................. 52, 100 EPINEPHrine .......................................................... 43, 82 Epoetin alfa ....................................................... 23, 43, 80 Epogen .............................................................. 23, 43, 80 Epsom Salt ............................................................ 55, 100 Ergocalciferol .................................................. 43, 76, 112 Erythromycin ......................................................... 43, 116 Erythromycin-Benzoyl Peroxide ............................ 43, 120 Escitalopram ..................................................... 16, 43, 87 Esidrix ..................................................................... 49, 80 Eskalith ............................................................. 17, 54, 91 Esomeprazole ................................................... 23, 43, 99 Estrace ............................................................ 43, 96, 103 Estraderm ............................................................... 43, 96 Estradiol .......................................................... 43, 96, 103 Estrogen-medroxyPROGESTERone ...................... 44, 96 Estrogens, Conjugated ................................... 44, 96, 103 Ethambutol ............................................................ 44, 109 Ethinyl Estradiol-Norethindrone .............................. 44, 96 Ethinyl Estradiol-Norgestrel .................................... 44, 96 Ethionamide .......................................................... 44, 109 Ethosuximide .................................................... 25, 44, 93 Ethyl Chloride ........................................................ 44, 120 Eucerin .................................................................. 42, 122 Evista .................................................................... 67, 113 Excedrine Migraine ................................................. 30, 96 Exelon ..................................................................... 68, 96 Exelon Patches ....................................................... 68, 96 Eye Stream ........................................................... 61, 118 Famotidine .............................................................. 44, 99 Fanapt ......................................................... 14, 23, 50, 89 Fazaclo ............................................................. 14, 22, 38 Felbamate ......................................................... 23, 44, 94 Felbatol ............................................................. 23, 44, 94 Felodipine ............................................................... 45, 81 Fenofibrate .............................................................. 45, 82 fentaNYL ................................................................. 45, 84 Feosol ............................................................. 45, 80, 112 Fer-In-Sol ........................................................ 45, 80, 112 Ferro-Sequels ................................................. 45, 80, 112 Ferrous Fumarate-Docusate Sodium ............. 45, 80, 112 Ferrous Sulfate ............................................... 45, 80, 112 Fexofenadine .................................................. 45, 79, 114 Fexofenadine-Pseudoephedrine ........................... 45, 114 Fibercon ................................................................ 64, 100 Fiber-Lax ............................................................... 64, 100 Filibon ................................................................... 58, 112 Finasteride ............................................................ 45, 103 Fish Oil .................................................................. 45, 125 Flagyl .................................................................... 57, 108 flavoxATE .............................................................. 45, 103 Flexeril .................................................................... 38, 95 Flomax .................................................................. 71, 103 Flonase ................................................................. 46, 120 Florinef .................................................................... 45, 97 Flovent .................................................................. 46, 114

Fluconazole ........................................................... 45, 109 Fludrocortisone........................................................ 45, 97 Fluocinolone .......................................................... 46, 122 Fluocinonide .......................................................... 46, 122 Fluorescein Sodium .............................................. 46, 118 FLUoxetine ..................................................16, 46, 87, 96 fluPHENAZine ...................................... 12, 13, 14, 46, 89 Fluphenazine ................................................................. 15 fluPHENAZine Decanoate ............................................. 14 Fluticasone .................................................... 46, 114, 120 Fluticasone-Salmeterol ................................. 46, 113, 114 Fluvastatin ............................................................... 46, 82 Fluviron .................................................................. 50, 104 fluvoxaMINE ...................................................... 16, 46, 87 Fluzone .................................................................. 50, 104 Folic Acid ............................................................... 46, 112 Folvite .................................................................... 46, 112 Fondaparinux .......................................................... 47, 80 Fosamax ................................................................ 27, 113 Fosphenytoin ........................................................... 47, 93 Fulvicin .................................................................. 48, 109 Fungoid ......................................................... 37, 119, 121 Furosemide ............................................................. 47, 81 Gabapentin ........................................................ 25, 47, 94 Gabatril .................................................................... 72, 94 Galantamine ............................................................ 47, 96 Garamycin ........................................................... 116, 121 Gaviscon ................................................................. 28, 98 Gemfibrozil .............................................................. 47, 82 Gentamicin ........................................... 47, 107, 116, 121 Geodon .............................................................. 15, 77, 90 glipiZIDE .................................................................. 47, 78 Glucagon ........................................................... 47, 78, 79 Glucophage ............................................................. 56, 78 Glucophage XR ....................................................... 56, 78 Glucosamine ......................................................... 47, 125 Glucose ................................................................... 48, 78 Glucotrol .................................................................. 47, 78 glyBURIDE .............................................................. 48, 78 Glycerin ................................................................. 48, 101 Glycopyrrolate ......................................................... 48, 98 Gly-Oxide .............................................................. 34, 119 GoLYTELY ............................................................ 64, 100 Granulex ................................................................ 75, 123 GranuloDerm ......................................................... 75, 123 Grifulvin V .............................................................. 48, 109 Griseofulvin ........................................................... 48, 109 Gris-Peg ................................................................ 48, 109 guaiFENesin .......................................................... 48, 114 guaiFENesin-Codeine ........................................... 48, 114 guaiFENesin-Dextromethorphan........................... 48, 114 guaiFENesin-Pseudoephedrine ............................ 48, 114 guanFACINE ..................................................... 18, 48, 92 guanFACINE Extended Release .................................. 18 Gyne-Lotrimin ........................................................ 37, 103 Habitrol .................................................................... 59, 79 Halcion .............................................................. 21, 74, 86 Haldol ................................................................ 14, 49, 89

Haldol Decanoate ......................................................... 14 Haloperidol ...................................... 12, 13, 14, 15, 49, 89 Haloperidol Decanoate ................................................. 14 Hartmann's Solution .............................................. 67, 111 Havrix .................................................................... 49, 104 HBIG ..................................................................... 49, 104 Hemocyte Plus ...................................................... 51, 112 Heparin ................................................................... 49, 80 Hepatitis A Vaccine ............................................... 49, 104 Hepatitis A-Hepatitis B Vaccine ............................ 49, 104 Hepatitis B Immune Globulin ................................ 49, 104 Hepatitis B Virus Vaccine, Recombinant .............. 49, 104 Hexachlorophene .................................................. 49, 121 Hexavitamins ........................................................ 58, 112 Hibiclens ............................................................... 36, 121 Homatropine ......................................................... 49, 116 HumaLOG ............................................................... 51, 78 HumaLOG Mix 75/25 .............................................. 51, 78 Hycotuss ............................................................... 49, 114 hydrALAZINE .......................................................... 49, 82 Hydrochlorothiazide ................................................ 49, 80 HYDROcodone-guaiFENesin ............................... 49, 114 Hydrocortisone ................................................ 50, 97, 122 HydroDIURIL ........................................................... 49, 80 Hydrogen Peroxide ....................................... 50, 118, 123 hydrOXYzine ............................. 12, 13, 21, 50, 79, 85, 86 Hygroton ................................................................. 36, 80 HypoTears ............................................................ 61, 118 HypoTears PF ....................................................... 61, 118 Ibandronate ........................................................... 50, 113 Ibuprofen ................................................................. 50, 83 Iloperidone .................................................. 14, 23, 50, 89 Imdur ....................................................................... 51, 81 Imipramine ........................................................ 16, 50, 88 Imitrex ..................................................................... 71, 96 Imodium ................................................................ 54, 101 Inderal ......................................................... 18, 66, 82, 96 Influenza Virus Vaccine ........................................ 50, 104 INH ........................................................................ 51, 109 Insulin, Aspart ......................................................... 50, 78 Insulin, Combination (70/30) ................................... 50, 78 Insulin, Detemir ................................................. 23, 51, 78 Insulin, Glargine ...................................................... 51, 78 Insulin, Lispro .......................................................... 51, 78 Insulin, Lispro-Insulin, Lispro Protamine ................. 51, 78 Insulin, NPH ............................................................ 51, 78 Insulin, Regular ....................................................... 51, 78 Intal ............................................................... 38, 114, 118 Intropin .............................................................. 23, 42, 82 Intuniv ........................................................................... 18 Invega ............................................................... 14, 61, 89 Invega Sustenna ..................................................... 14, 61 Invega Trinza ................................................................ 14 Ionil-T ............................................................ 38, 121, 123 Ipratropium ............................................................ 51, 113 Iron salts with or without vitamins and/or minerals51, 112 ISMO ....................................................................... 51, 81 Isoniazid ................................................................ 51, 109

Isoptin ................................................................ 76, 81, 96 Isopto Atropine ...................................................... 30, 116 Isopto Carpine ....................................................... 63, 115 Isopto Homatropine ............................................... 49, 116 Isopto Hyoscine ..................................................... 69, 116 Isordil ....................................................................... 51, 81 Isosorbide Dinitrate ................................................. 51, 81 Isosorbide Mononitrate ............................................ 51, 81 Ivermectin .............................................................. 52, 110 Kaolin-Pectin ......................................................... 52, 101 Kaopectate .................................................... 32, 101, 102 Kapvay .......................................................................... 18 Kayexalate ............................................................... 70, 83 Keflex .................................................................... 35, 106 Kefzol .................................................................... 35, 106 Kenacort .......................................................... 74, 97, 122 Keppra ..................................................................... 53, 94 Keri Lotion ............................................................. 42, 122 Ketoconazole................................................. 52, 109, 121 Ketorolac ................................................................. 52, 83 Ketotifen ................................................................ 52, 117 KlonoPIN .....................................................20, 37, 86, 93 Konakion ............................................................... 63, 112 Kwelcof .................................................................. 49, 114 Labetalol .................................................................. 52, 82 Lac-Hydrin ............................................................. 42, 122 Lacosamide ....................................................... 25, 52, 94 Lactinex ................................................................. 52, 101 Lactobacillus Acidophilus ...................................... 52, 101 Lactulose ............................................................... 52, 100 LaMICtal ......................................................17, 52, 91, 94 LamISIL ......................................................... 72, 109, 121 lamoTRIgine ......................................... 17, 25, 52, 91, 94 Lanacaine .............................................................. 31, 120 Lanacort ................................................................ 50, 122 Lanolin ................................................................... 42, 122 Lanoxin .................................................................... 41, 81 Lansoprazole ........................................................... 52, 99 Lantus ...................................................................... 51, 78 Lasix ........................................................................ 47, 81 Latanoprost ........................................................... 52, 115 Latuda ............................................................... 14, 54, 89 Lescol ...................................................................... 46, 82 Leucovorin ....................................................... 53, 79, 112 Levaquin ................................................................ 53, 107 Levarterenol ................................................23, 53, 60, 82 Levemir .............................................................. 23, 51, 78 LevETIRAcetam ................................................ 25, 53, 94 Levofloxacin .......................................................... 53, 107 Levonorgestrel-Ethinyl Estradiol ............................. 53, 96 Levophed .....................................................23, 53, 60, 82 Levothyroxine .......................................................... 53, 97 Levoxyl .................................................................... 53, 97 Lexapro ............................................................. 16, 43, 87 Librium ............................................................... 20, 35, 86 Lidex ...................................................................... 46, 122 Lidocaine ............................................................... 53, 120 Lidocaine-Prilocaine .............................................. 53, 120

Lidoderm ............................................................... 53, 120 Linezolid .......................................................... 23, 53, 108 Lioresal ................................................................... 31, 95 Lipitor ...................................................................... 30, 82 Liquitears .............................................................. 61, 118 Lisdexamfetamine ......................................................... 18 Lisdexamfetamine dimesylate .......................... 23, 53, 92 Lisinopril .................................................................. 54, 82 Lithium .............................................................. 17, 54, 91 Lithobid ................................................................... 17, 54 Lithonate ................................................................. 54, 91 Loestrin ................................................................... 44, 96 Lofibra ..................................................................... 45, 82 Lokara ................................................................... 39, 122 Lo-Ovral .................................................................. 44, 96 Loperamide ........................................................... 54, 101 Lopid ....................................................................... 47, 82 Lopressor .......................................................... 57, 82, 96 Loprox ................................................................... 36, 121 Loratadine ....................................................... 54, 79, 114 Loratadine-Pseudoephedrine ............................... 54, 114 LORazepam .................................... 12, 13, 20, 54, 86, 93 Lortab ...................................................................... 26, 84 Lotensin .................................................................. 31, 82 Lotrimin ................................................................. 37, 121 Lovenox .................................................................. 42, 80 Loxapine ........................................................... 14, 54, 89 Loxitane ............................................................ 14, 54, 89 Lubiprostone ......................................................... 54, 102 Lubriderm .............................................................. 42, 122 Lumigan ................................................................ 32, 115 Luminal ............................................................. 25, 63, 93 Lurasidone ........................................................ 14, 54, 89 Luvox ................................................................ 16, 46, 87 Lyrica ...................................................................... 65, 94 Maalox .................................................................... 28, 98 Macrodantin .................................................. 59, 103, 110 Magnesium Citrate ................................................ 54, 100 Magnesium Hydroxide .......................................... 54, 100 Magnesium L-lactate dihydrate ............................. 55, 125 Magnesium Sulfate ....................................... 55, 100, 111 Mag-Tab SR .......................................................... 55, 125 Maxipime ............................................................... 35, 106 Maxzide ................................................................... 74, 81 Measles-Mumps-Rubella Virus Vaccine, Live ...... 55, 104 Meclizine ................................................................. 55, 85 Mediplast ............................................................... 68, 122 Medrol ..................................................................... 56, 97 medroxyPROGESTERone ..................................... 55, 96 Megace ................................................................... 55, 85 Megace ES ............................................................. 55, 85 Megestrol ................................................................ 55, 85 Melatonin .............................................................. 55, 125 Mellaril ......................................................... 14, 23, 72, 90 Meloxicam ............................................................... 55, 83 Memantine .............................................................. 55, 96 Menthol ................................................................. 55, 122 Menthol-Methyl Salicylate ..................................... 55, 122

Menthol-Zinc Oxide ............................................... 55, 123 Mephyton ...................................................63, 79, 80, 112 Mepron ............................................................ 22, 30, 110 Mesalamine ........................................................... 56, 102 Metadate ........................................................... 18, 56, 92 Metadate CD ..................................................... 18, 56, 92 metFORMIN ............................................................ 56, 78 Methadone .............................................................. 56, 84 Methimazole ............................................................ 56, 97 Methocarbamol........................................................ 56, 95 Methylcellulose ...................................................... 56, 100 Methyldopa .............................................................. 56, 82 Methylin ............................................................. 18, 56, 92 Methylphenidate, immediate release ................ 18, 56, 92 Methylphenidate, sustained release ................. 18, 56, 92 methylPREDNISolone ............................................. 56, 97 Meticorten ................................................................ 65, 97 Metoclopramide ................................................. 56, 85, 99 Metoprolol .......................................................... 57, 82, 96 MetroGel ........................................................ 57, 120, 121 metroNIDAZOLE .................................. 57, 108, 120, 121 Mexsana ................................................................ 40, 122 Miacalcin ............................................................... 33, 113 Miconazole .................................................... 57, 103, 121 Micronase ................................................................ 48, 78 Midazolam ............................................................... 57, 86 Milk of Magnesia ................................................... 54, 100 Mineral Oil ............................................................. 57, 118 Minipress ................................................................. 65, 87 Minocycline ............................................................ 57, 106 MiraLax .................................................................. 64, 100 Mirapex .................................................................... 65, 95 Mirtazapine ........................................................ 16, 57, 88 Misoprostol ............................................................ 57, 102 MMR II ................................................................... 55, 104 Mobic ....................................................................... 55, 83 Mometasone.......................................................... 57, 114 Monistat ......................................................... 57, 103, 121 Monoket ................................................................... 51, 81 Montelukast ........................................................... 57, 114 Morphine ................................................................. 58, 84 Motrin ...................................................................... 50, 83 Moxeza ............................................................ 23, 58, 116 Moxifloxacin.............................................23, 58, 107, 116 Mucinex ................................................................. 48, 114 Mucinex D ............................................................. 48, 114 Mucomyst ........................................................ 27, 79, 114 Multivitamin ........................................................... 58, 112 Multivitamin, Prenatal ............................................ 58, 112 Multivitamin-Minerals ............................................ 58, 112 Multivitamins, Pediatric ......................................... 58, 112 Mupirocin ............................................................... 58, 121 Myambutol ............................................................. 44, 109 Mycelex ......................................................... 37, 103, 119 Mycobutin .............................................................. 67, 109 Mycostatin ............................................ 60, 109, 119, 121 Mydriacyl ............................................................... 75, 116 Mylanta .................................................................... 28, 98

Mylicon .................................................................... 69, 99 Mysoline .................................................................. 66, 93 Nabumetone ..................................................... 23, 58, 83 Nafcillin ................................................................. 58, 105 Naloxone ................................................................. 58, 79 Naltrexone ................................................... 18, 58, 79, 92 Namenda ................................................................ 55, 96 Naphazoline .......................................................... 59, 117 Naphcon ................................................................ 59, 117 Naprosyn ........................................................... 59, 83, 96 Naproxen .......................................................... 59, 83, 96 Narcan .................................................................... 58, 79 Nardil ................................................................. 16, 63, 87 Nasacort ................................................................ 74, 114 Nasonex ................................................................ 57, 114 Nature Made Fish Oil ............................................ 45, 125 Navane .............................................................. 15, 72, 90 Neo-Calglucon ...................................................... 34, 112 Neomycin .............................................................. 59, 107 Neomycin-Polymyxin B-Bacitracin ........................ 59, 121 Neomycin-Polymyxin B-Hydrocortisone ............... 59, 119 Neosporin .............................................................. 64, 121 Neo-Synephrine .................................... 63, 114, 116, 120 Nephrocaps ........................................................... 76, 112 Nephro-vite ........................................................... 76, 112 Neurontin ................................................................ 47, 94 Neutra-Phos-K ...................................................... 65, 112 Neutrogena ........................................................... 68, 122 NexIUM ............................................................. 23, 43, 99 Niacin-Nicotinamide ........................................ 59, 82, 112 Nicobid ............................................................ 59, 82, 112 Nicoderm ................................................................. 59, 79 Nicorette .................................................................. 59, 79 Nicotine ................................................................... 59, 79 Nicotrol .................................................................... 59, 79 NIFEdipine .............................................................. 59, 81 Niferex ................................................................... 51, 112 Niferex-150 ........................................................... 51, 112 Niferex-150 Forte .................................................. 51, 112 Nitrofurantoin ................................................ 59, 103, 110 Nitroglycerin ............................................................ 60, 81 NIX ........................................................................ 62, 123 Nizoral ........................................................... 52, 109, 121 Non-Soap Cleanser .............................................. 60, 123 Norepinephrine ................................................. 23, 60, 82 Norgestimate-Ethinyl Estradiol ............................... 60, 96 Noritate ......................................................... 57, 120, 121 Normodyne ............................................................. 52, 82 Norpramin ......................................................... 16, 39, 88 Nortriptyline ....................................................... 16, 60, 88 Norvasc ................................................................... 28, 81 NovoLog .................................................................. 50, 78 Nutraderm ............................................................. 42, 122 Nystatin ................................................. 60, 109, 119, 121 Olanzapine .................................................................... 15 OLANZapine ......................................... 12, 13, 14, 60, 89 OLANZapine pamoate ............................................ 14, 23 Olmesartan ....................................................... 23, 60, 82

Olopatadine ........................................................... 60, 117 Omeprazole ............................................................. 60, 99 OmniMed ............................................................... 70, 119 Omnipen ................................................................ 29, 105 Ondansetron............................................................ 61, 85 Onfi .......................................................................... 37, 93 Ophthalmic Irrigating Solution ............................... 61, 118 Ophthalmic Lubricant ............................................ 61, 118 Oracit ..................................................................... 70, 103 Oragel .................................................................... 31, 119 Ortho Tri-Cyclen ...................................................... 60, 96 Ortho-Novum 777 .................................................... 44, 96 Os-Cal ............................................................. 34, 98, 112 Os-Cal + D ............................................................ 34, 112 Os-Cal chewable ............................................. 34, 98, 112 Oseltamivir ............................................................ 61, 110 Ovral ........................................................................ 44, 96 Oxazepam ......................................................... 20, 61, 86 OXcarbazepine..................................... 17, 25, 61, 91, 94 Oxybenzone-PDO-Pet Hy-Phl ............................... 61, 122 Oxybutynin ............................................................ 61, 103 oxyCODONE ........................................................... 61, 84 OxyCONTIN ............................................................ 61, 84 Oxymetazoline....................................................... 61, 120 P.P.D. .................................................................... 75, 104 Pacerone ................................................................. 28, 81 Paliperidone ...................................................... 14, 61, 89 Paliperidone palmitate ................................................... 14 Pamelor ............................................................. 16, 60, 88 Pancrease ............................................................. 61, 102 Pancrelipase.......................................................... 61, 102 Pantoprazole ........................................................... 62, 99 Parlodel ................................................................... 33, 95 Parnate .............................................................. 16, 74, 87 PARoxetine ....................................................... 16, 62, 87 Patanol .................................................................. 60, 117 Paxil ................................................................... 16, 62, 87 PEG ....................................................................... 64, 100 penicillAMINE .......................................................... 62, 79 Penicillin G Benzathine ......................................... 62, 105 Penicillin G Benzathine-Penicillin G Procaine ....... 62, 105 Penicillin G Procaine ............................................. 62, 105 Penicillin G Sodium ............................................... 62, 105 Penicillin V Potassium ........................................... 62, 105 Penlac ................................................................... 36, 121 Pentam ............................................................ 23, 62, 110 Pentamidine .................................................... 23, 62, 110 Pentasa ................................................................. 56, 102 Pentrax .......................................................... 38, 121, 123 Pen-Vee K ............................................................. 62, 105 Pepcid ..................................................................... 44, 99 Pepto-Bismol ................................................. 32, 101, 102 Periactin .................................................................. 38, 79 Peri-Colace ............................................................ 42, 101 Peridex .................................................................. 36, 119 PerioMed ............................................................... 70, 119 Periostat ................................................................ 42, 119 Permethrin ............................................................. 62, 123

Pernox ................................................................... 26, 123 Perphenazine .............................................. 14, 15, 62, 89 Petrolatum, White ................................................. 62, 122 Phenazopyridine ................................................... 63, 102 Phenelzine ........................................................ 16, 63, 87 Phenergan .............................................................. 66, 85 PHENobarbital .................................................. 25, 63, 93 Phenol ................................................................... 63, 119 Phenylephrine ....................................... 63, 114, 116, 120 Phenytoin .......................................................... 25, 63, 93 pHisoHex .............................................................. 49, 121 Physostigmine ......................................................... 63, 79 Phytonadione ............................................ 63, 79, 80, 112 Pilocarpine ............................................................ 63, 115 Pimecrolimus ........................................................ 63, 123 Pioglitazone ............................................................ 63, 78 Piperacillin-Tazobactam ....................................... 63, 105 Plavix ................................................................ 22, 37, 80 Plendil ..................................................................... 45, 81 Pneumococcal Vaccine, Polyvalent ...................... 64, 104 Pneumovax ........................................................... 64, 104 Podocon-25 ........................................................... 64, 122 Podophyllum Resin ............................................... 64, 122 Polycarbophil ........................................................ 64, 100 Polycillin ................................................................ 29, 105 Polycitra ................................................................ 64, 103 Polycitra K ............................................................. 64, 103 Polycitra-LC .......................................................... 64, 103 Polyethylene Glycol .............................................. 64, 100 Polyethylene Glycol Electrolyte Solution .............. 64, 100 Polymox ................................................................ 29, 105 Polymyxin B-Bacitracin ......................................... 64, 116 Polymyxin B-Neomycin ......................................... 64, 121 Polymyxin B-Trimethoprim .................................... 64, 116 Polysporin ............................................... 30, 64, 116, 121 Polytar ........................................................... 38, 121, 123 Polytrim ................................................................. 64, 116 Poly-Vi-Sol ............................................................ 58, 112 Potassium Chloride ....................................... 64, 111, 112 Potassium Citrate.................................................. 64, 103 Potassium Citrate Combinations .......................... 64, 103 Potassium Iodide .................................................. 65, 114 Potassium Phosphate ........................................... 65, 112 Povidone-Iodine .................................................... 65, 121 Pramipexole ............................................................ 65, 95 Pramoxine ..................................................... 65, 101, 120 Pramoxine – Hydrocortisone ................................ 65, 101 Pramoxine-Zinc ..................................................... 65, 120 Prandin .................................................................... 67, 78 Pravachol ................................................................ 65, 82 Pravastatin .............................................................. 65, 82 Prazosin .................................................................. 65, 87 Pred Forte ............................................................. 65, 118 Pred Mild ............................................................... 65, 118 prednisoLONE ........................................................ 65, 97 predniSONE ............................................................ 65, 97 Pregabalin ......................................................... 25, 65, 94 Premarin ......................................................... 44, 96, 103

Premphase .............................................................. 44, 96 PremPro .................................................................. 44, 96 Prevacid .................................................................. 52, 99 PriLOSEC ................................................................ 60, 99 Primidone ................................................................ 66, 93 Prinivil ...................................................................... 54, 82 Pro-Banthine ........................................................... 66, 98 Procardia ................................................................. 59, 81 Procardia XL............................................................ 59, 81 Prochlorperazine ..................................................... 66, 85 Procrit ................................................................ 23, 43, 80 Prolia ..................................................................... 39, 113 Prolixin ............................................................... 14, 46, 89 Prolixin Decanoate ........................................................ 14 Promethazine .......................................................... 66, 85 Pronto .................................................................... 66, 123 Propantheline .......................................................... 66, 98 Proparacaine ......................................................... 66, 118 Propranolol ..................................................18, 66, 82, 96 Propylthiouracil ........................................................ 66, 97 Proscar .................................................................. 45, 103 ProStep ................................................................... 59, 79 Protamine .......................................................... 66, 79, 80 Protonix ................................................................... 62, 99 Protopic ................................................................. 71, 123 Protriptyline ................................................................... 16 Proventil ................................................................ 27, 113 Provera .................................................................... 55, 96 PROzac .......................................................16, 46, 87, 96 Pseudoephedrine .................................................. 66, 114 Pulmicort ............................................................... 33, 114 Pyrazinamide......................................................... 66, 109 Pyrethins 0.33%-Piperonyl Butoxide 4% .............. 66, 123 Pyridium ................................................................ 63, 102 Pyridoxine .............................................................. 67, 112 Questran .................................................................. 36, 82 QUEtiapine ........................................................ 14, 67, 90 QVAR .................................................................... 31, 114 Raloxifene ............................................................. 67, 113 Ranitidine ................................................................ 67, 99 Rasagiline ................................................................ 67, 95 Razadyne ................................................................ 47, 96 Reclast .................................................................. 77, 113 Recombivax HB..................................................... 49, 104 Rectal Hemorrhoidal Cream-Hydrocortisone ........ 67, 101 Rectal Hemorrhoidal Ointment .............................. 67, 102 Rectal Hemorrhoidal Suppositories....................... 67, 102 Rectal Hemorrhoidal Suppositories-Hydrocortisone .... 67,

102 Reglan ............................................................... 56, 85, 99 Relafen .............................................................. 23, 58, 83 Relenza ................................................................. 77, 110 Remeron ............................................................ 16, 57, 88 Remeron SolTab ..................................................... 57, 88 Renagel ................................................................. 69, 103 Repaglinide ............................................................. 67, 78 Restoril .............................................................. 21, 72, 86 Retin-A .................................................................. 74, 120

ReVia .......................................................... 18, 58, 79, 92 Revina ................................................................... 75, 123 Rexult ............................................................................ 14 RID ........................................................................ 66, 123 Rifabutin ................................................................ 67, 109 Rifadin ................................................................... 67, 109 Rifamate ................................................................ 67, 109 Rifampin ................................................................ 67, 109 Rifampin-Isoniazid ................................................ 67, 109 Ringer’s Lactate Solution ...................................... 67, 111 Risamine ............................................................... 55, 123 Risedronate ........................................................... 68, 113 RisperDAL ......................................................... 14, 68, 90 RisperDAL Consta .................................................. 14, 68 RisperDAL M-Tab ................................................... 14, 68 risperiDONE ...................................................... 14, 68, 90 Ritalin ................................................................ 18, 56, 92 Ritalin SR .......................................................... 18, 56, 92 Rivastigmine ........................................................... 68, 96 Robaxin ................................................................... 56, 95 Robinul .................................................................... 48, 98 Robitussin ............................................................. 48, 114 Robitussin AC ....................................................... 48, 114 Robitussin DM ....................................................... 48, 114 Rocephin ............................................................... 35, 106 Rosuvastatin ........................................................... 68, 82 Rowasa ................................................................. 56, 102 Rufinamide ........................................................ 25, 68, 94 Salac ..................................................................... 26, 123 Salex ..................................................................... 68, 122 Salicylic Acid ......................................................... 68, 122 Salicylic Acid-Sulfur .............................. 68, 120, 121, 123 Saliva Substitute ................................................... 68, 119 Salmeterol ............................................................. 69, 113 Sanctura ................................................................ 75, 103 Sani-Supp ............................................................. 48, 101 Santyl .................................................................... 38, 123 Saphris .............................................................. 14, 30, 89 Scopolamine ......................................................... 69, 116 Seba-Nil ................................................................ 26, 123 Sebizon ......................................................... 71, 120, 121 Selenium Sulfide ................................................... 69, 121 Selsun ................................................................... 69, 121 Senna .................................................................... 69, 100 Senokot ................................................................. 69, 100 Serax ................................................................. 20, 61, 86 Serevent ................................................................ 69, 113 Seromycin ............................................................. 22, 109 SEROquel ......................................................... 14, 67, 90 Sertraline ........................................................... 16, 69, 87 Sevelamer ............................................................. 69, 103 Silvadene ...................................................... 69, 121, 123 Silver Nitrate ......................................................... 69, 123 Silver Sulfadiazine ........................................ 69, 121, 123 Simethicone ............................................................ 69, 99 Simvastatin ............................................................. 69, 82 Sinemet ................................................................... 35, 95 SINEquan .......................................................... 16, 42, 88

Singulair ................................................................ 57, 114 Sodium Bicarbonate ...................................... 69, 103, 111 Sodium Chloride ........... 70, 103, 111, 114, 118, 119, 123 Sodium Chloride Intravenous Solution .................. 70, 111 Sodium Citrate-Citric Acid ..................................... 70, 103 Sodium Fluoride .................................................... 70, 119 Sodium Lactate ..................................................... 70, 111 Sodium Polystyrene Sulfonate ................................ 70, 83 Sonata ............................................................... 21, 77, 87 Sorbitol .................................................................. 70, 100 Sorbitrate ................................................................. 51, 81 Spironolactone ........................................................ 70, 81 Spironolactone-Hydrochlorothiazide ....................... 70, 81 Spriva .................................................................... 73, 113 SSKI ...................................................................... 65, 114 Stanous Fluoride ................................................... 70, 119 Stelazine ............................................................ 15, 74, 90 Stimate .................................................................... 39, 97 Strattera ............................................................. 18, 30, 92 Stresscaps ............................................................. 76, 112 Stromectol ............................................................. 52, 110 Sucralfate .............................................................. 71, 102 Sudafed ................................................................. 66, 114 Sulamyd ................................................................ 71, 116 Sulfacetamide Sodium ......................... 71, 116, 120, 121 Sulfamethoxazole-Trimethoprim ........................... 71, 108 sulfaSALAzine ....................................................... 71, 102 Sulindac ................................................................... 71, 83 SUMAtriptan ............................................................ 71, 96 Sunscreen-Block ................................................... 71, 123 Surfak .................................................................... 41, 101 Symbicort .............................................................. 33, 113 Symmetrel ............................................................... 28, 95 Synalar .................................................................. 46, 122 Synthroid ................................................................. 53, 97 Tacrolimus ............................................................. 71, 123 Tamiflu ................................................................... 61, 110 Tamoxifen ................................................................ 71, 80 Tamsulosin ............................................................ 71, 103 Tapazole .................................................................. 56, 97 Tazarotene .................................................... 71, 120, 121 Tazorac ......................................................... 71, 120, 121 TBC ....................................................................... 75, 123 Td .......................................................................... 41, 104 Tdap ...................................................................... 41, 104 TEGretol ............................................... 17, 25, 34, 91, 94 TEGretol XR ...................................................... 17, 25, 34 Tegrin ............................................................ 38, 121, 123 Teldrin ............................................................. 36, 79, 114 Temazepam ...................................................... 21, 72, 86 Temovate ........................................................ 22, 37, 122 Tenex ................................................................ 18, 48, 92 Tenormin ........................................................... 30, 82, 96 Terbinafine .................................................... 72, 109, 121 Terbutaline ............................................................ 72, 113 Tessalon Perle ...................................................... 31, 114 Testosterone ........................................................... 72, 96 Tetracycline ........................................................... 72, 106

Tetrahydrozoline ................................................... 72, 117 Theophylline .......................................................... 72, 113 Thiamine ............................................................... 72, 112 Thioridazine .......................................... 14, 15, 23, 72, 90 Thiothixene ....................................................... 15, 72, 90 Thorazine .......................................................... 14, 36, 89 tiaGABine .......................................................... 25, 72, 94 Tigan ....................................................................... 74, 85 Timolol .................................................................. 73, 115 Timolol-Dorzolamide ............................................. 73, 115 Timoptic ................................................................ 73, 115 Timoptic XE ........................................................... 73, 115 Tinactin ................................................................. 73, 121 Tioconazole ........................................................... 73, 103 Tiotropium ............................................................. 73, 113 Titralac ............................................................ 34, 98, 112 tiZANidine ......................................................... 23, 73, 95 TobraDex .............................................................. 73, 118 Tobramycin ................................................... 73, 107, 116 Tobramycin-Dexamethasone ................................ 73, 118 Tobrex ................................................................... 73, 116 Tofranil .............................................................. 16, 50, 88 Tolnaftate .............................................................. 73, 121 Tolterodine ............................................................ 73, 103 Topamax ............................................... 73, 91, 92, 94, 96 Topiramate ...................................... 25, 73, 91, 92, 94, 96 Toprol XL .......................................................... 57, 82, 96 Toradol .................................................................... 52, 83 traMADol ................................................................. 73, 84 Tranxene ..................................................... 20, 37, 86, 93 Tranylcypromine ............................................... 16, 74, 87 Travatan ................................................................ 74, 115 Travatan Z ............................................................. 74, 115 Travoprost ............................................................. 74, 115 traZODone ............................................ 16, 21, 74, 87, 88 Trecator ................................................................. 44, 109 Tretinoin ................................................................ 74, 120 Trexan ............................................................... 58, 79, 92 Triamcinolone ......................................... 74, 97, 114, 122 Triamterene ............................................................. 74, 81 Triamterene-Hydrochlorothiazide ........................... 74, 81 Triazolam .......................................................... 21, 74, 86 Tricor ....................................................................... 45, 82 Tridesilon .............................................................. 39, 122 Trifluoperazine .................................................. 15, 74, 90 Triglide .................................................................... 45, 82 Trihexyphenidyl ....................................................... 74, 95 Trilafon .............................................................. 14, 62, 89 Trileptal ....................................................... 17, 61, 91, 94 Tri-Levlen ................................................................ 53, 96 Trimethobenzamide ................................................ 74, 85 Triphasil .................................................................. 53, 96 Triple Antibiotic Ointment ...................................... 59, 121 Triprolidine-Pseudoephedrine ............................... 75, 114 Tronothane .................................................... 65, 101, 120 Tropicamide .......................................................... 75, 116 Trospium ............................................................... 75, 103 Trypsin-Balsam Peru-Castor Oil ........................... 75, 123

Tuberculin, Purified Protein Derivative .................. 75, 104 Twinrix ................................................................... 49, 104 Tylenol ..................................................................... 26, 84 Ultram ...................................................................... 73, 84 Unicap ................................................................... 58, 112 Unifiber .................................................................. 35, 100 Urea ....................................................................... 75, 122 Urecholine ............................................................. 32, 103 Urispas .................................................................. 45, 103 Urocit K .................................................................. 64, 103 Vagistat-1 .............................................................. 73, 103 valACYclovir .......................................................... 75, 110 Valisone ................................................................. 32, 122 Valium .................................................. 20, 40, 86, 93, 95 Valproate .....................................................17, 25, 75, 96 Valproic Acid ........................................ 17, 25, 75, 91, 94 Valsartan ........................................................... 24, 75, 82 Valtrex ................................................................... 75, 110 Vancocin ................................................................ 75, 108 Vancomycin ........................................................... 75, 108 Vaqta ..................................................................... 49, 104 Varicella Virus Vaccine, Live ................................. 75, 104 Varivax .................................................................. 75, 104 Vaseline ................................................................. 62, 122 Vaseline Lip Therapy ............................................ 61, 122 Vasolex .................................................................. 75, 123 Vasotec ................................................................... 42, 82 V-Cillin K ................................................................ 62, 105 Venlafaxine........................................................ 16, 75, 88 Ventolin ................................................................. 27, 113 Verapamil .......................................................... 76, 81, 96 Versacloz ........................................................... 14, 22, 38 Versed ..................................................................... 57, 86 Vibramycin ............................................................. 42, 106 Vicodin ..................................................................... 26, 84 Vicodin ES ............................................................... 26, 84 Vigamox .......................................................... 23, 58, 116 Vimpat ..................................................................... 52, 94 Visine Allergy Relief .............................................. 72, 117 Visine Moisturizing ................................................ 72, 117 Vistaril ................................................... 21, 50, 79, 85, 86 Vitamin A ............................................................... 76, 112 Vitamin A&D Topical ....................................... 40, 76, 122 Vitamin B Complex ................................................ 76, 112 Vitamin B Complex-Vitamin C ............................... 76, 112 Vitamin B Complex-Vitamin C-Zinc ....................... 76, 112 Vitamin B1 .............................................................. 72, 112 Vitamin B12 ............................................................ 38, 112 Vitamin B6 .............................................................. 67, 112 Vitamin C ............................................................... 29, 112 Vitamin D ............................................................... 76, 112 Vitamin E ............................................................... 76, 112 Vitamin K1 ..................................................63, 79, 80, 112 Vivactil ........................................................................... 16 Vivelle ...................................................................... 43, 96

VoSol .................................................................... 26, 118 VoSol HC .............................................................. 26, 118 Vospire ER ............................................................ 27, 113 Vraylar ........................................................................... 14 Vyvanse ............................................................ 23, 53, 92 Vyvnase ........................................................................ 18 Warfarin .................................................................. 76, 80 Water for Injection ......................................... 76, 111, 123 Water for Irrigation ................................................ 76, 103 Wellbutrin .......................................................... 16, 33, 88 Wellbutrin SR ................................................................ 16 Wellbutrin XL ................................................................. 16 Wellcovorin ..................................................... 53, 79, 112 Wound Cleanser ................................................... 76, 123 Wyanoids .............................................................. 67, 102 Wycillin .................................................................. 62, 105 Xalatan .................................................................. 52, 115 Xanax ................................................................ 20, 27, 86 Xanax XR ................................................................ 27, 86 Xenaderm ............................................................. 75, 123 Xylocaine .............................................................. 53, 120 Zaditor ................................................................... 52, 117 Zafirlukast ............................................................. 77, 114 Zaleplon ............................................................ 21, 77, 87 Zanaflex ............................................................ 23, 73, 95 Zanamivir .............................................................. 77, 110 Zantac ..................................................................... 67, 99 Zarontin ............................................................. 25, 44, 93 Zestril ...................................................................... 54, 82 Zinc Oxide ..................................................... 77, 122, 123 Zinc Oxide-Petrolatum-Imidazolidinyl Urea ............ 40, 77 Zinc Sulfate ................................................... 77, 111, 112 Ziprasidone ........................................... 12, 13, 15, 77, 90 Zithromax .............................................................. 30, 106 Zocor ....................................................................... 69, 82 Zofran ...................................................................... 61, 85 Zofran ODT ............................................................. 61, 85 Zoledronic Acid ..................................................... 77, 113 Zoloft ................................................................. 16, 69, 87 Zolpidem ........................................................... 21, 77, 87 Zometa .................................................................. 77, 113 Zonalon ................................................................. 42, 120 Zonegran ................................................................. 77, 94 Zonisamide ....................................................... 25, 77, 94 Zosyn .................................................................... 63, 105 Zovirax .......................................................... 27, 110, 121 Zyban ...................................................................... 33, 88 Zyloprim .................................................................. 27, 97 ZyPREXA .......................................................... 14, 60, 89 ZyPREXA Relprevv........................................... 14, 23, 60 ZyPREXA Zydis ...................................................... 14, 60 ZyrTEC .................................................................... 35, 79 ZyrTEC D .............................................................. 35, 114 Zyvox .............................................................. 23, 53, 108

APPENDIX 1: NEW DRUG APPLICATION FORM 415 ----- C

EXHIBIT A DSHS/DADS

(Formerly: Texas Department of Mental Health and Mental Retardation) NEW DRUG APPLICATION

(for inclusion in the DSHS/DADS Drug Formulary)

* * (THE NEW DRUG APPLICATION PROCESS IS DESCRIBED ON THE BACK OF THIS FORM.) * *

Date:

Name of practitioner submitting the application:

Name of entity with which the practitioner is associated by employment or contract (i.e., state hospital, state supported living center, state center, or local authority (state-operated community services (SOCS) or community MHMR center)):

Information regarding new drug:

Therapeutic Classification

Generic Name

Trade Name(s)

Manufacturer(s)

Dosage Form(s)

* ***********************************************************************************

Explain the pharmacological action or use of this drug:

Explain the advantages of this drug over those listed in the formulary:

State which drugs this new drug would replace or supplement:

application is approved signature of chairman of facility pharmacy and therapeutics committee

OR application is appropriate and complete

signature of clinical/medical director or designee

Section 415.108 of TDMHMR rules governing the use and maintenance of the THHSC Drug Formulary (25 TAC, Chapter 415, Subchapter C) describes the procedures for applying to have a drug added to the formulary, which are: §415.108. Applying to Have a Drug Added to the Formulary.

(a) Any member of the Executive Formulary Committee, any service system component* practitioner, or any contract practitioner may apply to have a drug added to the THHSC Drug Formulary by completing the New Drug Application Form DF-1, referenced as Exhibit A in §415.112 of this title (relating to Exhibit) and including: (1) published articles in biomedical literature that substantiate the efficacy and safety

of the proposed drug; (2) information on the advantages of the proposed drug compared with similar

formulary drugs; (3) a list of formulary drugs that the proposed drug would replace or supplement; and (4) cost effectiveness data.

(b) Submitting the application. (1) If the person submitting the application is a facility** practitioner or a facility contract

practitioner, then that practitioner submits the application to the facility’s pharmacy and therapeutics committee for approval. If the committee approves the application, then it forwards the application to the Executive Formulary Committee.

(2) If the person submitting the application is a non-facility service system component practitioner or a non-facility service system component contract practitioner, then that practitioner submits the application to the component’s clinical/medical director or designee who determines if the application is appropriate and complete, and if so, forwards the application to the Executive Formulary Committee.

(3) If the person completing the application is a member of the Executive Formulary Committee, then that person submits the application directly to Executive Formulary Committee.

(c) The Executive Formulary Committee considers the drug application and recommends:

(1) approving the proposed drug’s inclusion and, if appropriate, approving audit criteria and recommending dosage guidelines;

(2) denying the proposed drug’s inclusion; (3) approving the proposed drug on a trial basis for a specified period of time; (4) approving the proposed drug as a reserve drug, with guidelines; or (5) postponing the decision until a later meeting.

* The term “service system component” means a state hospital, state supported living center, state

center, or local authority (state-operated community services (SOCS) or community MHMR center). ** The term “facility” means a state hospital, state supported living center, or state center.

APPENDIX 2: EXECUTIVE FORMULARY COMMITTEE CONFLICT OF INTEREST POLICY Policy The Executive Formulary Committee (EFC) must ensure balance, independence, objectivity and scientific rigor in determining which drugs should be on the formulary. It is the policy of the Executive Formulary Committee to prohibit any apparent or actual conflict of interest. As such, each member of the Executive Formulary Committee and each requesting practitioner shall abide by this policy and submit a Conflict of Interest Disclosure Statement. The intent of this disclosure is not to prevent those with a significant financial interest or other relationship from participating in the formulary process, but rather to provide information to committee members and to the public so that conflicts can be resolved prior to the decision making process. It remains for the members of the Committee to determine whether the individual’s interests or relationships may influence them with regard to exposition or conclusions. A conflict of interest for these purposes includes any situation in which a Committee member or individual submitting a request to the EFC has a private or personal interest sufficient to appear to influence the objective exercise of his/her duties for the agency. An apparent conflict of interest is one in which a reasonable person would think that the person’s judgment is potentially compromised. All committee members, individuals submitting drug monographs and individuals requesting drugs for addition to the formulary are expected to disclose any significant financial interest or other relationship with (a) the manufacturer(s) of any commercial product and/or provider of commercial services for drugs on the formulary or being considered for the formulary (b) any commercial support for these drugs. (Significant financial interest or other relationship can include such things as grants or research support, employee, consultant, major stockholder, member of speaker’s bureau, etc.). Procedure 1. Committee members shall submit Disclosure Statements at least annually and as

needed as their situation changes. See Attachment A for the “Executive Formulary Committee Disclosure Form.”

2. Individuals submitting requests for addition to the Formulary or completing drug monographs shall submit the “Executive Formulary Committee Disclosure Form” along with the New Drug Application or drug monograph, respectively.

3. A review of Committee members’ conflict of interest shall be completed for all individuals present at each meeting. This information shall be documented in the minutes of each meeting.

4. Each facility Pharmacy and Therapeutics Committee or similarly functioning committee is encouraged to adopt a similar policy.

5. The following definitions are applicable to this policy “Companies” – include pharmaceutical and biotechnology companies. “Compensation” - includes direct and indirect remuneration or royalties, and may also include, among other things, items and services at reduced prices, or with discounts or rebates.

“Controlling Interest” - a direct or indirect ownership or beneficial interest, individually or in conjunction with members of your family, which permits election or selection of a majority of the governing body of a Company and/or which permits the exercise of control over the affairs of such Company.

“Gifts” or “Gratuities” include, among other things, entertainment or recreational items, subsidies given directly to a healthcare professional for continuing medical education (CME), educational (i.e. anatomical models) and non-educational and practice-related items (i.e. items that do not advance disease or treatment education).

“Financial Interest” – a direct or indirect, through business, investment or family: (a) Ownership Interest or investment interest in a Company; (b) Compensation arrangement with a Company or any of its affiliates; or (c) Ownership Interest or investment interest in, or Compensation arrangement

with, any Company or individual with which that Company or any of its affiliates is negotiating a transaction or arrangement.

“Ownership Interest” - owns or controls directly, indirectly, or beneficially through such person’s family, in excess of five percent (5%) of the total value of all securities of a Company.

“Significant Relationship” - a person or a member of such person’s family serves as an officer, general or limited partner, board member, employee, speaker or consultant to a company.

Executive Formulary Committee Disclosure Form Name: Date: Facility:

-or-

Member of Executive Formulary Committee? Yes No

Submitting a New Drug Application? Yes No

Preparing the Drug Monograph? Yes No I have read the Executive Formulary Committee policy on conflicts of interest. In agreement with this policy, I hereby disclose the following:

I have no conflicts of interest to disclose.

* The following is a list of my potential conflicts of interest: Company Consultant Grant

Research Speaker’s Bureau

Major Stockholder

Other (e.g., meals, gifts, travel, etc.)

* Attach an additional sheet describing your potential conflict of interest.

I have made all of the required disclosures. I understand that it is my continuing obligation to provide disclosure of potential conflicts of interest. If I become aware of any specific conflicts, or if there is a change in my professional activities, financial interests, or employment, I will submit an additional disclosure form in accordance with Executive Formulary Committee policies.

Signature Date

Reviewed by Executive Formulary Committee: Date

APPENDIX 4: ADVERSE DRUG REACTION REPORTING (MEDWATCH) FORM

APPENDIX 5: FOODS CONTAINING TYRAMINE

*High Amounts of Tyramine

Smoked, aged or pickled meat or fish

Sauerkraut Aged Cheeses such as Swiss and Cheddar

Yeast extracts Fava beans

**Moderate Amounts of Tyramine

Beer Avocados

Meat extracts Read wines such as Chianti

***Low Amounts of Tyramine Caffeine-containing beverages

Distilled spirits Chocolate Soy sauce

Cottage and cream cheeses Yogurt and sour cream

*May not consume **May consume in moderation

***May consume

Adapted from Shulman KI, et al. Dietary restriction,tyramine, and the use of monoamine oxidase inhibitors. J Clin Psychopharmacol. 1989; 9: 397.

texas health and human services · pdf filedisability services utilize a closed formulary...

Documents