FORMULARY: THERAPEUTIC CATEGORY LISTING* · 2017-06-27 · 45 N:\LCHC_Pharm\Formulary...

$: FORMULARY: THERAPEUTIC CATEGORY LISTING* · 2017-06-27 · 45 N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\Formulary of Drugs (therapeutic listing).docx 138/pdfs/2014-138.pdf)$
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\Formulary of Drugs (therapeutic listing).docx

FORMULARY: THERAPEUTIC CATEGORY LISTING* *Most current Formulary List of Drugs can be found:

1. DUH intranet [click on DRH (Duke Regional Hospital), Departments and Services, Pharmacy, then Lincoln Community Health Center Formulary] https://intranet.dm.duke.edu/hospitals/drh/pharmacy/Document%20Library/LCHC%20Formulary.pdf

2. LCHC website (http://www.lincolnchc.org/secondary/drug-formulary.html) 3. PADC website (http://www.projectaccessdurham.org/), then click on the Lincoln Pharmacy formulary. 4. LCHC Intranet/ Pharmacy Department/ Formulary of Drugs

Use Ctrl-F to quickly search the listing for a specific item.

Rx Pathways Plan Pfizer drugs are available to uninsured patients who are at or below 400% of the federal

poverty level. Only a dispensing fee is charged. NOTE: These medications are labeled as “RxP”.

Patient Assistance Program Patients who meet specific eligibility requirements may receive formualry medications

through manufacturer-sponsored patient assistance programs (PAPs). Medications labeled as “PAP” are available to eligible patients through manufacturer-sponsored PAPs. These medications may not be readily available and may require up to an 8-week processing period.

HIV Patient Assistance Program EI Clinic may access medications through for qualified patients. For patients that do not

qualify for ADAP, HIV medications may be obtained from manufacturer programs. http://epi.publichealth.nc.gov/cd/hiv/docs/ADAPProgrammanual.pdf

Project Access Durham County Project Access Durham County (PADC) serves eligible low-income, uninsured

Durham residents who have specialty medical care needs. PADC enrolls members based on referrals from a primary care provider at Lincoln Community Health Center (LCHC). PADC patients are eligible for LCHC formulary medications.

Lab Monitoring Some formulary drugs require laboratory monitoring and are labeled as “LAB”.

Safety in Lactation Lactation safety data from American Academy of Pediatrics (www.aap.org)

Medicaid Preferred Drug List http://www.ncdhhs.gov/dma/pharmacy/PDL.pdf Medicaid Prior Authorizations https://www.nctracks.nc.gov/content/public/providers.html Hazardous Drugs Drugs identified by National Institute of Occupational Safety and Health as hazardous are

labeled as “HD”. Use caution when handling. (http://www.cdc.gov/niosh/docs/2014-

https://intranet.dm.duke.edu/hospitals/drh/pharmacy/Document%20Library/LCHC%20Formulary.pdf

http://www.projectaccessdurham.org/

http://epi.publichealth.nc.gov/cd/hiv/docs/ADAPProgrammanual.pdf

http://www.aap.org/

http://www.ncdhhs.gov/dma/pharmacy/PDL.pdf

https://www.nctracks.nc.gov/content/public/providers.html

http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf

45


138/pdfs/2014-138.pdf)

Therapeutic Category

Medication Brand Name Pharmacologic Category Package Size (if applicable)

Preg Cat Safety in Lactation

Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ALZHEIMER DISEASE

Donepezil Tablet 10mg Aricept Acetylcholinesterase Inhibitor (Central)

C ? +

ALZHEIMER DISEASE

Memantine extended release tablet 14mg PAP

Namenda XR N-Methyl-D-Aspartate Receptor Antagonist

90 day supply PAP

B ? - K

ALZHEIMER DISEASE



90 day supply PAP

B ? - K

ALZHEIMER DISEASE



90 day supply PAP

B ? - K

ALZHEIMER DISEASE



90 day supply PAP

B ? - K

ANAGESICS AND ANTIPYRETICS

Pregabalin Capsule 150mg RxP

Lyrica Anticonvulsant, Analgesic

C ? - K




C ? - K


Gabapentin Capsule 100mg

Neurontin Anticonvulsant, Neuropathic pain (unlabeled)

C ? - K




C ? - K


Acetaminophen Suspension 160mg/5mL

Tylenol Susp Miscellaneous 120 mL B +

L


Acetaminophen Tablet 325mg

Tylenol Miscellaneous #100 tabs B + + L


Capsaicin 0.025% Cream Capzasin Miscellaneous, Topical 60 gm B +


Tramadol Tablet 50mg Ultram Nonopioid Analgesic

C - + + K/L


Ibuprofen Suspension 100mg/5mL

Motrin NSAID

B (D in 3rd trimester)

+

+ K


Ibuprofen Tablet 400mg Motrin NSAID


+ + (taste may be

unacceptable)

+

K


Indomethacin Capsule 25mg

Indocin NSAID


+ - + K


Indomethacin Capsule 50mg

Indocin NSAID


+ - + K


Naproxen Sodium Tablet 500mg

Naprosyn NSAID


+ + + K


Celecoxib Capsule 200mg RxP

Celebrex NSAID, COX-2 Inhibitor

C (D in 3rd trimester)

? - +HF K/L

http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf

46





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver


Acetaminophen/Codeine Tab 300mg/30mg

Tylenol With Codeine #3

Opioid

C ? + L


Buprenorphine/Naloxone SL Tab 2mg/ 0.5mg

Zubsolv Opioid C ? + K/L


Buprenorphine/Naloxone SL Tab 8mg/ 2mg

Zubsolv Opioid C ? + K/L


Hydrocodone and Aceta-minophen Tab 5mg/325mg

Norco Opioid

C ? + L

ANTIANEMIA AGENTS

Ferrous Sulfate Drops 75mg/mL (15mg/mL elemental)

Iron Preparations 50mL + +

ANTIANEMIA AGENTS

Ferrous Sulfate Elixer 220mg/5mL (44mg/5mL elemental)

Iron Preparations 480mL + +

ANTIANEMIA AGENTS

Ferrous Sulfate Tablet 325mg (65mg elemental)

Iron Preparations #100 tabs + + +

ANTICONVULSANT AGENTS



C ? - K




C ? - K




C ? - K




C ? - K


Phenobarbital Tablet 30mg

Barbiturate

D - + + K/L


Phenytoin Sodium Capsule 100mg LAB, HD

Dilantin Hydantoin

D + - L


Phenytoin Sodium Chewable tablet 50g LAB,

HD

Dilantin Infatabs Hydantoin

D + + L


Carbamazepine Tablet 200mg LAB, HD

Tegretol Miscellaneous

D + + K/L


Divalproex Sodium Tablet 250mg LAB, HD

Depakote Miscellaneous

X ? - L


Lamotrigine Tablet 25mg Lamictal Miscellaneous C - + L


Lamotrigine Tablet 100mg

Lamictal Miscellaneous C - + L


Lamotrigine Tablet 50mg PAP

Lamictal Miscellaneous 90 day supply PAP

C -

L

47





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver


Lamotrigine Tablet 200mg PAP

Lamictal Miscellaneous 90 day supply PAP

C - + L


Topiramate Tablet 200mg LAB, HD

Topamax Miscellaneous

D ? - (taste may be

unacceptable)

K/L


Topiramate Tablet 25mg LAB, HD

Topamax Miscellaneous

D ? - (taste may be

unacceptable)

K/L

ANTIDEPPRESSANT AGENTS

Mirtazapine Tablet 30mg Remeron Alpha2 Antagonist

C ? + K/L


Bupropion Tablet 100mg Wellbutrin Dopamine Reuptake Inhibitor

C - + + K/L


Fluoxetine Capsule 20mg Prozac Selective Serotonin Reuptake Inhibitor

C (- in 3rd trimester)

- - + L


Sertraline Tablet 50mg Zoloft Selective Serotonin Reuptake Inhibitor


+ + + L


Sertraline Tablet 100mg Zoloft Selective Serotonin Reuptake Inhibitor


+ + + L


Trazadone Tablet 50mg Desyrel Serotonin Reuptake Inhibitor/Antagonist

C - + + K/L


Duloxetine Capsule 20mg PAP

Cymbalta Serotonin/Norepinephrine Reuptake Inhibitor

120 day supply PAP

C ? - (may open & mix w/

applesauce, NOT choclate)

K/L




120 day supply PAP



K/L




120 day supply PAP



K/L


Amitriptyline Tablet 25mg Elavil Tricyclic

D - + +


Amitriptyline Tablet 50mg Elavil Tricyclic

D - + +


Doxepin Capsule 25mg Sinequan Tricyclic

C - - +

48





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver


Doxepin Capsule 50mg Sinequan Tricyclic

C - - +


Imipramine Tablet 10mg Tofranil Tricyclic

D - + +


Imipramine Tablet 25mg Tofranil Tricyclic

D - + +


Nortriptyline Tablet 25mg Pamelor Tricyclic

D + + + K/L

ANTIDOTE Disulfiram Tablet 250mg Antabuse Aldehyde Dehydrogenase Inhibitor

C ? +

ANTIDOTE Epinephrine IM Injection 0.15mg/0.15mL

EpiPen Alpha/Beta Adrenergic Agonist 2 Auto-Injectors

C -

ANTIDOTE Epinephrine IM Injection 0.3mg/0.3mL

EpiPen Alpha/Beta Adrenergic Agonist 2 Auto-Injectors

C -

ANTIDOTE Diphenhydramine Capsule 25mg

Benadryl Antihistamine

B - - +

ANTIDOTE Diphenhydramine Capsule 50mg


B - - +

ANTIDOTE Diphenhydramine Elixer 12.5ml/5mL


B -

+

ANTIDOTE Naloxone Nasal Kit 2 mg/mL

Narcan Opioid Antagonist C ?

ANTIDOTE Naltrexone Tablet 50mg Revia; Vivitrol Opioid Antagonist C ? +

ANTIEMETIC/ANTI-VERTIGO AGENTS

Ondansetron Tablet 4mg Zofran 5-HT3 Receptor Antagonist

B ? + L


Meclizine Tablet 12.5mg Antivert Anticholinergic, Antihistamine

B ? + +


Promethazine Suppository 25mg

Phenergan Antidopaminergic, Phenothiazine

C -

+ L


Promethazine Tablet 25mg

Phenergan Antidopaminergic, Phenothiazine

C -

+ L

ANTI-INFECTIVES Nystatin Cream 100,000 units/gm

Mycostatin Antifungal 15 gm C ?

ANTI-INFECTIVES Nystatin Suspension 100,000 units/mL

Nilstat Antifungal 60 mL bottle C ?

ANTI-INFECTIVES Fluconazole Tablet 200mg

HD Diflucan Antifungal

C (single dose vag

candida), D all other

indications

+ + K

ANTI-INFECTIVES Griseofulvin Susp 125mg/5mL

Grifulvin Antifungal

C ?

49





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTI-INFECTIVES Terbinafine Cream 1% LAB Lamisil AT Antifungal 15 gm B ?

ANTI-INFECTIVES Terbinafine Tablet 250mg LAB

Lamisil Antifungal

B - + K/L

ANTI-INFECTIVES Albendazole Tablet 200mg

Albenza Antihelmintic C ? + K

ANTI-INFECTIVES Levofloxacin Tablet 500mg

Levaquin Anti-Infective

C ? + K

ANTI-INFECTIVES Hydroxychloroquine Tablet 200mg

Plaquenil Antimalarial C + + K/L

ANTI-INFECTIVES Acyclovir Capsule 200mg Zovirax Antiviral B + - K/L

ANTI-INFECTIVES Acyclovir Suspension 200mg/5mL

Zovirax Antiviral B + K/L

ANTI-INFECTIVES Ledaspasvir/sofosbuvir Tablet 90 mg/ 400mg PAP

Harvoni Antiviral (Antihepaciviral) 90 day supply PAP

B ? -

(taste) L

ANTI-INFECTIVES Sofosbuvir/ velpatasvir Tablet 400 mg/ 100 mg PAP

Epclusa Antiviral (Antihepaciviral) 90 day supply PAP

B ? -

(taste)

ANTI-INFECTIVES Cefdinir Suspension 250mg/5mL

Omnicef Cephalosporin, 3rd gen

B ?

K

ANTI-INFECTIVES Cefuroxime Tablets 250mg

Ceftin Cephalosporin, 2nd gen B ? - (taste)

ANTI-INFECTIVES Cephalexin Capsule 250mg

Keflex Cephalosporin, 1st fen

B ? - K

ANTI-INFECTIVES Cephalexin Suspension 250mg/5ml

Keflex Cephalosporin, 1st gen

B ?

K

ANTI-INFECTIVES Azithromycin Suspension 200mg/5mL

Zithromax Macrolide

B ?

K/L

ANTI-INFECTIVES Azithromycin Tablet 250mg

Zithromax Macrolide

B ? + K/L

ANTI-INFECTIVES Clarithromycin Tablet 500mg

Biaxin Macrolide

C ? + K

ANTI-INFECTIVES Clindamycin Capsule 150mg

Cleocin Miscellaneous

B ? + K

ANTI-INFECTIVES Clindamycin Oral Solution 75mg/5mL

Cleocin Miscellaneous 100 mL B ? K

ANTI-INFECTIVES Clindamycin Topical Solution 1%

Cleocin-T Miscellaneous 60 mL B ?

ANTI-INFECTIVES Metronidazole Tablet 500mg

Flagyl Miscellaneous

B ? + K/L

ANTI-INFECTIVES Amoxicillin Capsule 250mg

Amoxil Penicillin

B + - K

ANTI-INFECTIVES Amoxicillin Suspension 250mg/5mL

Amoxil Penicillin B + K

50





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTI-INFECTIVES Amoxicillin/Clavulanic Acid Tablet 875mg/125mg

Augmentin Penicillin

B ? + K/L

ANTI-INFECTIVES Penicillin VK Suspension 250mg/5mL

Pen-Vee K Penicillin VK

B ?

K

ANTI-INFECTIVES Penicillin VK Tablet 500mg

Veetids Penicillin VK

B ? + K

ANTI-INFECTIVES Ciprofloxacin Ophth Soln 0.3%

Cipro Quinolone 5 mL bottle C (but teratogenicity unlikely)

?

ANTI-INFECTIVES Ciprofloxacin Tablets 500mg

Cipro Quinolone C (but teratogenicity unlikely)

? + K/L

ANTI-INFECTIVES Sulfamethoxazole/ Trimethoprim Suspension 200mg-40mg/5mL

Septra Suspension

Sulfonamide

C +

K/L

ANTI-INFECTIVES Sulfamethoxazole/ Trimethoprim Tablet 800mg/160mg

Septra DS Sulfonamide

C +

K/L

ANTI-INFECTIVES Sulfasalazine Tablet 500mg

Sulfazine, Azulfadine

Sulfonamide

D - + K/L

ANTI-INFECTIVES Doxycycline Tablet 100mg

Vibramycin Tetracycline

D ? +

ANTI-INFECTIVES Nitrofurantoin Capsule

100mg

Macrobid Urinary

B +? - + K/L

ANTINEOPLASTIC

AGENTS

Tamoxifen Tablet 10mg LAB HD

Nolvadex Anti-estrogen

D - -

ANTINEOPLASTIC

AGENTS

Anastrozole Tablet 1mg PAP,LAB, HD

Arimidex Aromatase Inhibitor 90 day

supply PAP

X -

ANTIPARKINSON

AGENTS

Trihexphenidyl Tablet

2mg

Artane Anticholinergic

C - + + K/L

ANTIPARKINSON

AGENTS

Carbidopa/Levodopa

Tablet 25mg/100mg

Sinemet Dopamine Agonist

C - + K/L

ANTIPSYCHOTIC AGENTS

Lurasidone Tablet 20mg PAP

Latuda Atypical, mixed serotonin-dopamine antagonist

90 day supply PAP

B ? + + K/L

ANTIPSYCHOTIC

AGENTS


Latuda Atypical, mixed serotonin-

dopamine antagonist

90 day

supply PAP

B ? + + K/L




90 day supply PAP

B ? + + K/L

51





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver




90 day supply PAP

B ? + + K/L




90 day supply PAP

B ? + + K/L


Quetiapine tablet 25mg LAB

Seroquel Atypical, Serotonin/Dopamine Receptor Antagonist

C - + + K




C - + + K




C - + + K




C - + + K




C - + + K


Quetiapine extended release tablet 50mg PAP,

LAB

Seroquel XR Atypical, Serotonin/Dopamine Receptor Antagonist

90 day supply PAP

C - - + K



LAB


90 day supply PAP

C - - + K



LAB


90 day supply PAP

C - - + K



LAB


90 day supply PAP

C - - + K



LAB


90 day supply PAP

C - - + K


Risperidone 0.5mg HD Risperdal Atypical, Serotonin/Dopamine Receptor Antagonist

C - + + K/L


Risperidone 1mg HD Risperdal Atypical, Serotonin/Dopamine Receptor Antagonist

C - + + K/L

52





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver


Risperidone 2mg HD Risperdal Atypical, Serotonin/Dopamine Receptor Antagonist

C - + + K/L


Lithium Carbonate Capsule 300mg LAB

Eskalith Bipolar Disorder 90 day supply available

D - - + K


Haloperidol Tablet 1mg Haldol Typical, D2 Antagonist

C - + +


Haloperidol Tablet 2mg Haldol Typical, D2 Antagonist

C - + +


Trifluoperazine Tablet 2mg

Stelazine Typical, D2 Antagonist

C - + + K/L

ANXIOLYTICS, SEDATIVES, HYPNOTICS

Buspirone Tablet 15mg Buspar Antianxiety Agent

B - + K/L


Diphenhydramine Capsule 25mg


B - - +


Diphenhydramine Capsule 50mg


B - - +


Diphenhydramine Elixer 12.5ml/5mL


B -

+


Hydroxyzine HCL Syrup 10mg/5mL

Atarax Antihistamine

C -

+ K/L


Hydroxyzine HCL Tablet 25mg


C - + + K/L


Hydroxyzine HCL Tablet 50mg


C - + + K/L


Diazepam Tablets 5mg Valium Benzodiazepine

D - + + L


Oxazepam Capsule 15mg Serax Benzodiazepine

D - - +


Melatonin Tablet 3mg

Neurohormone, indole #120 - -

CARDIOVASCULAR DRUGS

Lisinopril Tablet 5mg LAB Zestril ACE-Inhibitor 90 day supply available

D ? + K

53





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver



D ? + K



D ? + K


Lisinopril Tablet 40mg LAB Zestril ACE-Inhibitor 90 day supply

available

D ? + K


Lisinopril/HCTZ Tablet 20/12.5mg LAB

Zestoretic ACE-Inhibitor/ Diuretic, Thiazide

90 day supply available

D ? + K


Lisinopril/HCTZ Tablet 20/25mg LAB

Zestoretic ACE-Inhibitor/ Diuretic, Thiazide


D ? + K


Methyldopa Tablet 250mg Aldomet Alpha Adrenergic Inhibitor, Alpha2 Adrenergic Agonist

B + + + K/L


Doxazosin Tablet 2mg Cardura Alpha1 Blocker 90 day supply available

C ? + + L


Doxazosin Tablet 8mg Cardura Alpha1 Blocker 90 day supply available

C ? + + L


Prazosin Capsule 1mg Minipress Alpha1 Blocker C ? - + L






Clonidine Tablet 0.1mg Catapres Alpha2 Adrenergic Agonist 90 day supply available

C ? + + K



C ? + + K



C ? + + K


Losartan Tablet 100mg Cozaar Angiotensin Receptor Blocker

D ? + L



D ? + L



D ? + L


Amiodarone Tablet 200mg LAB

Cordarone Antiarrhythmic

D - + + L

54





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver


Digoxin Tablets 0.125mg LAB

Lanoxin Antiarrhythmic

C + + + K


Digoxin Tablets 0.25mg LAB

Lanoxin Antiarrhythmic

C + + + K


Apixaban Tablets 2.5 mg PAP

Eliquis Anticoagulant (Direct Oral Anticoagulant)

90 day supply PAP

B - + K


Apixaban Tablets 5 mg PAP Eliquis Anticoagulant (Direct Oral Anticoagulant)

90 day supply PAP

B - + K


Enoxaparin SQ Injection 30mg PAP, LAB

Lovenox Anticoagulant

B +

K




B +

K




B +

K




B +

K




B +

K




B +

K




B +

K


Rivaroxaban Tablet 10 mg PAP

Xarelto Anticoagulant (Direct Oral Anticoagulant)

30-day supply prescription card PAP

C - + K/L





C - + K/L





C - + K/L


Warfarin Tablet 5mg LAB Coumadin Anticoagulant

- (1st trimester),

C

Use caution

+ K/L


Ezetimibe tablet 10mg PAP Zetia Antihyperlipidemic, 2-Azetidinone

90 day supply PAP

C ? + L


Gemfibrozil Tablet 600mg Lopid Antihyperlipidemic, Fibric Acid

C ? + K


Atorvastatin Tablet 10mg Lipitor Antihyperlipidemic, HMG-CoA Reductase Inhibitor

X - + L



X - + L

55





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver



X - + L



X - + L


Clopidogrel Tablet 75mg Plavix Antiplatelet

B ? + L


Atenolol Tablet 100mg Tenormin Beta Blocker 90 day supply available

D - - K


Atenolol Tablet 50mg Tenormin Beta Blocker 90 day supply available

D - - K


Carvedilol Tablet 3.125mg

Coreg Beta Blocker w/ alpha blocking ability

90 day supply

available

C ? + L


Carvedilol Tablet 12.5mg Coreg Beta Blocker w/ alpha blocking ability


C ? + L


Carvedilol Tablet 25mg Coreg Beta Blocker w/ alpha blocking ability


C ? + L


Metoprolol Tartrate Tablet 25mg

Lopressor Beta Blocker 90 day supply available

C ? + L


Metoprolol Tartrate Tablet 50mg

Lopressor Beta Blocker 90 day supply available

C ? + L


Propranolol Tablet 10mg Inderal Beta Blocker 90 day supply available

C + + K/L


Propranolol Tablet 40mg Inderal Beta Blocker 90 day supply available

C + + K/L


Amlodipine Tablets 10mg Norvasc Calcium Channel Blocker

C ? + L


Amlodipine Tablets 5mg Norvasc Calcium Channel Blocker

C ? + L


Diltiazem HCl XR 180mg Capsule

Cardizem CD Calcium Channel Blocker

C + - +


Diltiazem HCl XR 240mg Capsule

Cardizem CD Calcium Channel Blocker

C + - +


Nifedipine XL Tablet 30mg

Procardia XL Calcium Channel Blocker

C - - L




C - - L

56





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver




C - - L


Verapamil SR Tablet 180mg

Calan SR Calcium Channel Blocker

C - + split/- crush

+ K/L


Verapamil SR Tablet 240mg

Calan SR Calcium Channel Blocker

C - + split/- crush

+ K/L


Acetazolamide Tablet 500mg ER 12 hr

Diamox Sequels Carbonic Anhydrase Inhibitor

C - + K/L


Furosemide Tablet 40mg Lasix Diuretic, Loop 90 day supply available

C ? + K/L


Spironolactone Tablet 25mg HD

Aldactone Diuretic, Potassium Sparing

D + + K


Spironolactone/HCTZ Tablet 25mg/25mg HD

Aldactazide Diuretic, Potassium Sparing / Thiazide

D + + K


Hydrochlorothiazide Tablet 25mg

Hydrodiuril Diuretic, Thiazide 90 day supply available

B (D is used in

pregnancy-induced HTN)

+ + K


Hydrochlorothiazide Tablet 50mg

Hydrodiuril Diuretic, Thiazide 90 day supply available

B (D is used in

pregnancy-induced HTN)

+ + K


Aspirin Tablet 81mg (enteric coated)

Ecotin Salicylate #120 tablets

D ? - K/L


Aspirin Tablet 325mg (enteric coated)

Ecotin Salicylate #100 tabs D ? - K/L


Hydralazine Tablet 25mg Apresoline Vasodilator 90 day supply available

C + + K


Hydralazine Tablet 50mg Apresoline Vasodilator 90 day supply available

C + + K


Isosorbide Dinitrate Tablet 10mg

Isordil Vasodilator

C ? +



Isordil Vasodilator

C ? +



Isordil Vasodilator

C ? +


Nitroglycerin SL Tablet 0.4mg

Nitrostat Vasodilator #100 tabs C ?


Nitroglycerin Transdermal Patch 0.2mg/hr

Transderm Nitro Vasodilator #30 patches C ? -

57





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver







DEVICE Nasal Aspirator

+ +

DEVICE Nasal Irrigation Kit Neti Pot

+ +

DEVICE Peak Flow Meter

+ +

DEVICE Pill Box

+ +

DEVICE Spacer Aerochamber

+ +

DEVICE Spacer, with mask Aerochamber,

+ +

DEVICE Syringes 31ga 5/16" 0.5mL

Monoject

+ +

DEVICE Syringes 31ga 5/16" 1mL Monoject

DEVICE Tablet Cutter

+ +

ELECTROLYTE SUPPLEMENT

Electrolyte Solution Pedialyte/ Infalyte

Treatment of Dehydration 1,000 mL ? ?

ELECTROLYTE SUPPLEMENT

Potassium Chloride Tablet 8mEq

Klor-Con Treatment of Hypokalemia

C ? - K

ENDOCRINE AND METABOLIC AGENTS

Finasteride Tablet 5mg HD Proscar Androgen Hormone Inhibitor, 5 Alpha-Reductase Inhibitor

X - -

HD L


Metformin Tablet 1000mg LAB

Glucophage Antidiabetic, Biguanide 90 day supply available

B ? + K/L


Sitagliptin Tablet 100mg PAP

Januvia Anti-diabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhib

90 day supply PAP

B ? - K/L




90 day supply PAP

B ? - K/L




90 day supply PAP

B ? - K/L


Insulin Aspart 100units/mL

Novolog Antidiabetic, Insulin Rapid-Acting

B/C + - + Sliding Scale


Insulin Lispro 100units/mL

Humalog Antidiabetic, Insulin Rapid-Acting

B/C + + Sliding Scale


Insulin Regular 100units/mL

Novolin R Antidiabetic, Insulin Short-Acting



Insulin Glulisine 100units/mL PAP

Apidra Antidiabetic, Insulin Rapid-Acting

90 day supply PAP



Insulin Aspart Protamine and Insulin Aspart 100units/mL

NovoLog Mix 70/30

Antidiabetic, Insulin Combination

B/C +

58





Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver


Insulin Lispro Protamine and Insulin Lispro 100units/mL

Humalog Mix 75/25

Antidiabetic, Insulin Combination

B/C +


Insulin NPH and Insulin Regular 100units/mL

Novolin 70/30 Antidiabetic, Insulin B/C +


Insulin NPH 100units/mL Novolin NPH Antidiabetic, Insulin B/C +


Insulin Detemir 100units/mL

Levemir Antidiabetic, Insulin B/C +


Insulin Glargine 100units/mL

Lantus Antidiabetic, Insulin 90 day supply PAP

B/C +


Insulin Regular 100units/mL

Novolin Regular Antidiabetic, Insulin

B/C +


Glipizide ER Tablet 10mg Glucotrol XL Antidiabetic, Sulfonylurea

C ? - L


Glipizide ER Tablet 5mg Glucotrol XL Antidiabetic, Sulfonylurea

C ? - L


Pioglitazone Tablet 15mg LAB

Actos Antidiabetic, Thiazolidinedione C ? + L


Pioglitazone Tablet 30mg LAB

Actos Antidiabetic, Thiazolidinedione C ? + L


Alendronate Tablet 4mg Fosamax Biphosphonates, Osteoporosis #4 tabs C - + K


Norethindrone/ E. Estradiol (triphasic) Tablet 0.5-0.75-1mg/0.035mg HD

Ortho-Novum 7/7/7

Contraceptive Hormone, Combination

#28 tabs X/D - + + L

ENDOCRINE AND

METABOLIC AGENTS

Norgestrol / E. Estradiol

Tablet 0.3mg/0.03mg HD

Lo-Ovral Contraceptive Hormone,

Combination

#28 tabs X - + + L

ENDOCRINE AND

METABOLIC AGENTS

Medroxyprogesterone

Acetate Tablet 10mg HD

Provera Contraceptive Hormone,

Progestin

X + + + L

ENDOCRINE AND

METABOLIC AGENTS

Norethindrone Tablet

0.35mg HD

Nor-Q-D Contraceptive Hormone,

Progestin

#28 tabs X - (may

start 6 wks after

preg)

+ + L


Norgestrol / E. Estradiol for postcoital contraception

LCHC version of Plan B

Contraceptive, POSTCOITAL (4 tab w/in 72 hrs unprotected sex, followed by 4 tabs 12 hrs later)

#8 tabs X - + + L


Clobetasol Ointment 0.05%

Temovate Corticosteroid 30gm C ?


Estrogens, conjugated Tablet 0.625mg HD

Premarin Estrogen

X - + +

59





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Dose Adjust

K=Kidney L=Liver


Estrogens, conjugated Tablet 1.25mg HD

Premarin Estrogen

X - + +


Prednisolone Syrup 15mg/mL

Prelone Glucocorticoids

C +

+ K/L


Prednisone Tablet 20mg Deltasone Glucocorticoids

C + + + K/L


Prednisone Tablet 5mg Deltasone Glucocorticoids 90 day supply available

C + + + K/L


Leuprolide IM Injection 11.25mg PAP,LAB, HD

Lupron Gonadotropin Releasing Hormone Agonist

90 day supply PAP

X -


Leuprolide IM Injection 22mg PAP,LAB, HD


90 day supply PAP

X -


Leuprolide IM Injection 30mg PAP,LAB, HD


90 day supply PAP

X -


Colchicine Tablet 0.6mg

HD Colcrys Gout

C ? + K/L


Allopurinol Tablet 100mg Zyloprim Gout, Xanthine Oxidase Inhibitors


C + + K


Allopurinol Tablet 300mg Zyloprim Gout, Xanthine Oxidase Inhibitors

90 day supply

available

C + + K


Megestrol Acetate Susp 40mg/mL HD

Megace Progestin

D ?

+ K


Levothyroxine 0.088 mg Tablet LAB

Levoxyl Thyroid A + +



Levoxyl Thyroid

A + +



Levoxyl Thyroid A + +



Levoxyl Thyroid

A + +



Levoxyl Thyroid

A + +



Levoxyl Thyroid

A + +



Levoxyl Thyroid

A + +


Methimazole Tablet 10mg Tapazole Thyroid

D + +

EYE, EAR, NOSE, AND THROAT

Lidocaine (Viscous) Oral Solution 2%

Xylocaine Analgesic 100 mL B +


Brimonidine Tartrate Ophthalmic 0.2%

Alphagan Antiglaucoma, Alpha2 Agonist 5 mL B ?

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Dose Adjust

K=Kidney L=Liver


Timolol Maleate Ophth Soln 0.5%

Timoptic Antiglaucoma, Beta-Adrenergic Blocker

5 mL C +


Dorzolamide 2% Trusopt Antiglaucoma, Carbonic Anhydrase Inhibitor

10 mL C -


Pilocarpine Ophth Soln 4%

Pilocar Antiglaucoma, Cholinergic Agent

15 mL C ?


Latanoprost Ophth Sol 0.005%

Xalatan Antiglaucoma, Prostaglandin Inhibitor

2.5 mL C ?


Chlorhexidine Oral Rinse 0.12%

Peridex Anti-infective 480 mL B ?


Erythromycin 5mg/gm Ilotycin Anti-infective 3.5 gm B +


Polymyxin/Trimethoprim Ophth Soln 10,000 units-1mg/mL

Polytrim Anti-infective 10 mL C ?


Neomycin/Polymyxin B/Hydrocortisone Otic Susp

Cortisporin Otic Anti-infective, Corticosteroid Otic 10mL ? ?


Carbamide Peroxide Otic Drops 6.5%

Debrox Cerumenolytic 15 mL ? ?


Fluticasone Propionate Nasal Spray 50mcg/spray

Flonase Corticosteroid 16 gm C ?


Ketorolac 0.5% Ophth Soln

Acular Corticosteroid 5 mL C ?


Prednisolone Acetate Ophth Soln 1%

Pred Forte Corticosteroid 15 mL C ?


Hydrocortisone, Nystatin, Diphenhydramine Susp

Duke's Mouthwash

Corticosteroid, Antifungal, Antihistamine

120 mL per bottle

? -


Saline Nose Spray Saline Spray Irrigation 45 mL + +


Artificial Tear Drops Artificial Tears Lubricant 15 Ml 90 day supply available

+ +


Artificial Tear Ointment Duratears Lubricant 3.5 gm 90 day supply available

+ +


Atropine Ophth Soln 1% Atropine Mydriatic 15 mL C +


Ketotifen Ophth Soln 0.025%

Zaditor

Antihistamine, Mast Cell Stabilizer

5 mL C ?


Naphazoline/Pheniramine Ophth Soln 0.025%/0.3%

Vasocon-A Vasoconstrictor/Antihistamine 15 mL C ?

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Dose Adjust

K=Kidney L=Liver

GASTROINTESTINAL DRUGS

Magnesium/Aluminum/ Simethicone Suspension

Maalox Max Strength

Antacid 480 mL C ?

K


Dicyclomine Capsules 10mg

Bentyl Anticholinergic

B - - +


Diphenoxylate/Atropine Sulf Tablets 2.5/0.025mg

Lomotil; Lonox Antidiarrheal

C - - K/L


Bismuth Subsalicylate Tablet 262mg

Pepto-Bismol Antidiarrheal #30 tabs D ? +


Loperamide Tablet 2mg Imodium Antidiarrheal #12 tabs C + +


Simethicone Drops 40mg/0.6mL

Mylicon Antiflatulent 30 mL C but + ?


Lactulose Syrup 10gm/15mL

Duphalac Syrup Constipation, Chronic

B ?


Lubiprostone Capsule 24mcg PAP

Amitiza Constipation, IBS 90 day supply PAP

C ? -


Ranitidine Syrup 15mg/mL

Zantac Histamine H2 Antagonist

B ?

+


Ranitidine Tablet 150mg Zantac Histamine H2 Antagonist 90 day supply available

B ? + +


Ranitidine Tablet 300mg Zantac Histamine H2 Antagonist 90 day supply available

B ? + +


Bisacodyl Tablet 5mg Dulcolax Laxative, Diphenylmethane C ? -


Glycerin 1 gm suppository

Pedia-Lax Rectal Laxative, Osmotic A + +


Glycerin 2 gm suppository

Sani-Supp Adult Rectal

Laxative, Osmotic A + +


Polyethylene Glycol MiraLax Laxative, Osmotic 255 gm C ?


Polyethylene Glycol with Electrolytes

GoLytely Laxative, Osmotic (for Bowel Prep)

4,000 mL C ?


Psyllium Hydrophilic Powder

Metamucil Laxative, Bulk 284 gm + ?


Pancreatic Enzymes Capsule Lipase/Protease/Amylase 12k/38k/60k PAP

Creon Pancreatic Enzymes 90 day supply PAP

C ? - (OK to open

and give with

apple-sauce or pudding)

K

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Dose Adjust

K=Kidney L=Liver


Pancreatic Enzymes Capsule Lipase/Protease/Amylase 24k/76k/120k PAP

Creon Pancreatic Enzymes 90 day supply PAP

C ? - (OK to open

and give with

apple-sauce or pudding)

K

GASTROINTESTINAL

DRUGS

Pancreatic Enzymes

Capsule Lipase/Protease/Amylase 6k/19k/30k PAP

Creon Pancreatic Enzymes 90 day

supply PAP

C ? - (OK to

open and give

with apple-

sauce or pudding)

K


Metoclopramide Tablet 10mg

Reglan Prokinetic

B ? + + K


Omeprazole Capsule 20mg

Prilosec Proton Pump Inhibitor

C ? - + L


Docusate Sodium Capsule 100mg

Colace Stool Softener #100 caps C ? - (taste may be

unacceptable)

GENITOURINARY AGENTS

Tamsulosin 0.4mg Capsule

Flomax Alpha1 Blocker

B + -


Phenazopyridine Tablet 100mg, 97.5mg or 95mg

Pyridium Analgesic, Urinary

B ? + K


Tolterodine Tartrate extended release tablet 4mg RxP

Detrol LA Anticholinergic, Urinary

C - - + K/L


Oxybutynin Chloride Tablet 5mg

Ditropan Antispasmodic, Urinary

B ? + + K/L

MIGRAINE AGENTS Butalbital, Acetaminophen and Caffeine Tablet 50mg/325mg/40mg

Note: Fioricet changed strength April 2014 and no longer has a generic

Migraine Combinations

C - + +

K/L

MIGRAINE AGENTS Eletriptan Tablet 40mg RxP Relpax Serotonin 5-HT1 Receptor Agonist

6 tabs per box

C ? + L

NEPHROLOGY Calcium Acetate Capsule 667mg

PhosLo Calcium, Phosphate Binder

C ? -

NEPHROLOGY Sodium Polystyrene Sulfonate Susp 15gm/60mL

Kayexalate Treatment of Hyperkalemia 60 mL per bottle

C ?

NEPHROLOGY Calcitriol Capsule 0.5mcg Rocaltrol Vitamin D Analog

C ? -

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Dose Adjust

K=Kidney L=Liver

NEPHROLOGY Paricalcitol Capsule 1mcg PAP

Zemplar Vitamin D Analog 90 day supply PAP

C ? -



C ? -



C ? -

NUTRIENTS AND NUTRITIONAL AGENTS

Calcium (elemental) Tablet 500mg

Calcium Calcium Supplement #60 tabs per bottle

+ (? 1st trimester)

? + K


Magnesium Oxide Tablet 400mg (240mg elemental)

MagOx Hypomagnesemia #120 A + + L


Thiamine Tablet 100mg Various Nutritional Supplement #100 tabs A + +


Cyanocobalamin Tablets 500mcg

Vitamin B12 Vitamin #130 tabs C + +


Folic Acid Tablet 1mg

Vitamin 90 day supply available

A + +


Multivitamin Drops with Iron

Poly-vi-sol Vitamin 50 mL + +


Multivitamin Tablet, Adult Centrum Vitamin #100 tabs + + +


Multivitamin tablet, Children

Flinstones Vitamin #100 tabs + + +


Omega-3 Fatty Acids (180 EPA / 120 DHA)

Fish Oil Vitamin #100 caps C ? - L


Prenatal Vitamins Natalins RX Vitamin #100 tablets + + +


Vitamin D3 Tablet 400 IU

Vitamin #100 tabs C Avoid high doses


Vitamin D3 Tablet 1,000 IU

Vitamin #100 tabs C Avoid high

doses

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Dose Adjust

K=Kidney L=Liver


Vitamin D3 Tablet 50,000 IU

Vitamin #100 caps C Avoid high doses

-

RESPIRATORY AGENTS

Cetirizine Solution 1mg/mL

Zyrtec Antihistamine 120 mL B -

K

RESPIRATORY AGENTS

Cetirizine Tablet 10mg Zyrtec Antihistamine #30 tablets 90 day supply available

B - + K

RESPIRATORY AGENTS

Loratadine Tablet 10mg Claritin Antihistamine #30 tabs 90 day supply available

B + + K

RESPIRATORY AGENTS

Triprolidine/ Pseudoephedrine Tablet 2.5mg/60mg

Actifed Antihistamine and Decongestant (Alpha/Beta Adrenergic Agonist)

#24 tabs - (1st trimester),

C

? + +

RESPIRATORY AGENTS

Benzonatate Capsule 100mg

Tessalon Perles Antitussive #20 caps C ? -

RESPIRATORY AGENTS

Fluticasone Propionate/Salmeterol Diskus 100/50 PAP

Advair Diskus Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant

90 day supply PAP

C ?

RESPIRATORY AGENTS



90 day supply PAP

C ?

RESPIRATORY AGENTS



90 day supply PAP

C ?

RESPIRATORY AGENTS

Ipratropium Bromide MDI 17mcg/actuation PAP

Atrovent Bronchodilator, Anticholinergic MDI: 90 day supply PAP

B ?

RESPIRATORY AGENTS

Ipratropium Bromide Nebulizer Soln 0.02%

Atrovent Bronchodilator, Anticholinergic 25 vials per box

B ?

RESPIRATORY AGENTS

Tiotropium Bromide Cap for inhalation 18mcg PAP

Spiriva Bronchodilator, Anticholinergic 90 day supply PAP

C - -

RESPIRATORY AGENTS

Albuterol MDI Proventil, Ventolin, ProAir

Bronchodilator, Beta2-Adrenergic Agonist

6.7 gm C ?

RESPIRATORY AGENTS

Albuterol Nebulizer Solution 0.083%

Proventil, Ventolin

Bronchodilator, Beta2-Adrenergic Agonist

#25 C ?

RESPIRATORY AGENTS

Beclomethasone MDI QVAR Corticosteroids, Inhalant 8.7 gm C ?

RESPIRATORY AGENTS

Fluticasone Propionate MDI 110mcg/puff PAP

Flovent Corticosteroids, Inhalant 90 day supply PAP

C ?

RESPIRATORY AGENTS



C ?

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Dose Adjust

K=Kidney L=Liver

RESPIRATORY AGENTS



C ?

RESPIRATORY AGENTS

Pseudoephedrine Syrup 30mg/5mL

Sudafed Decongestant (Alpha/Beta Adrenergic Agonist)

C +

+ K

RESPIRATORY AGENTS

Pseudoephedrine Tablet 30mg


#24 tabs C + + + K

RESPIRATORY AGENTS

Pseudoephedrine Tablet 60mg


C + + + K

RESPIRATORY AGENTS

Oxymetazoline Nasal Spray 0.05%

Afrin Decongestant (topical) 15 mL C ?

RESPIRATORY AGENTS

Guaifenesin Tablet 200mg

Humibid Expectorant #100 tabs C + +

RESPIRATORY AGENTS

Montelukast Tablet 10mg Singulair Leukotriene Inhibitor

B ? + L

RHEUMATOLOGY Methotrexate Tablet 2.5mg LAB, HD

Rheumatrex Disease Modifying Antirheumatic Drug (DMARD)

X - + K/L

RHEUMATOLOGY Adalimumab Injection 40mg PAP,LAB

Humira Tumor Necrosis Factor Blocking Agent

90 day supply PAP

B - - ?

SKELETAL MUSCLE RELAXANT

Cyclobenzaprine Tablets 5mg

Flexeril Centrally Acting

B ? + + L


Methocarbamol Tablet 500mg

Robaxin Centrally Acting

C ? + + L


Baclofen Tablet 10mg Lioresal Skeletal Muscle Relaxant

C + + K

SKIN AND MUCOUS MEMBRANE AGENTS

Benzoyl Peroxide Gel 5% Panoxyl Acne 42.5 gm C ?


Tretinoin Cream 0.05% HD Retin-A Acne 45 gm D -


Bacitracin Ointment 500 units/gm

Antibiotic, Topical 15 gm B ?


Mupirocin 2% Ointment Bactroban Antibiotic, Topical 22 gm B ?


Ketoconazole 2% Shampoo

Nizoral Antifungal 120 mL C ?


Miconazole Cream 2% Micatin Antifungal 30 gm + ?


Nystatin Cream 100,000 units/gm

Mycostatin Antifungal 15 gm C ?


Terconazole Vaginal Cream 0.8%

Terazol-3 Antifungal 20 gm C -


Silver Sulfadiazine Silvadene Anti-infective 20 gm B -

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Dose Adjust

K=Kidney L=Liver


Piperonyl Butoxide and Pyrethrum Extract Kit

Rid Shampoo Antiparasitic Agent, Pediculocide

120 mL C ?


Permethrin Cream 5% Elimite Antiparasitic Agent, Scabicidal 60 gm B ?


Imiquimod Cream 5% Aldara Anti-viral, topical immunomodulator

#12 single-use packets

C ?


Clobetasol Solution 0.05%

Temovate Corticosteroid 50mL C ?


Fluocinonide Cream 0.05%

Lidex Corticosteroid 30 gm C -


Hydrocortisone Cream 1%

Corticosteroid 30 gm C ?


Hydrocortisone Cream 2.5 %

Corticosteroid 20 gm C ?


Hydrocortisone Ointment 1%

Corticosteroid 30 gm


Hydrocortisone Suppository 25mg

Anusol-HC Corticosteroid #12 per box C ?


Triamcinolone Acetonide Cream 0.1%

Aristocort; Kenalog

Corticosteroid 15 gm, 80 gm

C ?


Triamcinolone Acetonide Dental Paste 0.1%

Oralone Corticosteroid 5 gm C ?


Sulfur/Salicylic Acid Shampoo 2%/2%

Sebulex Dandruff 120 mL C -


Estrogens, conjugated Cream 0.625mg/gm HD

Premarin Estrogen 30 gm X -


Metronidazole Gel 0.05% Metrogel Miscellaneous 45 gm B ?


Moisturizing Cream Eucerin Moisturizing 120 gm + +


Zinc Oxide Ointment 20% Desitin Ointment 30 gm + +


Selenium Sulfide Lotion 2.5%

Selsun Tinea Versicolor; Dandruff; Seborrheic Dermatitis

120 mL C ?

SMOKING CESSATION

Bupropion Tablet 100mg Wellbutrin Dopamine Reuptake Inhibitor

C - + + K/L

SMOKING CESSATION

Nicotine Gum 2mg Nicorette Gum Nicotine Product 110 pieces C -

K/L

SMOKING CESSATION

Nicotine Gum 4mg Nicorette Gum Nicotine Product 110 pieces C -

K/L

SMOKING CESSATION

Nicotine Transdermal Patch 14mg

Nicoderm CQ Nicotine Product #14 patches D -

K/L

SMOKING CESSATION


Nicoderm CQ Nicotine Product #14 patches D - K/L

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Dose Adjust

K=Kidney L=Liver

SMOKING CESSATION


Nicoderm CQ Nicotine Product #14 patches D - K/L

SMOKING CESSATION

Varenicline Tablet Starter Pack RxP

Chantix Partial Nicotine Agonist

C - + K

SMOKING CESSATION

VareniclineTablet Continuing Pack RxP

Chantix Partial Nicotine Agonist

C - + K

STIMULANT Dextroamphetamine /Amphetamine Tabs 10mg

Adderall ADHD, Narcolepsy C - + + K

STIMULANT Methylphenidate HCl Tablet 5mg

Ritalin ADHD, Narcolepsy C ? + +

Updated: June 27th, 2017

FORMULARY: THERAPEUTIC CATEGORY LISTING* · 2017-06-27 · 45 N:\LCHC_Pharm\Formulary...

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Transcript of FORMULARY: THERAPEUTIC CATEGORY LISTING* · 2017-06-27 · 45 N:\LCHC_Pharm\Formulary...