FORMULARY: THERAPEUTIC CATEGORY LISTING*€¦ · 04.06.2020 · Tamiflu B + + K Oseltamivir...

33

n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp33,51.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://lincolnchc.org/?page_id=6808)

2. LCHC website (https://lincolnchc.org/?page_id=6808) 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.

Pfizer Institutional Patient Assistance Program 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 “IPAP”.

Patient Assistance Program Patients who meet specific eligibility requirements may receive formulary 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 ADAP 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.

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 Hazardous Drugs (HD) identified by National Institute of Occupational Safety and Health as hazardous are labeled as “HD”. Use caution when handling.

(https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf?id=10.26616/NIOSHPUB2016161)

Beers List 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Jan 29. doi: 10.1111/jgs.15767.

https://lincolnchc.org/?page_id=6808

https://lincolnchc.org/?page_id=6808

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

https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf?id=10.26616/NIOSHPUB2016161

https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf?id=10.26616/NIOSHPUB2016161

34


Therapeutic Category

Pharmacologic Category

Medication Brand Name Package Size (if applicable)

Preg Cat Safety in Lactation

Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ALZHEIMER DISEASE

Acetylcholinesterase Inhibitor (Central)

Donepezil Tablet 10mg Aricept

C ? +

N-Methyl-D-Aspartate Receptor Antagonist

Memantine Extended Release Tablet 7mg, 14mg, 21mg, 28mg (Patient Assistance Program)

Namenda XR 90 day supply PAP

B ? - K

ANALGESIC AND ANTIPYRETICS

Anticonvulsant, Analgesic Pregabalin Capsule 75mg, 150mg IPAP

Lyrica

C ? - K

Anticonvulsant, Neuropathic pain (unlabeled)

Gabapentin Capsule 100mg, 300mg

Neurontin C ? - K

Miscellaneous Acetaminophen

Suspension 160mg/5mL

Tylenol Susp 120 mL B +

L

Acetaminophen Tablet

325mg

Tylenol #100 tabs B + + L

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

NSAID Ibuprofen Suspension

100mg/5mL

Motrin

B (D in 3rd

trimester)

+

+

See page 71

K

Ibuprofen Tablet 400mg Motrin

B (D in 3rd trimester)

+ + (taste may be

unacceptable)

+ See page

71

K

Indomethacin Capsule 25mg, 50mg

Indocin


+ - + See page

71

K

Naproxen Sodium Tablet 500mg

Naprosyn


+ + + See page

71

K

NSAID, COX-2 Inhibitor Celecoxib Capsule 200mg IPAP

Celebrex

C (D in 3rd trimester)

? - K/L

Opioid Acetaminophen/Codeine Tablet 300mg/30mg

Tylenol With Codeine #3

C ? + L

Buprenorphine/Naloxone SL Tablet 2mg/0.5mg, 8mg/ 2mg

Zubsolv C ? + K/L

Hydrocodone/ Acetaminophen Tablet 5mg/325mg

Norco

C ? + + See page

71

L

Tramadol Tablet 50mg Ultram C - + K/L

ANTIANEMIA AGENTS

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

50mL + +

35






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTIANEMIA AGENTS

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

480mL + +

Ferrous Sulfate Tablet 325mg (65mg elemental)

#100 tabs + + +

ANTICONVULSANT AGENTS

Anticonvulsant, Analgesic Pregabalin Capsule 150mg IPAP

Lyrica

C ? - K

Pregabalin Capsule 75mg IPAP

Lyrica

C ? - K

Anticonvulsant, Neuropathic pain (unlabeled)

Gabapentin Capsule 100mg, 300mg

Neurontin C ? - K

Barbiturate Phenobarbital Tablet 30mg

D - + +

See page 70

K/L

Hydantoin Phenytoin Sodium Capsule 100mg HD

Dilantin

D + - L

Phenytoin Sodium Chewable tablet 50g HD

Dilantin Infatabs

D + + L

Miscellaneous Carbamazepine Tablet 200mg HD

Tegretol

D + + K/L

Divalproex Sodium Tablet 250mg HD

Depakote

X ? - L

Lamotrigine Tablet 25mg, 100mg

Lamictal C - + L

Levetiracetam Tablet 250mg, 500mg, 750mg

Keppra C - + K

Topiramate Tablet 25mg, 200mgHD

Topamax

D ? - (taste may be

unacceptable)

K/L

ANTIDEPRESSANT AGENTS

Alpha2 Antagonist Mirtazapine Tablet 30mg Remeron

C ? + K/L

Dopamine Reuptake Inhibitor

Bupropion ER Tablet 150mg, 300mg

Wellbutrin XL

C - + K/L

Selective Serotonin Reuptake Inhibitor

Fluoxetine Capsule 20mg Prozac

C (- in 3rd trimester)

- - L

Sertraline Tablet 50mg, 100mg

Zoloft

C (- in 3rd trimester)

+ + L

Serotonin Reuptake Inhibitor/Antagonist

Trazodone Tablet 50mg Desyrel

C - + K/L

36






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTIDEPRESSANT AGENTS

Serotonin/Norepinephrine Reuptake Inhibitor

Duloxetine Capsule 20mg, 30mg, 60mg

Cymbalta

C ? - (may open & mix w/

applesauce, NOT chocolat

e)

K/L

Tricyclic Amitriptyline Tablet 25mg, 50mg

Elavil

D - + + See page

69

Doxepin Capsule 25mg, 50mg

Sinequan

C - - + See page

69

Imipramine Tablet 10mg, 25mg

Tofranil

D - + + See page

69

Nortriptyline Tablet 25mg

Pamelor

D + + + See page

69

K/L

ANTIDOTE Aldehyde Dehydrogenase Inhibitor

Disulfiram Tablet 250mg Antabuse C ? +

Alpha/Beta Adrenergic Agonist

Epinephrine IM Injection 0.15mg/0.15mL, 0.3mg/0.3mL

EpiPen 2 Auto-Injectors

C -

Antihistamine Diphenhydramine Capsule 25mg, 50mg

Benadryl

B - - + See page

68

Diphenhydramine Elixer 12.5ml/5mL

Benadryl

B -

+ See page

68

Opioid Antagonist Naloxone Nasal Spray 4 mg/0.1mL

Narcan 2 devices C ?

Naltrexone Tablet 50mg Revia C ? +

Naltrexone IM Injection 380 mg

Vivitrol C ?

ANTIEMETIC/ANTI-VERTIGO AGENTS

5-HT3 Receptor Antagonist

Ondansetron Disintegrating Tablet 4mg

Zofran ODT

B ? + L

Anticholinergic, Antihistamine

Meclizine Tablet 12.5mg Antivert

B ? + + See page

68

Antidopaminergic, Phenothiazine

Promethazine Suppository 25mg

Phenergan

C -

+ See page

68

L

Promethazine Tablet 25mg

Phenergan

C -

+ See page

68

L

37






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

ANTI-INFECTIVES Antifungal Nystatin Cream 100,000 units/gm

Mycostatin 15 gm C ?

Nystatin Suspension 100,000 units/mL

Nilstat 60 mL bottle C ?

Fluconazole Tablet 150mg HD

Diflucan

C (single dose vag

candida), D all other

indications

+ + K

Griseofulvin Suspension 125mg/5mL

Grifulvin

C ?

Terbinafine Cream 1% Lamisil AT 15 gm B ?

Terbinafine Tablet 250mg

Lamisil

B - + K/L

Antihelmintic Albendazole Tablet 200mg

Albenza C ? + K

Ivermectin Tablet 3 mg Stromectol C ? +

Praziquantel Tablet

600 mg

Biltricide B - + L

Antimalarial Hydroxychloroquine Tablet 200mg

Plaquenil C + + K/L

Antiviral Acyclovir Suspension 200mg/5mL

Zovirax B + K/L

Oseltamivir Capsule 75mg

Tamiflu B + + K

Oseltamivir Suspension 6mg/ mL

Tamiflu B + + K

Valacyclovir Tablet 1 gm Valtrex B + + K

Antiviral (Antihepaciviral) Glecaprevir-pibrentasvir Tablet 100-40mg (Patient Assistance Program)

Mavyret C ? -/+ L

Ledaspasvir/sofosbuvir Tablet 90 mg/ 400mg (Patient Assistance Program)

Harvoni 28 day supply PAP

B ? -

(taste) L

Sofosbuvir/ velpatasvir Tablet 400 mg/ 100 mg (Patient Assistance Program)

Epclusa 28 day supply PAP

B ? -

(taste)

Antiviral (PrEP) Tenofovir disoproxil/ emtricitabine Tablet 200 mg/ 300 mg (Patient Assistance Program)

Truvada 90 day supply PAP

B + + K

ANTI-INFECTIVES Cephalosporin, 1st gen Cephalexin Capsule 250mg

Keflex B ? - K

Cephalexin Suspension 250mg/5ml

Keflex B ? K

38






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Cephalosporin, 2nd gen Cefuroxime Tablet 250mg

Ceftin B ? - (taste)

Cephalosporin, 3rd gen Cefdinir Suspension 250mg/5mL

Omnicef B ? K

Macrolide Azithromycin Suspension 200mg/5mL

Zithromax

B ?

K/L

Azithromycin Tablet 250mg

Zithromax

B ? + K/L

Clarithromycin Tablet 500mg

Biaxin

C ? + K

Miscellaneous Bismuth/Metronidazole/ Tetracycline Capsule 140mg/125mg/125mg

Pylera #120 caps D ? - K/L

Clindamycin Capsule 150mg

Cleocin

B ? + K

Clindamycin Oral Solution 75mg/5mL

Cleocin 100 mL B ? K

Clindamycin Topical Solution 1%

Cleocin-T 60 mL B ?

Metronidazole Tablet 500mg

Flagyl

B ? + K/L

Penicillin Amoxicillin Capsule 500mg

Amoxil

B + - K

Amoxicillin Suspension 400mg/5mL

Amoxil B + K

Amoxicillin/Clavulanic Acid Suspension 600mg/42.9mg

Augmentin ES B ? + K/L

Amoxicillin/Clavulanic Acid Tablet 875mg/125mg

Augmentin XR

B ? + K/L

Penicillin VK Suspension 250mg/5mL

Pen-Vee K

B ?

K

Penicillin VK Tablet 500mg

Veetids

B ? + K

Quinolone Ciprofloxacin Ophth Soln 0.3%

Cipro 5 mL bottle C (but teratogenicity unlikely)

?

Ciprofloxacin Tablet 500mg

Cipro C (but teratogenicity unlikely)

? + K/L

ANTI-INFECTIVES Quinolone (cont) Levofloxacin Tablet 500mg

Levaquin C ? + K

Sulfonamide Sulfamethoxazole/ Trimethoprim Suspension 200mg-40mg/5mL

Septra Suspension

C +

+

See page 71

K/L

39






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Sulfonamide Sulfamethoxazole/ Trimethoprim Tablet 800mg/160mg

Septra DS

C +

+ See page

71

K/L

Sulfasalazine Tablet 500mg

Sulfazine, Azulfadine

D - + K/L

Tetracycline Doxycycline Tablet 100mg

Vibramycin

D ? +

Urinary Nitrofurantoin Capsule 100mg

Macrobid

B +? - + See page

68

K/L

ANTINEOPLASTIC AGENTS

Anti-estrogen Tamoxifen Tablet 10mg HD

Nolvadex

D - -

ANTIPARKINSON AGENTS

Anticholinergic Trihexphenidyl Tablet 2mg

Artane

C - + + See page

68

K/L

Dopamine Agonist Carbidopa/Levodopa Tablet 25mg/100mg

Sinemet

C - + K/L

ANTIPSYCHOTIC AGENTS

Atypical, mixed serotonin-dopamine antagonist

Aripiprazole Tablet 5mg, 15mg

Abilify C ? +

Lurasidone Tablet 20mg, 40mg, 60mg, 80mg, 120mg (Patient Assistance Program)

Latuda 90 day supply PAP

B ? + K/L

Quetiapine Tablet 25mg, 50mg, 100mg, 200mg, 300mg

Seroquel C - + K

Atypical, serotonin-dopamine antagonist

Risperidone Tablet 0.5mg, 1mg, 2mg HD

Risperdal C - + K/L

Bipolar Disorder Lithium Carbonate Capsule 300mg

Eskalith

D - - + See page

71

K

Typical, D2 Antagonist Haloperidol Tablet 1mg, 2mg

Haldol

C - +

ANXIOLYTICS, SEDATIVES, HYPNOTICS

Antianxiety Agent Buspirone Tablet 15mg Buspar

B - + K/L

ANXIOLYTICS, SEDATIVES, HYPNOTICS

Antihistamine Diphenhydramine Capsule 25mg, 50mg

Benadryl

B - - + See page

68

Diphenhydramine Elixer 12.5ml/5mL

Benadryl

B -

+ See page

68

Hydroxyzine HCL Syrup 10mg/5mL

Atarax

C -

+ See page

68

K/L

40






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Hydroxyzine HCL Tablet 25mg, 50mg

Atarax

C - + + See page

68

K/L

Benzodiazepine Diazepam Tablet 5mg Valium

D - + + See page

70, 71

L

Oxazepam Capsule 15mg

Serax

D - - + See page

70, 71

Neurohormone, indole Melatonin Tablet 3mg

#120 tabs - -

CARDIOVASCULAR DRUGS

Antihypertensive: ACE-Inhibitor

Lisinopril Tablet 5mg, 10mg, 20mg, 40mg

Zestril D ? + K

Antihypertensive: ACE-Inhibitor/ Diuretic, Thiazide

Lisinopril/HCTZ Tablet 20/12.5mg, 20/25mg

Zestoretic D ? + K

Antihypertensive: Alpha1 Blocker

Doxazosin Tablet 2mg, 8mg

Cardura

C ? + + See page

68

L

Antihypertensive: Alpha2 Adrenergic Agonist

Clonidine Tablet 0.1mg, 0.2mg, 0.3mg

Catapres

C ? + + See page

68

K

Antihypertensive: Angiotensin Receptor Blocker

Losartan Tablet 25mg, 50mg, 100mg

Cozaar

D ? +

L

Antihypertensive: Beta Blocker w/ alpha blocking ability

Carvedilol Tablet 3.125mg, 12.5mg, 25mg

Coreg

C ? +

L

Antihypertensive: Beta Blocker, cardioselective

Atenolol Tablet 50mg, 100mg

Tenormin

D - -

K

Antihypertensive: Beta Blocker, cardioselective

Metoprolol Succinate XL Tablet 25mg, 50mg, 100mg, 200mg

Toprol XL

C ? +

L

Antihypertensive: Calcium Channel Blocker

Amlodipine Tablet 5mg, 10mg

Norvasc

C ? +

L


Diltiazem HCl XR Capsule 180mg, 240mg

Cardizem CD

C + - +


Antihypertensive (cont): Calcium Channel Blocker

Nifedipine XL Tablet 30mg, 60mg, 90mg

Procardia XL

C - -

L


Verapamil SR Tablet 180mg, 240mg

Calan SR

C - + split/- crush

+ K/L

Antihypertensive: Calcium Channel Blocker- ACE-Inhibitor

Amlodipine-benazepril Capsule 2.5-10mg, 5-20mg, 10-40mg

Lotrel

D ? -

L,K

41






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Antihypertensive: Diuretic, Loop

Furosemide Tablet 40mg Lasix

C ? +

K/L

Antihypertensive: Diuretic, Potassium Sparing

Spironolactone/HCTZ Tablet 25mg/25mg HD

Aldactazide

D + +

K

Antihypertensive: Diuretic, Potassium Sparing

Spironolactone Tablet 25mg HD

Aldactone

D + +

K

Antihypertensive: Diuretic, Thiazide

Chlorthalidone Tablet 25mg

Thalitone

B ? +

K

Antihypertensive: Diuretic, Thiazide

Hydrochlorothiazide Tablet 25mg, 50mg

Hydrodiuril

B (D is used in

pregnancy-induced HTN)

+ +

K

Antihypertensive: Vasodilator

Hydralazine Tablet 25mg, 50mg

Apresoline

C + +

K

Alpha1 Blocker Prazosin Capsule

1mg, 2mg, 5mg Minipress

C ? -

L

Antiarrhythmic Amiodarone Tablet

200mg Cordarone

D - + +

See page 69, 71

L

Antiarrhythmic Digoxin Tablet

0.125mg, 0.25mg Lanoxin

C + + +

See page 69

K

Anticoagulant Enoxaparin SQ Injection

30mg, 40mg, 60mg, 80mg, 100mg, 120mg, 150mg (Patient Assistance Program)

Lovenox

B +

K


Anticoagulant (cont) Warfarin Tablet 5mg Coumadin

- (1st trimester),

C

Use caution

+ + See page

71

K/L

Anticoagulant (Direct Oral Anticoagulant)

Apixaban Tablets 2.5mg, 5mg, 10mg (Patient Assistance Program)

42






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Anticoagulant (Direct Oral Anticoagulant)

Rivaroxaban Tablet 15mg, 20mg

Xarelto

C - + + See page

69

K/L

Antihyperlipidemic, 2-Azetidinone

Ezetimibe tablet 10mg Zetia

C ? +

L

Antihyperlipidemic, Fibric Acid

Gemfibrozil Tablet 600mg

Lopid

C ? +

K

Antihyperlipidemic, HMG-CoA Reductase Inhibitor

Atorvastatin Tablet 10mg, 20mg, 40mg, 80mg

Lipitor

X - +

L

Antihyperlipidemic, HMG-CoA Reductase Inhibitor

Pravastatin Tablet 40mg Pravachol

X - +

K/L

Antiplatelet Aspirin Tablet (enteric

coated)81mg, 325mg Ecotrin

D ? -

K/L

Antiplatelet Clopidogrel Tablet 75mg Plavix

B ? +

L

Beta Blocker, non-selective

Propranolol Tablet 10mg, 40mg

Inderal

C + +

K/L

Carbonic Anhydrase Inhibitor

Acetazolamide Tablet 500mg ER 12 hr

Diamox Sequels

C - +

K/L

Vasodilator Isosorbide Dinitrate

Tablet 10mg, 20mg, 40mg

Isordil

C ? +

Vasodilator Nitroglycerin SL Tablet

0.4mg Nitrostat #100 tabs C ?

Vasodilator Nitroglycerin

Transdermal Patch 0.2mg/hr, 0.4mg/hr, 0.6mg/hr

Transderm Nitro #30 patches C ? -

DEVICE Nasal Aspirator + +

Nasal Irrigation Kit Neti Pot

+ +

Peak Flow Meter

+ +

DEVICE (cont) Pill Box

+ +

Spacer Aerochamber

+ +

Spacer, with mask Aerochamber

+ +

Syringes 31G 5/16" 0.5mL, 1mL

Monoject

+ +

Tablet Cutter

+ +

ELECTROLYTE SUPPLEMENT

Treatment of Dehydration Electrolyte Solution Pedialyte/ Infalyte

1,000 mL ? ?

ELECTROLYTE SUPPLEMENT

Treatment of Hypokalemia

Potassium Chloride Tablet 8mEq

Klor-Con

C ? - K

43






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Androgen Hormone Inhibitor, 5 Alpha-Reductase Inhibitor

Finasteride Tablet 5mg HD Proscar

X - - HD

L

ENDOCRINE AND METABOLIC AGENTS

Antidiabetic, Biguanide Metformin Tablet 1000mg

Glucophage

B ? + K/L

Antidiabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhib

Sitagliptin Tablet 25mg, 50mg, 100mg

Januvia

B ? - K/L

Antidiabetic, GLP-1 Agonist

Liraglutide 18mg/3mL Pen HD

(Patient Assistance Program)

Victoza 120 day supply PAP

C -

Antidiabetic, GLP-1 Agonist and Insulin Long-Acting Combination

Insulin glargine and lixisenatide 100units-33mcg/mL (Patient Assistance Program)

Soliqua 90 day supply PAP, 3 mL pen

B/C -

Antidiabetic, Insulin Rapid-Acting

Insulin Aspart 100units/mL

Novolog, Novolog FlexPen

10 mL vial, 3 mL pen

B/C + -

Antidiabetic, Insulin Rapid-Acting

Insulin Lispro 100units/mL

Humalog, Humalog KwikPen

Insured only, 10 mL vial, 3 mL pen

B/C +

Insulin Glulisine 100units/mL (Patient Assistance Program)

Apidra, Apidra Solostar

90 day supply PAP, 10 mL vial, 3 mL pen

B/C +

Antidiabetic, Insulin Short-Acting

Insulin Regular 100units/mL

Novolin R 10 mL vial B/C +

Antidiabetic, Insulin Combination

Insulin Aspart Protamine and Insulin Aspart

100units/mL

NovoLog Mix 70/30, NovoLog

Mix 70/30 FlexPen


B/C +

Insulin Lispro Protamine and Insulin Lispro 100units/mL

Humalog Mix 75/25

10 mL vial B/C +


Antidiabetic, Insulin Combination (cont)

Insulin NPH and Insulin Regular 100units/mL

Novolin 70/30, Humulin 70/30, Humulin 70/30 KwikPen

Humulin insured only, 10 mL vial, 3 mL pen

B/C +

Antidiabetic, Insulin Intermediate-Acting

Insulin NPH 100units/mL Novolin NPH 10 mL vial B/C +

Antidiabetic, Insulin Long-Acting

Insulin Detemir 100units/mL

Levemir, Levemir FlexTouch


B/C +

44






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Antidiabetic, Insulin Long-Acting

Insulin Glargine 100units/mL

Lantus, Lantus SoloStar

90 day supply PAP or insured only, 10 mL vial, 3 mL pen

B/C +

Antidiabetic, SGLT-2 Inhibitor

Empagliflozin Tablet 10mg, 25mg

Jardiance C - + K

Antidiabetic, Sulfonylurea Glipizide ER Tablet 5mg, 10mg

Glucotrol XL C ? - L

Antidiabetic, Thiazolidinedione

Pioglitazone Tablet 15mg, 30mg

Actos

C ? + L

Biphosphonates, Osteoporosis

Alendronate Tablet 4mg Fosamax #4 tabs C - + K

Contraceptive Hormone, Combination

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

Ortho-Novum 7/7/7

#28 tabs X/D - + + See page

70

L

Norgestrel/ E. Estradiol Tablet 0.3mg/0.03mg HD

Lo-Ovral #28 tabs X - + + See page

70

L

Contraceptive Hormone, Progestin

Medroxyprogesterone Acetate Tablet 10mg HD

Provera

X + + L

Norethindrone Tablet 0.35mg HD

Nor-Q-D #28 tabs X - (may start 6

wks after preg)

+ L

Contraceptive, Postcoital Levonorgestrel Tablet 1.5mg HD

Plan B One-Step #1 tab X - + L

Estrogen Estradiol Tablet 2mg HD Estrace

X - + + See page

70

L

Estrogen Estrogens, conjugated Tablet 0.625mg HD

Premarin X - + + See page

70

L

Glucocorticoids Methylprednisolone Tablet 4mg Dose Pack

Medrol #21 tabs C ? + K/L


Glucocorticoids (cont) Prednisolone Syrup 15mg/mL

Prelone C + K/L

Prednisone Tablet 5mg, 20mg

Deltasone

C + + K/L

Gonadotropin Releasing Hormone Agonist

Leuprolide IM Injection 11.25mg, 22mg, 30mgHD

(Patient Assistance Program)

Lupron 90 day supply PAP

X -

Gout Colchicine Tablet 0.6mg

HD Colcrys

C ? + K/L

45






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Gout, Xanthine Oxidase Inhibitors

Allopurinol Tablet 100mg, 300mg

Zyloprim

C + + K

Thyroid Levothyroxine Tablet 0.025mg, 0.1mg, 0.112mg, 0.125mg, 0.15mg, 0.175mg, 0.2mg

Levoxyl

A + +

Methimazole Tablet 10mg HD

Tapazole D + +

EYE, EAR, NOSE, AND THROAT

Analgesic Lidocaine (Viscous) Oral Solution 2%

Xylocaine 100 mL B +

Antiglaucoma, Alpha2 Agonist

Brimonidine Tartrate Ophthalmic Drops 0.2%

Alphagan 5 mL B ?

Antiglaucoma, Beta-Adrenergic Blocker

Timolol Maleate Ophth Soln 0.5%

Timoptic 5 mL C +

Antiglaucoma, Carbonic Anhydrase Inhibitor

Dorzolamide 2% Trusopt 10 mL C -

Antiglaucoma, Cholinergic Agent

Pilocarpine Ophth Soln 4%

Pilocar 15 mL C ?

Antiglaucoma, Prostaglandin Inhibitor

Latanoprost Ophth Soln 0.005%

Xalatan 2.5 mL C ?

Anti-infective Chlorhexidine Oral Rinse 0.12%

Peridex 480 mL B ?

Erythromycin Ophth Ointment 5mg/gm

Ilotycin 3.5 gm B +

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

Polytrim 10 mL C ?

Anti-infective, Corticosteroid

Neomycin/Polymyxin B/Hydrocortisone Otic Suspension

Cortisporin Otic Otic 10mL ? ?

Cerumenolytic Carbamide Peroxide Otic Drops 6.5%

Debrox 15 mL ? ?

Corticosteroid Fluticasone Propionate Nasal Spray 50mcg/spray

Flonase 16 gm C ?

Ketorolac Ophth Soln 0.5%

Acular 5 mL C ?

EYE, EAR, NOSE, AND THROAT

Corticosteroid (cont) Prednisolone Acetate Ophth Soln 1%

Pred Forte 15 mL C ?

Irrigation Saline Nose Spray Saline Spray 45 mL + +

Lubricant Artificial Tear Drops Artificial Tears 15 Ml + +

Artificial Tear Ointment Duratears 3.5 gm + +

46






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Mydriatic Atropine Ophth Soln 1% Atropine 15 mL C +

Antihistamine, Mast Cell Stabilizer

Ketotifen Ophth Soln 0.025%

Zaditor

5 mL C ?

Vasoconstrictor/ Antihistamine

Naphazoline/Pheniramine Ophth Soln 0.025%/0.3%

Vasocon-A 15 mL C ?

GASTROINTESTINAL DRUGS

Antacid Magnesium/Aluminum/ Simethicone 400mg/400mg/40mg Soln

Maalox Max Strength

480 mL C ?

K

Anticholinergic Dicyclomine Capsule 10mg

Bentyl

B - - + See page

68

Antidiarrheal Diphenoxylate/Atropine

Sulfate Tablet 2.5/0.025mg

Lomotil; Lonox

C - - K/L

Bismuth Subsalicylate Tablet 262mg

Pepto-Bismol #30 tabs D ? +

Loperamide Tablet 2mg Imodium #12 tabs C + +

Antiflatulent Simethicone Drops 40mg/0.6mL

Mylicon 30 mL C but + ?

Constipation, Chronic Lactulose Syrup 10gm/15mL

Duphalac Syrup

B ?

Constipation, IBS Lubiprostone Capsule 24mcg (Patient Assistance Program)

Amitiza 90 day supply PAP

C ? -

Histamine H2 Antagonist Famotidine Tablet 20mg, 40mg

Pepcid + + + K

Famotidine Suspension 40mg/5mL

Pepcid + + + K

Laxative, Diphenylmethane

Bisacodyl Tablet 5mg Dulcolax

C ? -

Laxative, Osmotic Glycerin suppository 1 gm

Pedia-Lax Rectal A + +

Glycerin suppository 2 gm

Sani-Supp Adult Rectal

A + +

Polyethylene Glycol MiraLax 255 gm C ?

GASTROINTESTINAL DRUGS

Laxative, Osmotic (for Bowel Prep)

Polyethylene Glycol with Electrolytes

GoLytely 4,000 mL C ?

Laxative, Bulk Psyllium Hydrophilic Powder

Metamucil 284 gm + ?

47






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Pancreatic Enzymes Pancreatic Enzymes Capsule Lipase/Protease/Amylase 6k/19k/30k, 12k/38k/60k, 24k/76k/120k (Patient Assistance Program)

Creon 90 day supply PAP

C ? - (OK to open

and give with

apple-sauce or pudding)

K

Prokinetic Metoclopramide Tablet 10mg

Reglan

B ? + K

Proton Pump Inhibitor Omeprazole Capsule

20mg

Prilosec

C ? - L

Stool Softener Docusate Sodium

Capsule 100mg

Colace #100 caps C ? - (taste

may be unaccept

able)

GENITOURINARY AGENTS

Alpha1 Blocker Tamsulosin Capsule 0.4mg

Flomax

B + -

Analgesic, Urinary Phenazopyridine Tablet 100mg, 97.5mg or 95mg

Pyridium

B ? + K

Anticholinergic, Urinary Tolterodine Tartrate Extended Release Tablet 4mg IPAP

Detrol LA

C - - K/L

Antispasmodic, Urinary Oxybutynin Chloride Tablet 5mg

Ditropan

B ? + K/L

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

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

C - + +

See page 70

K/L

Serotonin 5-HT1 Receptor Agonist

Eletriptan Tablet 40mg Relpax 6 tabs per box

C ? + L

NEPHROLOGY Calcium, Phosphate Binder

Calcium Acetate Capsule 667mg

PhosLo

C ? -

NEPHROLOGY Treatment of Hyperkalemia

Sodium Polystyrene Sulfonate Suspension 15gm/60mL

Kayexalate 60 mL per bottle

C ?

Vitamin D Analog Calcitriol Capsule 0.5mcg Rocaltrol

C ? -

48






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

NUTRIENTS AND NUTRITIONAL AGENTS

Calcium Supplement Calcium (elemental) Tablet 500mg

Calcium #60 tabs per bottle

+ (? 1st trimester)

? + K

Hypomagnesemia Magnesium Oxide Tablet 400mg (240mg elemental)

MagOx #120 tabs A + + L

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

Vitamin Cyanocobalamin Tablet 500mcg

Vitamin B12 #130 tabs C + +

Folic Acid Tablet 1mg

A + +

Multivitamin Drops with Iron

Poly-vi-sol 50 mL + +

Multivitamin Tablet, Adult

Centrum #100 tabs + + +

Multivitamin Tablet, Children

Flintstones #100 tabs + + +

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

Fish Oil #100 caps C ? - L

Prenatal Vitamin Tablet Natalins RX #100 tabs + + +

Vitamin Vitamin D3 Tablet 400 IU, 1000 IU

#100 tabs C Avoid high

doses

Vitamin D3 Capsule 50000 IU

C Avoid high

doses

Vitamin D3 Liquid 400 IU/mL

D-Vi-Sol 50 mL

RESPIRATORY AGENTS

Antihistamine Cetirizine Solution 1mg/mL

Zyrtec 120 mL B - K

Cetirizine Tablet 10mg Zyrtec #30 tabs B - + K

RESPIRATORY AGENTS

Antihistamine (cont) Loratadine Tablet 10mg Claritin #30 tabs B + + K

Antihistamine and Decongestant (Alpha/Beta Adrenergic Agonist)

Triprolidine/ Pseudoephedrine Tablet 2.5mg/60mg

Actifed #24 tabs - (1st trimester),

C

? + + See page

68

49






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Antitussive Benzonatate Capsule 100mg

Tessalon Perles #20 caps C ? -

Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant

Fluticasone Propionate/Salmeterol Diskus 100/50mcg, 250/50mcg, 500/50mcg

Advair Diskus

C ?

Bronchodilator, Anticholinergic

Ipratropium Bromide Nebulizer Soln 0.02%

Atrovent 25 vials per box

B ?

Tiotropium Bromide Capsule for inhalation 18mcg

Spiriva

C - -

Bronchodilator, Beta2-Adrenergic Agonist

Albuterol MDI Proventil, Ventolin, ProAir

C ?

Albuterol Nebulizer Solution 0.083%

Proventil, Ventolin

#25 C ?

Corticosteroids, Inhalant Fluticasone Propionate

MDI 44mcg/puff, 110mcg/puff, 220mcg/puff

Flovent

C ?

Decongestant (Alpha/Beta Adrenergic Agonist)

Pseudoephedrine Tablet 30mg, 60mg

Sudafed #24 tabs C + + K

Decongestant (topical) Oxymetazoline Nasal Spray 0.05%

Afrin 15 mL C ?

Expectorant Guaifenesin Tablet 200mg

Humibid #100 tabs C + +

Leukotriene Inhibitor Montelukast Chewable Tablet 4mg, 5mg

Singulair

B ? + L

Montelukast Tablet 10mg Singulair B ? + L

Disease Modifying Antirheumatic Drug (DMARD)

Methotrexate Tablet 2.5mgHD

Rheumatrex

X - + K/L

RHEUMATOLOGY Tumor Necrosis Factor Blocking Agent

Adalimumab Injection 40mg (Patient Assistance Program)

Humira 90 day supply PAP

B - - ?

SKELETAL MUSCLE RELAXANT

Centrally Acting Cyclobenzaprine Tablet 5mg

Flexeril

B ? + + See page

71

L

SKELETAL MUSCLE RELAXANT

Centrally Acting (cont) Methocarbamol Tablet 500mg

Robaxin

C ? + + See page

71

L

Baclofen Tablet 10mg Lioresal

C + + K

50






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

SKIN AND MUCOUS MEMBRANE AGENTS

Acne Benzoyl Peroxide Gel 5% Panoxyl 42.5 gm C ?

Tretinoin Cream 0.05%

HD Retin-A 45 gm D -

Antibiotic, Topical Bacitracin Ointment 500 units/gm

15 gm B ?

Mupirocin Ointment 2% Bactroban 22 gm B ?

Antifungal Ketoconazole Shampoo 2%

Nizoral 120 mL C ?

Miconazole Cream 2% Micatin 30 gm + ?

Nystatin Cream 100,000 units/gm

Mycostatin 15 gm C ?

Terconazole Vaginal Cream 0.8%

Terazol-3 20 gm C -

Anti-infective Silver Sulfadiazine Cream 1%

Silvadene 20 gm B -

Antiparasitic Agent, Pediculocide

Piperonyl Butoxide and Pyrethrum Extract Kit

Rid Shampoo 120 mL C ?

Permethrin Cream 5% Elimite 60 gm B ?

Anti-viral, topical immunomodulator

Imiquimod Cream 5% Aldara #12 single-use packets

C ?

Corticosteroid Clobetasol Ointment 0.05%

Temovate 15 gm C ?

Clobetasol Solution 0.05%

Temovate 50 mL C ?

Fluocinonide Cream 0.05%

Lidex 30 gm C -

Hydrocortisone Cream 1%, 2.5%

30gm (1%) 20gm(2.5%)

C ?

Hydrocortisone Ointment 1%

30 gm

Hydrocortisone Suppository 25mg

Anusol-HC #12 per box C ?

Triamcinolone Acetonide Cream 0.1%

Aristocort; Kenalog

15 gm, 80 gm

C ?


Corticosteroid (cont) Triamcinolone Acetonide Dental Paste 0.1%

Oralone 5 gm C ?

Dandruff Sulfur/Salicylic Acid Shampoo 2%/2%

Sebulex 120 mL C -


Estrogen Estrogens, conjugated Cream 0.625mg/gm HD

Premarin 30 gm X -

Miscellaneous Metronidazole Gel 0.75% (Topical)

Metrogel 45 gm B ?

51






Crush/ Split

Beers List

Dose Adjust

K=Kidney L=Liver

Moisturizing Moisturizing Cream Eucerin 120 gm + +

Protectant Zinc Oxide Ointment 20%

Desitin 30 gm + +

Tinea Versicolor; Dandruff; Seborrheic Dermatitis

Selenium Sulfide Lotion 2.5%

Selsun 120 mL C ?

Dopamine Reuptake Inhibitor

Bupropion Tablet 100mg Wellbutrin

C - + K/L

SMOKING CESSATION

Nicotine Product Nicotine Gum 2mg, 4mg Nicorette Gum 110 pieces C -

K/L

Nicotine Transdermal Patch 7mg/hr, 14mg/hr, 21mg/hr

Nicoderm CQ #14 patches D -

K/L

Partial Nicotine Agonist Varenicline Tablet Starter Pack IPAP

Chantix

C - + K

Varenicline Tablet Continuing Pack IPAP

Chantix

C - + K

ADHD, Narcolepsy Dextroamphetamine /Amphetamine Tablet 10mg

Adderall C - + K

STIMULANT Methylphenidate HCl Tablet 5mg

Ritalin C ? +

Updated: June 4th, 2020

FORMULARY: THERAPEUTIC CATEGORY LISTING*€¦ · 04.06.2020 · Tamiflu B + + K Oseltamivir...

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Transcript of FORMULARY: THERAPEUTIC CATEGORY LISTING*€¦ · 04.06.2020 · Tamiflu B + + K Oseltamivir...