formulary: therapeutic category...
TRANSCRIPT
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
FORMULARY: THERAPEUTIC CATEGORY LISTING* *Most current Formulary List of Drugs can be found:
1. DUH intranet [click on DRH (Duke Regional Hospital), Departments and Services, Pharmacy, then Lincoln Community Health Center Formulary] https://intranet.dm.duke.edu/hospitals/drh/pharmacy/Document%20Library/LCHC%20Formulary.pdf
2. LCHC website (http://www.lincolnchc.org/secondary/drug-formulary.html) 3. PADC website (http://www.projectaccessdurham.org/), then click on the Lincoln Pharmacy formulary. 4. LCHC Intranet/ Pharmacy Department/ Formulary of Drugs
Use Ctrl-F to quickly search the listing for a specific item.
Rx Pathways Plan Pfizer drugs are available to uninsured patients who are at or below 400% of the federal poverty
level. Only a dispensing fee is charged. NOTE: These medications are labeled as “RxP”. Patient Assistance Program Patients who meet specific eligibility requirements may receive formualry medications through
manufacturer-sponsored patient assistance programs (PAPs). Medications labeled as “PAP” are available to eligible patients through manufacturer-sponsored PAPs. These medications may not be readily available and may require up to an 8-week processing period.
HIV Patient Assistance Program EI Clinic may access medications through for qualified patients. For patients that do not qualify for
ADAP, HIV medications may be obtained from manufacturer programs. http://epi.publichealth.nc.gov/cd/hiv/docs/ADAPProgrammanual.pdf
Project Access Durham County Project Access Durham County (PADC) serves eligible low-income, uninsured Durham
residents who have specialty medical care needs. PADC enrolls members based on referrals from a primary care provider at Lincoln Community Health Center (LCHC). PADC patients are eligible for LCHC formulary medications.
Lab Monitoring Some formulary drugs require laboratory monitoring and are labeled as “LAB” (See Section VII.4.
Drugs Requiring Lab Monitoring pg 80)
Safety in Lactation Lactation safety data from American Academy of Pediatrics (www.aap.org) Medicaid Preferred Drug List http://www.ncdhhs.gov/dma/pharmacy/PDL.pdf Medicaid Prior Authorizations https://www.nctracks.nc.gov/content/public/providers.html Hazardous Drugs Drugs identified by National Institute of Occupational Safety and Health as hazardous are labeled
as “HD”. Use caution when handling. (http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf)
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
ALZHEIMER DISEASE
Acetylcholinesterase Inhibitor (Central)
Donepezil Tablet 10mg Aricept C ? +
N-Methyl-D-Aspartate Receptor Antagonist
Memantine extended release tablet 7mg, 14mg, 21mg, 28mg Patient Assistance Program
Namenda XR 90 day supply PAP
B ? - K
ANALGESIC AND ANTIPYRETICS
Anticonvulsant, Analgesic Pregabalin Capsule 75mg, 150mg RxP
Lyrica C ? - K
Anticonvulsant, Neuropathic pain (unlabeled)
Gabapentin Capsule 100mg, 300mg
Neurontin C ? - K
Miscellaneous Acetaminophen Suspension 160mg/5mL
Tylenol Susp 120 mL B + L
Acetaminophen Tablet 325mg
Tylenol #100 tabs B + + L
Miscellaneous, Topical Capsaicin 0.025% Cream Capzasin 60 gm B +
NSAID Ibuprofen Suspension 100mg/5mL
Motrin B (D in 3rd trimester)
+ + K
Ibuprofen Tablet 400mg Motrin B (D in 3rd trimester)
+ + (taste may be
unacceptable)
+
K
Indomethacin Capsule 25mg, 50mg
Indocin B (D in 3rd trimester)
+ - + K
Naproxen Sodium Tablet 500mg
Naprosyn B (D in 3rd trimester)
+ + + K
NSAID, COX-2 Inhibitor Celecoxib Capsule 200mg RxP
Celebrex C (D in 3rd trimester)
? - +HF K/L
Opioid Acetaminophen/Codeine Tab 300mg/30mg
Tylenol With Codeine #3
C ? + L
Buprenorphine/Naloxone SL Tab 2mg/0.5mg, 8mg/ 2mg
Zubsolv C ? + K/L
Hydrocodone/ Acetaminophen Tab 5mg/325mg
Norco C ? + L
Tramadol Tablet 50mg Ultram C - + + K/L
ANTIANEMIA
AGENTS
Iron Preparations Ferrous Sulfate Drops
75mg/mL (15mg/mL elemental)
50mL + +
Iron Preparations Ferrous Sulfate Elixer 220mg/5mL (44mg/5mL elemental)
480mL + +
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
ANTIANEMIA AGENTS
Ferrous Sulfate Tablet 325mg (65mg elemental)
#100 tabs + + +
ANTICONVULSANT AGENTS
Anticonvulsant, Analgesic Pregabalin Capsule 150mg RxP
Lyrica C ? - K
Pregabalin Capsule 75mg RxP
Lyrica C ? - K
Anticonvulsant, Neuropathic pain (unlabeled)
Gabapentin Capsule 100mg, 300mg
Neurontin C ? - K
Barbiturate Phenobarbital Tablet 30mg
D - + + K/L
Hydantoin Phenytoin Sodium Capsule 100mg LAB, HD
Dilantin D + - L
Phenytoin Sodium Chewable tablet 50g LAB,
HD
Dilantin Infatabs D + + L
Miscellaneous Carbamazepine Tablet 200mg LAB, HD
Tegretol D + + K/L
Divalproex Sodium Tablet 250mg LAB, HD
Depakote X ? - L
Miscellaneous Lamotrigine Tablet 25mg, 100mg
Lamictal C - + L
Lamotrigine Tablet 50mg, 200mg Patient Assistance Program
Lamictal 90 day supply PAP
C - L
Topiramate Tablet 25mg, 200mg LAB, HD
Topamax D ? - (taste may be
unacceptable)
K/L
ANTIDEPPRESSANT AGENTS
Alpha2 Antagonist Mirtazapine Tablet 30mg Remeron C ? + K/L
Dopamine Reuptake Inhibitor
Bupropion Tablet 100mg Wellbutrin C - + + K/L
Selective Serotonin Reuptake Inhibitor
Fluoxetine Capsule 20mg Prozac C (- in 3rd trimester)
- - + L
Sertraline Tablet 50mg, 100mg
Zoloft C (- in 3rd trimester)
+ + + L
Serotonin Reuptake Inhibitor/Antagonist
Trazadone Tablet 50mg Desyrel C - + + K/L
Serotonin/Norepinephrine Reuptake Inhibitor
Duloxetine Capsule 20mg, 30mg, 60mg Patient Assistance Program
Cymbalta 120 day supply PAP
C ? - (may open & mix w/
applesauce, NOT choclate)
K/L
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Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
ANTIDEPPRESSANT AGENTS
Tricyclic Amitriptyline Tablet 25mg, 50mg
Elavil D - + +
Doxepin Capsule 25mg, 50mg
Sinequan C - - +
Imipramine Tablet 10mg, 25mg
Tofranil D - + +
Nortriptyline Tablet 25mg
Pamelor D + + + K/L
ANTIDOTE Aldehyde Dehydrogenase Inhibitor
Disulfiram Tablet 250mg Antabuse C ? +
Alpha/Beta Adrenergic Agonist
Epinephrine IM Injection 0.15mg/0.15mL, 0.3mg/0.3mL
EpiPen 2 Auto-Injectors
C -
Antihistamine Diphenhydramine Capsule 25mg, 50mg
Benadryl B - - +
Diphenhydramine Elixer 12.5ml/5mL
Benadryl B - +
Opioid Antagonist Naloxone Nasal Spray 4 mg/0.1mL
Narcan 2 devices C ?
Naltrexone Tablet 50mg Revia; Vivitrol C ? +
ANTIEMETIC/ANTI-VERTIGO AGENTS
5-HT3 Receptor Antagonist
Ondansetron Tablet 4mg Zofran B ? + L
Anticholinergic, Antihistamine
Meclizine Tablet 12.5mg Antivert B ? + +
Antidopaminergic, Phenothiazine
Promethazine Suppository 25mg
Phenergan C - + L
Promethazine Tablet 25mg
Phenergan C - + L
ANTI-INFECTIVES Antifungal Nystatin Cream 100,000 units/gm
Mycostatin 15 gm C ?
Nystatin Suspension 100,000 units/mL
Nilstat 60 mL bottle C ?
Fluconazole Tablet 200mg HD
Diflucan C (single dose vag
candida), D all other
indications
+ + K
Antifungal Griseofulvin Susp 125mg/5mL
Grifulvin C ?
Terbinafine Cream 1% LAB
Lamisil AT 15 gm B ?
Terbinafine Tablet 250mg LAB
Lamisil B - + K/L
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
ANTI-INFECTIVES Antihelmintic Albendazole Tablet 200mg
Albenza C ? + K
Antimalarial Hydroxychloroquine Tablet 200mg
Plaquenil C + + K/L
Antiviral Acyclovir Capsule 200mg Zovirax B + - K/L
Acyclovir Suspension 200mg/5mL
Zovirax B + K/L
Antiviral (Antihepaciviral) Ledaspasvir/sofosbuvir Tablet 90 mg/ 400mg Patient Assistance Program
Harvoni 90 day supply PAP
B ? -
(taste) L
Sofosbuvir/ velpatasvir Tablet 400 mg/ 100 mg Patient Assistance Program
Epclusa 84 day supply PAP
B ? -
(taste)
Cephalosporin, 1st gen Cephalexin Capsule 250mg
Keflex B ? - K
Cephalosporin, 1st gen Cephalexin Suspension 250mg/5ml
Keflex B ? K
Cephalosporin, 2nd gen Cefuroxime Tablets 250mg
Ceftin B ? - (taste)
Cephalosporin, 3rd gen Cefdinir Suspension 250mg/5mL
Omnicef B ? K
Macrolide Azithromycin Suspension 200mg/5mL
Zithromax B ? K/L
Azithromycin Tablet 250mg
Zithromax B ? + K/L
Clarithromycin Tablet 500mg
Biaxin C ? + K
Miscellaneous Clindamycin Capsule 150mg
Cleocin B ? + K
Clindamycin Oral Solution 75mg/5mL
Cleocin 100 mL B ? K
Clindamycin Topical Solution 1%
Cleocin-T 60 mL B ?
Metronidazole Tablet 500mg
Flagyl B ? + K/L
Penicillin Amoxicillin Capsule 250mg
Amoxil B + - K
Penicillin Amoxicillin Suspension 250mg/5mL
Amoxil B + K
Amoxicillin/Clavulanic Acid Tablet 875mg/125mg
Augmentin B ? + K/L
Penicillin VK Suspension 250mg/5mL
Pen-Vee K B ? K
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
ANTI-INFECTIVES Penicillin VK Tablet 500mg
Veetids B ? + K
Quinolone Ciprofloxacin Ophth Soln 0.3%
Cipro 5 mL bottle C (but teratogenicity unlikely)
?
Ciprofloxacin Tablets 500mg
Cipro C (but teratogenicity unlikely)
? + K/L
Levofloxacin Tablet 500mg
Levaquin C ? + K
Sulfonamide Sulfamethoxazole/ Trimethoprim Suspension 200mg-40mg/5mL
Septra Suspension
C + K/L
Sulfamethoxazole/ Trimethoprim Tablet 800mg/160mg
Septra DS C + K/L
Sulfasalazine Tablet 500mg
Sulfazine, Azulfadine
D - + K/L
Tetracycline Doxycycline Tablet 100mg
Vibramycin D ? +
Urinary Nitrofurantoin Capsule 100mg
Macrobid B +? - + K/L
ANTINEOPLASTIC AGENTS
Anti-estrogen Tamoxifen Tablet 10mg LAB HD
Nolvadex D - -
Aromatase Inhibitor Anastrozole Tablet 1mg Patient Assistance ProgramLAB, HD
Arimidex 90 day supply PAP
X -
ANTIPARKINSON AGENTS
Anticholinergic Trihexphenidyl Tablet 2mg
Artane C - + + K/L
Dopamine Agonist Carbidopa/Levodopa Tablet 25mg/100mg
Sinemet C - + K/L
ANTIPSYCHOTIC AGENTS
Atypical, mixed serotonin-dopamine antagonist
Lurasidone Tablet 20mg, 40mg, 60mg, 80mg, 120mg Patient Assistance Program
Latuda 90 day supply PAP
B ? + + K/L
Atypical, Serotonin/Dopamine Receptor Antagonist
Quetiapine tablet 25mg, 50mg, 100mg, 200mg, 300mg LAB
Seroquel C - + + K
Atypical Risperidone 0.5mg, 1mg,
2mg HD
Risperdal C - + + K/L
Bipolar Disorder Lithium Carbonate Capsule 300mg LAB
Eskalith D - - + K
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
ANTIPSYCHOTIC AGENTS
Typical, D2 Antagonist Haloperidol Tablet 1mg, 2mg
Haldol C - + +
Trifluoperazine Tablet 2mg
Stelazine C - + + K/L
ANXIOLYTICS, SEDATIVES, HYPNOTICS
Antianxiety Agent Buspirone Tablet 15mg Buspar B - + K/L
Antihistamine Diphenhydramine Capsule 25mg, 50mg
Benadryl B - - +
Diphenhydramine Elixer 12.5ml/5mL
Benadryl B - +
Hydroxyzine HCL Syrup 10mg/5mL
Atarax C - + K/L
Hydroxyzine HCL Tablet 25mg, 50mg
Atarax C - + + K/L
Benzodiazepine Diazepam Tablets 5mg Valium D - + + L
Oxazepam Capsule 15mg
Serax D - - +
Neurohormone, indole Melatonin Tablet 3mg #120 - -
CARDIOVASCULAR DRUGS
ACE-Inhibitor Lisinopril Tablet 5mg, 10mg, 20mg, 40mg LAB
Zestril D ? + K
ACE-Inhibitor/ Diuretic, Thiazide
Lisinopril/HCTZ Tablet 20/12.5mg, 20/25mg LAB
Zestoretic D ? + K
Alpha Adrenergic Inhibitor, Alpha2 Adrenergic Agonist
Methyldopa Tablet 250mg
Aldomet B + + + K/L
Alpha1 Blocker Doxazosin Tablet 2mg, 8mg
Cardura C ? + + L
Prazosin Capsule 1mg, 2mg, 5mg
Minipress C ? - + L
CARDIOVASCULAR DRUGS
Alpha2 Adrenergic Agonist
Clonidine Tablet 0.1mg, 0.2mg, 0.3mg
Catapres C ? + + K
Angiotensin Receptor Blocker
Losartan Tablet 25mg, 50mg, 100mg
Cozaar D ? + L
Antiarrhythmic Amiodarone Tablet 200mg LAB
Cordarone D - + + L
Digoxin Tablets 0.125mg, 0.25mg LAB
Lanoxin C + + + K
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
Anticoagulant (Direct Oral Anticoagulant)
Apixaban Tablets 2.5 mg, 5mg, 10mg Patient Assistance Program
Eliquis 90 day supply PAP
B - + K
Rivaroxaban Tablet 15mg, 20mg Patient Assistance Program
Xarelto 30-day supply prescription card PAP
C - + K/L
Anticoagulant Enoxaparin SQ Injection 30mg, 40mg, 60mg, 80mg, 100mg, 120mg, 150mg Patient Assistance Program LAB
Lovenox B + K
Warfarin Tablet 5mg LAB Coumadin - (1st trimester),
C
Use caution
+ K/L
Antihyperlipidemic, 2-Azetidinone
Ezetimibe tablet 10mg Patient Assistance Program
Zetia 90 day supply PAP
C ? + L
Antihyperlipidemic, Fibric Acid
Gemfibrozil Tablet 600mg
Lopid C ? + K
Antihyperlipidemic, HMG-CoA Reductase Inhibitor
Atorvastatin Tablet 10mg, 20mg, 40mg, 80mg
Lipitor X - + L
Antiplatelet Aspirin Tablet 81mg, 325mg (enteric coated)
Ecotrin #120 tablets
D ? - K/L
Clopidogrel Tablet 75mg Plavix B ? + L
Beta Blocker, cardioselective
Atenolol Tablet 50mg, 100mg
Tenormin D - - K
Metoprolol Tartrate Tablet 25mg, 50mg
Lopressor C ? + L
Beta Blocker, non-selective
Propranolol Tablet 10mg, 40mg
Inderal C + + K/L
Beta Blocker w/ alpha blocking ability
Carvedilol Tablet 3.125mg, 12.5mg, 25mg
Coreg C ? + L
Calcium Channel Blocker Amlodipine Tablets 5mg, 10mg
Norvasc C ? + L
CARDIOVASCULAR DRUGS
Diltiazem HCl XR 180mg, 240mg Capsule
Cardizem CD C + - +
Nifedipine XL Tablet 30mg, 60mg, 90mg
Procardia XL C - - L
Verapamil SR Tablet 180mg, 240mg
Calan SR C - + split/- crush
+ K/L
Carbonic Anhydrase Inhibitor
Acetazolamide Tablet 500mg ER 12 hr
Diamox Sequels C - + K/L
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
Diuretic, Loop Furosemide Tablet 40mg Lasix C ? + K/L
Diuretic, Potassium Sparing
Spironolactone Tablet 25mg HD
Aldactone D + + K
Spironolactone/HCTZ Tablet 25mg/25mg HD
Aldactazide D + + K
Diuretic, Thiazide Hydrochlorothiazide Tablet 25mg, 50mg
Hydrodiuril B (D is used in
pregnancy-induced HTN)
+ + K
Vasodilator Hydralazine Tablet 25mg, 50mg
Apresoline C + + K
Isosorbide Dinitrate Tablet 10mg, 20mg, 40mg
Isordil C ? +
Nitroglycerin SL Tablet 0.4mg
Nitrostat #100 tabs C ?
Nitroglycerin Transdermal Patch 0.2mg/hr, 0.4mg/hr, 0.6mg/hr
Transderm Nitro #30 patches C ? -
DEVICE Nasal Aspirator + +
Nasal Irrigation Kit Neti Pot + +
Peak Flow Meter + +
Pill Box + +
Spacer Aerochamber + +
Spacer, with mask Aerochamber + +
Syringes 31G 5/16" 0.5mL, 1mL
Monoject + +
Tablet Cutter + +
ELECTROLYTE SUPPLEMENT
Treatment of Dehydration Electrolyte Solution Pedialyte/ Infalyte
1,000 mL ? ?
Treatment of Hypokalemia
Potassium Chloride Tablet 8mEq
Klor-Con C ? - K
ENDOCRINE AND METABOLIC AGENTS
Androgen Hormone Inhibitor, 5 Alpha-Reductase Inhibitor
Finasteride Tablet 5mg HD Proscar X - - HD
L
ENDOCRINE AND METABOLIC AGENTS
Antidiabetic, Biguanide Metformin Tablet 1000mg LAB
Glucophage B ? + K/L
Antidiabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhib
Sitagliptin Tablet 25mg, 50mg, 100mg
Januvia B ? - K/L
Antidiabetic, GLP-1 Agonist
Liraglutide 18mg/3mL Pen Injector Patient Assistance Program
Victoza 120 day supply PAP
C -
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
Antidiabetic, Insulin Rapid-Acting
Insulin Aspart 100units/mL
Novolog B/C + - + Sliding Scale
Insulin Lispro 100units/mL
Humalog B/C + + Sliding Scale
Insulin Glulisine 100units/mL Patient Assistance Program
Apidra 90 day supply PAP
B/C + + Sliding Scale
Antidiabetic, Insulin Short-Acting
Insulin Regular 100units/mL
Novolin R B/C + + Sliding Scale
Antidiabetic, Insulin Combination
Insulin Aspart Protamine and Insulin Aspart 100units/mL
NovoLog Mix 70/30
B/C +
Insulin Lispro Protamine and Insulin Lispro 100units/mL
Humalog Mix 75/25
B/C +
Insulin NPH and Insulin Regular 100units/mL
Novolin 70/30 B/C +
Antidiabetic, Insulin Intermediate-Acting
Insulin NPH 100units/mL Novolin NPH B/C +
Antidiabetic, Insulin Long-Acting
Insulin Detemir 100units/mL
Levemir B/C +
Insulin Glargine 100units/mL
Lantus 90 day supply PAP
B/C +
Antidiabetic, SGLT-2 Inhibitor
Empagliflozin Tablet 10mg, 25mg
Jardiance 90 day supply PAP
C - + K
Antidiabetic, Sulfonylurea Glipizide ER Tablet 5mg, 10mg
Glucotrol XL C ? - L
Antidiabetic, Thiazolidinedione
Pioglitazone Tablet 15mg, 30mg LAB
Actos C ? + L
Biphosphonates, Osteoporosis
Alendronate Tablet 4mg Fosamax #4 tabs C - + K
Contraceptive Hormone, Combination
Norethindrone/ E. Estradiol (triphasic) Tablet 0.5-0.75-1mg/0.035mg HD
Ortho-Novum 7/7/7
#28 tabs X/D - + + L
Norgestrel/ E. Estradiol Tablet 0.3mg/0.03mg HD
Lo-Ovral #28 tabs X - + + L
ENDOCRINE AND METABOLIC AGENTS
Contraceptive Hormone, Progestin
Medroxyprogesterone Acetate Tablet 10mg HD
Provera X + + + L
Norethindrone Tablet 0.35mg HD
Nor-Q-D #28 tabs X - (may start 6
wks after
preg)
+ + L
Contraceptive, Postcoital Levonorgestrel Plan B One-Step #1 X - + + L
Estrogen Estrogens, conjugated Tablet 0.625mg HD
Premarin X - + +
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N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
Glucocorticoids Prednisolone Syrup 15mg/mL
Prelone C + + K/L
Prednisone Tablet 5mg, 20mg
Deltasone C + + + K/L
Gonadotropin Releasing Hormone Agonist
Leuprolide IM Injection 11.25mg, 22mg, 30mg Patient Assistance ProgramLAB, HD
Lupron 90 day supply PAP
X -
Gout Colchicine Tablet 0.6mg
HD Colcrys C ? + K/L
Gout, Xanthine Oxidase Inhibitors
Allopurinol Tablet 100mg, 300mg
Zyloprim C + + K
Progestin Megestrol Acetate Susp 40mg/mL HD
Megace D ? + K
Thyroid Levothyroxine 0.088mg, 0.1mg, 0.112mg, 0.125mg, 0.15mg, 0.175mg, 0.2mg Tablet LAB
Levoxyl A + +
Methimazole Tablet 10mg
Tapazole D + +
EYE, EAR, NOSE, AND THROAT
Analgesic Lidocaine (Viscous) Oral Solution 2%
Xylocaine 100 mL B +
Antiglaucoma, Alpha2 Agonist
Brimonidine Tartrate Ophthalmic 0.2%
Alphagan 5 mL B ?
Antiglaucoma, Beta-Adrenergic Blocker
Timolol Maleate Ophth Soln 0.5%
Timoptic 5 mL C +
Antiglaucoma, Carbonic Anhydrase Inhibitor
Dorzolamide 2% Trusopt 10 mL C -
Antiglaucoma, Cholinergic Agent
Pilocarpine Ophth Soln 4%
Pilocar 15 mL C ?
Antiglaucoma, Prostaglandin Inhibitor
Latanoprost Ophth Sol 0.005%
Xalatan 2.5 mL C ?
EYE, EAR, NOSE, AND THROAT
Anti-infective Chlorhexidine Oral Rinse 0.12%
Peridex 480 mL B ?
EYE, EAR, NOSE, AND THROAT
Anti-infective Erythromycin 5mg/gm Ilotycin 3.5 gm B +
Polymyxin/Trimethoprim Ophth Soln 10,000 units-1mg/mL
Polytrim 10 mL C ?
Anti-infective, Corticosteroid
Neomycin/Polymyxin B/Hydrocortisone Otic Susp
Cortisporin Otic Otic 10mL ? ?
Cerumenolytic Carbamide Peroxide Otic Drops 6.5%
Debrox 15 mL ? ?
45
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
Corticosteroid Fluticasone Propionate Nasal Spray 50mcg/spray
Flonase 16 gm C ?
Ketorolac 0.5% Ophth Soln
Acular 5 mL C ?
Prednisolone Acetate Ophth Soln 1%
Pred Forte 15 mL C ?
Corticosteroid, Antifungal, Antihistamine
Hydrocortisone, Nystatin, Diphenhydramine Susp
Duke's Mouthwash
120 mL per bottle
? -
Irrigation Saline Nose Spray Saline Spray 45 mL + +
Lubricant Artificial Tear Drops Artificial Tears 15 Ml + +
Artificial Tear Ointment Duratears 3.5 gm + +
Mydriatic Atropine Ophth Soln 1% Atropine 15 mL C +
Antihistamine, Mast Cell Stabilizer
Ketotifen Ophth Soln 0.025%
Zaditor
5 mL C ?
Vasoconstrictor/ Antihistamine
Naphazoline/Pheniramine Ophth Soln 0.025%/0.3%
Vasocon-A 15 mL C ?
GASTROINTESTINAL DRUGS
Antacid Magnesium/Aluminum/ Simethicone Suspension
Maalox Max Strength
480 mL C ? K
Anticholinergic Dicyclomine Capsules 10mg
Bentyl B - - +
Antidiarrheal Diphenoxylate/Atropine Sulf Tablets 2.5/0.025mg
Lomotil; Lonox C - - K/L
Bismuth Subsalicylate Tablet 262mg
Pepto-Bismol #30 tabs D ? +
Antidiarrheal Loperamide Tablet 2mg Imodium #12 tabs C + +
GASTROINTESTINAL DRUGS
Antiflatulent Simethicone Drops 40mg/0.6mL
Mylicon 30 mL C but + ?
Constipation, Chronic Lactulose Syrup 10gm/15mL
Duphalac Syrup B ?
Constipation, IBS Lubiprostone Capsule 24mcg Patient Assistance Program
Amitiza 90 day supply PAP
C ? -
Histamine H2 Antagonist Ranitidine Syrup 15mg/mL
Zantac B ? +
Ranitidine Tablet 150mg, 300mg
Zantac B ? + +
46
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
Laxative, Diphenylmethane
Bisacodyl Tablet 5mg Dulcolax C ? -
Laxative, Osmotic Glycerin 1 gm suppository
Pedia-Lax Rectal A + +
Laxative, Osmotic Glycerin 2 gm suppository
Sani-Supp Adult Rectal
A + +
Polyethylene Glycol MiraLax 255 gm C ?
Laxative, Osmotic (for Bowel Prep)
Polyethylene Glycol with Electrolytes
GoLytely 4,000 mL C ?
Laxative, Bulk Psyllium Hydrophilic Powder
Metamucil 284 gm + ?
Pancreatic Enzymes Pancreatic Enzymes Capsule Lipase/Protease/Amylase 6k/19k/30k, 12k/38k/60k, 24k/76k/120k Patient Assistance Program
Creon 90 day supply PAP
C ? - (OK to open
and give with
apple-sauce or pudding)
K
Prokinetic Metoclopramide Tablet 10mg
Reglan B ? + + K
Proton Pump Inhibitor Omeprazole Capsule 20mg
Prilosec C ? - + L
Stool Softener Docusate Sodium Capsule 100mg
Colace #100 caps C ? - (taste may be
unacceptable)
GENITOURINARY AGENTS
Alpha1 Blocker Tamsulosin 0.4mg Capsule
Flomax B + -
Analgesic, Urinary Phenazopyridine Tablet 100mg, 97.5mg or 95mg
Pyridium B ? + K
Anticholinergic, Urinary Tolterodine Tartrate extended release tablet 4mg RxP
Detrol LA C - - + K/L
GENITOURINARY AGENTS
Antispasmodic, Urinary Oxybutynin Chloride Tablet 5mg
Ditropan B ? + + K/L
MIGRAINE AGENTS Migraine Combinations Butalbital, Acetaminophen and Caffeine Tablet 50mg/325mg/40mg
Note: Fioricet changed strength April 2014 and no longer has a generic
C - + +
K/L
Serotonin 5-HT1 Receptor Agonist
Eletriptan Tablet 40mg RxP
Relpax 6 tabs per box
C ? + L
NEPHROLOGY Calcium, Phosphate Binder
Calcium Acetate Capsule 667mg
PhosLo C ? -
47
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
Treatment of Hyperkalemia
Sodium Polystyrene Sulfonate Susp 15gm/60mL
Kayexalate 60 mL per bottle
C ?
Vitamin D Analog Calcitriol Capsule 0.5mcg Rocaltrol C ? -
Vitamin D Analog Paricalcitol Capsule 1mcg, 2mcg, 4mcg Patient Assistance Program
Zemplar 90 day supply PAP
C ? -
NUTRIENTS AND NUTRITIONAL AGENTS
Calcium Supplement Calcium (elemental) Tablet 500mg
Calcium #60 tabs per bottle
+ (? 1st trimester)
? + K
Hypomagnesemia Magnesium Oxide Tablet 400mg (240mg elemental)
MagOx #120 A + + L
Nutritional Supplement Thiamine Tablet 100mg Various #100 tabs A + +
Vitamin Cyanocobalamin Tablets 500mcg
Vitamin B12 #130 tabs C + +
Folic Acid Tablet 1mg A + +
Multivitamin Drops with Iron
Poly-vi-sol 50 mL + +
Multivitamin Tablet, Adult
Centrum #100 tabs + + +
Multivitamin tablet, Children
Flinstones #100 tabs + + +
NUTRIENTS AND NUTRITIONAL AGENTS
Omega-3 Fatty Acids (180 EPA / 120 DHA)
Fish Oil #100 caps C ? - L
Prenatal Vitamins Natalins RX #100 tablets + + +
Vitamin D3 Tablet 400 IU, 1000 IU
#100 tabs C Avoid high doses
Vitamin D3 Capsule 50000 IU
C Avoid high doses
RESPIRATORY AGENTS
Antihistamine Cetirizine Solution 1mg/mL
Zyrtec 120 mL B - K
Cetirizine Tablet 10mg Zyrtec #30 tablets B - + K
48
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Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
Loratadine Tablet 10mg Claritin #30 tabs B + + K
Antihistamine and Decongestant (Alpha/Beta Adrenergic Agonist)
Triprolidine/ Pseudoephedrine Tablet 2.5mg/60mg
Actifed #24 tabs - (1st trimester),
C
? + +
Antitussive Benzonatate Capsule 100mg
Tessalon Perles #20 caps C ? -
Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant
Fluticasone Propionate/Salmeterol Diskus 100/50mcg, 250/50mcg, 500/50mcg
Advair Diskus C ?
Bronchodilator, Anticholinergic
Ipratropium Bromide MDI 17mcg/actuation Patient Assistance Program
Atrovent MDI: 90 day supply PAP
B ?
Ipratropium Bromide Nebulizer Soln 0.02%
Atrovent 25 vials per box
B ?
Tiotropium Bromide Cap for inhalation 18mcg
Spiriva C - -
Bronchodilator, Beta2-Adrenergic Agonist
Albuterol MDI Proventil, Ventolin, ProAir
6.7 gm C ?
Albuterol Nebulizer Solution 0.083%
Proventil, Ventolin
#25 C ?
Corticosteroids, Inhalant Beclomethasone 40mcg, 80mcg MDI
QVAR 8.7 gm C ?
Fluticasone Propionate MDI 44mcg/puff, 110mcg/puff, 220mcg/puff
Flovent C ?
RESPIRATORY AGENT
Decongestant (Alpha/Beta Adrenergic Agonist)
Pseudoephedrine Tablet 30mg, 60mg
Sudafed #24 tabs C + + + K
Decongestant (topical) Oxymetazoline Nasal Spray 0.05%
Afrin 15 mL C ?
Expectorant Guaifenesin Tablet 200mg
Humibid #100 tabs C + +
Leukotriene Inhibitor Montelukast Chewable Tablet 4mg, 5mg
Singulair B ? + L
Montelukast Tablet 10mg Singulair B ? + L
RHEUMATOLOGY Disease Modifying Antirheumatic Drug (DMARD)
Methotrexate Tablet 2.5mg LAB, HD
Rheumatrex X - + K/L
Tumor Necrosis Factor Blocking Agent
Adalimumab Injection 40mg Patient Assistance
Humira 90 day supply PAP
B - - ?
49
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
ProgramLAB
SKELETAL MUSCLE RELAXANT
Centrally Acting Cyclobenzaprine Tablets 5mg
Flexeril B ? + + L
Methocarbamol Tablet 500mg
Robaxin C ? + + L
Baclofen Tablet 10mg Lioresal C + + K
SKIN AND MUCOUS MEMBRANE AGENTS
Acne Benzoyl Peroxide Gel 5% Panoxyl 42.5 gm C ?
Tretinoin Cream 0.05%
HD Retin-A 45 gm D -
Antibiotic, Topical Bacitracin Ointment 500 units/gm
15 gm B ?
Mupirocin 2% Ointment Bactroban 22 gm B ?
Antifungal Ketoconazole 2% Shampoo
Nizoral 120 mL C ?
Miconazole Cream 2% Micatin 30 gm + ?
Nystatin Cream 100,000 units/gm
Mycostatin 15 gm C ?
Terconazole Vaginal Cream 0.8%
Terazol-3 20 gm C -
Anti-infective Silver Sulfadiazine Silvadene 20 gm B -
Antiparasitic Agent, Pediculocide
Piperonyl Butoxide and Pyrethrum Extract Kit
Rid Shampoo 120 mL C ?
Permethrin Cream 5% Elimite 60 gm B ?
SKIN AND MUCOUS MEMBRANE AGENTS
Anti-viral, topical immunomodulator
Imiquimod Cream 5% Aldara #12 single-use packets
C ?
Corticosteroid Clobetasol Ointment 0.05%
Temovate 15 gm C ?
Clobetasol Solution 0.05%
Temovate 50 mL C ?
Fluocinonide Cream 0.05%
Lidex 30 gm C -
Hydrocortisone Cream 1%, 2.5%
30gm (1%) 20gm(2.5%)
C ?
Hydrocortisone Ointment 1%
30 gm
Hydrocortisone Suppository 25mg
Anusol-HC #12 per box C ?
Triamcinolone Acetonide Cream 0.1%
Aristocort; Kenalog
15 gm, 80 gm
C ?
50
N:\LCHC_Pharm\Formulary Management\Formulary of Drugs book\2018\8. Formulary of Drugs (therapeutic) pp34,51.docx
Therapeutic Category
Pharmacologic Category
Medication Brand Name Package Size (if applicable)
Preg Cat Safety in Lactation
Crush/ Split
Beers List
Dose Adjust
K=Kidney L=Liver
Triamcinolone Acetonide Dental Paste 0.1%
Oralone 5 gm C ?
Dandruff Sulfur/Salicylic Acid Shampoo 2%/2%
Sebulex 120 mL C -
Estrogen Estrogens, conjugated Cream 0.625mg/gm HD
Premarin 30 gm X -
Miscellaneous Metronidazole Gel 0.05% (Topical)
Metrogel 45 gm B ?
Moisturizing Moisturizing Cream Eucerin 120 gm + +
Protectant Zinc Oxide Ointment 20%
Desitin 30 gm + +
SKIN AND MUCOUS MEMBRANE AGENTS
Tinea Versicolor; Dandruff; Seborrheic Dermatitis
Selenium Sulfide Lotion 2.5%
Selsun 120 mL C ?
SMOKING CESSATION
Dopamine Reuptake Inhibitor
Bupropion Tablet 100mg Wellbutrin C - + + K/L
SMOKING CESSATION
Nicotine Product Nicotine Gum 2mg, 4mg Nicorette Gum 110 pieces C - K/L
Nicotine Transdermal Patch 7mg, 14mg, 21mg
Nicoderm CQ #14 patches D - K/L
Partial Nicotine Agonist Varenicline Tablet Starter Pack RxP
Chantix C - + K
VareniclineTablet Continuing Pack RxP
Chantix C - + K
STIMULANT ADHD, Narcolepsy Dextroamphetamine /Amphetamine Tabs 10mg
Adderall C - + + K
Methylphenidate HCl Tablet 5mg
Ritalin C ? + +
Updated: February 28th, 2018