FORMULARY: THERAPEUTIC CATEGORY LISTING*
Transcript of FORMULARY: THERAPEUTIC CATEGORY LISTING*
37 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.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.
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://adap.directory/sites/default/files/uploads/formularies/HMAPProgramManual_01142019.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.
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Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s 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
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 120 mL B (D in 3rd trimester)
+
+ See
page 76
K
Ibuprofen Tablet 400mg Motrin
B (D in 3rd trimester)
+ + taste may be
unacceptable
+ See page 76
K
Indomethacin Capsule 25mg, 50mg
Indocin
B (D in 3rd trimester)
+ - + See page 76
K
Naproxen Sodium Tablet 500mg
Naprosyn
B (D in 3rd trimester)
+ + + See page
76
K
NSAID, COX-2 Inhibitor Celecoxib Capsule 200mg
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 76
L
Tramadol Tablet 50mg Ultram C - + K/L
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Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
ANTIANEMIA AGENTS Iron Preparations Ferrous Sulfate Drops 75mg/mL (15mg/mL elemental)
50mL + +
Ferrous Sulfate Elixer 220mg/5mL (44mg/5mL
elemental)
480mL + +
ANTIANEMIA AGENTS Iron Preparations (cont) Ferrous Sulfate Tablet 325mg (65mg elemental)
#100 tabs + + +
ANTICONVULSANT AGENTS
Anticonvulsant, Analgesic
Pregabalin Capsule 150mg
Lyrica
C ? - K
Pregabalin Capsule 75mg
Lyrica
C ? - K
Anticonvulsant, Neuropathic pain (unlabeled)
Gabapentin Capsule 100mg, 300mg
Neurontin C ? - K
Barbiturate Phenobarbital Tablet 32.4mg
D - + +
See page 75
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
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Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Serotonin Reuptake Inhibitor/Antagonist
Trazodone Tablet 50mg Desyrel
C - + K/L
Serotonin/Norepinephrine Reuptake Inhibitor
Duloxetine Capsule 30mg, 60mg
Cymbalta
C ? - may open & mix w/
applesauce, NOT
chocolate
K/L
ANTIDEPRESSANT AGENTS
Tricyclic Amitriptyline Tablet 25mg, 50mg
Elavil
D - + + See page 74
Doxepin Capsule
25mg, 50mg
Sinequan
C - - +
See page 74
Imipramine Tablet 10mg, 25mg
Tofranil
D - + + See page 74
Nortriptyline Tablet 25mg
Pamelor
D + + + See page 74
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 73
Diphenhydramine Elixer 12.5ml/5mL
Benadryl 120 mL B -
+ See page 73
Opioid Antagonist Naloxone Nasal Spray 4 mg/0.1mL
Narcan 2 devices C ?
Naltrexone Tablet 50mg Revia 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
73
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Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Antidopaminergic, Phenothiazine
Promethazine Suppository 25mg
Phenergan
C -
+ See page 73
L
Promethazine Tablet
25mg
Phenergan
C -
+
See page 73
L
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
ANTI-INFECTIVES Antifungal (cont) 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
Valacyclovir Tablet 1 gm Valtrex B + + K
Antiviral (Antihepaciviral)
Glecaprevir-pibrentasvir Tablet 100-40mg (Patient Assistance Program)
Mavyret 28 day supply PAP
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
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Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Cephalosporin, 1st gen Cephalexin Capsule 250mg
Keflex B ? - K
Cephalexin Suspension 250mg/5ml
Keflex B ? K
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
ANTI-INFECTIVES Miscellaneous 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 Tablet 500mg
Cipro C (but teratogenicit
y unlikely)
? + K/L
Levofloxacin Tablet 500mg
Levaquin C ? + K
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Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Sulfonamide Sulfamethoxazole/ Trimethoprim Suspension 200mg-40mg/5mL
Septra Suspension
C +
+
See page 76
K/L
Sulfamethoxazole/
Trimethoprim Tablet 800mg/160mg
Septra DS
C +
+
See page 76
K/L
Tetracycline Doxycycline Tablet 100mg
Vibramycin
D ? +
Urinary Nitrofurantoin Capsule
100mg
Macrobid
B +? - +
See page 73
K/L
ANTINEOPLASTIC AGENTS
Aromatase Inhibitor Letrozole Tablet 2.5 mg HD
Femara X - L
Anti-estrogen Tamoxifen Tablet 10mg HD
Nolvadex D - -
ANTIPARKINSON AGENTS
Anticholinergic Trihexphenidyl Tablet 2mg
Artane
C - + + See page 73
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 76
K
Typical, D2 Antagonist Haloperidol Tablet 1mg, 2mg
Haldol
C - +
ANXIOLYTICS, SEDATIVES, HYPNOTICS
Antianxiety Agent Buspirone Tablet 15mg Buspar
B - + K/L
44 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Antihistamine Diphenhydramine Capsule 25mg, 50mg
Benadryl
B - - + See page 73
Diphenhydramine Elixer
12.5ml/5mL
Benadryl 120 mL B -
+
See page 73
Hydroxyzine HCL Syrup 10mg/5mL
Atarax
C -
+ See page
73
K/L
Hydroxyzine HCL Tablet 25mg, 50mg
Atarax
C - + + See page 73
K/L
Benzodiazepine Diazepam Tablet 5mg Valium
D - + + See
page 75, 76
L
Oxazepam Capsule 15mg
Serax
D - - + See page
75, 76
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
CARDIOVASCULAR
DRUGS Antihypertensive:
Alpha1 Blocker
Doxazosin Tablet 2mg,
8mg
Cardura
C ? + +
See page 73
L
Antihypertensive: Alpha2 Adrenergic Agonist
Clonidine Tablet 0.1mg, 0.2mg, 0.3mg
Catapres
C ? + + See page
73
K
Antihypertensive: Angiotensin Receptor Blocker
Losartan Tablet 25mg, 50mg, 100mg
Cozaar
D ? +
L
Antihypertensive: Angiotensin Receptor Blocker/Neprilysin
inhibitor
Sacubitril/Valsartan Tablet 24/26mg, 49/51mg, 97/103mg (Patient Assistance Program)
Entresto Up to 90 day supply PAP
X - + K/L
Antihypertensive: Beta Blocker w/ alpha blocking ability,
Carvedilol Tablet 3.125mg, 12.5mg, 25mg
Coreg
C ? +
L
45 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
non-cardioselective
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, dihydropyridine
Amlodipine Tablet 5mg, 10mg
Norvasc
C ? +
L
Antihypertensive: Calcium Channel Blocker, dihydropyridine
Nifedipine XL Tablet 30mg, 60mg, 90mg
Procardia XL C - - L
Antihypertensive: Calcium Channel Blocker, non-
dihydropyridine
Diltiazem HCl XR Capsule 180mg, 240mg
Cardizem CD
C + - +
Antihypertensive: Calcium Channel Blocker, non-dihydropyridine
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
Antihypertensive: Diuretic, Loop
Furosemide Tablet 40mg
Lasix
C ? +
K/L
Antihypertensive: Diuretic, Potassium Sparing, thiazide
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
CARDIOVASCULAR DRUGS
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
46 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Alpha1 Blocker Prazosin Capsule
1mg, 2mg, 5mg Minipress
C ? -
L
Antiarrhythmic Amiodarone Tablet
200mg Cordarone
D - + +
See page
74, 76
L
Antiarrhythmic Digoxin Tablet
0.125mg, 0.25mg Lanoxin
C + + +
See page 74
K
Anticoagulant Enoxaparin SQ Injection
30mg, 40mg, 60mg, 80mg, 100mg, 120mg, 150mg (Patient Assistance Program)
Lovenox
B +
K
Anticoagulant Warfarin Tablet 5mg Coumadin
- (1st trimester), C
Use caution
+ + See
page 76
K/L
Anticoagulant (Direct Oral Anticoagulant)
Apixaban Tablets 2.5mg, 5mg, 10mg (Patient Assistance Program)
90 day supply PAP
Anticoagulant (Direct
Oral Anticoagulant)
Rivaroxaban Tablet
15mg, 20mg
Xarelto
C - + +
See page 74
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
CARDIOVASCULAR DRUGS
Antiplatelet Aspirin Tablet (enteric coated)81mg, 325mg
Ecotrin #120 81mg #100
100mg
D ? -
K/L
Antiplatelet Clopidogrel Tablet 75mg Plavix
B ? +
L
Beta Blocker, non-selective
Propranolol Tablet 10mg, 40mg
Inderal
C + +
K/L
47 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
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 #25 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
+ +
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 ? ?
Treatment of Hypokalemia
Potassium Chloride Tablet 8mEq
Klor-Con
C ? - K
ENDOCRINE AND METABOLIC AGENTS
Androgen Hormone Inhibitor, 5 Alpha-Reductase Inhibitor
Finasteride Tablet 5mg
HD Proscar #30 tabs X - -
HD L
Antidiabetic, Biguanide Metformin Tablet
500mg, 1000mg
Glucophage
B ? + K/L
Antidiabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhibitor
Sitagliptin Tablet 25mg, 50mg, 100mg
Januvia
B ? - K/L
Antidiabetic, GLP-1 Agonist
Liraglutide 18mg/3mL Pen HD
Victoza 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 -
ENDOCRINE AND METABOLIC AGENTS
Antidiabetic, Insulin Rapid-Acting
Insulin Aspart 100units/mL
NovoLog, NovoLog
FlexPen
10 mL vial, 3 mL pen
B/C + -
48 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
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
10 mL vial,
3 mL pen
B/C +
Insulin Lispro Protamine and Insulin Lispro 100units/mL
Humalog Mix 75/25
10 mL vial B/C +
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
10 mL vial, 3 mL pen
B/C +
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 75
L
49 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Norgestrel/ E. Estradiol Tablet 0.3mg/0.03mg HD
Lo-Ovral #28 tabs X - + + See page 75
L
ENDOCRINE AND
METABOLIC AGENTS
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 75
L
Estrogen Estrogens, conjugated Tablet 0.625mg HD
Premarin X - + + See page 75
L
Glucocorticoids Methylprednisolone
Tablet 4mg Dose Pack
Medrol #21 tabs C ? + K/L
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
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 +
50 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
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 ?
EYE, EAR, NOSE, AND THROAT
Anti-infective Ciprofloxacin Ophth Soln 0.3%
Cipro 5 mL bottle C (but teratogenicity unlikely)
?
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
Ciprofloxacin-Dexamethasone 0.3-0.1% otic soln
Ciprodex 7.5 mL C (but teratogenicity unlikely)
?
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 ?
Prednisolone Acetate
Ophth Soln 1%
Pred Forte 15 mL C ?
Decongestant (topical) Oxymetazoline Nasal Spray 0.05%
Afrin 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 + +
Antihistamine, Mast Cell Stabilizer
Olopatadine 0.2% ophthalmic soln
Pataday
2.5 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
51 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Anticholinergic Dicyclomine Capsule 10mg
Bentyl
B - - + See page 73
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 Lactulose Syrup 10gm/15mL
Duphalac Syrup
B ?
GASTROINTESTINAL DRUGS
Constipation (cont) Linaclotide Capsule 145 mcg, 290 mcg
Linzess C ? -
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 238 gm C ?
Laxative, Osmotic (for Bowel Prep)
Polyethylene Glycol with Electrolytes
GoLytely 4,000 mL C ?
Laxative, Bulk Psyllium Hydrophilic
Powder
Metamucil 284 gm + ?
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
52 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Proton Pump Inhibitor Omeprazole Capsule 20mg
Prilosec
C ? - L
Stool Softener Docusate Sodium Capsule 100mg
Colace #100 caps C ? - (taste may be
unacceptable
)
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
Detrol LA
C - - K/L
GENITOURINARY AGENTS
Antispasmodic, Urinary (cont)
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 75
K/L
Serotonin 5-HT1 Receptor Agonist
Eletriptan Tablet 40mg Relpax #6 tabs C ? + L
NEPHROLOGY Alkalinizing Agent Sodium Bicarbonate
Tablet 650mg
Neut C ? +
Calcium, Phosphate Binder
Calcium Acetate Capsule 667mg
PhosLo
C ? -
Treatment of Hyperkalemia
Sodium Polystyrene Sulfonate Suspension 15gm/60mL
Kayexalate 60 mL per bottle
C ?
Vitamin D Analog Calcitriol Capsule 0.5mcg
Rocaltrol
C ? -
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
53 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
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 + + +
NUTRIENTS AND NUTRITIONAL AGENTS
Vitamin (cont) 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 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
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 73
Antitussive Benzonatate Capsule 100mg
Tessalon Perles
#20 caps C ? -
54 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant
budesonide/formoterol MDI 80/4.5mcg, 160/4.5mcg
Symbicort C ?
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 ?
RESPIRATORY AGENTS 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
Expectorant Guaifenesin Tablet 200mg
Humibid #100 tabs C + +
Leukotriene Inhibitor Montelukast Chewable Tablet 4mg, 5mg
Singulair
B ? + L
Montelukast Tablet 10mg
Singulair B ? + L
RHEUMATOLOGY Disease Modifying
Antirheumatic Drug (DMARD)
Methotrexate Tablet
2.5mgHD
Rheumatrex
X - + K/L
Sulfasalazine Tablet 500mg
Sulfazine, Azulfadine
D - + K/L
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 76
L
Methocarbamol Tablet 500mg
Robaxin
C ? + + See page
76
L
55 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
Baclofen Tablet 10mg Lioresal
C + + K
SKIN AND MUCOUS MEMBRANE AGENTS
Acne Benzoyl Peroxide Gel 5%
Panoxyl 42.5 gm C ?
Tretinoin Cream 0.05%
HD
Retin-A 20 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 ?
SKIN AND MUCOUS MEMBRANE AGENTS
Antifungal (cont) 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,60 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%, 2.5%
30gm (1%) 20gm
(2.5%)
Hydrocortisone Suppository 25mg
Anusol-HC #12 per box
C ?
Triamcinolone Acetonide Cream 0.1%
Aristocort; Kenalog
15 gm, 80 gm
C ?
Triamcinolone Acetonide Ointment 0.1%
Aristocort; Kenalog
15 gm, 80 gm
C ?
Triamcinolone Acetonide Dental Paste 0.1%
Oralone 5 gm C ?
56 n:\lchc_pharm\formulary management\formulary of drugs book\2022\revised for 2022 book\word\7. formulary of drugs (therapeutic) 6-2-21 pp37,56.docx
Therapeutic Category Pharmacologic
Category
Medication Brand
Name
Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/ Split Beer
s List
Dose
Adjust K=Kidney L=Liver
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 ?
Moisturizing Moisturizing Cream Eucerin 120 gm + +
Protectant Zinc Oxide Ointment 20%
Desitin 30 gm + +
Psoriasis Apremilast Tablet 30 mg Otezla C - - K
Tinea Versicolor; Dandruff; Seborrheic
Dermatitis
Selenium Sulfide Lotion 2.5%
Selsun 120 mL C ?
Dopamine Reuptake Inhibitor
Bupropion Tablet ER 150mg, 300 mg
Wellbutrin XL
C - + K/L
SMOKING CESSATION Nicotine Product Nicotine Gum 2mg, 4mg Nicorette Gum
110 pieces C -
K/L
SMOKING CESSATION Nicotine Product (cont) Nicotine Transdermal Patch 7mg/hr, 14mg/hr,
21mg/hr
Nicoderm CQ
#14 patches
D -
K/L
Partial Nicotine Agonist Varenicline Tablet Starter Pack
Chantix
C - + K
Varenicline Tablet Continuing Pack
Chantix
C - + K
STIMULANT ADHD, Narcolepsy Dextroamphetamine /Amphetamine Tablet 10mg, 20mg, 30mg
Adderall C - + K
Methylphenidate HCl Tablet 5mg
Ritalin C ? +
Updated: June 2, 2021