Texas HHS Psychiatric drug formulary · 2020-04-24 · dentist, nurse or pharmacist desires to have...

Texas Health and Human Services

Commission

Psychiatric Drug Formulary

State Hospitals

&

State Supported Living Centers

&

Community Mental Health Centers

18T2020

Approved October 2019

Updated April 2020

Texas HHS Psychiatric Drug Formulary 2020

Table of Contents 2

Table of Contents

Table of Contents ................................................................................... 2

Introduction ........................................................................................... 4

Members of the HHSC Psychiatric Executive Formulary Committee........ 7

Ex-Officio Members ................................................................................ 7

HHS Psychiatric Drug Formulary editor .................................................. 7

Procedure for Addition of Drugs to the Formulary .................................. 8

Psychotropic Dosage Guidelines ............................................................. 9

Children and Adolescent Treatment of Behavioral Emergencies.................. 10 Adult Treatment of Behavioral Emergencies ............................................ 11 Antipsychotics ..................................................................................... 12

Antidepressants ................................................................................... 15 Mood Stabilizers .................................................................................. 17

Stimulants .......................................................................................... 19 Miscellaneous Drugs Used for Psychotropic Purposes ................................ 20 Anxiolytics .......................................................................................... 21

Hypnotics ........................................................................................... 21

Reserve Drugs ...................................................................................... 23

Therapeutic Serum Concentrations of Some Anticonvulsants ............... 31

Alphabetical Listing .............................................................................. 32

Therapeutic Classification/Cost Index ................................................. 80

Antidiabetic Agents .............................................................................. 80 Antidotes ............................................................................................ 80

Antineoplastic Agents ........................................................................... 81 Blood Modifying Agents ........................................................................ 81 Cardiovascular Agents .......................................................................... 82

Central Nervous System Agents ............................................................ 85 Endocrine Agents ................................................................................. 93

Gastrointestinal Agents ........................................................................ 94 Genitourinary Agents ........................................................................... 97 Immunological Agents .......................................................................... 99

Infectious Disease Agents ................................................................... 100 Parenteral Solutions and Additives ....................................................... 103

Nutritional Agents .............................................................................. 103 Respiratory Agents ............................................................................ 105

Topical Agents ................................................................................... 107 Nutritional Supplements ..................................................................... 115


Table of Contents 3

Index ................................................................................................. 117

Appendix A. New Drug Application Form .............................................. A1

Appendix B. PEFC Conflict of Interest Policy ........................................ B1

Appendix C. PEFC Disclosure Form ....................................................... C1

Appendix D. Non-Formulary Drug Justification Form ........................... D1

Appendix E. Adverse Drug Reaction Reporting (MedWatch) Form ........ E1

Appendix F. Foods Containing Tyramine............................................... F1

Appendix G. Oral Morphine Conversion Table ....................................... G1


Introduction 4

Introduction

The Texas Health and Human Services Psychiatric Drug Formulary is the publication that outlines

the medications that have been approved for use in Community Mental Health Centers, Mental

Health State Hospitals and the State Supported Living Centers. The formulary is published

annually around the beginning of the calendar year. This document is divided into three sections

(Alphabetical Listing, Therapeutic Classification/Cost Index, and Alphabetical Index) to facilitate

usage.

Alphabetical Listing:

This section lists all the medications alphabetically by generic (nonproprietary) name. Trade

(proprietary) names and abbreviations are listed in parenthesis after the generic name. In this

section, all approved dosage forms are listed. All available strengths of approved dosage forms

are considered formulary unless specifically noted otherwise.

Therapeutic Classification/Cost Index:

This section groups the medications by therapeutic usage and lists them alphabetically by

generic (nonproprietary) name. Medications may be listed in multiple categories. For trade

names, consult the alphabetical index. Also in this section is a relative cost index so that

medications used in similar situations can be evaluated keeping cost of care in mind. Relative

cost is noted as either low, moderate, or high and is based on cost per day of the average dose.

The relative cost of bulk items is indexed per unit (gram, ml).

Alphabetical Index:

This section lists all the medications alphabetically by trade name, generic name, and

abbreviations. Page numbers for each of the listings is provided.


Introduction 5

The purpose of the HHSC Psychiatric Executive Formulary Committee is to maintain and update

the Formulary and to recommend standards for drug use within the Community Mental Health

Centers, State Hospitals and the State Supported Living Centers. The Committee is concerned

with maintaining the highest standards for drug use. To assist the clinician in prescribing the

most cost effective agents a Therapeutic Classification with relative cost data is provided.

Because of their frequency of use, the highest level of concern and vigilance centers on the

psychotropic medications. For the clinician's reference, the Formulary provides tables

summarizing the recommended dosage ranges for the psychotropic drugs; however, these

guidelines are not intended to replace other references or the clinician's clinical judgment. The

clinician is urged to check with other references, including the Texas Administrative Code, Title

25, Part 1, Chapter 415, Subchapter A, Prescribing of Psychoactive Medication, The American

Hospital Formulary Service Drug Information, Facts & Comparisons, and The AMA Drug

Evaluations among other reliable sources.

This Formulary, is not intended to be a reference for drug use. Rather it is to serve the clinician

as a listing of drugs, which are approved for use. Approval of a drug entity for inclusion in the

Formulary does not imply approval of all formulations containing that entity. The HHSC

Psychiatric Executive Formulary Committee will decide which formulations are approved for use.

Not all drugs listed in the Formulary will be stocked at each facility's pharmacy. If a physician,

dentist, nurse or pharmacist desires to have a drug added to the Formulary, he or she should

complete and submit the appropriate form (New Drug Application, see Appendix 1) to the

facility’s Pharmacy and Therapeutics Committee. If it is approved at the facility level, the

facility’s Director of Pharmacy must then forward the request to the HHSC Psychiatric Executive

Formulary Committee in care of the State Hospitals. Requests received at least 30 days prior to

the quarterly meeting will be considered at that meeting. Requests received less than 30 days

before the meeting will not be considered until the following meeting. Clinicians and facilities are

encouraged to submit supporting documents with their formulary request. The HHSC Psychiatric

Executive Formulary Committee will evaluate the submission's appropriateness based upon the

efficacy and safety of the proposed drug compared with existing formulary items and cost

effectiveness of the new agent. When appropriate, the HHSC Psychiatric Executive Formulary

Committee will add the new drug or replace old agents in the same pharmacological/therapeutic

category with the new agent.

The Formulary consists of routine and reserve drugs. Drugs in the reserve class have specific

guidelines for use printed in the Formulary. These guidelines will be used to audit the

appropriate use of reserve drugs. Based on the audit results, continuing education will be

developed and targeted as needed. The purpose of reserve status is to stimulate thought and

promote care in prescribing. Discussions about the use of reserve status drugs with peers are

encouraged. Use of reserve status drugs requires documentation of justification in the patient’s

progress notes.


Introduction 6

As a means of preventing medication errors, the Formulary has incorporated TALL MAN

characters to assist in distinguishing look-alike drug names. TALL MAN characters are being

implemented in various parts of the pharmaceutical industry in order to prevent medication

errors. Even though the Formulary may not play a major role in preventing medication errors,

hopefully this change will stimulate the awareness of TALL MAN characters and assist in

implementing this print style in other areas of our medication use process.

The HHSC System utilizes a closed formulary system. Only drugs listed in the Formulary are to

be stocked, prescribed and dispensed in State Hospitals and State Supported Living Centers

including pharmaceutical products recommended by consultants for specialized treatments.

When a patient's condition requires a drug not listed in the Formulary, limited quantities can be

obtained for use in that particular patient. However, documentation (Non-Formulary Drug

Justification Form, see Appendix 3) or other appropriate pharmacy software generated report

should be submitted to the facility Medical Director and the State Hospital Chief Medical

Director’s office where it will be reviewed by the HHSC Psychiatric Executive Formulary

Committee to assure reasonable compliance with the Formulary.

When requested by the Commissioner, the HHSC Psychiatric Executive Formulary Committee will

make other recommendations regarding drug use. If facility clinicians have topics for committee

consideration, these requests should be sent to the Chairperson, HHSC Psychiatric Executive

Formulary Committee in care of the State Hospitals (mail code 2023). The Committee also

appreciates your comments concerning the printing of the Formulary and Committee

deliberations and decisions. Please feel free to provide input.

Mark Messer, D.O. Chairperson

HHSC Psychiatric Executive Formulary Committee October 2019


Introduction 7

Members of the HHSC Psychiatric Executive Formulary

Committee

Angela Babin, RPh

The Harris Center for Mental Health & IDD

Jean Baemayr, PharmD

State Hospitals

John Bennett, MD

Dallas Metrocare Services

Bonnie Burroughs, PharmD

Abilene State Supported Living Center

German Corso, MD

Tropical Texas Behavioral Health

Catherine S. Hall, PharmD, BCPP, BCACP

San Antonio State Hospital

Jeanna Heidel, PharmD

Rusk State Hospital

Dana Hopkins, RN

Austin State Hospital

Jeffery Matthews, MD

UT Health Science Center Tyler

Mark Messer, DO

Terrell State Hospital

David Moron, MD

Rio Grand State Center

Kenda Pittman, PharmD


Rishi Sawhney, MD

BHS Community Behavioral Health

Glenn Shipley, DO


Ashton Wickramasinghe, MD

Austin State Supported Living Center

Ex-Officio Members

Tim Bray

Associate Commissioner

State Hospitals

Mike Maples

Deputy Executive Commissioner

HHS Facilities

Brad Fitzwater, MD

Medical Director

HHSC Substance Use

Nina Muse, MD

Chief Medical Officer

State Hospitals

Connie Horton, RNP

HHSC Nursing Services Coordinator


Peggy Perry

Director of Quality Management

State Hospitals

Raul Luna, RN, MSN

Chief of Nursing

State Hospitals

Rachel Samsel

Director of Policy and Projects

State Hospitals

HHS Psychiatric Drug Formulary editor

Jean Baemayr, PharmD


Procedure for Addition of Drugs to the Formulary 8

Procedure for Addition of Drugs to the Formulary

A physician, dentist, nurse or pharmacist desiring that a new drug be added to the Formulary

should submit a new drug application (New Drug Application, see Appendix 1) to the facility's

formulary committee. If approved, the new drug application should be forwarded to the HHSC

Psychiatric Executive Formulary Committee. The following information should accompany the

application:

1. published articles in the biomedical literature that substantiate the efficacy and safety of

the proposed new drug;

2. advantages of the proposed new drug compared with similar therapeutic agents presently

in the Formulary;

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

4. cost effectiveness data.

New drug applications should be received by the secretary of the committee thirty days prior to

the committee's scheduled meeting date. Applications received after this time will be considered

at the next meeting.

The chairperson will assign a committee member to present an objective treatise and

recommendations concerning the proposed to new drug to the HHSC Psychiatric Executive

Formulary Committee. The committee may decide to approve or deny the drug's inclusion,

approve the drug on a trial basis, or postpone a decision until the following meeting of the

committee. The committee, at its discretion, may approve a drug's inclusion in the Formulary

subject to specific limitations (e.g., recommendation by qualified specialists or consultants) or as

a reserve drug.

The specific limitations or guidelines for use of a reserve drug are stated in the formulary. A

credentialed clinician may prescribe reserve drugs outside Formulary guidelines; however, such

exceptions must be justified in the patient record and must be reviewed in routine facility audits

of reserve drug utilization.

HHSC Psychiatric Executive Formulary Committee

Texas Health and Human Services, Health and Specialty Care System P.O. Box 149347

Mail Code 2023 Austin, TX 78714-9347


Psychotropic Dosage Guidelines 9

Psychotropic Dosage Guidelines

The following is a list of psychotropic drug dosages. These guidelines are not intended to

establish rigid standards of treatment but to assist in monitoring the pharmacotherapy of the

patient. Furthermore, guidelines for special patient populations are not intended to be absolute.

For those medications that have a well-established therapeutic serum range, the dosage should

be based upon the desired serum range and response rather than a specific maximum

administered daily dosage. These guidelines should be used in conjunction with sound clinical

judgment and the prescriber’s experience.

In children and adolescents, metabolic and physiologic differences from adults should be

considered when prescribing. Dosing based on body weight may be more accurate when treating

these patients.

Different dosage requirements are usually necessary in the geriatric population. Since there is no

standard definition for “geriatric”, the arbitrary age of 65 has been chosen to identify geriatric

patients. In general, geriatric patient dosing guidelines should reflect a “go low, go slow”

approach. Standard reference books should be consulted if needed for appropriate dosages when

treating this population.

In general, when treating patients with intellectual disabilities, a “go low, go slow” approach is

recommended when increasing or decreasing psychotropic medication. The use of psychotropic

medication can be therapeutic and empowering for a person with both intellectual disabilities

and mental illness. The primary goal is to obtain an accurate diagnosis of behavioral and

psychiatric symptoms so that the patients’ treatment is appropriate. A functional analysis by a

psychologist is vital prior to starting any psychotropic medication except in an emergency.

Prescribing psychotropic medication should be based on the following resources:

Texas Administrative Code, Title 25, Part 1, Chapter 415, Subchapter A, Prescribing of

Psychoactive Medications

Other useful resources that reflect current Standards of Care for the mentally ill include but are

not limited to the following:

American Psychiatric Association Practice Guidelines

Texas Health and Human Services: Psychotropic Medication Utilization Parameters for

Children and Youth in Texas Public Behavioral Health



Children and Adolescent Treatment of Behavioral

Emergencies

Intramuscular Short-Acting Agents

Unless noted by reference, the dose was obtained from a survey of use that was completed by

practitioners that treat this population within our agency.

Children (< 12 y/o)

Drug Maximum Single

dose (mg)

Minimum Interval

(hrs)

Maximum Total

Dose per day (mg)

chlorproMAZINE1,2,4,7 0.55 mg/kg 25 – 50 6 to 8 < 5 y/o: 40

≥ 5 y/o: 75

*diphenhydrAMINE1,2,4,7 1 mg/kg 50 4 to 6 100

Haloperidol1,2,3,4,5,6 0.05-0.15 mg/kg 5 4 to 6 10

hydrOXYzine 25 – 50 4 to 6 150

LORazepam1,2,3,4,5 0.05-0.1 mg/kg 2 4 to 8 4

OLANZapine1,3,5,6 5 4 to 6 10-20

^Ziprasidone3,5,6 5 4 to 6 20

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

Drug Maximum Single

dose (mg)

Minimum Interval

(hrs)

Maximum Total

Dose per day (mg)

chlorproMAZINE1,2,4,7 0.55 mg/kg 25 – 50 6 to 8 75

*diphenhydrAMINE1,2,4,7 1 mg/kg 50 4 to 6 200

Haloperidol1,2,3,4,5,6 0.05-0.15 mg/kg 5 4 to 6 15

hydrOXYzine 50 – 100 4 to 6 200

LORazepamP1,2,3,4,5 0.05-0.1 mg/kg 2 4 to 8 8

OLANZapine1,3,5,6 10 4 to 6 20

^Ziprasidone3,5,6 10 4 to 6 20



*diphenhydrAMINE use in behavioral emergencies is not supported in the literature and there

are a high rate of paradoxical reactions in this population

^ Gerson and colleagues did not recommend ziprasidone due to activating potential and QT

prolongation

1. Gerson R, Malas N, Feuer V, et. Al. Best Practices for Evaluation and Treatment of agitated

children and Adolescents (BETA) in the Emergency Department: Consensus Statement of

the American Association of Emergency Psychiatry. West J of Emerg Med. 2019;20(2):409-

418.

2. Fox, S (2016, August 5; Updated 2017, August 29). Agitation. Pediatric EM Morsels.

Retrieved from https://pedemmorsels.com/agitation/

3. Chun TH, Mace SE, Katz ER. Evaluation and Management of Children and Adolescents with

Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of

Patients with Mental Health and/or Behavioral Emergencies. Pediatrics. 2016;138(3):e1-

e22.

4. Carubia B, Becker A, Levine BH. Child Psychiatric Emergencies: Updates on Trends, Clinical

Care, and Practice Challenges Curr Psychiatry Rep. 2016;18(41):1-8.

5. Marzullo LR. Pharmacologic Management of the Agitated Child. Pediatric Emergency Care.

2014;30(4):269-275.

6. Sonnier L, Barzman D. Pharmacologic Management of Acutely Agitated Pediatric Patients.

Pediatr Drugs. 2011;13(1):1-10.

7. Lexicomp® Drug Information Handbook, 27PthP Edition, American Pharmacist Association.

Tables added February 2009; Reviewed October 2019

Adult Treatment of Behavioral Emergencies

Intramuscular Short-Acting Agents

Drug Maximum Single

dose (mg)

Minimum Interval

(hrs)

Maximum Total

Dose per day (mg)

IM chlorproMAZINE1 100* 2 400

IM diphenhydrAMINE2,3 100 1 400

IM fluPHENAZine3,4 10 1 10^

IM Haloperidol1 10 1 40

IM hydrOXYzine2,3 100 1 400

IM LORazepam1,5 4 0.5 12

IM OLANZapine1,6 10 2 30



Drug Maximum Single

dose (mg)

Minimum Interval

(hrs)

Maximum Total

Dose per day (mg)

IM Ziprasidone7 10 2 40

IM Ziprasidone7 20 4 40

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

^Use doses exceeding 10 mg daily with caution

1. Allen MG, Currier GW, Carpenter D, et al. Treatment of Behavioral Emergencies Expert

Consensus Guidelines Series. Journal of Psychiatric Practice 2005; 11 [Suppl 1]:1-108.

2. Lexicomp® Drug Information Handbook, 27PthP Edition, American Pharmacists Association

3. Micromedex® [electronic version]. Truven Health Analytics, Greenwood Village, CO, USA

(cited 07-15-19)

4. Product Information: Fluphenazine hydrochloride injection. Fesenius Kabi, Lake Zurich, IL,

2016.

5. Lukens TW, Wolf SJ, Edlow JA, et al. Clinical Policy: Critical Issues in the Diagnosis and

Management of the Adult Psychiatric Patient in the Emergency Department. From the

American College of Emergency Physicians Clinical Policies Subcommittee (Writing

Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric

Patient in the Emergency Department. Ann Emerg Med 2006; 47:79-99.

6. Product Information: Zyprexa®, olanzapine intramuscular injection. Eli Lilly and Company,

Indianapolis, IN, USA, 3-2018.

7. Product Information: GEODON® ziprasidone mesylate IM injection. Pfizer, Inc, New York,

NY, 11-2018.

Reviewed October 2019

Antipsychotics

Suggested maximum doses (mg/day)

Drug Adult Child (< 12 y/o) Adolescent

(12 y/o to < 18

y/o)

ARIPiprazole (Abilify) 30 4 to 11 y/o: 15 (Lit)

Tourette’s (FDA)

6 - < 12 y/o

104 (<50 kg)

204 (≥50 kg)

30

Tourette’s (FDA)

104 (<50 kg)

204 (≥50 kg)




(12 y/o to < 18

y/o)

ARIPiprazole Extended

Release

(Abilify Maintena)

400 per 4 weeks ID ID

ARIPiprazole lauroxil

(Aristada)

882 per 4 weeks

1064 per 8 weeks

ID ID

Asenapine (Saphris) 20 10 to < 12 y/o: 20 20

Brexpiprazole (Rexulti) 4 ID ID

Cariprazine (Vraylar) 6 ID ID

chlorproMAZINE

(Thorazine)

2,000 5 – 12 y/o: 75 (Lit) 800 (Lit)

cloZAPine (Clozaril,

Fazaclo, Versacloz)

RESERVE USE

900 8 – 11 y/o: 300 (Lit) 600 (Lit)

fluPHENAZine (oral)

(Prolixin)

40 ID ID

fluPHENAZine Decanoate

(Prolixin Decanoate)


Haloperidol (oral)

(Haldol)

40 3 – 12 y/o:

Lesser of 0.15 mg/kg

or 6 (Lit)

> 12 y/o:

Acute agitation 10

Psychosis 15

Tourette 15 (Lit)4

Haloperidol Decanoate

(Haldol Decanoate)

450 per month ID ID

Iloperidone (Fanapt)

RESERVE USE

24 ID ID

Loxapine (Loxitane) 250 ID ID

Lurasidone (Latuda) 160 10 – 11 y/o: 805 (Lit) 13 – 17 y/o: 80

OLANZapine (ZyPREXA,

ZyPREXA Zydis)

30 4 – 5 y/o: 12.5 (Lit)

6 – 12 y/o: 20 (Lit)

13 – 17 y/o: 20




(12 y/o to < 18

y/o)

OLANZapine pamoate

(ZyPREXA Relprevv)

RESERVE USE

300 per 2 weeks

405 per 4 weeks

ID ID

Paliperidone (Invega) 12

ID 6 (< 51 kg)

12 (≥ 51 kg)

Paliperidone palmitate

(Invega Sustenna)


Paliperidone palmitate

(Invega Trinza)

NON-Formulary

819 per 3 months ID ID

Perphenazine (Trilafon) 64 ID > 12 y/o: 64 (Lit)

QUEtiapine (SEROquel) 800 5 – 9 y/o: 400 (Lit)

10–12 y/o: 800 (Lit)

13 – 17 y/o: 800

risperiDONE (RisperDAL,

RisperDAL M-Tab)

81 *5 to < 12 y/o: 3 6

RisperDAL Consta 50 per 2 weeks ID ID

Thioridazine (Mellaril)2

RESERVE USE

(ABSOLUTE) 800 ID ID

Thiothixene (Navane) 60 ID ID

Trifluoperazine

(Stelazine)

40 ID ID

Ziprasidone (Geodon) 240 10 – 11 y/o:

803 (≤ 45 kg)

1603 (> 45 kg) (Lit)

1603 (> 45 kg) (Lit)

1. Risperidone doses > 6 mg/day have increased risk of EPS

2. A boxed warning has been added to advise clinicians of prolongation of the QTc interval

3. Bipolar Disorder

4. Tourette’s Disorder

5. Bipolar I Depression

* Any approved indication

ID- insufficient data Lit- Literature support




Drug Therapeutic reference

range/Recommended drug

concentration

cloZAPine 350 – 600 ng/mL

fluPHENAZine 1 – 10 ng/mL

Haloperidol 1 – 10 ng/mL

OLANZapine 20 – 80 ng/mL

Perphenazine 0.6 – 2.4 ng/mL

Thioridazine 100 – 200 ng/mL


Antidepressants



(12 y/o to < 18

y/o)

Amitriptyline (Elavil) 300 Not Recommended Not Recommended

buPROPion (Wellbutrin) 450 (with no

single dose > 150)

6 to < 12 y/o: Lesser of

6 mg/kg or 300 (Lit)1

(with no single dose >

150)

Lesser of 6 mg/kg

or 300 (Lit)1

(with no single

dose > 150)

buPROPion SR

(Wellbutrin SR)

400 (with no

single dose > 200)

ID 400 (Lit)1

buPROPion XL

(Wellbutrin XL)

450 ID 450 (Lit)1

Citalopram** (CeleXA) 40

120 (OCD)

6 to < 12 y/o: 40 (Lit) 40 (Lit)

clomiPRAMINE

(Anafranil)

250 10 – 11 y/o: Lesser of 3

mg/kg or 200 mg (OCD)

Lesser of 3 mg/kg

or 200 mg (OCD)

Desipramine

(Norpramin)

300* Not Recommended Not Recommended




(12 y/o to < 18

y/o)

Doxepin (SINEquan) 300 Not Recommended Not Recommended

DULoxetine (Cymbalta) 120 7 – 12 y/o: 1203 1203

Escitalopram**

(Lexapro)

20

60 (OCD)

6 – 11 y/o: 20 (Lit) ≥ 12 y/o: 30 (Lit)

FLUoxetine** (PROzac) 80

120 (OCD – Lit)

6 to < 12 y/o: 60 (Lit) 60

fluvoxaMINE (Luvox) 300

450 (OCD)

8 – 11 y/o: 200 (OCD) 12 – 17 y/o: 300

(OCD)

Imipramine (Tofranil) 300* Not Recommended Not Recommended

Mirtazapine (Remeron) 45 3 to < 12 y/o: 45 (Lit) 45 (Lit)

Nortriptyline (Pamelor) 150* Not Recommended Not Recommended

PARoxetine (Paxil) 60

100 (OCD)

Not Recommended

Possible Harm

Not Recommended

Possible Harm

Phenelzine (Nardil) 90 Not Recommended Not Recommended

Protriptyline (Vivactil)

NON-Formulary

60 Not Recommended Not Recommended

Sertraline** (Zoloft) 200

400 (OCD – Lit)

≥ 6 y/o 200 200

Tranylcypromine

(Parnate)

60 Not Recommended Not recommended

traZODone (Desyrel) 600 ID 100 (Lit)2

Venlafaxine (Effexor) 375 Not Recommended

Possible Harm

Not Recommended

Possible Harm

Venlafaxine XR (Effexor

XR)

225 Not Recommended

Possible Harm

Not Recommended

Possible Harm

*Plasma concentration monitoring is recommended if these doses are exceeded

**Dose varies with diagnosis 1For ADHD 2For sedative hypnotic 3FDA approved GAD 120



ID- insufficient data to suggest support regarding its efficacy or to provide maximum dosing guidelines in this patient group

Lit- Literature support OCD- Obessive Compulsive Disorder


Drug Therapeutic reference range

Amitriptyline 120 – 250 ng/mL

Desipramine 100 – 300 ng/mL

Doxepin 30 – 150 ng/mL

Imipramine 150 – 250 ng/mL

Nortriptyline 50 – 150 ng/mL


Mood Stabilizers



(12 y/o to < 18

y/o)

carBAMazepine

(TEGretol, TEGretol XR,

Carbatrol)

1,600 < 6 y/o: 35 mg/kg

6 to < 12 y/o: 1,000 mg (6

– 12 mcg/ml)

#

12 – 15 y/o: 1,000

> 15 y/o: 1,200

lamoTRIgine (LaMICtal) With VPA: 100

Monotherapy:

200

With EIAED:

400

6 to < 12 y/o:

With VPA: 1 - 3 mg/kg

With VPA & EIAED: 1 - 5

mg/kg

Monotherapy: 4.5 - 7.5

mg/kg

With EIAED: 5 - 15 mg/kg

With VPA: 200

With VPA & EIAED:

400

Monotherapy: 375

With EIAED: 500

Lithium (Lithobid,

Eskalith)

< 65 y/o:

3,600

≥ 65 y/o:

1,800

#

7 to < 12 y/o

20 – 30 kg:

Acute: 1,500

Maintenance: 1,200

#

> 30 kg

1,800 or 1.2 mEq/L

(Lit)




(12 y/o to < 18

y/o)

OXcarbazepine

(Trileptal)

2,400 ID ID

Valproic Acid/Valproate,

Divalproex (Depakene,

Depakote, Depakote

ER)

60 mg/kg 6 to < 10 y/o: 60 mg/kg

(Lit)

≥ 10 y/o: 60 mg/kg #

60 mg/kg #

Plasma concentration monitoring recommended if these doses are exceeded

#- Maximum daily dose typically determined by drug serum concentration and individual patient tolerability Lit- Literature support

EIAED- Enzyme inducing anti-epileptic drugs (e.g., carbamazepine, phenobarbital, phenytoin, primidone)

ID- insufficient data to suggest support regarding its efficacy or to provide maximum dosing guidelines in this patient group VPA- valproic acid-valproate


Drug Therapeutic reference range

carBAMazepine Adult: 4 – 12 mcg/mL

Adol Max: 12 mcg/mL

lamoTRIgine Bipolar Disorder: 1 – 6 mcg/mL

Epilepsy: 3 – 15 mcg/mL

Lithium Acute: 0.5 – 1.2 mEq/L

Maintenance: 0.6 – 1.0 mEq/L

Child & Adol Max: 1.2 mEq/L (Lit)

OXcarbazepine nd

Valproic

Acid/Valproate,

Divalproex

50 – 125 mcg/mL

Adol Max: 125 mcg/mL (Lit)

Divalproex ER: 85 – 125 mcg/mL

nd= not yet determined




Stimulants



(12 y/o to < 18

y/o)

Amphetamine Mixture

(Adderall)

60 3-5 y/o: 30 (Lit)

≥ 6 y/o:

≤ 50 kg: 40

> 50 kg: 60 (Lit)

≤ 50 kg: 40

> 50 kg: 60 (Lit)

Amphetamine Mixture

(Adderall XR)

60 ≥ 6 y/o:

≤ 50 kg: 30

> 50 kg: 60 (Lit)

≤ 50 kg: 30

> 50 kg: 60 (Lit)

Dexmethylphenidate,

extended release

(Focalin XR)

40 ≥ 6 y/o: 50 (Lit) 50 (Lit)

Dextroamphetamine

(Dexedrine, Dexedrine

Spansules, Zenzedi)

60 3 – 5 y/o: 30 (Lit)

≥ 6 y/o:

≤ 50 kg: 40

> 50 kg: 60 (Lit)

≤ 50 kg: 40

> 50 kg: 60 (Lit)

Lisdexamfetamine

(Vyvanse)

70 6 – 12 y/o: 70 70

Methylphenidate,

immediate release

(Ritalin, Methylin,

Metadate), sustained

release (Ritalin XR)

60 3 – 5 y/o: 32.5 (Lit)

≥ 6 y/o:

≤ 50 kg: 60

> 50 kg: 100 (Lit)*

≤ 50 kg: 60

> 50 kg: 100 (Lit)*

Methylphenidate,

sustained release,

osmotic release

(Concerta)

72 3-5 y/o: 36 (Lit)

≥ 6 y/o: 72 (Lit)

12 y/o: 72 (Lit)

≥ 13 y/o: 72

* Any dose exceeding 60 mg/day should be used with caution and with attentive monitoring




Miscellaneous Drugs Used for Psychotropic Purposes



(12 y/o to < 18

y/o)

atoMOXetine (Strattera) 100 ≥ 6 y/o: whichever is

less 1.8 mg/kg or 100

(Lit)

Whichever is less 1.8

mg/kg or 100 (Lit)

cloNIDine (Catapres) 0.4 ≥ 6 y/o:

(27 – 40.5 kg) 0.2

(40.5 – 45 kg) 0.3

# (Lit)

(> 45 kg) 0.4

# (Lit)

cloNIDine Extended

Release (Kapvay) NON-

Formulary

0.4 ≥ 6 y/o: 0.4* 0.4

guanFACINE (Tenex) 4 ≥ 6 y/o:

(27 – 40.5 kg) 2

(40.5 – 45 kg) 3

# (Lit)

(> 45 kg) 4

# (Lit)

guanFACINE Extended

Release (Intuniv)

ID 6 - 12 y/o: 4* ≥ 13 y/o: 7

Naltrexone (ReVia) 200 ID ID

Naltrexone microspheres

(Vivitrol) RESERVE USE


Propranolol (Inderal) 160

(anxiety)***

ID ID

*Not studied in children < 6 years old

***Maximum dose has not been determined for aggression or self-injurious behavior (SIB) #For ADHD Lit- Literature support




Anxiolytics


Drug Under 65 years

(mg/day)

65 years and over

(mg/day)

ALPRAZolam (Xanax)

(exception: for panic

disorder)

4

10

2

N/A

busPIRone (BuSpar) 60 60

chlordiazePOXIDE (Librium) 100* 40*

clonazePAM (KlonoPIN) 4^ 4^

ClorazepateP1P (Tranxene) 60 30

diazePAMP1P (Valium) 60 20

LORazepam (Ativan) 10* 3*

Oxazepam (Serax) 90 60

*Larger doses may be necessary in some cases of alcohol-substance withdrawal. 1Long acting benzodiazepines are not recommended in the geriatric population.

^doses up to 20 mg have been used to treat seizure disorders


Hypnotics


Drug Under 65

years

(mg/day)

65 years and

older

(mg/day)

Child

(< 12 y/o)

Adolescent

(12 y/o to <

18 y/o)

∆*diphenhydrAMINE

(Benadryl)

300 300 25 – 37 lb:

12.5

38-49 lb: 19

50 – 99 lb: 25

≥ 100 lb: 50

(Lit)

50 – 99 lb: 25

≥ 100 lb: 50

(Lit)



Drug Under 65

years

(mg/day)

65 years and

older

(mg/day)

Child

(< 12 y/o)

Adolescent

(12 y/o to <

18 y/o)

∆hydrOXYzine

(Atarax, Vistaril)

400 300 3 – 5 y/o: 25

6 – 12 y/o: 50

(Lit)

> 12 y/o: 100

(Lit)

∆Temazepam

(Restoril)

30 15 Not

Recommended

Possible Harm

Not

Recommended

Possible Harm

traZODone

(Desyrel)

200 150 ID 100 (Lit)

∆Triazolam

(Halcion)

(Conscious sedation

dosing)

0.25

(0.5)

0.125

(0.25)

ID ID

∆Zolpidem

(Ambien)

Males: 10

Females: 5

5 Not

Recommened

Possible Harm

Not

Recommended

Possible Harm

*Evidence suggests that tolerance develops to the hypnotic effects within 5 – 7 nights of

continuous use

∆Medication found on the 2019 American Geriatrics Society (AGS) Beers Criteria Medication List ID- Insufficient data to suggest support regarding its efficacy or to provide maximum dose

guidelines for this patient population



Reserve Drugs 23

Reserve Drugs

The purpose of the reserve drug class is to stimulate thought and promote care in prescribing.

Discussions and interaction with other prescribers is strongly encouraged. When reserve status

drugs are utilized, documentation of justification in the patient’s progress notes is mandated. To

assist the prescriber, specific guidelines have been developed by the HHSC Psychiatric Executive

Formulary Committee for use of each drug so classified. The guidelines will be used to audit the

appropriate use of reserve drugs. Based on the audit results, continuing education will be

developed and targeted as needed.

Drug Guidelines for Use

ARIPiprazole

lauroxil (Aristada

Initio)

To be used if the patient has demonstrated tolerability to ARIPiprazole

through either a two-week trial of oral ARIPiprazole or a history of

ARIPiprazole LAI use

Adenosine

(Adenocard)

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

Betamethasone

dipropionate,

augmented

(Diprolene A/F)

To be used under the direction of a dermatologist

Buprenorphine

(Subutex)

1. Admitted on the drug and the medication is continued. Use must

be verified with the treating physician/clinic.

2. If initiated, the prescribing physician must meet the Drug Addiction

Treatment Act (DATA) criteria and thus have been assigned a

Unique Identification Number (or “X” number).

Buprenorphine-

naloxone

(Suboxone)

1. Admitted on the drug and the medication is continued. Use must

be verified with the treating physician/clinic.

2. If initiated, the prescribing physician must meet the Drug Addiction

Treatment Act (DATA) criteria and thus have been assigned a

Unique Identification Number (or “X” number).

Cannabidiol

(Epidiolex)

1. To be used in patients with a diagnosis of Lennox-Gastaut

syndrome or Dravet syndrome; and

2. Having treatment-resistant seizures after failed trials of adequate

dose and duration of two other antepileptic agents; and

3. When recommended by a neurologist.


Reserve Drugs 24


Celecoxib

(CeleBREX)

1. Patients with a history of serious gastrointestinal complications with

nonselective-NSAID use; or

2. Those patients with ongoing gastrointestinal complications in whom

NSAID therapy is necessary.

CloBAZam (Onfi ) To be used for the treatment of seizures

Clobetasol

(Temovate)

To be used under the direction of a dermatologist

cloZAPine

(Clozaril, Fazaclo,

Versacloz)

1. For use in patients with refractory schizophrenia or schizoaffective

disorder [defined as failure on two antipsychotics from two different

chemical families given for sufficient time (6-12 weeks) at a

sufficient dose (1,000 mg/day of chlorpromazine equivalents); or

2. For use in schizophrenic or schizoaffective patients who cannot

tolerate other antipsychotics; or

3. Psychosis associated with other organic conditions who have failed

two antipsychotics or who cannot tolerate other antipsychotics; or

4. Manic disorders with psychosis in patients who have failed two

antipsychotics

5. Reduction in the risk of recurrent suicidal behavior in patients with

schizophrenia or schizoaffective

Diclofenac Gel

(Voltaren Gel)

1. Oral therapy is deemed too risky due to cardiac and gastrointestinal

complications, or;

2. Other topical therapies have proven to be ineffective

DOPamine

(Inotropin)

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

Epoetin alfa

(Epogen, Procrit)

When recommended by a consultant physician


Reserve Drugs 25


Esketamine

(Spravato)

1. All REMS requirements must be followed.

2. The patient must have a history of three failed antidepressant trials

of adequate dose and duration involving more than one class of

antidepressant.

3. The patient’s blood pressure must be monitored for two hours post

administration.

4. The patient should have a depressive episode rating of severe as

measured using the Montgomery-Asberg Depression Rating Scale

(MADRS).

5. The severity of the depression should be measured using the

MADRS at baseline and then weekly for the duration of treatment

with esketamine nasal spray.

Felbamate

(Felbatol)

Weekly progress note by physician monitoring for response and adverse

effects for at least two weeks following initiation of therapy

Iloperidone

(Fanapt)

1. For use in patients that have failed on two antipsychotics given for

a sufficient time; or

2. For patients who cannot tolerate other antipsychotics due to

akathisia

Insulin, Detemir

(Levemir)

For those who are unable to tolerate Insulin, glargine.


Reserve Drugs 26

Ketamine

(Ketalar)

1. A comprehensive diagnostic assessment should be completed to

establish current diagnosis and evaluate history of substance use

and psychotic disorders.

2. Assessment of baseline symptom severity should be completed to

allow later assessments of clinical change with treatmenta.

3. A thorough history of antidepressant treatment should be collected

and documented to confirm previous adequate trials of

antidepressant treatments.

4. A thorough review of systems should be performed to evaluate

potential risk factors associated with ketamine treatmentb.

5. Decisions on the specific physical examination and laboratory

screening assessments should be made according to established

guidelines and advisories issued by the American College of

Cardiology Foundation/American Heart Association and the

American Society of Anesthesiologists and should be based on a

patient’s individual clinical characteristicsc.

6. A careful review of past medical and psychiatric records and/or

corroboration of the past history by family members are strongly

encouraged; all current medications and allergies should be

reviewed, including histories of opiate and benzodiazepine use; the

use of a baseline urine toxicology screen is strongly encouraged to

ensure the accuracy of the reported substance use and medication

record.

7. An informed consent process, including discussion of the risks

associated with the treatmentPdP, the limits of the available

information pertaining to the potential benefits of the treatment,

the fact that this is an off-label use of ketamine, and a discussion of

alternative treatment options should be completed; this discussion

should be complemented with written materials, and the patient

should provide written informed consent before initiating treatment. a Self-report versions of the Inventory of Depressive Symptomatology

and Quick Inventory of Depressive Symptomatology

(http://counsellingresource.com/quizzes/depression-testing/qids-depression/) are

examples of scales that are available at no cost to clinicians and

researchers. b This review should also include questions pertaining to functional

exercise capacity, which has been demonstrated to provide a good

screening tool for patients that are at increased risk for adverse events

associated with anesthesia exposure and surgical procedures. c American College of Cardiology Foundation and the American Heart

Association guidelines for perioperative cardiovascular evaluation and


Reserve Drugs 27


management of patients undergoing noncardiac surgery and practice

advisory from the American Society of Anesthesiologists. d The Ketalar package insert provides essential information related to risk

of ketamine administration.

Linaclotide

(Linzess)

Patients who are receiving enteral nutrition or who require a modified diet

texture

Linezolid (Zyvox) When recommended by a consultant physician

Lisdexamfetamine

(Vyvanse)

1. Continued therapy on admission; or

2. Failed other stimulants

Mirabegron

(Myrbetriq)

Unable to tolerate anticholinergic medications

Moxifloxacin

(Moxeza,

Vigamox)

For bacterial conjunctivitis where MRSA or gram negative microorganisms

is identified or suspected.

Nabumetone

(Relafen)

For the treatment of chronic osteoarthritis or chronic rheumatoid arthritis

Naloxone

(Narcan) Nasal

spray

To be dispensed only as a discharge medication for patients that have

been determined to be at risk of an opiate overdose.


Reserve Drugs 28


Naltrexone

microspheres

(Vivitrol)-

Alcohol Use

Disorders

1. For those that are not candidates for or who have not responded to

or tolerated other available formulary therapies for alcohol use

disorders and do not have a contraindication to the use of extended

release naltrexone.

2. Failure of at least a 30-day trial of oral naltrexone may be

considered before use of extended release naltrexone.

3. Use should be part of a comprehensive management program that

includes psychosocial support for the specific substance use.

4. FDA REMS process must be followed which includes review of the

potential risks associated with extended release naltrexone use.

5. Medication Guide must be provided to patients before each

administration.

6. Monitor closely for treatment emergent depression and/or suicidal

ideation.

7. Those with serious mental illness should be monitored closely for

exacerbation of psychiatric symptoms including psychosis, mania or

depression during treatment with extended release naltrexone.

8. Initiate only after a 7-14-day opioid-free interval, negative urine

drug screen for opiates, and negative naloxone challenge test.

9. Other required monitoring includes liver function tests, baseline and

periodic serum creatinine and assessment of CrCl, pregnancy test in

females of child bearing potential, signs and symptoms of opioid

withdrawal, injection site reactions.

10.The patient must be given a safety bracelet and wallet card that

indicates treatment with extended release naltrexone in case of

emergency.

11.Hospital use requires MHA approval prior to initiation.


Reserve Drugs 29


Naltrexone

microspheres

(Vivitrol)-

Opioid Use

Disorders

1. For those with opioid use disorder for whom opioid agonist

treatment (buprenorphine/naloxone, methadone) is contraindicated,

unacceptable, unavailable, or discontinued and who have

established abstinence for a sufficient period of time.

2. Failure of at least a 30-day trial of oral naltrexone may be

considered before use of extended release naltrexone.

3. Use should be part of a comprehensive management program that

includes psychosocial support for the specific substance use.

4. FDA REMS process must be followed which includes review of the

potential risks associated with extended release naltrexone use.

5. Medication Guide must be provided to patients before each

administration.

6. Monitor closely for treatment emergent depression and/or suicidal

ideation.

7. Those with serious mental illness should be monitored closely for

exacerbation of psychiatric symptoms including psychosis, mania or

depression during treatment with extended release naltrexone.

8. Initiate only after a 7-14 day opioid-free interval, negative urine

drug screen for opiates, and negative naloxone challenge test.

9. Other required monitoring includes liver function tests, baseline and

periodic serum creatinine and assessment of CrCl, pregnancy test in

females of child bearing potential, signs and symptoms of opioid

withdrawal, injection site reactions.

10.The patient must be given a safety bracelet and wallet card that

indicate treatment with extended release naltrexone in case of

emergency.

11.Hospital use requires MHA approval prior to initiation.

Norepinephrine or

Levarterenol

(Levophed)

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

OLANZapine

pamoate

(ZyPREXA

Relprevv)

1. Written approval by the Hospital Clinical Director and the local

mental health authority clinical director prior to initiation of therapy

with olanzapine pamoate

2. Compliance with the Risk Evaluation and Mitigation Strategy (REMS)

Olmesartan

(Benicar)

Prior failure to ACE inhibitor therapy due to intolerable side effects or in

cases of drug shortages of formulary ARBs.


Reserve Drugs 30


Ophthalmic

agents containing

a steroid

Consultation with an Ophthalmologist or Therapeutic Optometrist prior to

initiation.

Pentamidine

(Pentam)

1. Prophylaxis post-treatment of documented Pneumocystis carinii

pneumonia; or

2. Prophylaxis of Pneumocystis carinii in patients with CD4 counts less

than 200

Thioridazine

(Mellaril)

1. Indicated only for patients with refractory schizophrenia (failed

other classes of antipsychotics)

2. EKG prior to initiating therapy: 7 – 14 days after dose change; 7 –

14 days after other medication changes that could significantly alter

the cardiac effects of Thioridazine; every six months; and as

clinically indicated

3. Potassium level prior to initiating therapy; every six months; and as

clinically indicated

4. Magnesium level prior to initiating therapy; and as clinically

indicated (especially if potassium level is low)

tiZANidine

(Zanaflex)

1. Documented failure or intolerance to baclofen

2. Liver enzymes obtained at baseline, 1, 3, and 6 months and at least

annually

3. Documentation of efficacy after one month of therapy

4. The dose should be decreased in severe renal dysfunction (CrCl <25

mL/min)


Therapeutic Serum Concentrations of Some Anticonvulsants 31

Therapeutic Serum Concentrations of Some Anticonvulsants

Drug (mcg/ml)

carBAMazepine (TEGretol, TEGretol XR,

Carbatrol)

4 – 12

Ethosuximide (Zarontin) 40 – 100

lamoTRIgine Bipolar Disorder: 1 – 6 mcg/mL

Epilepsy: 3 – 15 mcg/mL

PHENobarbital (Luminal) 10 – 40

Phenytoin (Dilantin) 10 – 20

Valproic Acid/Valproate, Divalproex

(Depakene, Depakote, Depakote ER)

Seizure Disorder: 50 – 100

Bipolar Disorder: 50 – 125

Aggression: not established

Depakote ER

Seizure Disorder: 50 – 100

Bipolar Disorder: 85 - 125

Serum concentrations are useful in the evaluation of therapy. However, they should only be

considered as a guide to treatment, not the sole criterion for determination of dosage regimens.

The following anticonvulsants do not have an established therapeutic serum concentration

range. Routine monitoring of these anticonvulsants is not warranted as serum concentrations

cannot be correlated with clinical efficacy.

Benzodiazepines cloBAZam RESERVE USE Gabapentin Lacosamide levETIRAcetam OXcarbazepine

Pregabalin Rufinamide tiaGABine Topiramate

Zonisamide

Sources:

1. Lexicomp® Drug Information Handbook, 27PthP Edition, American Pharmacists Association

2. Micromedex® [electronic version], Truven Health Analytics, Greenwood Village, CO, USA

(cited 8-20-2019)

3. Facts & Comparison® [electronic version], Walters Kluwer (cited 8-20-19)



Alphabetical Listing 32

Alphabetical Listing

Acamprosate (Campral) Tablet, delayed release

Acetaminophen (Tylenol)

Capsule, oral Liquid, oral Suppository, rectal

Tablet, oral Tablet, chewable, oral

Acetaminophen-Codeine C-III

Liquid, oral: Acetaminophen 120 mg-Codeine 12 mg per 5 ml (C-V)

Tablet: #2: Acetaminophen 300 mg-Codeine 15 mg #3: Acetaminophen 300 mg-Codeine 30 mg #4: Acetaminophen 300 mg-Codeine 60 mg

Acetaminophen-HYDROcodone (Lortab, Vicodin, Vicodin ES) C-II

Elixir: Acetaminophen 300 mg- HYDROcodone 10 mg per 15 mL Acetaminophen 325 mg- HYDROcodone 7.5 mg per 15 mL Acetaminophen 325 mg- HYDROcodone 10 mg per 15 mL

Tablet: Acetaminophen 300 mg- HYDROcodone 5 mg Acetaminophen 300 mg- HYDROcodone 7.5 mg

Acetaminophen 300 mg- HYDROcodone 10mg Acetaminophen 325 mg- HYDROcodone 2.5 mg

Acetaminophen 325 mg- HYDROcodone 5 mg

Acetaminophen 325 mg- HYDROcodone 7.5 mg Acetaminophen 325 mg- HYDROcodone 10 mg

AcetaZOLAMIDE (Diamox)

Capsule, sustained release, oral

Tablet, oral

Acetic Acid (Acetasol, VoSol)

Solution, otic

Acetic Acid-Aluminum Acetate (Domeboro Otic)

Solution, otic: 2% acetic acid in aluminum acetate

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

HC)

Solution, otic: 1% Hydrocortisone, 2% Acetic Acid, 3% Propylene Glycol, 0.015% Sodium Acetate, and .02%Benzethonium

Acetylcysteine



Solution, inhalation

Acyclovir (Zovirax)

Capsule, oral Cream, topical

Powder for injection Ointment, topical

Suspension, oral Tablet, oral

Adapalene (Differin)

Cream, topical

Gel, topical

Adenosine (Adenocard)- RESERVE USE

Injection

Albuterol (ProAir Respiclick, Proventil, Ventolin)

Aerosol, oral inhalation, HFA Powder, oral inhalation (ProAir Respiclick)

Nebulization solution, oral inhalation Tablet, oral

Albuterol-Ipratropium (Combivent)

Nebulization solution, oral inhalation

Solution, oral inhalalation (Combivent Respimat)

Alendronate (Fosamax, Binosto)

Solution, oral Tablet, oral Tablet, effervescent, oral

Allopurinol (Zyloprim)

Tablet, oral

ALPRAZolam (Xanax, Xanax XR) C-IV

Tablet, oral Tablet, sustained release, oral

Aluminum Chloride Hexahydrate (Drysol)

Liquid, topical

Aluminum Hydroxide

Suspension/gel, oral

Aluminum Hydroxide-Magnesium Trisilicate (Gaviscon)

Tablet, chewable, oral

Suspension, oral



Aluminum Hydroxide-Magnesium Hydroxide (Maalox)

Suspension, oral

Aluminum Hydroxide-Magnesium Hydroxide-Simethicone (Mylanta)

Suspension, oral

Tablet, oral

Amantadine

Capsule, oral

Syrup, oral

Amikacin

Injection

Amino Acid Injection (Aminosyn)

Infusion

Amino Acid Injection-Dextrose-Electrolytes (Clinimix E)

Infusion

Amiodarone (Pacerone, Cordarone)

Tablet, oral

Amitriptyline (Elavil)

Tablet, oral

amLODIPine (Norvasc)

Tablet, extended release, oral

Amoxicillin (Amoxil, Polymox)

Capsule, oral Powder for suspension, oral


Amoxicillin-Clavulanate (Augmentin)

Suspension, oral



Amphetamine Mixture (Adderall, Adderall XR) CII

Capsule, extended release, oral

Tablet, oral



Ampicillin (Polycillin, Omnipen)

Capsule, oral

Powder for suspension, oral

Powder for injection

Antineoplastic Agents

In consultation with the oncologist or field specialist

Antiviral Agents

All commercially available antiviral agents used in the treatment of AIDS/HIV are considered to

be formulary agents

Apixaban (Eliquis)

Tablet, oral

ARIPiprazole (Abilify, Abilify discmelt, Abilify Maintena, Aristada, Aristada Initio)

Injection

Injection, extended release (Maintena): 300 mg, 400 mg Injection, extended release (Aristada): 441 mg, 662 mg, 882 mg, 1,064 mg

Injection, extended release (Aristada Initio): 675 mg RESERVE USE Solution, oral

Tablet, oral Tablet, rapid dissolving, oral

Ascorbic Acid (Vitamin C)

Solution, oral


Asenapine (Saphris)

Tablet, sublingual

Aspirin

Caplet, oral

Suppository, rectal

Tablet, oral Tablet, buffered, oral Tablet, chewable, oral

Tablet, enteric coated, oral

Aspirin-Acetaminophen-Caffeine (Excedrin Migraine)

Tablet, oral

Atenolol (Tenormin)

Tablet, oral



atoMOXetine (Strattera)

Capsule, oral

atorvaSTATin (Lipitor)

Tablet, oral

Atropine Sulfate (Isopto Atropine)

Ointment, ophthalmic

Solution, ophthalmic

Azelastine (Astelin)

Spray, nasal inhalation

Azithromycin (Zithromax)

Powder for solution, oral

Tablet, oral

Bacitracin

Injection

Ointment, ophthalmic Ointment, topical

Bacitracin-Polymyxin B (Polysporin)


Ointment, topical

Baclofen

Tablet, oral

Beclomethasone, (QVAR)

Aerosol, oral inhalation

Suspension, nasal inhalation

Benazepril (Lotensin)

Tablet, oral

Benzocaine (Lanacaine, Cepacol, Orajel)

Topical, for mucous membranes:

Gel: 6%, 20% Liquid: 20%

Topical, dermatologic:

Cream, topical: 5%, 6% Ointment: 5%

Spray: 20% Mouth-Throat preparations:

Gel: 6.3%, 7.5%, 10%, 15%, 20%



Liquid: 5%, 6.3%, 10%, 20%

Benzoin, Compound Tincture

Tincture, topical (may also contain aloe, storax, tolu balsam, 74% to 80% alcohol)

Benzonatate

Capsule, oral

Benzoyl Peroxide

Gel, topical

Liquid, topical Wash, topical

Benzoyl Peroxide-Clindamycin (BenzaClin)

Gel, topical: Benzoyl Peroxide 5%-Clindamycin 1%

Benztropine (Cogentin)

Injection

Tablet, oral

Betamethasone dipropionate (Diprolene)

Cream, topical

Lotion, topical Ointment, topical

Betamethasone dipropionate, augmented (Diprolene A/F)- RESERVE USE

Cream, topical

Gel, topical Lotion, topical

Ointment, topical

Betamethasone Valerate (Valisone)

Cream, topical

Lotion, topical

Ointment, topical

Betaxolol (Betoptic S)


Suspension, ophthalmic

Bethanechol (Urecholine)

Tablet, oral

Bimatoprost (Lumigan)




Bisacodyl (Dulcolax)

Suppository, rectal

Tablet, enteric coated, oral

Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate)

Liquid, oral


Brexpiprazole (Rexulti)

Tablet, oral

Brimonidine (Alphagan P)


Bromocriptine

Capsule, oral

Tablet, oral

Brompheniramine-Phenylephrine (Dimetapp Children’s Cold and Allergy)

Liquid, oral

Brompheniramine-Pseudoephedrine, Rynex PSE)

Liquid, oral

Budesonide (Pulmicort)

Nebulization suspension, oral inhalation

Powder, oral inhalation

Budesonide-Formoterol (Symbicort)


Buprenorphine (Subutex)- RESERVE USE

Tablet, sublingual

Buprenorphine-naloxone (Suboxone)- RESERVE USE

Film, sublingual Tablet, sublingual

buPROPion (Budeprion, Wellbutrin, Zyban)

Tablet, oral

Tablet, sustained release, oral Tablet, extended release, oral

busPIRone (BuSpar)

Tablet, oral



Calamine-Zinc Oxide-Glycerin (Calamine Lotion)

Lotion, topical

Calamine-Pramoxine (Caladryl)

Lotion, topical

Calcipotriene (Dovonex)

Cream, topical

Ointment, topical

Solution, topical

Calcitonin-Salmon (Miacalcin)

Spray, Nasal inhalation

Calcium Carbonate (Os-Cal, Tums) [40% elemental calcium]

Suspension, oral

Tablet, oral Tablet, oral, chewable

Calcium Carbonate-Vitamin D3 (Os-Cal + D, Os-Cal chewable)

Tablet, oral


Calcium Citrate (Citracal) [20% elemental calcium]

Tablet, oral

Calcium Citrate-Vitamin D3 (Citracal-D)

Tablet, oral

Camphor-Phenol (Campho-Phenique)

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

Cannabidiol (Epidiolex) C-V RESERVE USE

Solution, oral

Captopril (Capoten)

Table, oral

carBAMazepine (TEGretol, TEGretol XR, Carbatrol)

Capsule, extended release 12 h, oral

Suspension, oral Tablet, oral

Tablet, chewable, oral Tablet, extended release 12 hr, oral



Carbamide Peroxide (Debrox, Gly-Oxide)

Solution, mouth/throat mucous membrane

Solution, otic

Carbidopa-Levodopa (Sinemet)

Tablet, oral:

Tablet, Sustained release, oral

Carboxymethylcellulose

Liquigel, ophthalmic

Cariprazine (Vraylar)

Capsule, oral

Carvedilol (Coreg, Coreg CR)

Tablet, oral

Capsule, extended release 24 hr, oral

ceFAZolin (Kefzol)

Injection

Cefdinir (Omnicef)

Capsule, oral

Powder for suspension, oral

Cefepime (Maxipime)

Injection

cefTRIAXone (Rocephin)

Solution premixed in dextrose for injection Powder for injection

Cefuroxime Axetil (Ceftin) - Oral form only -

Tablet, oral

Celecoxib (CeleBREX)- RESERVE USE

Capsule, oral

Cellulose (Unifiber)

Powder, oral

Cephalexin (Keflex)

Capsule, oral

Powder for suspension, oral Tablet, oral



Cetirizine (ZyrTEC)

Syrup, oral

Tablet, oralt

Cetirizine-Pseudoephedrine (ZyrTEC D)

Tablet, 12hr, oral

chlordiazePOXIDE (Librium) - oral form only - C-IV

Capsule, oral

Chlorhexidine (Peridex)

Liquid, topical, with 4% isopropyl alcohol

Rinse, oral, with 12% alcohol

Chlorpheniramine

Syrup, oral

Tablet, oral Tablet, timed release, oral

chlorproMAZINE (Thorazine)

Injection

Tablet, oral

Chlorthalidone

Tablet, oral

Cholecalciferol (Calcitrol, Rocaltrol)

See Vitamin D3

Cholestyramine

**Product may contain phenylalanine**

Powder, oral Powder for oral suspension light (aspartame)

Ciclopirox (Loprox, Penlac)

Cream, topical

Shampoo, topical Solution, topical

Ciprofloxacin (Cipro, Ciloxan)

Injection


Solution, ophthalmic Suspension, oral Table, oral



Ciprofloxacin-Dexamethasone (Ciprodex)

Suspension, otic

Ciprofloxacin-Hydrocortisone (Cipro Otic)

Solution, otic

Citalopram (CeleXA)

Solution, oral

Tablet, oral

Clarithromycin (Biaxin)

Granules for suspension, oral

Tablet, film coated, oral

Clindamycin (Cleocin, Cleocin T)

Capsule, oral

Gel, topical

Granules for solution, oral Injection

Lotion, topical Solution, topical

cloBAZam (Onfi) C-IV RESERVE USE

Suspension, oral

Tablet, oral

Clobetasol (Temovate, Cormax, Clobex)- RESERVE USE

Cream, topical

Cream, topical, in emollient base

Gel, topical Lotion, topical

Ointment, topical Solution, topical scalp application

clomiPRAMINE (Anafranil)

Capsule, oral

clonazePAM (KlonoPIN) C-IV

Tablet, oral

Tablet, oral disintegrating, oral

cloNIDine (Catapres)

Patch, weekly transdermal

Tablet, oral

Clopidogrel (Plavix)

Tablet, oral



Clorazepate (Tranxene) C-IV

Tablet, oral

Clotrimazole (Lotrimin, Gyne-Lotrimin, Fungoid)

Cream, topical

Cream, vaginal Solution, topical

Troche, oral

Clotrimazole-Betamethasone dipropionate (Lotrisone)

Cream, topical

cloZAPine (Clozaril, Fazaclo, Versacloz)- RESERVE USE

Suspension, oral

Tablet, oral Tablet, oral disintegrating, oral

Coal Tar

Shampoo, topical

Solution, topical

Cod Liver Oil-Zinc Oxide-Talc (Desitin)

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

Methylparaben]

Colchicine

Tablet, oral

Collagenase (Santyl)

Ointment, topical

Oral Contraceptives

All commercially available oral contraceptive agents are considered to be formulary agents

Cromolyn


Cyanocobalamin (Vitamin B12)

Injection

Tablet, oral

Cyclobenzaprine

Tablet, oral

Cyproheptadine (Periactin)

Syrup, oral



Tablet, oral

Dantrolene (Dantrium)

Capsule, oral


Dapsone

Tablet, oral

Darifenacin (Enablex)

Tablet, extended release 24 hour, oral

Denosumab (Prolia)

Injection

Desipramine (Norpramin)

Tablet, oral

Desmopressin (DDAVP, Stimate)

Injection

Solution, nasal inhalation Tablet, oral

Desonide (Desowen, Tridesilon)

Cream, topical


Dexamethasone

Injection, as sodium phosphate

Solution, oral

Suspension, ophthalmicRESERVE USE Tablet, oral

Dexmethylphenidate, extended release (Focalin XR) CII

Capsule, oral, extended release

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


Tablet, oral (5 mg tablet contain tartrazine)

Dextromethorphan

Any combination of drugs with dextromethorphan are on Formulary as long as the individual ingredients are on the Formulary and the dosage form is listed as being on formulary.

Capsule, oral Liquid, oral

Liquid, sustained release, oral



Lozenge, oral

Dextrose 5%-Sodium Chloride Intravenous Solution

Infusion

Dextrose 5%-Sodium Chloride-Potassium Chloride Intravenous Solution

Infusion

Dextrose 5% in Water

Infusion

Dextrose 5% in Ringer's Lactate

Infusion

Dextrose 50% in Water

Infusion

Syringe

Vials

Diaper Rash Ointment

Diaper Rash Powder (Mexsana)

Powder, topical: contains kaolin, eucalyptus oil, camphor, corn starch, lemon oil, zinc oxide

diazePAM (Valium, Diastat) C-IV

Gel, rectal

Injection Solution, oral Tablet, oral

Diclofenac Gel (Voltaren Gel)- RESERVE USE

Gel, topical

Dicyclomine (Bentyl)

Capsule, oral

Injection

Syrup, oral Tablet, oral

Digoxin (Lanoxin)

Elixir, oral

Injection Tablet, oral

dilTIAZem (Cardizem)

Capsule, extended release 12 hr:



Generic: 60 mg, 90 mg, 120 mg Capsule, extended release 24 hr:

Generic: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Cardizem CD: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

Tiazac: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Diltiazem CD: 120 mg, 180 mg, 240 mg Tablet:

Generic: 30 mg, 60 mg, 90 mg, 120 mg Cardizem: 30 mg, 60 mg, 120 mg

Tablet, sustained release 24 hr: Generic: 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Cardizem LA 24 hr: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

diphenhydrAMINE (Benadryl)

Capsule, oral

Cream, topical

Injection Liquid, oral Tablet, oral

Diphtheria-Tetanus Toxoids Adsorbed (DT)

Injection, single dose

Diphtheria-Tetanus Toxoids Adsorbed for Adult Use (Td)


Diphtheria-Tetanus-Acellular Pertussis (Tdap, Boostrix, Adacel)


Disulfiram (Antabuse)

Tablet, oral

Divalproex (Depakote, Depakote ER)

Capsule, delayed release sprinkles, oral

Tablet, delayed release, oral Tablet, extended release 24 hr, oral

Docusate Calcium (Surfak)

Capsule, oral

Docusate Sodium (Colace)

Capsule, oral

Liquid, oral

Syrup, oral

Docusate Sodium-Sennosides (Peri-Colace)

Tablet, oral



Donepezil (Aricept)

Tablet, oral

Tablet, oral disintegrating

DOPamine (Intropin)- RESERVE USE

Infusion in D5W

Injection

Doxepin (SINEquan, Zonalon)

Capsule, oral

Concentrate, oral

Doxycycline (Vibramycin, Periostat)

Capsule, oral

Powder for suspension, oral Tablet, oral

DULoxetine (Cymbalta)

Capsule, delayed release, oral

Emollient Gel

Gel, topical

Emollient Lotion-Cream (Lubriderm, Keri Lotion, Cetaphil, Eucerin, Nutraderm)

Cream, topical

Lotion, topical

Emollient Ointment (Lanolin, Aquaphor)

Ointment, topical

Enalapril (Vasotec)

Tablet, oral

Enoxaparin (Lovenox)

Injection

Entacapone (Comtan)

Tablet, oral

EPINEPHrine (Adrenalin)

Auto-injector

Injection

Epoetin alfa (Epogen, Procrit)- RESERVE USE

Injection



Ergocalciferol (Calciferol, Drisdol)

See Vitamin D2

Erythromycin

Erythromycin base (Eryc, Erythrocin):

Capsule, delayed release, oral Tablet, film coated, oral

Erythromycin Ethylsuccinate (EryPed, E.E.S.): Granules/Powder for oral suspension Suspension, oral

Tablet, oral Ointment, ophthalmic

Erythromycin-Benzoyl Peroxide (Benzamycin)

Gel, topical: Erythromycin 3%-Benzoyl Peroxide 5% (with 20% alcohol)

Escitalopram (Lexapro)

Solution, oral

Tablet, oral

Esketamine (Spravato) C-III RESERVE USE

Intravenous

Esomeprazole (NexIUM)

Capsule, oral

Suspension packet, oral

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

Cream, vaginal

Systems, transdermal Tablet, oral

Tablet, vaginal

Estrogen-medroxyPROGESTERone (PremPro, Premphase)

Tablet, oral

Estrogens, Conjugated (Premarin)

Cream, vaginal

Injection Tablet, oral

Ethambutol (Myambutol)

Tablet, oral

Ethionamide (Trecator)

Tablet, sugar coated, oral



Ethosuximide (Zarontin)

Capsule, oral

Syrup, oral

Ethyl Chloride

Spray, topical

Famotidine (Pepcid)

Injection

Powder for oral suspension Tablet, oral

Felbamate (Felbatol)- RESERVE USE

Suspension, oral

Tablet, oral

Felodipine


Fenofibrate (Antara, Lofibra, Tricor, Triglide)

Capsule, oral

Capsule, micronized, oral Tablet, oral Tablet, nanocrystallized, oral

fentaNYL (Duragesic) C-II

Patch, transdermal

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

Tablet, timed released, oral

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

Elixir with 5% alcohol, oral

Tablet, oral Tablet, extended release, oral

Fexofenadine (Allegra)

Tablet, oral

Fexofenadine - Pseudoephedrine (Allegra-D)



Finasteride (Proscar)

Tablet, oral



Fish Oil (Nature Made Fish Oil NUTRITIONAL SUPPLEMENT)

Capsule, oral

Fluconazole (Diflucan)

Suspension, oral

Tablet, oral

Fludrocortisone

Tablet, oral

Fluocinolone (Capex, Derma-Smooth/FS, Synalar)

Cream, topical

Oil, topical Ointment, topical Shampoo

Solution, topical

Fluocinonide

Cream, topical

Gel, topical Ointment, topical Solution, topical

Fluorescein Sodium

Injection

Strip, ophthalmic

Fluorescein-benoxinate (Flurox)

Solution, ophthalmic: fluorescein sodium 0.25% and benoxinate hydrochloride 0.4%

Fluoride(OmniMed, PerioMed)

Liquid, oral

Solution, oral Tablet, chewable, oral

FLUoxetine (PROzac)

Capsule, oral

Liquid, oral Tablet, oral

fluPHENAZine (Prolixin)

Concentrate, oral, 14% alcohol

Elixir, oral, with 14% alcohol

Injection, as decanoate Injection, as hydrochloride Tablet, oral



Fluticasone (Flonase, Flovent)


Solution, nasal inhalation

Powder, oral inhalation diskus

Fluticasone-Salmeterol (Advair)

Aerosol, oral inhalation (HFA)


Fluvastatin

Capsule, oral

fluvoxaMINE (Luvox)

Tablet, oral

Folic Acid (Folvite)

Tablet, oral

Fondaparinux (Arixtra)

Injection

Fosfomycin (Monurol)

Sachet, oral

Fosphenytoin (Cerebyx)

Injection

Furosemide (Lasix)

Injection

Solution, oral Tablet, oral

Gabapentin (Neurontin)

Capsule, oral

Solution, oral

Tablet, oral

Galantamine (Razadyne)

Capsule, 24hr, oral

Solution, oral


Gemfibrozil (Lopid)




Gentamicin

Cream, topical

Infusion, premixed in NS

Injection Injection, intrathecal, preservative free

Ointment, ophthalmic Ointment, topical Solution, ophthalmic

glipiZIDE (Glucotrol)

Tablet, oral


Glucosamine NUTRITIONAL SUPPLEMENT

Capsule, oral

Tablet, oral

Glucagon


Glucose

Gel, oral

Tablet, oral

Glycerin (Sani-Supp)

Suppository, rectal

Glycopyrrolate (Robinul)

Tablet, oral

Griseofulvin (Fulvicin, Grifulvin V, Gris-Peg)

Suspension, Microsize, oral Tablet, Microsize, oral

Tablet, Ultramicrosize, oral

guaiFENesin (Robitussin, Mucinex)

Any combination of drugs with guiaFENesin are on Formulary as long as the individual

ingredients are on the Formulary and the dosage form is listed as being on formulary

Liquid, oral

Tablet, oral Tablet, sustained release, oral

guaiFENesin-Codeine C-V

Syrup, oral



guaiFENesin-Dextromethorphan

Liquid, oral

Tablet, sustained release

guaiFENesin-Pseudoephedrine (Mucinex D)

Tablet, oral

guanFACINE (Tenex, Intuniv)

Tablet, oral

Tablet, extended release 24 hr, oral

Haloperidol (Haldol)

Concentrate, oral

Injection, as decanoate

Injection, as lactate Tablet, oral

Heparin

Injection

Hepatitis A Vaccine (Vaqta, Havrix)


Hepatitis A-Hepatitis B Vaccine (Twinrix)


Hepatitis B Immune Globulin (HBIG)


Hepatitis B Virus Vaccine, Recombinant (Recombivax HB, Engerix-B, Heplisav-B )

Injection

Hexachlorophene

Liquid, topical

Homatropine (Isopto Homatropine)


hydrALAZINE

Tablet, oral

hydroCHLOROthiazide

Capsule, oral

Tablet, oral

Hydrocortisone (Cortef, Lanacort, Corticaine, Anusol-HC, Proctofoam-HC)



Injection, as sodium succinate Cream, topical


Cream, rectal Foam, rectal Suppositories, rectal

Tablet, oral

Hydrogen Peroxide

Solution, topical

hydrOXYzine (Atarax, Vistaril)

Capsule, oral

Injection, as hydrochloride Syrup, as hydrochloride, oral

Tablet, oral

Ibandronate (Boniva)

Tablet, oral

Injection

Ibuprofen (Motrin)

Capsule, oral

Suspension, oral


Iloperidone (Fanapt)- RESERVE USE

Tablet, oral

Imipramine (Tofranil)

Tablet, oral

Influenza Virus Vaccine


Insulin, Aspart (NovoLOG)

Injection: 100 units/mL

Insulin, Combination (70/30)


Insulin, Detemir (Levemir)- RESERVE USE




Insulin, Glargine (Lantus)


Insulin, Lispro (HumaLOG)


Insulin, Lispro protamine suspension-insulin lispro, (HumaLOG Mix 75/25), HumaLOG

Mix 50/50


Insulin, NPH


Insulin, Regular (HumuLIN, NovoLIN)


Ipratropium (Atrovent)


Nebulization solution, oral inhalation Solution, nasal inhalation

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

Niferex-150 Forte)

Capsule, oral


Isoniazid (INH)

Injection


Isosorbide Dinitrate (Isordil)


Tablet, oral

Tablet, sustained release, oral

Isosorbide Mononitrate

Tablet, oral


Ivermectin (Stromectol)

Tablet, oral

Kaolin-Pectin

Suspension, oral



Ketamine (Ketalar) C-III RESERVE USE

Intravenous

Ketoconazole (Nizoral)

Cream, topical

Shampoo, topical

Tablet, oral

Ketorolac (Toradol)

Injection

Tablet, oral

Ketotifen (Zaditor)


Labetalol (Normodyne)

Tablet, oral

Lacosamide (Vimpat) C-V

Solution, oral

Solution, intravenous

Tablet, oral

Lactobacillus Acidophilus (Lactinex, Bacid, Florajen)

Capsule, oral

Granules, oral


Lactulose (Enulose)

Syrup, oral

lamoTRIgine (LaMICtal)

Tablet, oral

Tablet, chewable, oral Tablet, dispersible, oral

Lansoprazole (Prevacid)

Capsule, enteric coated granules, oral

Latanoprost (Xalatan)


Levalbuterol (Xopenex)

Aerosol, oral inhalation, HFA

Nebulization Solution, oral inhalation



Levarterenol (Levophed)or Norepinephrine -RESERVE USE

Injection

levETIRAcetam (Keppra)

Solution, oral

Tablet, oral

Levocarnitine (Carnitor)

Tablet, oral Solution, oral

levoFLOXacin (Levaquin)

Injection


Levothyroxine (Synthroid, Levoxyl)


Tablet, oral

Lidocaine (Lidoderm, Xylocaine)

Injection

Gel, topical Liquid, viscous, oral

Ointment, topical Patch, topical Solution, topical

Lidocaine-Prilocaine (EMLA)

Cream, topical

Linezolid (Zyvox)- RESERVE USE

Suspension, oral

Tablet, oral

Linaclotide (Linzess)- RESERVE USE

Capsule, oral

Liraglutide (Victoza)

Injection

Lisdexamfetamine (Vyvanse) C-II- RESERVE USE

Capsule, oral

Lisinopril (Prinivil, Zestril)

Tablet, oral



Lithium Carbonate (Eskalith, Lithonate, Lithobid)

Capsule, oral

Tablet, oral

Tablet, controlled release, oral Tablet, slow release, oral

Lithium Citrate

Syrup, oral

Loperamide (Imodium)

Capsule, oral

Liquid, oral

Tablet, oral

Loratadine (Claritin)

Liquid, oral

Tablet, oral

Loratadine-Pseudoephedrine (Claritin D)

Tablet, 12 hour sustained release, oral Tablet, 24 hour sustained release, oral

LORazepam (Ativan) C-IV

Injection


Losartan (Cozaar)

Tablet, oral

Loxapine (Loxitane)

Capsule, oral

Lurasidone (Latuda)

Tablet, oral

Lubiprostone (Amitiza)

Capsule, oral

Magnesium Citrate

Solution, oral

Magnesium Hydroxide (Milk of Magnesia)

Suspension, oral

Tablet, chewable



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

Tablet, oral

Magnesium Sulfate (Epsom Salt)

Granules, topical

Injection Infusion, premixed

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


Meclizine (Antivert, Bonine)

Tablet, oral

medroxyPROGESTERone (Provera)

Injection

Tablet, oral

Megestrol (Megace, Megace ES)

Suspension, oral

Tablet, oral

Melatonin NUTRITIONAL SUPPLEMENT

Capsule, oral

Tablet, oral

Tablet, sublingual Tablet, sustained release, oral

Meloxicam (Mobic)

Tablet, oral

Memantine (Namenda)

Tablet, oral

Menthol

Menthol-Methyl Salicylate (Ben-Gay)

Cream, topical

Ointment, topical

Menthol-Zinc Oxide (Calmoseptine, Risamine)

Ointment, topical

Mesalamine (Asacol HD, Pentasa, Rowasa, Canasa)

Capsule, controlled release, oral

Suppository, rectal



Suspension, rectal enema Tablet, delayed release, oral

metFORMIN (Glucophage, Glucophage XR)

Tablet, oral


Solution, oral

Methadone (Dolophine) C-II

Solution, oral

Tablet, oral

Tablet for oral suspension

methIMAzole (Tapazole)

Tablet, oral

Methocarbamol (Robaxin)

Tablet, oral

Methylcellulose (Citrucel)

Powder, oral, with sucrose and maltodextrin

Powder, oral, sugar free, with phenylalanine

Methyldopa

Injection

Tablet, oral

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

Tablet, oral

Methylphenidate, sustained release (Ritalin SR, Concerta, Metadate CD) C-II

Capsule, extended release, oral (Metadate CD)

Tablet, extended release, oral (Concerta) Tablet, sustained release, oral (Ritalin SR)

methylPREDNISolone (Medrol, DEPO-Medrol, SOLU-Medrol)

Injection, as acetate

Injection, as sodium succinate

Tablet, oral

Metoclopramide (Reglan)

Injection Liquid, oral Tablet, oral

Metoprolol (Lopressor, Toprol XL)

Tablet, oral




metroNIDAZOLE (Flagyl, Noritate, MetroGel)

Capsule, oral

Cream, topical Gel, topical

Gel, vaginal Injection Powder for injection

Tablet, oral

Miconazole

Cream, topical

Cream, vaginal Injection Powder, topical Spray, topical

Suppository, vaginal

Midazolam (Versed, Nayzilam ) C-IV

Injection

Spray, nasal Syrup, oral

Mineral Oil - for topical use only

Minocycline

Capsule, oral

Capsule, pellet filled, oral

Mirabegron (Myrbetriq)- RESERVE USE


Mirtazapine (Remeron, Remeron SolTab)

Tablet, oral

Tablet, rapid dissolving, oral

miSOPROStol (Cytotec)

Tablet, oral

Mometasone (Nasonex)

Inhalation, nasal

Montelukast (Singulair)


Tablet, oral



morphine C-II

Injection

Solution, oral

Suppository, rectal Tablet, controlled release, oral

Tablet, sublingual

Moxifloxacin (Avelox, Moxeza, Vigamox)

Infusion

Solution, Ophthalmic: RESERVE USE

Tablet, oral

Multivitamin (Unicap, Hexavitamins)

Liquid, oral


Multivitamin-Minerals

Liquid, oral Tablet, oral


Multivitamins, Pediatric (Poly-Vi-Sol)

Liquid, oral

Multivitamin, Prenatal (Filibon)

Tablet, oral

Mupirocin (Bactroban)

Cream, topical

Ointment, intranasal

Ointment, topical

Nabumetone (Relafen)- RESERVE USE

Tablet, oral

Nafcillin


Naloxone (Narcan)

Injection

Solution, nasal RESERVE USE

Naltrexone (ReVia, Vivitrol)

Tablet, oral

Injection, long-acting - RESERVE USE



Naphazoline (Naphcon, AK-Con)


Naproxen (Naprosyn)

Tablet, oral

Tablet, delayed release, oral

Neomycin

Tablet, oral

Neomycin-Polymyxin B-Bacitracin (Triple Antibiotic Ointment)

Ointment, topical

Neomycin-Polymyxin B-Hydrocortisone (Cortisporin)

Cream, topical

Solution, otic

Suspension, otic

Niacin-Nicotinamide (Nicobid)



Nicotine (Nicoderm, Nicotrol, Nicorette)

Patch, transdermal:

Gum, chewing, as polacrilex

NIFEdipine (Procardia, Procardia XL, Adalat CC)

Capsule, liquid-filled, oral


Nitrofurantoin (Macrodantin)

Capsule, macrocrystal, oral

Capsule, macrocrystal/monohydrate, oral

Suspension, oral

Nitroglycerin


Ointment, topical

Patch 24 hour, transdermal

Spray, translingual

Tablet, sublingual

Non-Soap Cleanser (Cetaphil)

Bar



Lotion

Norepinephrine or Levarterenol (Levophed)- RESERVE USE

Injection

Nortriptyline (Pamelor)

Capsule, oral

Solution, oral

Nystatin (Mycostatin)

Cream, topical

Ointment, topical Powder, topical Suspension, oral

Tablet, oral

OLANZapine (ZyPREXA, ZyPREXA Zydis, ZyPREXA Relprevv)

Injection

Injection as pamoate- RESERVE USE Tablet, oral Tablet, rapid dissolving, oral

Olmesartan (Benicar)- RESERVE USE

Tablet, oral

Olopatadine (Patanol)


Omega-3-acid ethyl esters (Lovaza)

Capsule, oral

Omeprazole (PriLOSEC)

Capsule, delayed release, oral

Suspension, oral

Ondansetron (Zofran, Zofran ODT)

Tablet, oral

Tablet, oral disintegrating

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


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





Oseltamivir (Tamiflu)

Capsule, oral

Suspension, oral

Oxazepam (Serax) C-IV

Capsule, oral

Tablet, oral

OXcarbazepine (Trileptal)

Suspension, oral

Tablet, oral

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

Ointment, topical

Oxybutynin (Ditropan XL)

Syrup, oral


oxyCODONE (OxyCONTIN) C-II

Tablet, oral

Tablet, controlled release, oral

Oxymetazoline (Afrin)

Solution, drops, nasal inhalation

Solution, spray, nasal inhalation

Paliperidone (Invega, Invega Sustenna)

Injection, long acting


Pancrelipase (Pancreaze, Creon)

Capsule, oral: contains lipase, protease and amylase

Pantoprazole (Protonix)

Injection

Suspension Packets, oral Tablet, oral

PARoxetine (Paxil)

Suspension, oral

Tablet, oral




penicillin G Benzathine (Bicillin LA)

Injection

penicillin V Potassium (Pen-Vee K, V-Cillin K)

Powder for solution, oral

Tablet, oral

Pentamidine (Pentam)- RESERVE USE

Inhalation


Permethrin (Elimite, NIX)

Cream, topical

Lotion, topical

Cream rinse, topical

Perphenazine (Trilafon)

Tablet, oral

Petrolatum, White (Vaseline)

Ointment, topical

Phenazopyridine (Pyridium)

Tablet, oral

Phenelzine (Nardil)

Tablet, oral

PHENobarbital (Luminal) C-IV

Injection


Phenol (Chloraseptic)

Mouthwash/Gargle

Throat Spray

Phenylephrine (Neo-Synephrine(Preparation H)

Ointment, rectal

Cream, rectal Suppository, rectal

Solution, drops, nasal inhalation Solution, spray, nasal inhalation




Phenytoin (Dilantin)


Injection

Suspension, oral Tablet, chewable, oral

Phytonadione (Vitamin K1, Mephyton

Tablet, oral

Pilocarpine (Isopto Carpine)

Solution, ophthalmic, as hydrochloride

Pimecrolimus (Elidel)

Cream, topical

Pioglitazone (Actos)

Tablet, oral

Piperacillin-Tazobactam (Zosyn)

Injection

Pneumococcal Vaccine, Conjugate (Prevnar 13)


Pneumococcal Vaccine, Polyvalent (Pneumovax 23)


Podophyllum Resin (Podocon-25)

Liquid, topical

Polycarbophil (Fibercon, Fiber-Lax)

Tablet, oral

Polyethylene Glycol (MiraLax)

Powder for oral solution

Polyethylene Glycol Electrolyte Solution (PEG, Co-Lyte, GoLYTELY)


Polymyxin B-Bacitracin (Polysporin)


Ointment, topical Powder, topical

Polymyxin B-Trimethoprim (Polytrim)




Potassium Chloride

Capsule, oral


Liquid, oral Powder for suspension, oral

Injection, concentrate Tablet, controlled release (microencapsulated) Tablet, controlled release (wax matrix)

Potassium Citrate (Urocit K)

Tablet, oral


Potassium Citrate Combinations (Polycitra-LC, Polycitra K

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

Solution, oral: containing Sodium Citrate-Potassium Citrate

Potassium Iodide (SSKI)

Solution, oral

Potassium Phosphate (Neutra-Phos-K)


Povidone-Iodine (Betadine)

Ointment, topical

Surgical scrub, topical

Solution, topical

Pramipexole (Mirapex)

Tablet, oral

Pramoxine

Cream, topical

Foam, topical Gel, topical

Lotion, topical Spray, topical

Pramoxine–Hydrocortisone (Analpram HC)

Cream, Rectal

Pramoxine-Zinc (Caladryl Clear)

Lotion, topical

Pravastatin (Pravachol)

Tablet, oral



Prazosin (Minipress)

Capsule, oral

prednisoLONE (Pred Mild, Pred Forte)

Solution, oral


Solution, ophthalmic RESERVE USE

predniSONE (Deltasone)

Solution, oral

Tablet, oral

Pregabalin (Lyrica) C-V

Capsule, oral

Primidone (Mysoline)

Tablet, oral

Prochlorperazine (Compazine)

Injection

Suppository, rectal Tablet, oral

Promethazine (Phenergan)

Injection

Suppository, rectal Syrup, oral

Tablet, oral

Proparacaine (Alcaine)


Propranolol (Inderal)


Injection Solution, oral

Tablet, oral

Propylthiouracil

Tablet, oral

Pseudoephedrine (Sudafed)

Liquid, oral

Tablet, immediate release, oral Tablet, extended release, oral



Psyllium (Konsyl, Metamucil)

All products of psyllium, psyllium husk, and psyllium seed, alone or in combination with dextrose, aspartame, sugar or sucrose are considered to be formulary.

Pyrazinamide

Tablet, oral

Pyrethins 0.33%-Piperonyl Butoxide 4% (Pronto, RID)

Liquid, topical

Shampoo, topical

Pyridoxine (Vitamin B6)

Injection

Tablet, oral

QUEtiapine (SEROquel)

Tablet, oral

Raloxifene (Evista)

Tablet, oral

raNITIdine (Zantac)

Injection


Rasagiline (Azilect)

Tablet, oral

Rectal Hemorrhoidal Suppositories (Wyanoids, Anusol)

Suppository, rectal

Repaglinide (Prandin)

Tablet, oral

Rifabutin (Mycobutin)

Capsule, oral

rifAMPin (Rifadin)

Capsule, oral

Injection

rifAMPin-Isoniazid (Rifamate)

Capsule, oral



Risedronate (Actonel)

Tablet, oral

risperiDONE (RisperDAL, RisperDAL M-Tab, RisperDAL Consta)

Injection, long acting


Tablet, orally disintegrating

Rivaroxaban (Xarelto)

Tablet, oral

Rivastigmine (Exelon, Exelon Patches)

Capsule, oral

Patch, transdermal

Rosuvastatin (Crestor)

Tablet, oral

Rufinamide (Banzel)

Tablet, oral

Saccharomyces boulardii (Florastor)

Capsule, oral

Salicylic Acid

All available salicylic acid products as a single agent are considered to be on formulary

Salicylic Acid-Sulfur

All commercially available forms are on formulary

Saliva Substitute

Gel

Mouthwash Spray Toothpaste

Salmeterol (Serevent)


Scopolamine (Isopto Hyoscine)


Selegiline (Eldepryl)

Capsule, oral

Tablet, oral



Selenium Sulfide

Shampoo, topical

Senna (Senokot)

Tablet, oral

Sertraline (Zoloft)

Concentrate, oral

Tablet, oral

Sevelamer (Renagel)

Tablet, oral

Silver Nitrate

Applicator sticks, topical

Silver SulfADIAZINE (Silvadene)

Cream, topical

Simethicone (Gas-X, Phazyme )

Drops, oral


Simvastatin (Zocor)

Tablet, oral

Sodium Bicarbonate

Tablet, oral

Sodium Chloride

Drops, nasal Infusion Injection, bacteriostatic

Injection, for admixtures Injection, for reconstitution

Nebulization solution, oral inhalation Ointment, ophthalmic Solution, irrigation, topical

Solution, nasal inhalation Solution, ophthalmic

Tablet, oral Tablet, enteric coated, oral Tablet, slow release, oral

Sodium Chloride Intravenous Solution

Infusion



Sodium Citrate-Citric Acid (Oracit)

Solution, oral

Sodium Polystyrene Sulfonate

Powder for suspension, oral Suspension, oral (with sorbitol and alcohol)

Solifenacin (Vesicare)

Tablet, oral

Sorbitol

Solution, oral

Spironolactone (Aldactone)

Tablet, oral

Spironolactone-hydroCHLOROthiazide (Aldactazide)

Tablet, oral

Sucralfate (Carafate)

Suspension, oral

Tablet, oral

Sulfacetamide Sodium (Bleph-10)

Lotion, topical

Ointment, ophthalmic Solution, ophthalmic

Sulfamethoxazole-Trimethoprim (Bactrim)

The 5:1 ratio of Sulfamethoxazole to Trimethoprim is constant in all dosage forms

Injection Suspension, oral

Tablet, oral

sulfaSALAzine (Azulfidine)

Tablet, oral

Tablet, delayed release, oral

Sulindac (Clinoril)

Tablet, oral

SUMAtriptan (Imitrex)

Injection

Spray, nasal

Tablet, oral



Sunscreen-Block

Cream-Lotion, topical: contains a minimum SPF of 15

Tacrolimus (Protopic)

Ointment, topical

Tamoxifen

Tablet, oral

Tamsulosin (Flomax)

Capsule, oral

Tazarotene (Tazorac, Avage)

Cream, topical

Gel, topical

Temazepam (Restoril) C-IV

Capsule, oral

Terbinafine (LamISIL)

Cream, topical

Tablet, oral

Testosterone (Androlan) C-IV

Injection, in oil, as cypionate

Tetracycline

Capsule, oral

Tetrahydrozoline (Visine Allergy Relief, Visine Moisturizing)


Thiamine (Vitamin B1)

Injection

Tablet, oral

Thioridazine (Mellaril)- RESERVE USE

Tablet, oral

Thiothixene (Navane)

Capsule, oral

tiaGABine (Gabatril)

Tablet, oral



Timolol (Timoptic)

Gel, ophthalmic Solution, as maleate, ophthalmic Solution, as maleate, ophthalmic, preservative free, single use

Timolol-Dorzolamide (Cosopt)


Tioconazole

Ointment, vaginal

Tiotropium (Spiriva)

Capsule, oral inhalation (with device)

Aerosol solution, oral inhalation (Spiriva Respimat)

tiZANidine (Zanaflex)- RESERVE USE

Capsule, oral

Tablet, oral

Tobramycin (Tobrex)

Injection

Ointment, ophthalmic Solution, ophthalmic

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


Suspension, ophthalmic

Tolnaftate (Tinactin)

Aerosol, topical, liquid

Aerosol, topical, powder Cream, topical Powder, topical

Solution, topical

Tolterodine (Detrol, Detrol LA)


Tablet, oral

Topiramate (Topamax)

Capsule, sprinkle, oral

Tablet, oral

traMADol (Ultram) C-IV

Tablet, oral



Tranylcypromine (Parnate)

Tablet, oral

Travoprost (Travatan Z)


traZODone (Desyrel)

Tablet, oral

Tretinoin (Retin-A)

Cream, topical

Gel, topical

Triamcinolone (Azmacort, Nasacort)

Aerosol, topical

Cream, topical

Lotion, topical Ointment, topical Paste, dental

Spray, nasal inhalation

Triamterene (Dyrenium)

Capsule, oral

Triamterene-hydroCHLOROthiazide (Dyazide, Maxzide)

Capsule, oral

Tablet, oral

Triazolam (Halcion) C-IV

Tablet, oral

Trifluoperazine (Stelazine)

Tablet, oral

Trihexyphenidyl (Artane)

Elixir, oral

Tablet, oral

Trimethobenzamide (Tigan)

Capsule, oral

Injection, oral

Triprolidine-Pseudoephedrine (Aprodine)

Tablet, oral



Tropicamide (Mydriacyl)


Trospium

Tablet, oral

Capsule, extended release 24 hour, oral

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

Aeroso, topical

Ointment, topical

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

Intermediate test strength: 5 TU/0.1 mL

Urea

Cream, topical

Lotion, topical

valACYclovir (Valtrex)

Caplet, oral

Tablet, oral

Valproic Acid/Valproate (Depakene)

Capsule, oral

Syrup, oral

Valsartan (Diovan)

Tablet, oral

Vancomycin (Vancocin)

Capsule, oral


Varicella Virus Vaccine, Live (Varivax)


Venlafaxine (Effexor)


Tablet, oral Tablet, extended release 24 hr, oral

Verapamil (Calan, Isoptin, Calan SR, Isoptin SR, Verelan Verelan PM)


Injection Tablet, immediate release, oral




Vitamin A (Aquasol A)

Capsule, oral

Vitamin A&D Topical

Ointment, topical

Vitamin B Complex

Tablet, oral

Vitamin B Complex-Vitamin C (Stresscaps, Allbee with C, Nephrocaps, Nephro-vite)

Capsule, oral

Tablet, oral

Vitamin B Complex-Vitamin C-Zinc

Tablet, oral

Vitamin D2 (Ergocalciferol, Calciferol, Drisdol)

Capsule, oral

Drops, oral Tablet, oral

Vitamin D3 (Calcitrol, Rocaltrol, Cholecalciferol)

Capsule, oral

Drops, oral Tablets, oral

Vitamin E (Aquasol E)

Capsule, oral

Warfarin (Coumadin)

Tablet, oral

Water for Injection

Injection, for constitution

Water for Irrigation

Solution, irrigation, topical

Wound Cleanser (Carrington Clara-Klenz)

Spray, topical

Zanamivir (Relenza)

Powder for Inhalation

Zinc Oxide

Ointment, topical



Paste, topical

Zinc Oxide-Petrolatum-Imidazolidinyl Urea (Diaperene)

Ointment, topical

Zinc Sulfate

Capsule, oral

Tablet, oral

Ziprasidone (Geodon)

Capsule, oral

Injection

Zoledronic Acid (Reclast)

Injection

Zolpidem (Ambien) C-IV

Tablet, oral

Zonisamide (Zonegran)

Capsule, oral

Zoster Vaccine- Recombinant, Adjuvanted (Shingrix)

Intramuscular Suspension


Therapeutic Classification/Cost Index 80

Therapeutic Classification/Cost Index

Antidiabetic Agents

Insulins, Human Cost Index

Insulin, Aspart (NovoLOG) High

Insulin, Combination (70/30) High

Insulin, Detemir (Levemir) RESERVE USE High

Insulin, Glargine (Lantus) High

Insulin, Lispro (HumaLOG) Moderate

Insulin, Combination, lispro protamine suspension-insulin lispro,

(HumaLOG Mix 75/25, HumaLOG Mix 50/50) Moderate

Insulin, NPH Moderate

Insulin, Regular (HumuLIN, NovoLIN) Moderate

Sulfonylureas Cost Index

glipiZIDE (Glucotrol) Low

Miscellaneous Antidiabetic Agents Cost Index

Liraglutide (Victoza) High

metFORMIN (Glucophage, Glucophage XR) Low

Pioglitazone (Actos) Low

Repaglinide (Prandin) Low

Antidotes

Antidotes Cost Index

Glucagon High

Glucose, oral Moderate

Naloxone (Narcan) High

Phytonadione (Vitamin K1, Mephyton) High



Antidotes Cost Index

Sodium Polystyrene Sulfonate High

Antineoplastic Agents

Antineoplastic Agents Cost Index

Tamoxifen Low

All commercially available oncologic agents used in the treatment of cancer are considered to be

formulary agents, if prescribed by an oncologist for the active treatment of cancer. All

commercially available oncologic agents prescribed by field specialists are considered to be on

formulary.

Blood Modifying Agents

Antiplatelet Agents Cost Index

Aspirin Low

Clopidogrel (Plavix) Low

Anticoagulants Cost Index

Apixaban (Eliquis) High

Enoxaparin (Lovenox) High

Fondaparinux (Arixtra) High

Heparin Moderate

Rivaroxaban (Xarelto) High

Warfarin (Coumadin) Low

Anticoagulation Antagonists Cost Index

Phytonadione (Vitamin K1, Mephyton) High

Miscellaneous Blood Modifying Agents Cost Index

Epoetin alfa (Epogen, Procrit) RESERVE USE High

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



Miscellaneous Blood Modifying Agents Cost Index

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

Cardiovascular Agents

Diuretics-Thiazides & Related Diuretics Cost Index

Chlorthalidone Low

hydroCHLOROthiazide Low

Diuretics-Loop Diuretics Cost Index

Furosemide (Lasix) Low

Diuretics-Potassium-Sparing Diuretics Cost Index

Spironolactone (Aldactone) Low

Triamterene (Dyrenium) High

Diuretics-Carbonic Anhydrase Inhibitors Cost Index

acetaZOLAMIDE (Diamox) Moderate

Diuretics-Combination Diuretics Cost Index

Spironolactone-hydroCHLOROthiazide (Aldactazide) Low

Triamterene-hydroCHLOROthiazide (Dyazide, Maxzide) Low

Cardiac Glycosides Cost Index

Digoxin (Lanoxin) Low

Antianginals Cost Index

Isosorbide Dinitrate (Isordil) Low

Isosorbide Mononitrate Low



Antianginals Cost Index

Nitroglycerin Low

Antiarrhythmics Cost Index

Adenosine (Adenocard) Reserve Use High

Amiodarone (Pacerone, Cordarone) Low

Calcium Channel Blockers Cost Index

amLODIPine (Norvasc) Low

dilTIAZem (Cardizem) Low

Felodipine Low

NIFEdipine (Procardia, Procardia XL, Adalat CC) Low

Verapamil (Calan, Isoptin, Calan SR, Isoptin SR, Verelan Verelan PM) Low

Beta-Adrenergic Blockers Cost Index

Atenolol (Tenormin) Low

Carvedilol (Coreg, Coreg CR) Low-High

Labetalol (Normodyne) Low

Metoprolol (Lopressor, Toprol XL) Low

Propranolol (Inderal) Low

Antihyperlipidemics Cost Index

atorvaSTATin (Lipitor) Low

Cholestyramine Moderate

Fenofibrate (Antara, Lofibra, Tricor, Triglide) Low

Fluvastatin Moderate

Gemfibrozil (Lopid) Low

Niacin-Nicotinamide (Nicobid) Low



Antihyperlipidemics Cost Index

Pravastatin (Pravachol) Low

Rosuvastatin (Crestor) Low

Simvastatin (Zocor) Low

Omega-3-acid ethyl esters (Lovaza) Moderate

Angiotensin Converting Enzyme Inhibitors Cost Index

Benazepril (Lotensin) Low

Captopril (Capoten) Moderate

Enalapril (Vasotec) Low

Lisinopril (Prinivil, Zestril) Low

Angiotensin Receptor Blockers Cost Index

Losartan (Cozaar) Low

Olmesartan (Benicar) RESERVE USE Low

Valsartan (Diovan) Low

Vasopressors Cost Index

DOPamine (Intropin) RESERVE USE High

EPINEPHrine (Adrenalin) High

Norepinephrine or Levarterenol (Levophed) RESERVE USE High

Miscellaneous Antihypertensives Cost Index

cloNIDine (Catapres) Low-High

hydrALAZINE Low

Methyldopa Low



Central Nervous System Agents

Agents for Migraine Cost Index

Amitriptyline (Elavil) Low

Aspirin-Acetaminophen-Caffeine (Excedrine Migraine) Low

Atenolol (Tenormin) Low

Divalproex (Depakote, Depakote ER) Low

Metoprolol (Lopressor, Toprol XL) Low

Naproxen (Naprosyn) Low

Propranolol (Inderal) Low

SUMAtriptan (Imitrex) Low-High

Topiramate (Topamax) Low

Valproic Acid/Valproate (Depakene) Low

Venlafaxine (Effexor) Low

Verapamil (Calan, Isoptin, Verelan Verelan PM) Low

Analgesics-Nonsteroidal Anti-Inflammatory Agents Cost Index

Aspirin Low

Celecoxib (CeleBREX)- RESERVE USE Low

Ibuprofen (Motrin) Low

Ketorolac (Toradol) Low-Moderate

Meloxicam (Mobic) Low

Nabumetone (Relafen) - RESERVE USE Low

Naproxen (Naprosyn) Low

Sulindac (Clinoril) Low

Analgesics-Opiate Agonists Cost Index

Acetaminophen-Codeine C-III Low

Acetaminophen-HYDROcodone (Lortab, Vicodin, Vicodin ES) C-II Low-Moderate



Analgesics-Opiate Agonists Cost Index

morphine-II Low-Moderate

oxyCODONE (OxyCONTIN) C-II High

Opiate agonists include a range of dosage forms and strengths. Dosing of each is dependent on

the individual patient and condition treated.

Miscellaneous Analgesic, Antipyretic, & Anti-Inflammatory Agents Cost Index

Acetaminophen (Tylenol) Low

Colchicine High

traMADol (Ultram) C-IV Low

Anticonvulsants-Barbiturates Cost Index

PHENobarbital (Luminal) C-IV Low

Primidone (Mysoline) Low

Anticonvulsants-Benzodiazepines Cost Index

cloBAZam (Onfi) C-IV RESERVE USE Low

clonazePAM (KlonoPIN) C-IV Low

Clorazepate (Tranxene) C-IV Low-moderate

diazePAM (Valium, Diastat) C-IV Low-High

LORazepam (Ativan) C-IV Low

Midazolam (Nayzilam) C-IV High

Anticonvulsants-Hydantoins Cost Index

Fosphenytoin (Cerebyx) High

Phenytoin (Dilantin) Low-High

Anticonvulsants-Succinimides Cost Index

Ethosuximide (Zarontin) Low



Miscellaneous Anticonvulsants Cost Index

Cannabidiol (Epidiolex) C-V RESERVE USE High

carBAMazepine (TEGretol) Moderate-High

Divalproex (Depakote) Low

Felbamate (Felbatol) - RESERVE USE Moderate

Gabapentin (Neurontin) Low

Lacosamide (Vimpat) C-V High

lamoTRIgine (LaMICtal) Low-High

levETIRAcetam (Keppra) Low

OXcarbazepine (Trileptal) Low

Pregabalin (Lyrica) C-V Low

Rufinamide (Banzel) High

tiaGABine (Gabatril) High


Valproic Acid/Valproate

(Depakene)

Low

Zonisamide (Zonegran) Low

Antiemetics-Antivertigo Cost Index

diphenhydrAMINE (Benadryl) Low

hydrOXYzine (Atarax, Vistaril) Low-High

Meclizine (Antivert, Bonine) Low

Metoclopramide (Reglan) Low

Ondansetron (Zofran, Zofran ODT) Low

Prochlorperazine (Compazine) Low-High

Promethazine (Phenergan) Low-High

Trimethobenzamide (Tigan) Moderate



Miscellaneous Central Nervous System Agents Cost Index

Megestrol (Megace, Megace ES) Moderate

Antiparkinson Agents Cost Index

Amantadine Moderate

Benztropine (Cogentin) Low-High

Bromocriptine Moderate

Entacapone (Comtan) Low

Carbidopa-Levodopa (Sinemet) Low

Pramipexole (Mirapex) Low

Rasagiline (Azilect) High

Selegiline (Eldepryl) Low

Trihexyphenidyl (Artane) Low

Dementia Agents Cost Index

Donepezil (Aricept) Low-Moderate

Galantamine (Razadyne) Low-High

Memantine (Namenda) Low

Rivastigmine (Exelon, Exelon Patches) Low-Moderate

Muscle Relaxants-Antispasticity Agents Cost Index

Baclofen Low

Dantrolene (Dantrium) Moderate

diazePAM (Valium) C-IV Low-High

tiZANidine (Zanaflex) - RESERVE USE Low

Muscle Relaxants-Muscle Relaxant Agents Cost Index

Cyclobenzaprine Low



Muscle Relaxants-Muscle Relaxant Agents Cost Index

diazePAM (Valium) C-IV Low-high

Methocarbamol (Robaxin) Low

Psychotropic Agents-Benzodiazepine Anxiolytics and Hypnotics Cost Index

ALPRAZolam (Xanax, Xanax XR) C-IV Low

chlordiazePOXIDE (Librium) Uoral onlyU C-IV Low

clonazePAM (KlonoPIN) C-IV Low

Clorazepate (Tranxene) C-IV Low

diazePAM (Valium) C-IV Low-High

LORazepam (Ativan) C-IV Low

Midazolam (Versed) C-IV Moderate

Oxazepam (Serax) C-IV Moderate

Temazepam (Restoril) C-IV Low

Triazolam (Halcion) C-IV Moderate

Psychotropic Agents-Miscellaneous Anxiolytics and Hypnotics Cost Index

busPIRone (BuSpar) Low


hydrOXYzine (Atarax, Vistaril) Low-High

Prazosin (Minipress) Low

traZODone (Desyrel) Low

Zolpidem (Ambien) C-IV Low

Psychotropic Agents-Antidepressants-Monoamine Oxidase

Inhibitors (MAOI)

Cost Index

Phenelzine (Nardil) Moderate

Tranylcypromine (Parnate) Moderate



Psychotropic Agents-Antidepressants-Serotonin Selective Reuptake

Inhibitors (SSRI)

Cost Index

Citalopram (CeleXA) Low

Escitalopram (Lexapro) Low-High

FLUoxetine (PROzac) Low-High

fluvoxaMINE (Luvox) Low-High

PARoxetine (Paxil) Low-High

Sertraline (Zoloft) Low-High

Psychotropic Agents-Antidepressants-Serotonin Norepinephrine

Reuptake Inhibitors (SNRI)

Cost Index

DULoxetine (Cymbalta) Low

Venlafaxine (Effexor) Low

Psychotropic Agents-Antidepressants-Tricyclic Agents Cost Index

Amitriptyline (Elavil) Moderate

clomiPRAMINE (Anafranil) - for OCD High

Desipramine (Norpramin) Moderate-High

Doxepin (SINEquan) Moderate

Imipramine (Tofranil) Low

Nortriptyline (Pamelor) Low

Psychotropic Agents-Miscellaneous Antidepressants Cost Index

buPROPion (Budeprion, Wellbutrin, Zyban) Low

Mirtazapine (Remeron, Remeron SolTab) Low

traZODone (Desyrel) Low

Esketamine (Spravato) C-III RESERVE USE High

Ketamine (Ketalar) C-III RESERVE USE High



Psychotropic Agents-Antipsychotics Cost Index

ARIPiprazole (Abilify, Abilify discmelt, Abilify Maintena, Aristada, Aristada

Initio -RESERVE USE)

Low-High

Asenapine (Saphris) High

Brexpiprazole (Rexulti) High

Cariprazine (Vraylar) High

chlorproMAZINE (Thorazine) High

cloZAPine (Clozaril)- RESERVE USE Moderate-High

fluPHENAZine (Prolixin) High

Haloperidol (Haldol) Low-High

Iloperidone (Fanapt) RESERVE USE High

Loxapine (Loxitane) Moderate

Lurasidone (Latuda) High

OLANZapine (ZyPREXA) Low

Paliperidone (Invega) High

Perphenazine (Trilafon) Low-Moderate

QUEtiapine (SEROquel) Low

risperiDONE (RisperDAL) Low-High

Thioridazine (Mellaril) - RESERVE USE Moderate

Thiothixene (Navane) Moderate

Trifluoperazine (Stelazine) Moderate

Ziprasidone (Geodon) Moderate

Psychotropic Agents-Mood Stabilizers Cost Index

carBAMazepine (TEGretol) Moderate-High

Divalproex (Depakote) Low

lamoTRIgine (LaMICtal) Low-High

Lithium Carbonate (Eskalith, Lithonate) Low-Moderate

Lithium Citrate Moderate-High



Psychotropic Agents-Mood Stabilizers Cost Index

OXcarbazepine (Trileptal) Low


Valproic Acid/Valproate (Depakene) Low

Psychotropic Agents-Stimulants Cost Index

Amphetamine Mixture (Adderall) CII Low-Moderate

atoMOXetine (Strattera) Moderate-High

Dexmethylphenidate, extended release (Focalin XR) CII High

Rarely used in adults

Dextroamphetamine (Dexedrine, Dextrostat) C-II

Low-Moderate

Lisdexamfetamine (Vyvanse) C-II Reserve Use High


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

Low-Moderate


Methylphenidate, sustained release (Ritalin SR, Metadate CD Concerta) C-II

Moderate-High

Psychotropic Agents-Other ADHD Agents Cost Index

cloNIDine (Catapres) Low

guanFACINE (Tenex, Intuniv) Low

Substance Use Treatments Cost Index

Acamprosate (Campral) High

Buprenorphine (Subutex) C-II- RESERVE USE Moderate

Buprenorphine-naloxone (Suboxone) C-II- RESERVE USE Moderate

Disulfiram (Antabuse) Moderate

Naltrexone (ReVia, Vivitrol- RESERVE USE) Low-High

Nicotine (Nicoderm, Nicotrol, Nicorette) Low-Moderate




Endocrine Agents

Estrogens Cost Index

Estradiol (Estrace, Vivelle, Alora, Climara, Estraderm) Low-High

Estrogens, Conjugated (Premarin) High

Progesterones Cost Index

medroxyPROGESTERone (Provera) Low-High

Combination Products Cost Index

Estrogen-medroxyPROGESTERone (PremPro, Premphase) Low

All commercially available oral contraceptive agents are considered to be formulary agents

Androgens Cost Index

Testosterone (Androlan) C-IV Low

Osteoporosis Agents Cost Index

Alendronate (Fosamax, Binosto) Low

Calcitonin-Salmon (Miacalcin) Low

Denosumab (Prolia) High

Ibandronate (Boniva) Moderate

Raloxifene (Evista) Moderate

Risedronate (Actonel) Low

Zoledronic Acid (Reclast) High

Adrenal Cortical Steroids Cost Index

Dexamethasone Moderate

Fludrocortisone Low



Adrenal Cortical Steroids Cost Index

Hydrocortisone (Cortef) Low-High

methylPREDNISolone (Medrol, DEPO-Medrol, SOLU-Medrol) Low-High

prednisoLONE Moderate-high

predniSONE (Deltasone) Low

Thyroid Agents Cost Index

Levothyroxine (Synthroid, Levoxyl) Low

methIMAzole (Tapazole) Low

Propylthiouracil Moderate

Miscellaneous Endocrine Agents Cost Index

Allopurinol (Zyloprim) Low

Desmopressin (DDAVP, Stimate) Low-High

Gastrointestinal Agents

Antacids Cost Index

Aluminum Hydroxide Low

Aluminum Hydroxide-Magnesium Trisilicate (Gaviscon) Low

Aluminum Hydroxide-Magnesium Hydroxide (Maalox) Low

Aluminum Hydroxide-Magnesium Hydroxide-Simethicone (Mylanta) Low

Calcium Carbonate (Os-Cal, Os-Cal chewable, Tums ) - 40% elemental

calcium

Low

Antispasmodics/Anticholinergic Agents Cost Index

Dicyclomine (Bentyl) Low

Glycopyrrolate (Robinul) Low



Histamine (H2) Antagonists-Preferred Agents Cost Index

Famotidine (Pepcid) Low-Moderate

Histamine (H2) Antagonists-Other Agents Cost Index

raNITIdine (Zantac) Low-High

Proton Pump Inhibitors-Preferred Agents Cost Index

Lansoprazole (Prevacid) Low

Pantoprazole (Protonix) Low-High

Proton Pump Inhibitors-Other Agents Cost Index

Esomeprazole (NexIUM) Low-High

Omeprazole (PriLOSEC) Low-High

Antiflatulants Cost Index

Simethicone (Gas-X, Phazyme ) Low

Stimulants Cost Index

Metoclopramide (Reglan) Low

Laxatives-Saline Osmotic Cost Index

Magnesium Citrate Moderate

Magnesium Hydroxide (Milk of Magnesia) Low

Laxatives-Irritant/Stimulant Cost Index

Bisacodyl (Dulcolax) Low

Senna (Senokot) Low



Laxatives-Bulking Agents

Cost Index

Cellulose (Unifiber) Low

Methylcellulose (Citrucel) Low

Polycarbophil (Fibercon, Fiber-Lax) Low

Psyllium (Konsyl, Metamucil) Low

All products of psyllium, psyllium husk, and psyllium seed, alone or in combination with

dextrose, aspartame, sugar or sucrose are considered to be formulary.

Laxatives-Osmotic Cost Index

Lactulose (Enulose) Low

Polyethylene Glycol (MiraLax) Low

Polyethylene Glycol Electrolyte Solution (PEG, Co-Lyte, GoLYTELY, ) Moderate

Sorbitol Low

Laxatives-Combination Agents Cost Index

Docusate Sodium-Sennosides (Peri-Colace) Low

Laxatives-Surfactants Cost Index

Docusate Calcium (Surfak) Low

Docusate Sodium (Colace) Low

Laxatives-Calcium Channel Activators Cost Index

Linaclotide (Linzess) RESERVE USE High

Lubiprostone (Amitiza) High

Miscellaneous Laxatives Cost Index

Glycerin Suppository (Sani-Supp) Low



Antidiarrheals Cost Index

Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate) Low

Kaolin-Pectin Low

Lactobacillus Acidophilus (Lactinex, Bacid, Florajen) Low-High

Loperamide (Imodium) Low

Rectal Agents Cost Index

Hydrocortisone Rectal Foam, suppositories, cream, ointment (Proctofoam-

HC, Anusol-HC)

High

Pramoxine – Hydrocortisone (Analpram HC) High

Pramoxine (Anusol) Rectal ointment, suppository Low

Phenylepherine Rectal cream, ointment, suppositories (Preparation H) Low

Miscellaneous Gastrointestinal Agents Cost Index

Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate) Low

Mesalamine (Asacol HD, Pentasa, Rowasa, Canasa) High

miSOPROStol (Cytotec) Moderate

Pancrelipase (Pancreaze, Creon) High

Saccharomyces boulardii (Florastor) Moderate

Sucralfate (Carafate) Low

sulfaSALAzine (Azulfidine) Low-Moderate

Genitourinary Agents

Interstitial Cystitis Agents Cost Index

Phenazopyridine (Pyridium) Low

Genitourinary Irrigants Cost Index

Sodium Chloride Moderate-High

Water for Irrigation Low



Medications for BPH Cost Index

Finasteride (Proscar) Low

Tamsulosin (Flomax) Low

Urinary Alkalinizers Cost Index

Potassium Citrate (Urocit K) Moderate

Potassium Citrate Combinations (Polycitra-LC, Polycitra K) Low

Sodium Bicarbonate Low

Sodium Citrate-Citric Acid (Oracit) Moderate

Urinary Anticholinergics Cost Index

Darifenacin (Enablex) Moderate

Oxybutynin (Ditropan XL) Low

Solifenacin (Vesicare) Low

Trospium Moderate

Tolterodine (Detrol, Detrol LA) Moderate

Urinary Cholinergics Cost Index

Bethanechol (Urecholine) Moderate

Vaginal Antifungals Cost Index

Clotrimazole (Gyne-Lotrimin) Low

Miconazole Low

Tioconazole Moderate

Miscellaneous Genitourinary Agents Cost Index

Mirabegron (Myrbetriq)- RESERVE USE High



Miscellaneous Genitourinary Agents Cost Index

Sevelamer (Renagel) High

Immunological Agents

Immune Serums Cost Index

Hepatitis B Immune Globulin (HBIG) High

Bacterial Vaccines Cost Index

Pneumococcal Vaccine, Polyvalent (Pneumovax 23) High

Pneumococcal Vaccine, Conjugate (Prevnar 13) High

Viral Vaccines Cost Index

Hepatitis A Vaccine (Vaqta, Havrix) High

Hepatitis A-Hepatitis B Vaccine (Twinrix) High

Hepatitis B Virus Vaccine, Recombinant (Recombivax HB, Engerix-B,

Heplisav-B )

High

Influenza Virus Vaccine High

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

Varicella Virus Vaccine, Live (Varivax) High

Zoster Vaccine- Recombinant, Adjuvanted (Shingrix) High

Toxoids Cost Index

Diphtheria-Tetanus Toxoids Adsorbed (DT) High

Diphtheria-Tetanus Toxoids Adsorbed for Adult Use (Td) High

Diphtheria-Tetanus-Acellular Pertussis (Tdap) (Boostrix, Adacel) High

In-Vivo Diagnostic Biologicals Cost Index

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



Infectious Disease Agents

Antibiotics-Penicillins Cost Index

Amoxicillin (Amoxil, Polymox) Low

Amoxicillin-Clavulanate (Augmentin) Low

Ampicillin (Polycillin, Omnipen) Low-High

Nafcillin High

penicillin G Benzathine (Bicillin LA) High

penicillin V Potassium (Pen-Vee K, V-Cillin K) Low

Piperacillin-Tazobactam (Zosyn) High

Antibiotics-Cephalosporins Cost Index

ceFAZolin (Kefzol) Moderate

cefdinir (Omnicef) Moderate

Cefepime (Maxipime) High

cefTRIAXone (Rocephin) Moderate

Cefuroxime Axetil (Ceftin) - Oral form only Low

Cephalexin (Keflex) Low

Antibiotics-Macrolides Cost Index

Azithromycin (Zithromax) Low-Moderate

Clarithromycin (Biaxin) Moderate

Antibiotics-Tetracyclines Cost Index

Doxycycline (Vibramycin) Low

Minocycline Moderate

Tetracycline High



Antibiotics-Quinolones Cost Index

Ciprofloxacin (Cipro) Low-High

levoFLOXacin (Levaquin) Low

Moxifloxacin (Avelox) High

Antibiotics-Aminoglycosides Cost Index

Amikacin High

Gentamicin High

Neomycin High

Tobramycin Moderate

Miscellaneous Antibiotics Cost Index

Clindamycin (Cleocin) Low-Highh

Fosfomycin (Monurol) High

Linezolid (Zyvox) RESERVE USE High

metroNIDAZOLE (Flagyl) Low-Moderate

Sulfamethoxazole -Trimethoprim (Bactrim)

The 5:1 ratio of Sulfamethoxazole to Trimethoprim is constant in all dosage

forms

Low-High

Vancomycin (Vancocin) High

Antifungals Cost Index

Fluconazole (Diflucan) Low-Moderate

Griseofulvin (Fulvicin, Grifulvin V, Gris-Peg) High

Ketoconazole (Nizoral) Low

Nystatin (Mycostatin) Low

Terbinafine (LamISIL) Low



Antituberculars Cost Index

Ethambutol (Myambutol) Low

Ethionamide (Trecator) High

Isoniazid (INH) Low

Pyrazinamide Moderate

Rifabutin (Mycobutin) High

rifAMPin (Rifadin) Moderate

rifAMPin - Isoniazid (Rifamate) High

Antivirals

Cost Index

Acyclovir (Zovirax) High

Oseltamivir (Tamiflu) High

valACYclovir (Valtrex) Moderate

Zanamivir (Relenza) High

All commercially available antiviral agents used in the treatment of AIDS/HIV are considered to

be formulary agents

Antihelmintics Cost Index

Ivermectin (Stromectol) High

Urinary Anti-Infectives Cost Index

Nitrofurantoin (Macrodantin) Moderate

Miscellaneous Anti-Infectives Cost Index

Dapsone Low

Pentamidine (Pentam) - RESERVE USE High



Parenteral Solutions and Additives

Parenteral Solutions Cost Index

Amino Acid Injection (Aminosyn) High

Amino Acid Injection-Dextrose-Electrolytes (Clinimix E) High

Dextrose 5%-Sodium Chloride Intravenous Solution High

Dextrose 5% in Water Moderate

Dextrose 5% in Ringer's Lactate Moderate

Dextrose 5%-Sodium Chloride-Potassium Chloride Intravenous Solution High

Dextrose 50% in Water High

Sodium Chloride Intravenous Solution High

Sodium Chloride Low

Water for Injection Low

Electrolyte Replacement Additives Cost Index

Magnesium Sulfate Low

Potassium Chloride Low

Sodium Chloride Low

Nutritional Agents

Vitamins Cost Index

Ascorbic Acid (Vitamin C) Low

Cyanocobalamin ( Vitamin B12) Low-High

Folic Acid (Folvite) Low

Niacin Low

Pyridoxine (Vitamin B6) Low

Thiamine (Vitamin B1) Low

Vitamin A (Aquasol A) High

Vitamin D2 (Ergocalciferol, Calciferol, Drisdol) Low-Moderate

Vitamin D3 (Calcitrol, Rocaltrol, Cholecalciferol) Low



Vitamins Cost Index

Vitamin E (Aquasol E) Low

Minerals, Trace Elements, and Electrolytes Cost Index

Calcium Carbonate (Os-Cal, Os-Cal chewable, Tums) - 40% elemental

calcium

Low

Calcium Citrate (Citracal) 20% elemental calcium Low

Ferrous Sulfate (Feosol, Fer-In-Sol) -20% elemental iron Low

Potassium Chloride Low

Zinc Sulfate Low

Combination Products Cost Index

Calcium Carbonate-Vitamin D3 (Os-Cal + D) 40% elemental calcium Low

Calcium Citrate-Vitamin D3 (Citracal-D) 20% elemental calcium Low

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

150 Forte)

Low

Multivitamin (Unicap, Hexavitamins) Low

Multivitamin-Minerals Low

Multivitamins, Pediatric (Poly-Vi-Sol) Low

Multivitamins, Prenatal Low

Vitamin B Complex Low

Vitamin B Complex-Vitamin C (Stresscaps, Allbee with C, Nephrocaps,

Nephro-vite)

Low

Vitamin B Complex-Vitamin C-Zinc Low

Miscellaneous nutritional agents Cost Index

Levocarnitine (Carnitor) High



Respiratory Agents

Beta2 Agonist-Short acting (SABA) Cost Index

Albuterol (Proventil, Ventolin) Low-Moderate

Levalbuterol (Xopenex) Moderate

Beta2 Agonist-Long Acting (LABA) Cost Index

Salmeterol (Serevent) High

Anticholinergics-Short Acting (SAMA) Cost Index

Ipratropium (Atrovent) Low-Moderate

Anticholinergics-Long Acting (LAMA) Cost Index

Tiotropium (Spiriva) Moderate

Combination Short-Acting Beta2 Agonists Plus Anticholinergics

(SABA/SAMA)

Cost Index

Albuterol-Ipratropium (Combivent) Moderate

Combination Long Acting Beta-2 Agonists Plus Corticosteroids

(LABA/ICS)

Cost Index

Budesonide-Formoterol (Symbicort) Moderate

Fluticasone-Salmeterol (Advair) High

Inhaled Corticosteroids (ICS) Cost Index

Beclomethasone (QVAR) Moderate

Budesonide (Pulmicort) Moderate

Fluticasone (Flovent) Moderate



Miscellaneous Respiratory Drugs Cost Index

Acetylcysteine High

Montelukast (Singulair) Low

Sodium Chloride Low

Antihistamine, Cough and Decongestant Preparations

Cost Index

Benzonatate Antitussive Low

Brompheniramine-Phenylephrine (Dimetapp Children’s Cold and Allergy) Low

Brompheniramine-Pseudoephedrine, Rynex PSE) Low

Cetirizine (ZyrTEC) Low

Cetirizine-Pseudoephedrine (ZyrTEC D) Low

Chlorpheniramine Low

Cyproheptadine (Periactin) Low

*Dextromethorphan Antitussive Low


Fexofenadine (Allegra) Low

Fexofenadine - Pseudoephedrine (Allegra-D) Low

guaiFENesin-Codeine C-V Low

*guaiFENesin-Dextromethorphan Low

guaiFENesin-Pseudoephedrine (Mucinex D) Low

hydrOXYzine (Atarax, Vistaril) Low

Loratadine (Claritin) Low

Loratadine-Pseudoephedrine (Claritin D) Low

Pseudoephedrine (Sudafed) Decongestant Low

Triprolidine-Pseudoephedrine (Aprodine) Low

*Any combination of products containing dextromethorphan or guaifenesin are considered

formulary if individual ingredients are on formulary AND the dosage form is on formulary.



Expectorants Cost Index

*guaiFENesin (Robitussin, Mucinex) Low

Potassium Iodide (SSKI) High

*ANY COMBINATION OF PRODUCTS CONTAINING DEXTROMETHORPHAN OR

DEXTROMETHORPHAN-GUAIFENESIN ARE CONSIDERED FORMULARY IF INDIVIDUAL

INGREDIENTS ARE ON FORMULARY AND THE DOSAGE FORM IS ON FORMULARY.

Topical Agents

Ophthalmics-Agents for Glaucoma Cost Index

Betaxolol (Betoptic S) High

Bimatoprost (Lumigan) High

Brimonidine (Alphagan P) Low

Latanoprost (Xalatan) Moderate

Pilocarpine (Isopto Carpine) Moderate

Timolol (Timoptic, Timoptic XE) Low

Timolol-Dorzolamide (Cosopt) Low

Travoprost (Travatan Z) High

Ophthalmics-Antibiotics Cost Index

Bacitracin High

Ciprofloxacin (Ciloxan) Moderate

Erythromycin High

Gentamicin (Garamycin) Moderate

Moxifloxacin (Moxeza, Vigamox) Reserve Use High

Polymyxin B-Bacitracin (Polysporin) Low

Polymyxin B-Trimethoprim (Polytrim) Low

Sulfacetamide Sodium (Bleph-10) Moderate

Tobramycin (Tobrex) Moderate



Ophthalmics-Mydriatics Cost Index

Atropine Sulfate (Isopto Atropine) Moderate

Homatropine (Isopto Homatropine) High

Phenylephrine (Neo-Synephrine) Moderate

Scopolamine (Isopto Hyoscine) N/A

Tropicamide (Mydriacyl) Low

Ophthalmics-Decongestant/Antiallergy Cost Index

Ketotifen (Zaditor) Low

Naphazoline (Naphcon, AK-Con) Low

Olopatadine (Patanol) High

Tetrahydrozoline (Visine Allergy Relief, Visine Moisturizing) Low

Miscellaneous Ophthalmics Cost Index

Carboxymethylcellulose Low

Cromolyn (Intal) Low

Dexamethasone - RESERVE USE High

Fluorescein Sodium Low

Fluorescein-benoxinate (Flurox) N/A

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

Ophthalmic Lubricant (Artifical Tears, Liquitears, HypoTears, HypoTears PF) Moderate

prednisolone (Pred Mild, Pred Forte) RESERVE USE High

Proparacaine (Alcaine) Moderate

Sodium Chloride Low

Tobramycin-Dexamethasone (TobraDex)- RESERVE USE High

Otics Cost Index

Acetic Acid (Acetasol, VoSol) Low



Otics Cost Index

Acetic Acid-Aluminum Acetate (Domeboro Otic) Low

Acetic Acid-Hydrocortisone-Propylene Glycol-Sodium Acetate-Benzethonium

(VoSol HC)

High

Carbamide Peroxide-Glycerin-Propylene Glycol-Sodium Stannate (Debrox) Low

Ciprofloxacin-Dexamethasone (Ciprodex) High

Ciprofloxacin-Hydrocortisone (Cipro HC Otic) High

Hydrogen Peroxide Low

Mineral Oil Low

Neomycin-Polymyxin B-Hydrocortisone (Cortisporin) Moderate

Mouth and Throat Agents Cost Index

Benzocaine (Orajel, Cepacol) Low

Carbamide Peroxide (Gly-Oxide) Low

Chlorhexidine (Peridex) Low

Clotrimazole ( Fungoid) Low

Doxycycline (Periostat) N/A

Fluoride (OmniMed, PerioMed) Low

Lidocaine (Viscous Lidocaine) Low

Nystatin (Mycostatin) Low

Phenol (Chloraseptic) Low

Saliva Substitute OTC Low

Saliva Substitute Rx Low

Sodium Chloride Low

Triamcinolone High

Nasal Agents Cost Index

Azelastine (Astelin) 0.1% nasal spray 137 mcg/spray Low

Fluticasone (Flonase) Low



Nasal Agents Cost Index

Mometasone (Nasonex) Low

Oxymetazoline (Afrin) Low

Phenylephrine (Neo-Synephrine) Low

Sodium Chloride Low

Triamcinolone (Azmacort, Nasacort) Low

Dermatologicals-Acne Agents Cost Index

Adapalene (Differin) Moderate

Benzoyl Peroxide Low

Benzoyl Peroxide-Clindamycin (BenzaClin) High

Clindamycin (Cleocin T) Moderate

Erythromycin-Benzoyl Peroxide (Benzamycin) Moderate

metroNIDAZOLE (Noritate, MetroGel) Moderate

Salicylic Acid-Sulfur Low

Sulfacetamide Sodium Low

Tazarotene (Tazorac, Avage) High

Tretinoin (Retin-A) High

Dermatologicals-Analgesics Cost Index

Diclofenac Gel (Voltaren Gel)- RESERVE USE Low

Dermatologicals-Anesthetics, local Cost Index

Benzocaine (Lanacaine) Low

Ethyl Chloride Low

Lidocaine (Xylocaine) Low

Lidocaine-Prilocaine (EMLA, Lidoderm) Low

Pramoxine Low



Dermatologicals-Anti-Histamine Agents Cost Index

Calamine-Zinc Oxide-Glycerin (Calamine Lotion) Low

Calamine-Pramoxine (Caladryl) Low


Pramoxine-Zinc (Caladryl Clear) Low

Dermatologicals-Anti-Infectives-Antibiotics Cost Index

Bacitracin Low

Bacitracin-Polymyxin B (Polysporin) Low

Clindamycin (Cleocin T) Moderate

Gentamicin (Garamycin) Moderate

metroNIDAZOLE (Noritate, MetroGel) Moderate

Mupirocin (Bactroban) Low-High

Neomycin-Polymyxin B-Bacitracin (Triple Antibiotic Ointment) Low

Dermatologicals-Anti-Infectives-Antiviral Cost Index

Acyclovir (Zovirax) High

Dermatologicals-Anti-Infectives-Antifungals Cost Index

Ciclopirox Low

Clotrimazole Low

Clotrimazole-Betamethasone dipropionate (Lotrisone ) Low

Ketoconazole Low

Miconazole Low

Nystatin Low

Terbinafine Low

Tolnaftate Low



Dermatologicals-Antipsoriatics Cost Index

Calcipotriene (Dovonex) High

Coal Tar Low

Selenium Sulfide Low

Tazarotene (Tazorac, Avage) High

Dermatologicals-Antiseborrheic Agents Cost Index

Coal Tar Low

Salicylic Acid-Sulfur Low

Selenium Sulfide Low

Sulfacetamide Sodium Low

Dermatologicals-Antiseptics & Germacides Cost Index

Chlorhexidine Low

Hexachlorophene Low

Povidone-Iodine (Betadine) Low

Dermatologicals-Burn Agents Cost Index

Bacitracin Low

Silver SulfADIAZINE (Silvadene) Low

Dermatologicals-Corticosteroids-Ultra High Potency Cost Index

Betamethasone dipropionate, augmented (Diprolene A/F) - RESERVE USE Low

Clobetasol (Clobex, Cormax,Temovate) - RESERVE USE Moderate

Dermatologicals-Corticosteroids- High Potency Cost Index

Betamethasone dipropionate (Diprolene) Moderate

Fluocinonide Low



Dermatologicals-Corticosteroids- Medium Potency Cost Index

Betamethasone Valerate (Valisone) Moderate

Fluocinolone (Capex, Derma-Smooth/FS, Synalar) Moderate

Triamcinolone Low

Dermatologicals-Corticosteroids- Low Potency Cost Index

Desonide (Desowen, Tridesilon) Low-High

Hydrocortisone (Lanacort, Corticaine) Low

Dermatologicals-Diaper Rash Agents Cost Index

Diaper Rash Ointment Low

Diaper Rash Powder (Mexsana) Low

Zinc Oxide Low

Dermatologicals-Emollients Cost Index

Emollient Gel Low

Emollient Lotion-Cream (Lubriderm, Keri Lotion, Cetaphil, Eucerin,

Nutraderm)

Low

Emollient Ointment (Lanolin, Aquaphor) Low

Dermatologicals-Keratolytics Cost Index

Podophyllum Resin (Podocon-25) High

Salicylic Acid

All available salicylic acid products as a single agent are considered to be on

formulary

Low-High

Urea Low



Dermatologicals-Ointments Cost Index

Petrolatum, White (Vaseline) Low

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

Dermatologicals-Rubs and Liniments Cost Index

Menthol Low

Menthol-Methyl Salicylate (Ben-Gay) Low

Dermatologicals-Skin Cleansers Cost Index

Abrasive Cleanser (Brasivol, Pernox, Salac, Seba-Nil) Low

Non-Soap Cleanser (Cetaphil) Low

Salicylic Acid-Sulfur

All commercially available salicylic acid sulfur forms are on formulary

Low

Dermatologicals-Scabicides & Pediculicides Cost Index

Permethrin 1% Liquid (NIX) Low

Permethrin 5% Cream (Elimite) Low

Pyrethins 0.33%-Piperonyl Butoxide 4% (Pronto, RID) Low

Dermatologicals-Skin Protectants Cost Index

Benzoin, Compound Tincture Low

Menthol-Zinc Oxide (Calmoseptine, Risamine) Low

Silver SulfADIAZINE (Silvadene) Low

Zinc Oxide Low

Dermatologicals-Sunscreens Cost Index

Sunscreen-Block- Contains minimum SPF 15 Low



Dermatologicals-Tar-Containing Agents Cost Index

Coal Tar Low

Dermatologicals-Wound Agents Cost Index

Collagenase (Santyl) High

Trypsin-Balsam Peru-Castor Oil (Granulex, Revina, TBC) Low

Wound Cleanser (Carrington Clara-Klenz) Low

Miscellaneous Dermatologicals Cost Index

Aluminum Chloride Hexahydrate (Drysol) Low

Camphor-Phenol (Campho-Phenique) Low

Hydrogen Peroxide Low

Pimecrolimus (Elidel) High

Silver Nitrate Low

Tacrolimus (Protopic) High

Trypsin-Balsam Peru-Castor Oil (Granulex) Low

Irrigation Solutions Cost Index

Sodium Chloride Solution, irrigation: 0.45%, 0.9% Moderate-High

Water for Irrigation Low

Nutritional Supplements

Certification Process Used Product Line Certified

Good Manufacturer Practices (GMP) Nature’s Way

Good Manufacturer Practices (GMP) Country Life

Good Manufacturer Practices (GMP) Twin

Consumer Labs (CL) Good Neighbor Pharmacy

Consumer Labs (CL) Sundown



Certification Process Used Product Line Certified

United States Pharmacopoeia (USP) Nature Made

National Sanitation Foundation (NSF) GNC Nutritional Supplements

Supplement Cost Index

Fish Oil (Nature Made Fish Oil) Low

Glucosamine Low

Magnesium L-lactate dihydrate (Mag-Tab SR) Low

Melatonin Low


Index 117

Index

A

Abilify ........................................ 12, 35, 91

Abilify discmelt ................................ 35, 91

Abilify Maintena .......................... 13, 35, 91

Abrasive Cleanser ................................ 114

Acamprosate ................................... 32, 92

Acetaminophen ................................ 32, 86

Acetaminophen-Codeine ................... 32, 85

Acetaminophen-HYDROcodone ........... 32, 85

Acetasol ........................................ 32, 108

acetaZOLAMIDE ............................... 32, 82

Acetic Acid .................................... 32, 108

Acetic Acid-Aluminum Acetate ......... 32, 109

Acetic Acid-Hydrocortisone-Propylene Glycol-

Sodium Acetate-Benzethonium ..... 32, 109

Acetylcysteine ............................... 32, 106

Actonel ........................................... 71, 93

Actos .............................................. 67, 80

Acyclovir ................................ 33, 102, 111

Adacel ............................................ 46, 99

Adalat CC ........................................ 63, 83

Adapalene ..................................... 33, 110

Adderall .................................... 19, 34, 92

Adderall XR ..................................... 19, 34

Adenocard ................................. 23, 33, 83

Adenosine ................................. 23, 33, 83

Adrenalin......................................... 47, 84

Advair ........................................... 51, 105

Afrin ............................................. 65, 110

AK-Con ......................................... 63, 108

AK-Rinse ....................................... 64, 108

Albuterol ....................................... 33, 105

Albuterol-Ipratropium ..................... 33, 105

Alcaine .......................................... 69, 108

Aldactazide ...................................... 73, 82

Aldactone ........................................ 73, 82

Alendronate ..................................... 33, 93

Allbee with C ................................. 78, 104

Allegra .......................................... 49, 106

Allegra-D ....................................... 49, 106

Allopurinol ....................................... 33, 94


Index 118

Alora .............................................. 48, 93

Alphagan P .................................... 38, 107

ALPRAZolam ............................... 21, 33, 89

Aluminum Chloride Hexahydrate ...... 33, 115

Aluminum Hydroxide ........................ 33, 94

Aluminum Hydroxide-Magnesium Hydroxide

................................................... 34, 94

Aluminum Hydroxide-Magnesium Hydroxide-

Simethicone ................................. 34, 94

Aluminum Hydroxide-Magnesium Trisilicate

................................................... 33, 94

Amantadine ..................................... 34, 88

Ambien ...................................... 22, 79, 89

Amikacin ....................................... 34, 101

Amino Acid Injection ....................... 34, 103

Amino Acid Injection-Dextrose-Electrolytes

................................................. 34, 103

Aminosyn ...................................... 34, 103

Amiodarone ..................................... 34, 83

Amitiza ........................................... 58, 96

Amitriptyline ....................15, 17, 34, 85, 90

amLODIPine .................................... 34, 83

Amoxicillin .................................... 34, 100

Amoxicillin-Clavulanate ................... 34, 100

Amoxil .......................................... 34, 100

Amphetamine Mixture .................. 19, 34, 92

Ampicillin ...................................... 35, 100

Anafranil ................................... 15, 42, 90

Analpram HC ................................... 68, 97

Androlan ......................................... 74, 93

Antabuse ......................................... 46, 92

Antara ............................................ 49, 83

Antineoplastic Agents ............................. 35

Antivert ........................................... 59, 87

Antiviral Agents ..................................... 35

Anusol ............................................ 70, 97

Anusol-HC ..................................... 53, 97

Apixaban ......................................... 35, 81

Aprodine ....................................... 76, 106

Aquaphor ...................................... 47, 113

Aquasol A ...................................... 78, 103

Aquasol E ...................................... 78, 104

Aricept ............................................ 47, 88

ARIPiprazole .............................. 12, 35, 91

ARIPiprazole Extended Release ............... 13

ARIPiprazole lauroxil ......................... 13, 23

Aristada .................................... 13, 35, 91

Aristada Initio ............................ 23, 35, 91

Arixtra ............................................ 51, 81

Artane ............................................ 76, 88


Index 119

Artifical Tears ................................ 64, 108

Asacol HD ....................................... 59, 97

Ascorbic Acid ................................. 35, 103

Asenapine .................................. 13, 35, 91

Aspirin ....................................... 35, 81, 85

Aspirin-Acetaminophen-Caffeine ........ 35, 85

Astelin .......................................... 36, 109

Atarax .......................... 22, 54, 87, 89, 106

Atenolol ..................................... 35, 83, 85

Ativan .................................. 21, 58, 86, 89

atoMOXetine ............................... 20, 36, 92

atorvaSTATin ................................... 36, 83

Atropine Sulfate ............................. 36, 108

Atrovent ....................................... 55, 105

Augmentin .................................... 34, 100

Avage .................................... 74, 110, 112

Avelox .......................................... 62, 101

Azelastine ..................................... 36, 109

Azilect ............................................ 70, 88

Azithromycin ................................. 36, 100

Azmacort ...................................... 76, 110

Azulfidine ........................................ 73, 97

B

Bacid .............................................. 56, 97

Bacitracin ....................... 36, 107, 111, 112

Bacitracin-Polymyxin B .................... 36, 111

Baclofen .......................................... 36, 88

Bactrim ......................................... 73, 101

Bactroban ...................................... 62, 111

Banzel ............................................ 71, 87

Beclomethasone ............................. 36, 105

Benadryl ............... 21, 46, 87, 89, 106, 111

Benazepril ....................................... 36, 84

Ben-Gay ........................................ 59, 114

Benicar ..................................... 29, 64, 84

Bentyl ............................................. 45, 94

BenzaClin ...................................... 37, 110

Benzamycin ................................... 48, 110

Benzocaine ............................. 36, 109, 110

Benzodiazepines ......................... 31, 86, 89

Benzoin, Compound Tincture ........... 37, 114

Benzonatate .................................. 37, 106

Benzoyl Peroxide ............................ 37, 110

Benzoyl Peroxide-Clindamycin .......... 37, 110

Benztropine ..................................... 37, 88

Betadine ....................................... 68, 112

Betamethasone dipropionate............ 37, 112


Index 120

Betamethasone dipropionate, augmented. 23,

37

Betamethasone Valerate ................. 37, 113

Betaxolol ....................................... 37, 107

Bethanechol .................................... 37, 98

Betoptic S ..................................... 37, 107

Biaxin ........................................... 42, 100

Bicillin LA ...................................... 66, 100

Bicitra ................................................... 98

Bimatoprost .................................. 37, 107

Binosto ........................................... 33, 93

Bisacodyl ........................................ 38, 95

Bismatrol ........................................ 38, 97

Bismuth Subsalicylate ....................... 38, 97

Bleph-10 ....................................... 73, 107

Bonine ............................................ 59, 87

Boniva ............................................ 54, 93

Boostrix .......................................... 46, 99

Brasivol .............................................. 114

Brexpiprazole ............................. 13, 38, 91

Brimonidine ................................... 38, 107

Bromocriptine .................................. 38, 88

Brompheniramine-Phenylephrine...... 38, 106

Brompheniramine-Pseudoephedrine . 38, 106

BSS .............................................. 64, 108

Budeprion........................................ 38, 90

Budesonide .................................... 38, 105

Budesonide-Formoterol ................... 38, 105

Buprenorphine ................................. 23, 38

Buprenorphine-naloxone ................... 23, 38

buPROPion ................................. 15, 38, 90

buPROPion SR ....................................... 15

buPROPion XL ....................................... 15

BuSpar ...................................... 21, 38, 89

busPIRone ................................. 21, 38, 89

C

Caladryl ........................................ 39, 111

Caladryl Clear ................................ 68, 111

Calamine Lotion ............................. 39, 111

Calamine-Pramoxine ....................... 39, 111

Calamine-Zinc Oxide-Glycerin .......... 39, 111

Calan ........................................ 77, 83, 85

Calan SR ......................................... 77, 83

Calciferol ..................................48, 78, 103

Calcipotriene .................................. 39, 112

Calcitonin-Salmon ............................ 39, 93

Calcitrol ...................................41, 78, 103

Calcium Carbonate ....................39, 94, 104


Index 121

Calcium Carbonate-Vitamin D3 ................ 39

Calcium Carbonate-Vitamin DR3R .......... 104

Calcium Citrate .............................. 39, 104

Calcium Citrate-Vitamin D3 ..................... 39

Calcium Citrate-Vitamin DR3R ............... 104

Calmoseptine ................................. 59, 114

Campho-Phenique .......................... 39, 115

Camphor-Phenol ............................ 39, 115

Campral .......................................... 32, 92

Canasa ........................................... 59, 97

Cannabidiol ................................ 23, 39, 87

Capex ........................................... 50, 113

Capoten .......................................... 39, 84

Captopril ......................................... 39, 84

Carafate .......................................... 73, 97

carBAMazepine .......... 17, 18, 31, 39, 87, 91

Carbamide Peroxide ....................... 40, 109

Carbamide Peroxide-Glycerin-Propylene

Glycol-Sodium Stannate ..................... 109

Carbatrol.................................... 17, 31, 39

Carbidopa-Levodopa ......................... 40, 88

Carboxymethylcellulose .......................... 40

Cardizem ........................................ 45, 83

Cariprazine ................................. 13, 40, 91

Carnitor ........................................ 57, 104

Carrington Clara-Klenz .................... 78, 115

Carvedilol ........................................ 40, 83

Catapres .............................. 20, 42, 84, 92

ceFAZolin ...................................... 40, 100

Cefdinir ......................................... 40, 100

Cefepime ....................................... 40, 100

Ceftin............................................ 40, 100

cefTRIAXone .................................. 40, 100

Cefuroxime Axetil ........................... 40, 100

CeleBREX .................................. 24, 40, 85

Celecoxib .................................. 24, 40, 85

CeleXA ...................................... 15, 42, 90

Cellulose ......................................... 40, 96

Cepacol ......................................... 36, 109

Cephalexin .................................... 40, 100

Cerebyx .......................................... 51, 86

Cetaphil ........................... 47, 63, 113, 114

Cetirizine ....................................... 41, 106

Cetirizine-Pseudoephedrine .............. 41, 106

Chloraseptic ................................... 66, 109

chlordiazePOXIDE ....................... 21, 41, 89

Chlorhexidine .......................... 41, 109, 112

Chlorpheniramine ........................... 41, 106


Index 122

chlorproMAZINE ...............10, 11, 13, 41, 91

Chlorthalidone ................................. 41, 82

Cholecalciferol .......................... 41, 78, 103

Cholestyramine ................................ 41, 83

Ciclopirox ...................................... 41, 111

Ciloxan ......................................... 41, 107

Cipro ............................................ 41, 101

Cipro HC Otic ....................................... 109

Cipro Otic .............................................. 42

Ciprodex ....................................... 42, 109

Ciprofloxacin .......................... 41, 101, 107

Ciprofloxacin-Dexamethasone .......... 42, 109

Ciprofloxacin-Hydrocortisone ........... 42, 109

Citalopram ................................. 15, 42, 90

Citracal ......................................... 39, 104

Citracal-D ..................................... 39, 104

Citrucel ........................................... 60, 96

Clarithromycin ............................... 42, 100

Claritin ......................................... 58, 106

Claritin D ...................................... 58, 106

Cleocin ......................................... 42, 101

Cleocin T ................................ 42, 110, 111

Climara ........................................... 48, 93

Clindamycin .................... 42, 101, 110, 111

Clinimix E ...................................... 34, 103

Clinoril ............................................ 73, 85

cloBAZam ............................. 24, 31, 42, 86

Clobetasol ................................24, 42, 112

Clobex .......................................... 42, 112

clomiPRAMINE ........................... 15, 42, 90

clonazePAM .......................... 21, 42, 86, 89

cloNIDine ............................. 20, 42, 84, 92

cloNIDine Extended Release ................... 20

Clopidogrel ...................................... 42, 81

Clorazepate .......................... 21, 43, 86, 89

Clotrimazole ..................... 43, 98, 109, 111

Clotrimazole- Betamethasone

dipropionate ............................. 43, 111

cloZAPine ....................... 13, 15, 24, 43, 91

Clozaril ................................ 13, 24, 43, 91

Coal Tar ................................. 43, 112, 115

Cod Liver Oil-Zinc Oxide-Talc .................. 43

Cogentin ......................................... 37, 88

Colace ............................................. 46, 96

Colchicine ........................................ 43, 86

Collagenase ................................... 43, 115

Co-Lyte ........................................... 67, 96

Combivent ..................................... 33, 105


Index 123

Compazine ...................................... 69, 87

Comtan ........................................... 47, 88

Concerta .................................... 19, 60, 92

Cordarone ....................................... 34, 83

Coreg ............................................. 40, 83

Coreg CR ........................................ 40, 83

Cormax ......................................... 42, 112

Cortef ............................................. 53, 94

Corticaine ............................................. 53

Cortisporin .................................... 63, 109

Cosopt .......................................... 75, 107

Coumadin ....................................... 78, 81

Cozaar ............................................ 58, 84

Creon ............................................. 65, 97

Crestor ........................................... 71, 84

Cromolyn ...................................... 43, 108

Cyanocobalamin ............................. 43, 103

Cyclobenzaprine ............................... 43, 88

Cymbalta ................................... 16, 47, 90

Cyproheptadine ............................. 43, 106

Cytotec ........................................... 61, 97

D

Dantrium ........................................ 44, 88

Dantrolene ...................................... 44, 88

Dapsone ........................................ 44, 102

Darifenacin ...................................... 44, 98

DDAVP ............................................ 44, 94

Debrox .......................................... 40, 109

Deltason .............................................. 69

Deltasone ............................................. 94

Denosumab ..................................... 44, 93

Depakene .................. 18, 31, 77, 85, 87, 92

Depakote .................. 18, 31, 46, 85, 87, 91

Depakote ER ......................... 18, 31, 46, 85

DEPO-Medrol ................................... 60, 94

Derma-Smooth/FS.......................... 50, 113

Desipramine ......................... 15, 17, 44, 90

Desitin ................................................. 43

Desmopressin .................................. 44, 94

Desonide ....................................... 44, 113

Desowen ....................................... 44, 113

Desyrel .......................... 16, 22, 76, 89, 90

Detrol ............................................. 75, 98

Detrol LA ......................................... 75, 98

Dexamethasone ........................44, 93, 108

Dexedrine.................................. 19, 44, 92

Dexedrine spansules .............................. 44

Dexedrine Spansules ............................. 19


Index 124

Dexmethylphenidate XR ............... 19, 44, 92

Dextroamphetamine ......................... 19, 44

Dextroamphetamine XR .......................... 92

Dextromethorphan ......................... 44, 106

Dextrose 5% in Ringer's Lactate ...... 45, 103

Dextrose 5% in Water .................... 45, 103

Dextrose 5%-Sodium Chloride Intravenous

Solution ..................................... 45, 103

Dextrose 5%-Sodium Chloride-Potassium

Chloride Intravenous Solution ....... 45, 103

Dextrose 50% in Water ................... 45, 103

Dextrostat ....................................... 44, 92

Diamox ........................................... 32, 82

Diaper Rash Ointment..................... 45, 113

Diaper Rash Powder ....................... 45, 113

Diaperene ............................................. 79

Diastat ............................................ 45, 86

diazePAM ........................21, 45, 86, 88, 89

Diclofenac Gel ........................... 24, 45, 110

Dicyclomine ..................................... 45, 94

Differin ......................................... 33, 110

Diflucan ........................................ 50, 101

Digoxin ........................................... 45, 82

Dilantin ...................................... 31, 67, 86

dilTIAZem ....................................... 45, 83

Dimetapp Children’s Cold and Allergy 38, 106

Diovan ............................................ 77, 84

diphenhydrAMINE ...... 10, 11, 21, 46, 87, 89,

106, 111

Diphtheria-Tetanus Toxoids Adsorbed . 46, 99

Diphtheria-Tetanus Toxoids Adsorbed for

Adult Use ...................................... 46, 99

Diphtheria-Tetanus-Acellular Pertussis 46, 99

Diprolene ...................................... 37, 112

Diprolene A/F ............................23, 37, 112

Disulfiram ........................................ 46, 92

Ditropan XL ..................................... 65, 98

Divalproex ................. 18, 31, 46, 85, 87, 91

Docusate Calcium ............................. 46, 96

Docusate Sodium ............................. 46, 96

Docusate Sodium-Sennosides ............ 46, 96

Dolophine ............................................. 60

Domeboro Otic ............................... 32, 109

Donepezil ........................................ 47, 88

DOPamine ................................. 24, 47, 84

Dovonex ....................................... 39, 112

Doxepin ............................... 16, 17, 47, 90

Doxycycline ............................ 47, 100, 109

Drisdol .....................................48, 78, 103

Drysol ........................................... 33, 115


Index 125

DT .................................................. 46, 99

Dulcolax .......................................... 38, 95

DULoxetine ................................ 16, 47, 90

Duragesic .............................................. 49

Dyazide .......................................... 76, 82

Dyrenium ........................................ 76, 82

E

E.E.S. ................................................... 48

Effexor ................................. 16, 77, 85, 90

Effexor XR ............................................. 16

Elavil ................................... 15, 34, 85, 90

Eldepryl .......................................... 71, 88

Elidel ............................................ 67, 115

Elimite .......................................... 66, 114

Eliquis ............................................ 35, 81

EMLA ............................................ 57, 110

Emollient Gel ................................. 47, 113

Emollient Lotion-Cream ................... 47, 113

Emollient Ointment ........................ 47, 113

Enablex .......................................... 44, 98

Enalapril ......................................... 47, 84

Engerix-B ........................................ 53, 99

Enoxaparin ...................................... 47, 81

Entacapone ..................................... 47, 88

Enulose ........................................... 56, 96

Epidiolex ................................... 23, 39, 87

EPINEPHrine .................................... 47, 84

Epoetin alfa ............................... 24, 47, 81

Epogen ..................................... 24, 47, 81

Epsom Salt ........................................... 59

Ergocalciferol ............................48, 78, 103

Eryc ..................................................... 48

EryPed ................................................. 48

Erythrocin ............................................ 48

Erythromycin ................................. 48, 107

Erythromycin base ................................. 48

Erythromycin Ethylsuccinate ................... 48

Erythromycin-Benzoyl Peroxide ........ 48, 110

Escitalopram .............................. 16, 48, 90

Eskalith ..................................... 17, 58, 91

Esketamine ................................ 25, 48, 90

Esomeprazole .................................. 48, 95

Estrace ........................................... 48, 93

Estraderm ....................................... 48, 93

Estradiol .......................................... 48, 93

Estrogen-medroxyPROGESTERone ...... 48, 93

Estrogens, Conjugated ...................... 48, 93

Ethambutol .................................... 48, 102


Index 126

Ethionamide .................................. 48, 102

Ethosuximide .............................. 31, 49, 86

Ethyl Chloride ................................ 49, 110

Eucerin ......................................... 47, 113

Evista ............................................. 70, 93

Excedrine Migraine ........................... 35, 85

Exelon ............................................ 71, 88

Exelon Patches ................................ 71, 88

Eye Stream ................................... 64, 108

F

Famotidine ...................................... 49, 95

Fanapt ................................. 13, 25, 54, 91

Fazaclo ...................................... 13, 24, 43

Felbamate .................................. 25, 49, 87

Felbatol ..................................... 25, 49, 87

Felodipine ....................................... 49, 83

Fenofibrate ...................................... 49, 83

fentaNYL ............................................... 49

Feosol ...................................... 49, 82, 104

Fer-In-Sol ................................ 49, 82, 104

Ferro-Sequels .................................. 49, 81

Ferrous Fumarate-Docusate Sodium ... 49, 81

Ferrous Sulfate ......................... 49, 82, 104

Fexofenadine ................................. 49, 106

Fexofenadine - Pseudoephedrine ............. 49

Fexofenadine-Pseudoephedrine .............. 106

Fibercon .......................................... 67, 96

Fiber-Lax ......................................... 67, 96

Filibon .................................................. 62

Finasteride ...................................... 49, 98

Fish Oil ......................................... 50, 116

Flagyl ............................................ 61, 101

Flomax ............................................ 74, 98

Flonase ......................................... 51, 109

Florajen .......................................... 56, 97

Florastor ......................................... 71, 97

Flovent.......................................... 51, 105

Fluconazole ................................... 50, 101

Fludrocortisone ................................ 50, 93

Fluocinolone .................................. 50, 113

Fluocinonide .................................. 50, 112

Fluorescein Sodium ........................ 50, 108

Fluorescein-benoxinate ................... 50, 108

Fluoride ......................................... 50, 109

FLUoxetine ................................ 16, 50, 90

fluPHENAZine .................. 11, 13, 15, 50, 91

fluPHENAZine Decanoate ........................ 13

Flurox ........................................... 50, 108


Index 127

Fluticasone ............................. 51, 105, 109

Fluticasone-Salmeterol ................... 51, 105

Fluvastatin ...................................... 51, 83

fluvoxaMINE ............................... 16, 51, 90

Focalin XR .................................. 19, 44, 92

Folic Acid .............................................. 51

Folvite .................................................. 51

Fondaparinux .................................. 51, 81

Fosamax ......................................... 33, 93

Fosfomycin .................................... 51, 101

Fosphenytoin ................................... 51, 86

Fulvicin ......................................... 52, 101

Fungoid ........................................ 43, 109

Furosemide ..................................... 51, 82

G

Gabapentin ................................ 31, 51, 87

Gabatril .......................................... 74, 87

Galantamine .................................... 51, 88

Garamycin ................................... 107, 111

Gas-X ............................................. 72, 95

Gaviscon ......................................... 33, 94

Gemfibrozil ...................................... 51, 83

Gentamicin ...................... 52, 101, 107, 111

Geodon ...................................... 14, 79, 91

glipiZIDE ......................................... 52, 80

Glucagon ......................................... 52, 80

Glucophage ..................................... 60, 80

Glucophage XR ................................. 60, 80

Glucosamine .................................. 52, 116

Glucose, oral ................................... 52, 80

Glucotrol ......................................... 52, 80

Glycerin .......................................... 52, 96

Glycopyrrolate ................................. 52, 94

Gly-Oxide ...................................... 40, 109

GoLYTELY ........................................ 67, 96

Granulex ....................................... 77, 115

Grifulvin V ..................................... 52, 101

Griseofulvin ................................... 52, 101

Gris-Peg ........................................ 52, 101

guaiFENesin ................................... 52, 107

guaiFENesin-Codeine ...................... 52, 106

guaiFENesin-Dextromethorphan ....... 53, 106

guaiFENesin-Pseudoephedrine .......... 53, 106

guanFACINE .............................. 20, 53, 92

guanFACINE Extended Release ................ 20

Gyne-Lotrimin .................................. 43, 98

H

Halcion...................................... 22, 76, 89


Index 128

Haldol ........................................ 13, 53, 91

Haldol Decanoate ................................... 13

Haloperidol ................ 10, 11, 13, 15, 53, 91

Haloperidol Decanoate ............................ 13

Havrix ............................................ 53, 99

HBIG .............................................. 53, 99

Hemocyte Plus ............................... 55, 104

Heparin ........................................... 53, 81

Hepatitis A Vaccine ........................... 53, 99

Hepatitis A-Hepatitis B Vaccine .......... 53, 99

Hepatitis B Immune Globulin ............. 53, 99

Hepatitis B Virus Vaccine, Recombinant ... 53,

99

Heplisav-B....................................... 53, 99

Hexachlorophene ........................... 53, 112

Hexavitamins ................................. 62, 104

Homatropine ................................. 53, 108

HumaLOG ....................................... 55, 80

HumaLOG Mix 50/50 ........................ 55, 80

HumaLOG Mix 75/25 ........................ 55, 80

HumuLIN ........................................ 55, 80

hydrALAZINE ................................... 53, 84

hydroCHLOROthiazide ....................... 53, 82

Hydrocortisone ......................... 53, 94, 113

Hydrocortisone ...................................... 97

Hydrogen Peroxide .................. 54, 109, 115

hydrOXYzine ...... 10, 11, 22, 54, 87, 89, 106

HypoTears ..................................... 64, 108

HypoTears PF ................................. 64, 108

I

Ibandronate ..................................... 54, 93

Ibuprofen ........................................ 54, 85

Iloperidone ........................... 13, 25, 54, 91

Imipramine ........................... 16, 17, 54, 90

Imitrex ........................................... 73, 85

Imodium ......................................... 58, 97

Inderal ................................. 20, 69, 83, 85

Influenza Virus Vaccine ..................... 54, 99

INH .............................................. 55, 102

Inotropin .............................................. 24

Insulin, Aspart ................................. 54, 80

Insulin, Combination (70/30) ............. 54, 80

Insulin, Combination, lispro protamine

suspension-insulin lispro ...................... 80

Insulin, Detemir ......................... 25, 54, 80

Insulin, Glargine ............................... 55, 80

Insulin, Lispro .................................. 55, 80

Insulin, lispro protamine suspension-

insulin lispro .................................... 55


Index 129

Insulin, NPH .................................... 55, 80

Insulin, Regular ............................... 55, 80

Intal ................................................... 108

Intropin .......................................... 47, 84

Intuniv ...................................... 20, 53, 92

Invega ....................................... 14, 65, 91

Invega Sustenna .............................. 14, 65

Invega Trinza ........................................ 14

Ipratropium ................................... 55, 105

Iron salts with or without vitamins and/or

minerals ..................................... 55, 104

Isoniazid ....................................... 55, 102

Isoptin ....................................... 77, 83, 85

Isoptin SR ....................................... 77, 83

Isopto Atropine .............................. 36, 108

Isopto Carpine ............................... 67, 107

Isopto Homatropine ........................ 53, 108

Isopto Hyoscine ............................. 71, 108

Isordil ............................................. 55, 82

Isosorbide Dinitrate .......................... 55, 82

Isosorbide Mononitrate ..................... 55, 82

Ivermectin .................................... 55, 102

K

Kaolin-Pectin ................................... 55, 97

Kaopectate ...................................... 38, 97

Kapvay ................................................ 20

Keflex ........................................... 40, 100

Kefzol ........................................... 40, 100

Keppra ............................................ 57, 87

Keri Lotion ..................................... 47, 113

Ketalar ...................................... 26, 56, 90

Ketamine .................................. 26, 56, 90

Ketoconazole .......................... 56, 101, 111

Ketorolac ......................................... 56, 85

Ketotifen ....................................... 56, 108

KlonoPIN .............................. 21, 42, 86, 89

Konsyl ............................................ 70, 96

L

Labetalol ......................................... 56, 83

Lacosamide ............................... 31, 56, 87

Lactinex .......................................... 56, 97

Lactobacillus Acidophilus ................... 56, 97

Lactulose ......................................... 56, 96

LaMICtal............................... 17, 56, 87, 91

LamISIL ........................................ 74, 101

lamoTRIgine .............. 17, 18, 31, 56, 87, 91

Lanacaine ...................................... 36, 110

Lanacort ............................................... 53


Index 130

Lanolin ......................................... 47, 113

Lanoxin ........................................... 45, 82

Lansoprazole ................................... 56, 95

Lantus ............................................ 55, 80

Lasix .............................................. 51, 82

Latanoprost ................................... 56, 107

Latuda ....................................... 13, 58, 91

Levalbuterol .................................. 56, 105

Levaquin ....................................... 57, 101

Levarterenol ......................... 29, 57, 64, 84

Levemir ..................................... 25, 54, 80

levETIRAcetam ........................... 31, 57, 87

Levocarnitine ................................. 57, 104

levoFLOXacin ................................. 57, 101

Levophed ............................. 29, 57, 64, 84

Levothyroxine .................................. 57, 94

Levoxyl ........................................... 57, 94

Lexapro ..................................... 16, 48, 90

Librium ...................................... 21, 41, 89

Lidocaine ............................... 57, 109, 110

Lidocaine-Prilocaine ........................ 57, 110

Lidoderm ...................................... 57, 110

Linaclotide .................................. 27, 57, 96

Linezolid .................................. 27, 57, 101

Linzess ...................................... 27, 57, 96

Lipitor ............................................. 36, 83

Liquitears ...................................... 64, 108

Liraglutide ....................................... 57, 80

Lisdexamfetamine ................. 19, 27, 57, 92

Lisinopril ......................................... 57, 84

Lithium ..................................... 17, 18, 91

Lithium Carbonate ................................. 58

Lithium Citrate ...................................... 58

Lithobid ........................................... 17, 58

Lithonate ......................................... 58, 91

Lofibra ............................................ 49, 83

Loperamide ..................................... 58, 97

Lopid .............................................. 51, 83

Lopressor .................................. 60, 83, 85

Loprox ................................................. 41

Loratadine ..................................... 58, 106

Loratadine-Pseudoephedrine ............ 58, 106

LORazepam ............... 10, 11, 21, 58, 86, 89

Lortab ............................................. 32, 85

Losartan .......................................... 58, 84

Lotensin .......................................... 36, 84

Lotrimin ............................................... 43

Lotrisone ..................................... 43, 111


Index 131

Lovaza ............................................ 64, 84

Lovenox .......................................... 47, 81

Loxapine .................................... 13, 58, 91

Loxitane ..................................... 13, 58, 91

Lubiprostone ................................... 58, 96

Lubriderm ..................................... 47, 113

Lumigan ....................................... 37, 107

Luminal ..................................... 31, 66, 86

Lurasidone ................................. 13, 58, 91

Luvox ........................................ 16, 51, 90

Lyrica ............................................. 69, 87

M

Maalox ............................................ 34, 94

Macrodantin .................................. 63, 102

Magnesium Citrate ........................... 58, 95

Magnesium Hydroxide ...................... 58, 95

Magnesium L-lactate dihydrate ........ 59, 116

Magnesium Sulfate ......................... 59, 103

Mag-Tab SR................................... 59, 116

Maxipime ...................................... 40, 100

Maxzide .......................................... 76, 82

Measles-Mumps-Rubella Virus Vaccine, Live

................................................... 59, 99

Meclizine ......................................... 59, 87

Medrol ............................................ 60, 94

medroxyPROGESTERone ................... 59, 93

Megace ........................................... 59, 88

Megace ES ....................................... 59, 88

Megestrol ........................................ 59, 88

Melatonin ...................................... 59, 116

Mellaril ................................. 14, 30, 74, 91

Meloxicam ....................................... 59, 85

Memantine ...................................... 59, 88

Menthol ......................................... 59, 114

Menthol-Methyl Salicylate ................ 59, 114

Menthol-Zinc Oxide ......................... 59, 114

Mephyton .................................. 67, 80, 81

Mesalamine ..................................... 59, 97

Metadate ................................... 19, 60, 92

Metadate CD .................................... 60, 92

Metamucil........................................ 70, 96

metFORMIN ..................................... 60, 80

Methadone ........................................... 60

methIMAzole.................................... 60, 94

Methocarbamol ................................ 60, 89

Methylcellulose................................. 60, 96

Methyldopa ...................................... 60, 84

Methylin .................................... 19, 60, 92


Index 132

Methylphenidate, immediate release .. 19, 60,

92

Methylphenidate, sustained release ... 19, 60,

92

Methylphenidate, sustained release, osmotic

release ............................................... 19

methylPREDNISolone ........................ 60, 94

Metoclopramide .......................... 60, 87, 95

Metoprolol .................................. 60, 83, 85

MetroGel ................................ 61, 110, 111

metroNIDAZOLE .............. 61, 101, 110, 111

Mexsana ....................................... 45, 113

Miacalcin ......................................... 39, 93

Miconazole ............................... 61, 98, 111

Midazolam .................................. 61, 86, 89

Milk of Magnesia .............................. 58, 95

Mineral Oil ..................................... 61, 109

Minipress ........................................ 69, 89

Minocycline ................................... 61, 100

Mirabegron ................................. 27, 61, 98

MiraLax ........................................... 67, 96

Mirapex .......................................... 68, 88

Mirtazapine ................................ 16, 61, 90

miSOPROStol ................................... 61, 97

MMR II ........................................... 59, 99

Mobic .............................................. 59, 85

Mometasone .................................. 61, 110

Montelukast ................................... 61, 106

Monurol......................................... 51, 101

morphine ........................................ 62, 86

Motrin ............................................. 54, 85

Moxeza ....................................27, 62, 107

Moxifloxacin ...................... 27, 62, 101, 107

Mucinex ........................................ 52, 107

Mucinex D ..................................... 53, 106

Multivitamin ................................... 62, 104

Multivitamin, Prenatal ..................... 62, 104

Multivitamin-Minerals ...................... 62, 104

Multivitamins, Pediatric ................... 62, 104

Mupirocin ...................................... 62, 111

Myambutol .................................... 48, 102

Mycobutin ..................................... 70, 102

Mycostatin .............................. 64, 101, 109

Mydriacyl....................................... 77, 108

Mylanta ........................................... 34, 94

Myrbetriq .................................. 27, 61, 98

Mysoline .......................................... 69, 86

N

Nabumetone .............................. 27, 62, 85


Index 133

Nafcillin ........................................ 62, 100

Naloxone ................................... 27, 62, 80

Naltrexone ................................. 20, 62, 92

Naltrexone microspheres .............. 20, 28, 29

Namenda ........................................ 59, 88

Naphazoline .................................. 63, 108

Naphcon ....................................... 63, 108

Naprosyn ........................................ 63, 85

Naproxen ........................................ 63, 85

Narcan ....................................... 27, 62, 80

Nardil ........................................ 16, 66, 89

Nasacort ....................................... 76, 110

Nasonex ....................................... 61, 110

Nature Made Fish Oil ...................... 50, 116

Navane ...................................... 14, 74, 91

Nayzilam ......................................... 61, 86

Neomycin ...................................... 63, 101

Neomycin-Polymyxin B-Bacitracin .... 63, 111

Neomycin-Polymyxin B-Hydrocortisone .... 63,

109

Neo-Synephrine ...................... 66, 108, 110

Nephrocaps ................................... 78, 104

Nephro-vite ................................... 78, 104

Neurontin ........................................ 51, 87

Neutra-Phos-K ...................................... 68

NexIUM ........................................... 48, 95

Niacin-Nicotinamide .......................... 63, 83

Nicobid ........................................... 63, 83

Nicoderm ........................................ 63, 92

Nicorette ......................................... 63, 92

Nicotine .......................................... 63, 92

Nicotrol ........................................... 63, 92

NIFEdipine ....................................... 63, 83

Niferex-150 .......................................... 55

Niferex-150 Forte ........................... 55, 104

Nitrofurantoin ................................ 63, 102

Nitroglycerin .................................... 63, 83

NIX ............................................... 66, 114

Nizoral .......................................... 56, 101

Non-Soap Cleanser ......................... 63, 114

Norepinephrine ..................... 29, 57, 64, 84

Noritate ................................. 61, 110, 111

Normodyne ...................................... 56, 83

Norpramin ................................. 15, 44, 90

Nortriptyline ......................... 16, 17, 64, 90

Norvasc ........................................... 34, 83

NovoLIN .......................................... 55, 80

NovoLOG ......................................... 54, 80


Index 134

Nutraderm .................................... 47, 113

Nystatin .......................... 64, 101, 109, 111

O

OLANZapine .............. 10, 11, 13, 15, 64, 91

OLANZapine pamoate ....................... 14, 29

Olmesartan ................................ 29, 64, 84

Olopatadine ................................... 64, 108

Omega-3-acid ethyl esters ................ 64, 84

Omeprazole ..................................... 64, 95

Omnicef ........................................ 40, 100

OmniMed ...................................... 50, 109

Omnipen ....................................... 35, 100

Ondansetron ................................... 64, 87

Onfi ........................................... 24, 42, 86

Ophthalmic Irrigating Solution ......... 64, 108

Ophthalmic Lubricant ...................... 64, 108

Oracit ............................................. 73, 98

Orajel ........................................... 36, 109

Os-Cal ..................................... 39, 94, 104

Os-Cal + D .................................... 39, 104

Os-Cal chewable ....................... 39, 94, 104

Oseltamivir .................................... 65, 102

Oxazepam .................................. 21, 65, 89

OXcarbazepine .................18, 31, 65, 87, 92

Oxybenzone-PDO-Pet Hy-Phl ........... 65, 114

Oxybutynin ...................................... 65, 98

oxyCODONE .................................... 65, 86

OxyCONTIN ..................................... 65, 86

Oxymetazoline ............................... 65, 110

P

P.P.D. ............................................. 77, 99

Pacerone ......................................... 34, 83

Paliperidone ............................... 14, 65, 91

Paliperidone palmitate ............................ 14

Pamelor .................................... 16, 64, 90

Pancreaze........................................ 65, 97

Pancrelipase .................................... 65, 97

Pantoprazole .................................... 65, 95

Parnate ..................................... 16, 76, 89

PARoxetine ................................ 16, 65, 90

Patanol ......................................... 64, 108

Paxil ......................................... 16, 65, 90

PEG ................................................ 67, 96

penicillin G Benzathine .................... 66, 100

penicillin V Potassium ..................... 66, 100

Penlac .................................................. 41

Pentam ....................................30, 66, 102

Pentamidine .............................30, 66, 102


Index 135

Pentasa .......................................... 59, 97

Pen-Vee K ..................................... 66, 100

Pepcid ............................................ 49, 95

Pepto-Bismol ................................... 38, 97

Periactin ....................................... 43, 106

Peri-Colace ...................................... 46, 96

Peridex ......................................... 41, 109

PerioMed ....................................... 50, 109

Periostat ....................................... 47, 109

Permethrin .................................... 66, 114

Pernox ................................................ 114

Perphenazine ........................ 14, 15, 66, 91

Petrolatum, White .......................... 66, 114

Phazyme ......................................... 72, 95

Phenazopyridine ............................... 66, 97

Phenelzine.................................. 16, 66, 89

Phenergan ....................................... 69, 87

PHENobarbital ............................. 31, 66, 86

Phenol .......................................... 66, 109

Phenylephrine ................... 66, 97, 108, 110

Phenytoin ................................... 31, 67, 86

Phytonadione .............................. 67, 80, 81

Pilocarpine .................................... 67, 107

Pimecrolimus ................................. 67, 115

Pioglitazone ..................................... 67, 80

Piperacillin-Tazobactam ................... 67, 100

Plavix .............................................. 42, 81

Pneumococcal Vaccine, Conjugate ...... 67, 99

Pneumococcal Vaccine, Polyvalent ...... 67, 99

Pneumovax 23 ................................. 67, 99

Podocon-25 ................................... 67, 113

Podophyllum Resin ......................... 67, 113

Polycarbophil ................................... 67, 96

Polycillin ........................................ 35, 100

Polycitra K ....................................... 68, 98

Polycitra-LC ..................................... 68, 98

Polyethylene Glycol........................... 67, 96

Polyethylene Glycol Electrolyte Solution .. 67,

96

Polymox ........................................ 34, 100

Polymyxin B-Bacitracin .................... 67, 107

Polymyxin B-Trimethoprim .............. 67, 107

Polysporin ........................ 36, 67, 107, 111

Polytrim ........................................ 67, 107

Poly-Vi-Sol .................................... 62, 104

Potassium Chloride .................. 68, 103, 104

Potassium Citrate ............................. 68, 98

Potassium Citrate Combinations ......... 68, 98


Index 136

Potassium Iodide ........................... 68, 107

Potassium Phosphate .............................. 68

Povidone-Iodine ............................. 68, 112

Pramipexole .................................... 68, 88

Pramoxine ................................ 68, 97, 110

Pramoxine – Hydrocortisone .................... 97

Pramoxine–Hydrocortisone ...................... 68

Pramoxine-Zinc .............................. 68, 111

Prandin ........................................... 70, 80

Pravachol ........................................ 68, 84

Pravastatin ...................................... 68, 84

Prazosin .......................................... 69, 89

Pred Forte ..................................... 69, 108

Pred Mild ....................................... 69, 108

prednisoLONE .................................. 69, 94

predniSONE ..................................... 69, 94

Pregabalin .................................. 31, 69, 87

Premarin ......................................... 48, 93

Premphase ...................................... 48, 93

PremPro .......................................... 48, 93

Preparation H .................................. 66, 97

Prevacid .......................................... 56, 95

Prevnar 13 ...................................... 67, 99

PriLOSEC ........................................ 64, 95

Primidone ........................................ 69, 86

Prinivil ............................................ 57, 84

ProAir Respiclick .................................... 33

Procardia ......................................... 63, 83

Procardia XL .................................... 63, 83

Prochlorperazine .............................. 69, 87

Procrit ....................................... 24, 47, 81

Proctofoam-HC ................................. 53, 97

Prolia .............................................. 44, 93

Prolixin ..................................... 13, 50, 91

Prolixin Decanoate ................................. 13

Promethazine ................................... 69, 87

Pronto ........................................... 70, 114

Proparacaine .................................. 69, 108

Propranolol ........................... 20, 69, 83, 85

Propylthiouracil ................................ 69, 94

Proscar ........................................... 49, 98

Protonix .......................................... 65, 95

Protopic ........................................ 74, 115

Protriptyline .......................................... 16

Proventil ....................................... 33, 105

Provera ........................................... 59, 93

PROzac ..................................... 16, 50, 90

Pseudoephedrine ............................ 69, 106


Index 137

Psyllium .......................................... 70, 96

Pulmicort ...................................... 38, 105

Pyrazinamide ................................. 70, 102

Pyrethins 0.33%-Piperonyl Butoxide 4% .. 70,

114

Pyridium ......................................... 66, 97

Pyridoxine ..................................... 70, 103

Q

QUEtiapine ................................. 14, 70, 91

QVAR............................................ 36, 105

R

Raloxifene ....................................... 70, 93

raNITIdine ....................................... 70, 95

Rasagiline ....................................... 70, 88

Razadyne ........................................ 51, 88

Reclast ........................................... 79, 93

Recombivax HB ................................ 53, 99

Rectal Hemorrhoidal Suppositories ........... 70

Reglan ....................................... 60, 87, 95

Relafen ...................................... 27, 62, 85

Relenza ......................................... 78, 102

Remeron .................................... 16, 61, 90

Remeron SolTab .............................. 61, 90

Renagel .......................................... 72, 99

Repaglinide ...................................... 70, 80

Restoril ..................................... 22, 74, 89

Retin-A ......................................... 76, 110

ReVia ........................................ 20, 62, 92

Revina .......................................... 77, 115

Rexulti ...................................... 13, 38, 91

RID .............................................. 70, 114

Rifabutin ....................................... 70, 102

Rifadin .......................................... 70, 102

Rifamate ....................................... 70, 102

rifAMPin ........................................ 70, 102

rifAMPin - Isoniazid ............................... 102

rifAMPin-Isoniazid .................................. 70

Risamine ....................................... 59, 114

Risedronate ..................................... 71, 93

RisperDAL ................................. 14, 71, 91

RisperDAL Consta ............................. 14, 71

RisperDAL M-Tab .............................. 14, 71

risperiDONE ............................... 14, 71, 91

Ritalin ....................................... 19, 60, 92

Ritalin SR ........................................ 60, 92

Ritalin XR ............................................. 19

Rivaroxaban .................................... 71, 81

Rivastigmine .................................... 71, 88


Index 138

Robaxin .......................................... 60, 89

Robinul ........................................... 52, 94

Robitussin ..................................... 52, 107

Rocaltrol .................................. 41, 78, 103

Rocephin ....................................... 40, 100

Rosuvastatin ................................... 71, 84

Rowasa ........................................... 59, 97

Rufinamide ................................. 31, 71, 87

Rynex PSE .................................... 38, 106

S

Saccharomyces boulardii ................... 71, 97

Salac .................................................. 114

Salicylic Acid ................................. 71, 113

Salicylic Acid-Sulfur .......... 71, 110, 112, 114

Saliva Substitute ............................ 71, 109

Salmeterol .................................... 71, 105

Sani-Supp ....................................... 52, 96

Santyl ........................................... 43, 115

Saphris ...................................... 13, 35, 91

Scopolamine .................................. 71, 108

Seba-Nil .............................................. 114

Selegiline ........................................ 71, 88

Selenium Sulfide ............................ 72, 112

Senna ............................................. 72, 95

Senokot .......................................... 72, 95

Serax ........................................ 21, 65, 89

Serevent ....................................... 71, 105

SEROquel .................................. 14, 70, 91

Sertraline .................................. 16, 72, 90

Sevelamer ....................................... 72, 99

Shingrix .......................................... 79, 99

Silvadene ............................... 72, 112, 114

Silver Nitrate ................................. 72, 115

Silver SulfADIAZINE ................ 72, 112, 114

Simethicone..................................... 72, 95

Simvastatin ..................................... 72, 84

Sinemet .......................................... 40, 88

SINEquan .................................. 16, 47, 90

Singulair ....................................... 61, 106

Sodium Bicarbonate .......................... 72, 98

Sodium Chloride . 72, 97, 103, 106, 108, 109,

110, 115

Sodium Chloride Intravenous Solution..... 72,

103

Sodium Citrate-Citric Acid.................. 73, 98

Sodium Polystyrene Sulfonate ............ 73, 81

solifenacin ....................................... 73, 98

SOLU-Medrol ................................... 60, 94

Sorbitol ........................................... 73, 96


Index 139

Spiriva .......................................... 75, 105

Spironolactone ................................. 73, 82

Spironolactone-hydroCHLOROthiazide . 73, 82

Spravato .................................... 25, 48, 90

SSKI ............................................. 68, 107

Stelazine .................................... 14, 76, 91

Stimate ........................................... 44, 94

Strattera .................................... 20, 36, 92

Stresscaps .................................... 78, 104

Stromectol .................................... 55, 102

Suboxone ........................................ 23, 38

Subutex .......................................... 23, 38

Sucralfate ....................................... 73, 97

Sudafed ........................................ 69, 106

Sulfacetamide Sodium ...... 73, 107, 110, 112

Sulfamethoxazole-Trimethoprim ...... 73, 101

sulfaSALAzine .................................. 73, 97

Sulindac .......................................... 73, 85

SUMAtriptan .................................... 73, 85

Sunscreen-Block ............................ 74, 114

Surfak ............................................ 46, 96

Symbicort ..................................... 38, 105

Synalar ......................................... 50, 113

Synthroid ........................................ 57, 94

T

Tacrolimus ..................................... 74, 115

Tamiflu ......................................... 65, 102

Tamoxifen ....................................... 74, 81

Tamsulosin ...................................... 74, 98

Tapazole ......................................... 60, 94

Tazarotene ............................. 74, 110, 112

Tazorac .................................. 74, 110, 112

TBC .............................................. 77, 115

Td .................................................. 46, 99

Tdap ............................................... 46, 99

TEGretol ......................... 17, 31, 39, 87, 91

TEGretol XR ............................... 17, 31, 39

Temazepam ............................... 22, 74, 89

Temovate .................................24, 42, 112

Tenex ....................................... 20, 53, 92

Tenormin .................................. 35, 83, 85

Terbinafine ............................. 74, 101, 111

Testosterone .................................... 74, 93

Tetracycline ................................... 74, 100

Tetrahydrozoline ............................ 74, 108

Thiamine ....................................... 74, 103

Thioridazine .................... 14, 15, 30, 74, 91

Thiothixene ............................... 14, 74, 91


Index 140

Thorazine ................................... 13, 41, 91

tiaGABine ................................... 31, 74, 87

Tigan .............................................. 76, 87

Timolol ......................................... 75, 107

Timolol-Dorzolamide ....................... 75, 107

Timoptic........................................ 75, 107

Timoptic XE ......................................... 107

Tinactin ................................................ 75

Tioconazole ..................................... 75, 98

Tiotropium .................................... 75, 105

tiZANidine .................................. 30, 75, 88

TobraDex ...................................... 75, 108

Tobramycin ............................ 75, 101, 107

Tobramycin-Dexamethasone ........... 75, 108

Tobrex .......................................... 75, 107

Tofranil ...................................... 16, 54, 90

Tolnaftate ..................................... 75, 111

Tolterodine ...................................... 75, 98

Topamax .............................. 75, 85, 87, 92

Topiramate ......................31, 75, 85, 87, 92

Toprol XL ................................... 60, 83, 85

Toradol ........................................... 56, 85

traMADol ......................................... 75, 86

Tranxene ............................. 21, 43, 86, 89

Tranylcypromine ........................ 16, 76, 89

Travatan Z .................................... 76, 107

Travoprost ..................................... 76, 107

traZODone ..................... 16, 22, 76, 89, 90

Trecator ........................................ 48, 102

Tretinoin ....................................... 76, 110

Triamcinolone ................. 76, 109, 110, 113

Triamterene ..................................... 76, 82

Triamterene-hydroCHLOROthiazide ..... 76, 82

Triazolam .................................. 22, 76, 89

Tricor .............................................. 49, 83

Tridesilon ...................................... 44, 113

Trifluoperazine ........................... 14, 76, 91

Triglide ........................................... 49, 83

Trihexyphenidyl ................................ 76, 88

Trilafon ..................................... 14, 66, 91

Trileptal ............................... 18, 65, 87, 92

Trimethobenzamide .......................... 76, 87

Triple Antibiotic Ointment ................ 63, 111

Triprolidine-Pseudoephedrine ........... 76, 106

Tropicamide ................................... 77, 108

Trospium ......................................... 77, 98

Trypsin-Balsam Peru-Castor Oil ........ 77, 115

Tuberculin, Purified Protein Derivative . 77, 99


Index 141

Tums ....................................... 39, 94, 104

Twinrix ........................................... 53, 99

Tylenol ........................................... 32, 86

U

Ultram ............................................ 75, 86

Unicap .......................................... 62, 104

Unifiber ........................................... 40, 96

Urea ............................................. 77, 113

Urecholine ....................................... 37, 98

Urocit K .......................................... 68, 98

V

Vagifem ................................................ 48

valACYclovir .................................. 77, 102

Valisone ........................................ 37, 113

Valium ............................21, 45, 86, 88, 89

Valproic Acid/Valproate ....18, 31, 77, 85, 87,

92

Valsartan ........................................ 77, 84

Valtrex.......................................... 77, 102

Vancocin ....................................... 77, 101

Vancomycin ................................... 77, 101

Vaqta ............................................. 53, 99

Varicella Virus Vaccine, Live .............. 77, 99

Varivax ........................................... 77, 99

Vaseline ........................................ 66, 114

Vaseline Lip Therapy ....................... 65, 114

Vasotec ........................................... 47, 84

V-Cillin K ....................................... 66, 100

Venlafaxine .......................... 16, 77, 85, 90

Ventolin ........................................ 33, 105

Verapamil .................................. 77, 83, 85

Verelan ..................................... 77, 83, 85

Verelan PM ................................ 77, 83, 85

Versacloz .................................. 13, 24, 43

Versed ............................................ 61, 89

Vesicare .......................................... 73, 98

Vibramycin .................................... 47, 100

Vicodin ............................................ 32, 85

Vicodin ES ....................................... 32, 85

Victoza ............................................ 57, 80

Vigamox ...................................27, 62, 107

Vimpat ............................................ 56, 87

Viscous Lidocaine ................................. 109

Visine Allergy Relief ........................ 74, 108

Visine Moisturizing .......................... 74, 108

Vistaril ......................... 22, 54, 87, 89, 106

Vitamin A ...................................... 78, 103

Vitamin A&D Topical .............................. 78


Index 142

Vitamin B Complex ......................... 78, 104

Vitamin B Complex-Vitamin C .......... 78, 104

Vitamin B Complex-Vitamin C-Zinc ... 78, 104

Vitamin B1 .................................... 74, 103

Vitamin B12 .................................. 43, 103

Vitamin B6 .................................... 70, 103

Vitamin C ...................................... 35, 103

Vitamin D2 .................................... 78, 103

Vitamin D3 .................................... 78, 103

Vitamin E ...................................... 78, 104

Vitamin K1 ................................. 67, 80, 81

Vivactil ................................................. 16

Vivelle ............................................ 48, 93

Vivitrol ............................20, 28, 29, 62, 92

Voltaren Gel ............................. 24, 45, 110

VoSol ........................................... 32, 108

VoSol HC ...................................... 32, 109

Vraylar ...................................... 13, 40, 91

Vyvanse ............................... 19, 27, 57, 92

W

Warfarin ......................................... 78, 81

Water for Injection ......................... 78, 103

Water for Irrigation ................... 78, 97, 115

Wellbutrin .................................. 15, 38, 90

Wellbutrin SR ........................................ 15

Wellbutrin XL ........................................ 15

Wound Cleanser ............................. 78, 115

Wyanoids ............................................. 70

X

Xalatan ......................................... 56, 107

Xanax ....................................... 21, 33, 89

Xanax XR ........................................ 33, 89

Xarelto ............................................ 71, 81

Xopenex ........................................ 56, 105

Xylocaine ...................................... 57, 110

Z

Zaditor .......................................... 56, 108

Zanaflex .................................... 30, 75, 88

Zanamivir ...................................... 78, 102

Zantac ............................................ 70, 95

Zarontin .................................... 31, 49, 86

Zenzedi ................................................ 19

Zestril ............................................. 57, 84

Zinc Oxide .............................. 78, 113, 114

Zinc Oxide-Petrolatum-Imidazolidinyl Urea 79

Zinc Sulfate ................................... 79, 104

Ziprasidone .................... 10, 12, 14, 79, 91

Zithromax ..................................... 36, 100


Index 143

Zocor.............................................. 72, 84

Zofran ............................................ 64, 87

Zofran ODT ..................................... 64, 87

Zoledronic Acid ................................ 79, 93

Zoloft ........................................ 16, 72, 90

Zolpidem ................................... 22, 79, 89

Zonalon ................................................ 47

Zonegran ........................................ 79, 87

Zonisamide ................................ 31, 79, 87

Zoster Vaccine- Recombinant, Adjuvanted 79,

99

Zosyn ........................................... 67, 100

Zovirax .................................. 33, 102, 111

Zyban ............................................. 38, 90

Zyloprim ......................................... 33, 94

ZyPREXA ................................... 13, 64, 91

ZyPREXA Relprevv ...................... 14, 29, 64

ZyPREXA Zydis................................. 13, 64

ZyrTEC .......................................... 41, 106

ZyrTEC D ...................................... 41, 106

Zyvox ......................................27, 57, 101


A-1

Appendix A. New Drug Application Form

New Drug Application

for inclusion in the Texas HHSC Psychiatric Drug Formulary **(The new drug application process is described on the back of this form)**

Screenshot of New Drug Application Form


A-2

Section 415.108 of TDMHMR rules governing the use and maintenance of the THHSC Drug

Formulary (25 TAC, Chapter 415, Subchapter C) describes the procedures for applying to have a

drug added to the formulary, which are:

§415.108. Applying to Have a Drug Added to the Formulary.

(a) Any member of the Executive Forumlary Committee, any service system component*

practitioner, or any contract practictioner may apply to have a drug added to the THHSC

Drug Formulary by completing the New Drug Application Form, referenced as Figure: 25

TAC §415.108(d) § of this title and including:

1) Published articles in biomedical literature that substantiate the efficacy and safety of

the proposed drug.

2) information on the advantages of the proposed drug compared with similar

formulary drugs;

3) a list of formulary drugs that the proposed drug would replace or supplement; and

4) cost effectiveness data

(b) Submitting the application.

1) If the person submitting the application is a facility** practitioner or a facility

contract practitioner, then that practitioner submits the application to the facility’s

pharmacy and therapeutics committee for approval. If the committee approves the

application, then it forwards the application to the HHSC Psychiatric Executive

Formulary Committee.

2) If the person submitting the application is a non-facility service system component

practitioner or a non-facility service system component contract practitioner, then

that practitioner submits the application to the component’s clinical/medical director

or designee who determines if the application is appropriate and complete, and if so,

forwards the application to the HHSC Psychiatric Executive Formulary Committee.

3) If the person completing the application is a member of the HHSC Psychiatric

Executive Formulary Committee, then that person submits the application directly to

HHSC Psychiatric Executive Formulary Committee.

(c) The HHSC Psychiatric Executive Formulary Committee considers the drug application and

recommends:

1) approving the proposed drug’s inclusion and, if appropriate, approving audit criteria

and recommending dosage guidelines;

2) denying the proposed drug’s inclusion;

3) approving the proposed drug on a trial basis for a specified period of time;

4) approving the proposed drug as a reserve drug, with guidelines; or

5) postponing the decision until a later meeting.

* The term “service system component” means a state hospital, state supported living center, state center, or local authority (state-operated community services (SOCS) or

community MHMR center). ** The term “facility” means a state hospital, state supported living center, or state center.


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Appendix B. PEFC Conflict of Interest Policy

Policy

The HHSC Psychiatric Executive Formulary Committee (PEFC) must ensure balance,

independence, objectivity and scientific rigor in determining which drugs should be on the

formulary and their use in special populations. It is the policy of the PEFC to prohibit any

apparent or actual conflict of interest. As such, each member of the PEFC, individuals preparing

drug monographs, each requesting practitioner, and those appointed to work groups that report

to the PEFC shall abide by this policy and submit a Conflict of Interest Disclosure Statement. The

intent of this disclosure is not to prevent those with a significant financial interest or other

relationship from participating in the formulary process, but rather to provide information to

committee members and to the public so that conflicts can be resolved prior to the decision

making process. It remains for the members of the committee to determine whether the

individual’s interests or relationships may influence them with regard to exposition or

conclusions. A conflict of interest for these purposes includes any situation in which a Committee

member, individual preparing a drug monograph, individual submitting a request to the PEFC,

work group member or a first degree relative of said person has a private or personal interest

sufficient to appear to influence the objective exercise of his/her duties for the agency. An

apparent conflict of interest is one in which a reasonable person would think that the person’s

judgment is potentially compromised.

All committee members, individuals submitting drug monographs, individuals requesting drugs

for addition to the formulary, and work group members are expected to disclose any financial

interest or other relationship with (a) the manufacturer(s) of any commercial product and/or

provider of commercial services for drugs on the formulary or being considered for the formulary

(b) any commercial support for these drugs. Significant financial interest or other relationship

can include such things as grants or research support, employee, consultant, major stockholder,

member of speaker’s bureau, etc. The disclosure shall include any conflict of interest of a first

degree relative.

PEFC members shall also abide by the HHS Ethics Policy.

Definitions

“Companies” – includes pharmaceutical and biotechnology companies.

“Compensation” - includes direct and indirect remuneration or royalties, and may also

include, among other things, items and services at reduced prices, or with discounts or

rebates.

“Controlling Interest” - a direct or indirect ownership or beneficial interest, individually or

in conjunction with members of your family, which permits election or selection of a


B-2

majority of the governing body of a company and/or which permits the exercise of control

over the affairs of such company.

“Financial Interest” – a direct or indirect, through business, investment or family:

(a) Ownership Interest or investment interest in a company;

(b) Compensation arrangement with a company or any of its affiliates; or

(c) Ownership Interest or investment interest in, or compensation arrangement with,

any company or individual with which that company or any of its affiliates is

negotiating a transaction or arrangement.

“First Degree Relative” – spouse, parent, siblings, children

“Gifts” or “Gratuities” - includes, among other things, meals, entertainment or

recreational items, subsidies given directly to a healthcare professional for continuing

medical education (CME), educational (i.e. anatomical models) and non-educational and

practice-related items (i.e. items that do not advance disease or treatment education).

“Ownership Interest” - owning or controling directly, indirectly, or beneficially through

such person’s family, in excess of five percent (5%) of the total value of all securities of a

Company.

Procedure

1. Committee members shall submit Disclosure Statements at least annually and as needed

as their situation changes. See Appendix C for the “HHSC Psychiatric Executive Formulary

Committee Disclosure Form.”

2. Individuals submitting requests for addition to the formulary or completing drug

monographs shall submit the “HHSC Psychiatric Executive Formulary Committee Disclosure

Form” along with the New Drug Application or drug monograph, respectively.

3. Members of work groups appointed by the PEFC shall submit Disclosure Statements no

later than the first meeting and then annually if the work group exists for more than a

year. The work group shall forward each work group members’ conflict of interest to the

PEFC for their review.

4. A review of committee members’ conflict of interest shall be completed for all individuals

present at each meeting. This information shall be documented in the minutes of each

meeting.

5. Each facility Pharmacy and Therapeutics Committee or similarly functioning committee is

encouraged to adopt a similar policy.

6. New Drug Applications submitted without the HHSC Psychiatric Executive Formulary

Committee Disclosure Form will be considered incomplete and returned to the requestor.

7. Failure to disclose will result in written notification and may be reported to the individual’s

facility. The determination of the action shall be based on the nature on the non-

disclosure.

Determining Conflict of Interest: Committee members present at the meeting shall determine if

a conflict of interest exists and if it exists, the degree of conflict. The degree of conflict shall be

determined based on the involvement of the individual with the manufacturer(s) as well as the


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role the individual plays within the Committee membership or meeting. For example, conflicts

by an individual preparing a monograph for presentation at a meeting maybe viewed differently

than a Committee member voting on a formulary addition.

Determination of conflict of interest is not limited to the manufacturer of the drug in the New

Drug Application but shall include all relationships with manufacturers. For example, individuals

shall be identified with a conflict of interest for any activities related to the products of any

manufacturer that paid them, and any competing products.

Action Taken for Conflict of Interest: Action taken to minimize bias from the individual identified

as having a conflict of interest shall be based on the individual’s role and relationship to the

committee and the degree of conflict. Actions taken may include but are not limited to:

Committee Member identified with a significant conflict of interest

● Removal from the room during the discussion and voting on a formulary addition

● Removal from the Committee

● Having no communication with other committee members regarding the specific New Drug

Application prior to any deliberations and voting.

Individual completing a monograph that is identified with a significant conflict of interest

● Identifying the specific conflict in relationship regarding the monograph verbally prior to

and after the presentation of the monograph at the meeting

● Identifying the specific conflict in relationship regarding the monograph in writing at the

end of monograph

● Not allowing the individual to develop a monograph

Individual submitting a New Drug Application that is identified with a significant conflict of

interest

● Declining to review the New Drug Application request

Identification of conflict of interest and action taken regarding conflict of interest shall be

documented in the minutes.

This policy applies to members of work groups as appointed by PEFC. Work groups will follow

the same procedure and consequences for reporting, determining and action taken for conflict of

interest.


C-1

Appendix C. PEFC Disclosure Form

HHSC Psychiatric Executive Formulary Committee (PEFC) Disclosure Form


D-1

Appendix D. Non-Formulary Drug Justification Form

Texas HHS

Non-Formulary Drug Justification


E-1

Appendix E. Adverse Drug Reaction Reporting (MedWatch) Form


E-2


F-1

Appendix F. Foods Containing Tyramine

Relative Amount of Tyramine Food

High Amounts of Tyramine May not consume

Smoked, aged or pickled meat or fish Sauerkraut

Aged Cheeses such as Swiss and Cheddar Yeabst extracts

Fava beans

Moderate Amounts of Tyramine

May consume in moderation

Beer

Avacados Meat extracts Red wines such as Chianti

Low Amounts of Tyramine May consume

Caffeine-containing beverages Distilled spirits

Chocolate Soy sauce

Cottage and cream cheeses Yogurt and sour cream

Adapted from Shulman KI, et al. Dietary restriction, tyramine, and the use of monoamine

oxidase inhibitors. J Clin Psychopharmacol. 1989; 9: 397.


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Appendix G. Oral Morphine Conversion Table

Opioid Conversion Factor*

Codeine 0.15

Hydrocodone 1

Hydromorphone 4

Morphine 1

Oxycodone 1.5

Oxymorphone 3

Tramadol 0.1

The following cautions should be noted:

1. Opioid conversion charts should NOT be utilized for converting methadone or non-

injectable fentanyl. Thus, they have been excluded from this chart. See product package

insert for prescribing information.

2. Equianalgesic dose conversions are only estimates and cannot account for individual

variability in genetics and pharmacokinetics.

3. When converting patients from one opioid to another opioid, it is recommended to

decrease the dose of the new opioid by 50% due to incomplete cross-tolerance and

individual variability in opioid pharmacokinetics. The patient can then be titrated to a safe,

effective response.

* Multiply the dose for each opioid by the conversion factor to determine the dose in morphine

milligram equivalents (MMEs).

For example:

1. Tablets containing hydrocodone 5 mg and acetaminophen 300 mg taken four times a day

would contain a total of 20 mg of hydrocodone daily, equivalent to 20 MME daily

20 mg hydrocodone/day x 1 (conversion factor) = 20 MME/day

2. Extended release tables containing oxycodone 10 mg taken twice a day would contain a

total of 20 mg oxycodone daily, equivalent to 30 MME daily.

20 mg oxycodone/day x 1.5 (conversion factor) = 30 MME/day

References:

1. Dowell D, Haegerich TM, Chou R. CDC Guidelines for Prescribing Opioids for Chronic Pain.-

United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1-49. DOI:

http://dx.doi.org/10.15585/mmwr.rr6501e1

2. PL Detail-Document, Equianalgesic Dosing of Opioids for Pain Management. Pharmacist’s

Letter/Prescriber’s Letter. July 2015.

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