ykhc formulary

YKHC Formulary Edited March 2022

Table of Contents

YKHC Formulary......................................................................................................................................................................... 1 ANALGESICS .............................................................................................................................................................................. 2 ANESTHESIA .............................................................................................................................................................................. 5 ANTIMICROBIALS ....................................................................................................................................................................... 5 CARDIOVASCULAR .................................................................................................................................................................... 9 DERMATOLOGY ....................................................................................................................................................................... 13 ENDOCRINE & METABOLIC ..................................................................................................................................................... 16 ENT ............................................................................................................................................................................................ 21 GASTROENTEROLOGY ........................................................................................................................................................... 22 HEMATOLOGY .......................................................................................................................................................................... 25 IMMUNOLOGY .......................................................................................................................................................................... 26 NEUROLOGY ............................................................................................................................................................................ 27 OB/GYN ..................................................................................................................................................................................... 29 ONCOLOGY .............................................................................................................................................................................. 31 OPHTHALMOLOGY................................................................................................................................................................... 31 PSYCHIATRY ............................................................................................................................................................................ 34 PULMONARY ............................................................................................................................................................................ 36 TOXICOLOGY ........................................................................................................................................................................... 38 UROLOGY ................................................................................................................................................................................. 39 IV SOLUTIONS .......................................................................................................................................................................... 39 OTHER ....................................................................................................................................................................................... 40

YKHC FORMULARY • Pharmacy Dept. 2

ANALGESICS PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Antirheumatic Agents

Biologic Response Modifiers

ETANERCEPT (Enbrel) B Injection 25 mg, 50 mg

Disease Modifying Antirheumatic Drugs

ABATACEPT (Orencia®)—Restricted to use by rheumatology. Will not routinely keep in stock, but will order as requested.

C Injection 125 mg/mL, 250 mg vial

ADALIMUMAB B Injection 40 mg/0.4mL

AZATHIOPRINE (Imuran®) D Tablet, oral 50 mg

HYDROXYCHLOROQUINE SULFATE (Plaquenil®)

C Tablet, oral 200 mg

INFLIXIMAB (Remicade) B Injection 100 mg vial

LEFLUNOMIDE (Arava) X Tablet, oral 10 mg, 20 mg

METHOTREXATE X Tablet, oral 2.5 mg

METHOTREXATE X Injection 25 mg/ml

TOCILIZUMAB (Actemra®) – restricted to patients recommended by a specialist. For COVID 19 treatment restricted to patients recommended by a specialist, requiring mechanical ventilation, CRP> 7.5mg/dl and who a not going to be imminently medically evacuated.

C Injection 162 mg/0.9 ml, 20 mg, 80 mg vial

TOFACITINIB (Xeljanz®) – restricted to patients recommended by a specialist

N/A Tablet, oral 5 mg, 10 mg

TOFACITINIB (Xeljanz®) – restricted to patients recommended by a specialist

N/A Extended Release Tablet, Oral

11 mg

USTEKINUMAB (Stelara®)– restricted to patients recommended by a specialist

N/A Injection 45mg, 90mg

Miscellaneous antirheumatic agents

HYALURONANATE DERIVATIVES (Synvisc One®)

N/A Injection 48 mg/6mL

Muscle Relaxants

BACLOFEN (Lioresal®) C Tablet, oral 10 mg, 20 mg

CYCLOBENZAPRINE (Flexeril®) B Tablet, oral 10 mg

DANTROLENE (Ryanodex®)**Restricted to the treatment of malignant hyperthermia**

C Injection 250 mg vial

TIZANIDINE C Tablet, oral 2 mg, 4 mg

Nonsteroidal Anti-inflammatories

Salicylic acid derivatives

ASPIRIN C/D (full dose in 3rd trimester)

Tablet, oral 81 mg chewable, 81 mg enteric coated, 325 mg, 325 mg enteric coated

Other

CELECOXIB (Celebrex)**Restricted to use by patients who do not have heart disease

C/D (3rd trimester)

Capsule, Oral 100 mg, 200 mg


PRODUCT PREGNANCY CATEGORY

VIA DOSAGE

IBUPROFEN (Motrin®, Advil®) B/D (3rd trimester)

Tablet, oral 200 mg, 400 mg

IBUPROFEN (Motrin®) B/D (3rd trimester)

Suspension, oral

100 mg/5ml

INDOMETHACIN (Indocin®) B/D (after 34 weeks

gestation)

Capsule, oral 25 mg

KETOROLAC (Toradol®, Acular®) C/D (3rd trimester)

Injection 30 mg/ml, 60 mg/2ml

NABUMETONE (Relafen®) C/D (3rd trimester)

Tablet, oral 500 mg

NAPROXEN (Naprosyn®) C/D (3rd trimester)

Tablet, oral 250 mg

MELOXICAM (Mobic®) C/D (3rd trimester)

Tablet, oral 7.5 mg, 15 mg

Opioid Agonist-antagonist

NALBUPHINE (Nubane®) B/D (3rd trimester)

Injection 10 mg/ml

Opioid Agonists/ Opioid Analgesic Combinations

ACETAMINOPHEN/CODEINE (Tylenol #3) C/D (if prolonged use or high doses

at term)

Tablet, oral 300 mg/30mg

ACETAMINOPHEN/CODEINE C/D (if prolonged use or high doses

at term)

Elixir, oral 120 mg/12mg/5ml

BUTORPHANOL (Stadol) C/D (if prolonged use or high doses

at term)

Injection 2 mg/ml

FENTANYL (Sublimaze®) C/D (if prolonged use or high doses

at term)

Injection 50 mcg/ml

FENTANYL (Duragesic®) C/D (if prolonged use or high doses

at term)

Patch, topical 12, 25, 50, 75, 100 mcg/hr

HYDROCODONE/ACETAMINOPHEN (Hycet®)

C/D (if prolonged use or high doses

at term)

Solution, oral 7.5 mg/325mg/15ml

HYDROCODONE/ACETAMINOPHEN (Norco®)


at term)

Tablet, oral 5 mg/325mg

HYDROMORPHONE (Dilaudid®) B/D (if prolonged use or high doses

at term)

Injection 2 mg/ml



VIA DOSAGE

MEPERIDINE (Demerol®)**Restricted to treatment of rigors only**

B/D (if prolonged use or high doses

at term)

Injection 50 mg/ml

METHADONE B/D (if prolonged use or high doses

at term)


MORPHINE SULFATE C/D (if prolonged use or high doses

at term)

Injection 2 mg/ml, 10 mg/ml, 1 mg/mL PF


at term)

Solution, oral 10 mg/5 mL, 20 mg/mL


at term)


MORPHINE SULFATE EXTENDED RELEASE


at term)


OXYCODONE B/D (if prolonged use or high doses

at term)

Tablet, oral 5 mg

OXYCODONE B/D (if prolonged use or high doses

at term)

Solution, oral 5 mg/5 mL

OXYCODONE EXTENDED RELEASE (Oxycontin®)


at term)

Tablet, oral 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg

OXYCODONE/ACETAMINOPHEN (Percocet®)


at term)

Tablet, oral 5 mg/325 mg

Opioid Antagonist

NALOXONE (Narcan®) B Injection 0.4 mg/mL, 1 mg/mL

NALOXONE (Narcan®) B Nasal Spray 4 mg

Topical Analgesics

BENZOCAINE (Hurricaine®) C Spray, oral 20%

COCAINE C Solution, topical

40mg/ml

CLOVE OIL N/A Solution, topical

N.F.

LIDOCAINE B Patch, topical 5%

LIDOCAINE B Solution, topical

4%



VIA DOSAGE

LIDOCAINE B Jelly, topical 2%

MENTHOL/METHYLSALICYLATE (Ben-Gay)

N/A Greaseless cream, topical

10%/15%

Other Analgesics

ACETAMINOPHEN (Tylenol®) C Tablet, oral 325 mg

ACETAMINOPHEN (Tylenol®) C Suppository, Rectal

120mg, 325mg, 650mg

ACETAMINOPHEN (Tylenol®) C Suspension, Oral

160mg/5ml

ACETAMINOPHEN (Ofirmev®) – restricted to use in NPO patients

C Injection 1000 mg/vial

BUTALBITAL/APAP/CAFFEINE (Fioricet) C Tablet, oral 50mg/325mg/40mg

TRAMADOL (Ultram®) C Tablet, oral 50mg

ANESTHESIA PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

BUPIVACAINE (Marcaine®) C Injection 0.5%

DEXMEDETOMIDINE (Precedex®) N/A Injection 4 mcg/mL

ETOMIDATE (amidate) C Injection 2mg/ml 10ml vial, 20ml syringe

KETAMINE (Ketalar®) N/A Injection 100mg/ml

LIDOCAINE B Injection 1%, 2% Preservative Free

LIDOCAINE (Xylocaine®) B Injection 1% (20ml, 10ml MDV),

LIDOCAINE WITH EPINEPHRINE 1:100,000

C Injection 1%, 2%

MIDAZOLAM (Versed®) D Injection 1mg/ml, 5mg/ml

MIDAZOLAM (Versed®) D Syrup, oral 2mg/ml

NITROUS OXIDE

PROPOFOL (Diprivan®) B Injection 10mg/ml

ROCURONIUM (Zemuron) C Injection 10mg/ml

SEVOFLURANE (Ultane®) B General Anesthetic, inhalation

250ml bottle

SUCCINYLCHOLINE (Anectine®) C Injection 20 mg/ml

SUGAMMADEX N/A Injection 500mg/5ml

VECURONIUM BROMIDE (Norcuron®) C Injection 1 mg/ml

ANTIMICROBIALS PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Aminoglycosides

GENTAMICIN (Garamycin®) D Injection 10 mg/ml, 40 mg/ml

TOBRAMYCIN (Tobrex®) D Injection 40 mg/ml

TOBRAMYCIN (Tobi®)-restricted to patients colonized with pseudomonoas with complications, and cystic fibrosis patients

D Solution for inhalation

300 mg/5mL

Antifungal Agents



VIA DOSAGE

AMPHOTERICIN B B Injection 50 mg

FLUCONAZOLE (Diflucan®) D Tablet, oral 150 mg, 200 mg

FLUCONAZOLE (Diflucan®) D Suspension, oral

10 mg/ml

FLUCONAZOLE (Diflucan®) Injection

GRISEOFULVIN MICROSIZE N/A Suspension, oral

125 mg/5ml

NYSTATIN C Suspension, oral

100,000 units/ml

TERBINAFINE (Lamisil®) B Tablet, oral 250 mg

Antimalarials

Artemether and Lumefantrine (Coartem®) N/A Tablet 120/20mg

Antimycobacterial Agents

ETHAMBUTOL (Myambutol®) C Tablet, oral 400 mg

ISONIAZID (INH) N/A Syrup, oral 50 mg/5ml

ISONIAZID (INH) N/A Tablet, oral 100 mg, 300mg

PYRAZINAMIDE (PZA®) C Tablet, oral 500 mg

RIFABUTIN (Mycobutin) – restricted to infections resistant to rifampin

B Capsule, oral 150 mg

RIFAMPIN C Capsule, oral 150 mg, 300 mg

Antiparasitics

IVERMECTIN (Stromectol) C Tablet, oral 3 mg

PYRANTEL PAMOATE (Antiminth®) C Suspension, oral

144 mg/mL (50 mg/mL base)

ALBENDAZOLE (Albenza®) n/a Tablet, oral 200mg

Antiviral Agents

Anti-Herpetic

ACYCLOVIR (Zovirax®) B Capsule, oral 200 mg

ACYCLOVIR (Zovirax®) B Tablet, oral 400 mg, 800 mg

ACYCLOVIR (Zovirax®) B Injection 500 mg (50 mg/ml)

ACYCLOVIR (Zovirax®) B Suspension, oral

200mg/5ml

VALACYCLOVIR (Valtrex) B Tablets, oral 500 mg

Anti HIV Agents

As decided by P&T committee July 16, 2010, all HIV treatments will be treated as an "open formulary items". Pharmacy will routinely stock those HIV meds which are currently being used by our patients. If a patient is to be started on a therapy we do not carry, we will obtain the requested medication upon pharmacy notification (P&T agreed on a 2 week notice to allow time for acquisition of the drug). The following products will be routinely stocked.

ZIDOVUDINE (Retrovir®, AZT) N/A oral solution

ZIDOVUDINE (Retrovir®, AZT) N/A injection

Anti-Influenza

AMANTADINE (Symmetrel®) C Capsule, oral 100 mg

OSELTAMIVIR (Tamiflu) C Capsule, oral Suspension, oral

30 mg, 45 mg, 75 mg 6 mg/ml



VIA DOSAGE

Hepatitis B&C

As decided by P&T committee April 24, 2019, all hepatitis C medications and on July 29, 2020 all hepatitis B medications will be treated as an "open formulary.” Pharmacy will not routinely stock the medications, but will order in the medication when it is prescribed without a non-formulary request needing to be filled out.

Other

PALIVIZUMAB (Synagis®) C Injection, IM 50 mg vial, 100 mg vial

REMDESIVIR – restricted to patients recommended by COVID team

Injection 100 mg vial

Cephalosporins

CEFAZOLIN (Ancef®, Kefzol®) B Injection 1 gm, 10gm

CEFDINIR (OMNICEF) B Suspension, oral

250 mg/5mL

CEFEPIME (Maxipime ®) B Injection 1 gm, 2 gm

CEFIXIME (Suprax) *Restricted to treatment of gonorrhea

B Tablet, oral 400 mg

CEFOXITIN B Injection 2 gm

CEFPODOXIME (Vantin) B Tablet, oral 200 mg

CEFTAZIDIME (Fortaz®)**Restricted for suspected or documented Pseudomonas infections

B Injection 1 gm, 2 gm

CEFTRIAXONE (Rocephin®) B Injection 250 mg, 1 gm, 2 gm

CEFUROXIME (Ceftin) B Tablet, oral 250 mg, 500 mg

CEPHALEXIN (Keflex®) B Capsule, oral 250 mg, 500 mg

CEPHALEXIN (Keflex®) B Suspension, oral

250 mg/5ml

Macrolides

AZITHROMYCIN (Zithromax®) B Tablet, oral 250 mg

AZITHROMYCIN (Zithromax®) B Injection 500 mg/vial

AZITHROMYCIN (Zithromax®) B Suspension, oral

200 mg/5ml

CLARITHROMYCIN (Biaxin) Restricted to treatment of H-Pylori

C Tablet, oral 500 mg

CLARITHROMYCIN (Biaxin) Restricted to treatment of H-Pylori

C Suspension, oral

250 mg/5ml

ERYTHROMYCIN B Suspension, oral

200 mg (eryth. activity)/5ml

ERYTHROMYCIN **Note: base or stearate is therapeutically interchangeable per P&T committee

B Tablet, oral 250 mg (eryth. activity)

Penicillins

AMOXICILLIN (Amoxil®, Polymox®) B Capsule, oral 250 mg, 500 mg

AMOXICILLIN (Amoxil®, Polymox®) B Chewable, oral 250 mg

AMOXICILLIN (Amoxil®, Polymox®) B Suspension, oral

400 mg/5mL

AMOXICILLIN/CLAVULANIC ACID (Augmentin®)

B Suspension, oral

600 mg/42.9 mg/5mL



VIA DOSAGE

AMOXICILLIN/CLAVULANIC ACID (Augmentin®)

B Tablet, oral 875 mg, 500 mg restricted to use in patients with CrCl<30mL/min

AMPICILLIN (Polycillin®) B Injection 500 mg, 1 gm, 2 gm

AMPICILLIN/SULBACTAM B Injection 1.5 gm, 3 gm

DICLOXACILLIN (Dynapen®, Pathocil®) N/A Capsule, oral 250 mg

PENICILLIN G, BENZATHINE SUSPENSION (Bicillin-LA®)

B Injection 600,000 units/ml

PENICILLIN G, BENZATHINE SUSPENSION (Bicillin-LA®)

B Injection 1,200,000 units/ml

PENICILLIN G, POTASSIUM B Injection 5 million units

PENICILLIN VK (Pen-Vee K®) B Tablet, oral 250mg, 500mg

PENICILLIN VK (Pen-Vee K®) B Suspension, oral

250mg/ 5ml

PIPERACILLIN/TAZOBACTAM (Zosyn®) B Injection 3.375gm, 4.5gm

Fluoroquinolones

CIPROFLOXACIN HCL (Cipro®) C Tablet, oral 500mg

CIPROFLOXACIN HCL (Cipro®) C Injection 400mg/200ml Premix

LEVOFLOXACIN (Levaquin®) C Tablet, oral 250mg, 500mg, 750 mg

LEVOFLOXACIN (Levaquin®) C Injection 500mg vial, 250mg/50ml premix, 500mg/100ml premix, 750mg/150ml premix

Sulfonamides

SULFAMETHOXAZOLE/TRIMETHOPRIM (Bactrim®, Septra®, Co-trimoxazole)

D Injection 400mg/80mg/5ml


D Tablet, oral 400mg/80mg/tablet for SRCs and village clinics, 800mg/160mg/tablet for ER, within hospital, and outpatient prescriptions


D Suspension, oral

200mg/40mg/5ml

Tetracyclines

DOXYCYCLINE (Vibramycin®) D Tablet, oral 100mg

DOXYCYCLINE (Vibramycin®) D Injection 100mg

DOXYCYCLINE (Vibramycin®) D Suspension, oral

25mg/5ml

Other Antimicrobials

CLINDAMYCIN (Cleocin®) B Capsule, oral 150mg, 300mg

CLINDAMYCIN (Cleocin®) B Injection 900mg/6ml vial, 600mg/50ml premix, 900mg/50ml premix

CLINDAMYCIN (Cleocin®) B Suspension, oral

75mg/5ml

FOSFOMYCIN (Monurol®) Powder, oral 3gm

METRONIDAZOLE (Flagyl®) B Tablet, oral 250mg, 500 mg

METRONIDAZOLE (Flagyl®) B Injection 500mg Premix

METRONIDAZOLE/TETRACYCLINE/ BISMUTH (Pylera®)

D Capsule, oral 125mg/125mg/140mg



VIA DOSAGE

NITROFURANTOIN B Capsule, oral 100mg

NITROFURANTOIN – restrict to patients recommended by specialist due to high cost

B Suspension, oral

25mg/5ml

TINIDAZOLE (Tindamax®)-restricted to trichomonas treatment failure with metronidazole

VANCOMYCIN (Vancocin®) C Injection 500mg/vial, 1000mg/vial

LINEZOLID (Zyvox)**Restricted to Inpatient use—oral tablets are intended for continuation of therapy following intravenous therapy. (Oral dosage form may be given initially if suspected MRSA and documented allergies to vancomycin and septra when the patient wouldn't otherwise be hospitalized. *Suspected MRSA infection treatment failure with Septra AND documented true vancomycin allergy *Suspected MRSA infection treatment failure with both Septra and vancomycin *Suspected MRSA infection with true allergy to both vancomycin and septra *Culture/sensitivities demonstrating no other susceptible treatment *Life-threatening/limb-threatening infection - IV dose prior to transfer out of Bethel

Suspension, oral

100mg/5ml

LINEZOLID (Zyvox)**Same restrictions as listed above

C Tablet, oral 600mg

LINEZOLID (Zyvox)**Same restrictions as listed above

C Injection 600mg/300ml premix

MEROPENEM (Merrem®)—Restricted to treatment of severe infections requiring hospitalization that includes: culture-documented ESBL with no alternative drug available, or history of ESBL with active infection.

B Injection 1000mg

CARDIOVASCULAR PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

ACE Inhibitors

ENALAPRIL D Tablet, oral 2.5mg, 5mg, 10mg

ENALAPRIL (Epaned® D Solution, oral 1mg/ml

ENALAPRILAT C(1st)/D(2nd 3rd) Injection 1.25mg/ml

LISINOPRIL (Zestril®, Prinivil®) D Tablet, oral 2.5mg. 5mg, 10mg, 20mg, 40mg

Aldosterone Antagonists

SPIRONOLACTONE (Aldactone®) C Tablet, oral 25mg

Alpha2 Adrenergic Agonists

GUANFACINE (Tenex®) B Tablet, oral 1mg

Angiotensin II Receptor Blockers (ARBs)

LOSARTAN (Cozaar) D Tablet, oral 25mg, 50mg, 100mg

Antiadrenergic Agents

CLONIDINE (Catapres®) C Tablet, oral 0.1mg, 0.2mg



VIA DOSAGE

CLONIDINE (Catapres®) C Patch, topical 0.1mg/24h, 0.2mg/24h, 0.3mg/24h

DOXAZOSIN MESYLATE (Cardura®) C Tablet, oral 1mg, 2mg, 4mg, 8mg

METHYLDOPA (Aldomet®) B Tablet, oral 250mg, 500mg

PRAZOSIN (Minipress®) C Capsule, oral 1mg, 2mg, 5mg

Anti-Dysrhythmics/Cardiac Arrest

ADENOSINE (Adenocard®) C Injection 6mg/2ml vial

AMIODARONE (Cordarone®) D Tablet, oral 200mg

AMIODARONE (Cordarone®) D Injection 150mg/3ml Amp

ATROPINE C Injection 1 mg/ml

ATROPINE C Injection 0.1 mg/ml

DIGOXIN (Lanoxin®) C Elixir, oral 0.05mg/ml

DIGOXIN (Lanoxin®) C Injection 0.25mg/ml

DIGOXIN (Lanoxin®) C Tablet, oral 0.125mg, 0.25mg

DRONEDARONE (Multaq)**restricted to initiation by cardiology

X Tablet, oral 400mg

FLECAINIDE (Tambocor®) C Tablet, oral 50mg, 100mg

ISOPROTERENOL HCL (Isuprel®) C Injection 1mg/5ml

LIDOCAINE B Injection 2% prefilled syringe

LIDOCAINE B Injection 4mg/ml in 250ml D5, 8mg/ml in 250ml D5

PROCAINAMIDE (Procan®) C Injection 100mg/ml

PROPAFENONE C Tablet, oral 150mg

SOTALOL (Betapace®) B Tablet, oral 80mg

Anti-Hyperlipidemic Agents

Bile Acid Sequestrants

CHOLESTYRAMINE (Questran Light®) C Powder, oral 4gm

HMG-CoA Reductase Inhibitors

ATORVASTATIN (Lipitor®) X Tablet, oral 10mg, 20mg, 40mg, 80mg

PRAVASTATIN (Pravachol®) X Tablet, oral 10mg, 20mg, 40mg, 80mg

ROSUVASTATIN (Crestor®) X Tablet, oral 10mg, 20mg, 40mg

SIMVASTATIN (Zocor®) X Tablet, oral 10mg, 20mg, 40mg, 80mg

Other

EZETIMIBE (Zetia®) C Tablet, oral 10mg

FENOFIBRATE (Tricor®) C Tablet, oral 145mg

FISH OIL C Capsule, oral 1000mg

GEMFIBROZIL (Lopid®) C Tablet, oral 600mg

Antihypertensives

HYDRALAZINE (Apresoline®) C Injection 20mg/ml

HYDRALAZINE (Apresoline®) C Tablet, oral 10mg, 25mg

NITROPRUSSIDE, SODIUM (Nipride®) C Injection 50mg/2ml vial

Antiplatelet Drugs

ASPIRIN/DIPYRIDAMOLE (Aggrenox) D Capsule, Oral 25mg/200mg



VIA DOSAGE

CLOPIDOGREL (Plavix®) B Tablet, oral 75mg

EPTIFIBATIDE (Integrilin®) B Injection 0.75mg/ml, 2mg/ml,

PRASUGREL (Effient)**restricted to patients with documented allergy to or lack of effectiveness with clopidogrel

B Tablet, oral 10mg

TICAGRELOR (Brilinta) – restricted to patients started on by cardiology and for patients having an acute NSTEMI

C Tablet, oral 60mg, 90mg

Beta Blockers

ATENOLOL (Tenormin®) D Tablet, oral 25mg, 50mg

CARVEDILOL (Coreg®) C Tablet, oral 3.125mg, 6.25mg, 12.5mg, 25mg

ESMOLOL C Injection 100mg/10ml

LABETALOL (Normodyne®, Trandate®) C Injection 5mg/ml

LABETALOL (Normodyne®, Trandate®) C Tablet, oral 100mg

METOPROLOL SUCCINATE (Toprol XL®) C Tablet, oral 25mg, 50mg, 100mg, 200mg

METOPROLOL TARTRATE (Lopressor®) *Restricted to inpatient/ER/clinic use, not to be filled for outpatient prescription. Will be kept in the inpatient pharmacy only.

C Tablet, oral 25mg (unit dose only)

METOPROLOL TARTRATE (Lopressor®) C Injection 5mg/5ml

NADOLOL C Tablet, oral 20mg, 40mg

PROPRANOLOL (Inderal®) C Injection 1mg/ml

PROPRANOLOL (Inderal®) C Tablet, oral 10mg, 20mg, 40mg, 80mg

PROPRANOLOL sustained release (Inderal LA®)


PROPRANOLOL (Inderal®) C Liquid, oral 20mg/5ml

Calcium Channel Blockers

Dihydropyridines

AMLODIPINE (Norvasc®) C Tablet, oral 2.5mg, 5mg, 10mg

NICARDIPINE C Injection 2.5 mg/mL

NIFEDIPINE (Procardia, Adalat)**restricted to OB patients or patients with a documented allergy to amlodipine or an indication that specifically requires the use of nifedipine

C Tablet, oral 10mg, 30mg, 60mg, 90mg

Non-dihyrdopyridines

DILTIAZEM (Cardizem®) C Tablet, oral 60mg

DILTIAZEM SUSTAINED RELEASE C Capsule, oral 60mg, 120mg, 180mg, 240mg, 300mg

DILTIAZEM (Cardizem®) C Injection 25mg/5ml

VERAPAMIL (Calan, Isoptin) C Tablet, oral 80mg

VERAPAMIL SUSTAINED RELEASE C Capsule, oral 120mg, 180mg, 240mg

VERAPAMIL C Injection 5mg/2ml

Diuretics

Carbonic Anhydrase Inhibitors

ACETAZOLAMIDE (Diamox®) C Tablet, oral 250mg



VIA DOSAGE

ACETAZOLAMIDE (Diamox®) C Injection 500mg/vial

Loop

BUMETANIDE (Bumex®) C Tablet, oral

FUROSEMIDE (Lasix®) C Tablet, oral 20mg, 40mg

FUROSEMIDE (Lasix®) C Injection 10mg/ml (2ml, 10ml)

FUROSEMIDE (Lasix®) C Solution, oral 10mg/ml

TORSEMIDE (Demadex) B Tablet, oral 20mg

Thiazide Type

CHLORTHALIDONE (Apo-Chlorthalidone®) B Tablet, oral 25mg

HYDROCHLOROTHIAZIDE (Hydrodiuril®, Oretic®, etc)

B Tablet, oral 25mg, 50mg

INDAPAMIDE(Apo-Indapamide®) – restricted to pts ≥ 65 and BP not at goal with thiazide diuretic or for pts with poor renal function and BP not at goal

B Tablet, oral

METOLAZONE (Zaroxyln®) B Tablet, oral 2.5mg, 5mg

Potassium Sparing

AMILORIDE B Tablet, oral 5mg

Combinations

TRIAMTERENE/ HYDROCHLOROTHIAZIDE (Dyazide)

C Tablet, oral 37.5mg/25mg

Nitrates

ISOSORBIDE DINITRATE (Isordil®) C Tablet, oral 10mg, 40mg

ISOSORBIDE DINITRATE SR (Dilatrate®) C Tablet, oral 40mg sustained release

ISOSORBIDE DINITRATE (Isordil®) C Tablet, sublingual

5mg

NITROGLYCERIN (Nitrostat) C Tablet, sublingual

0.4mg

NITROGLYCERIN (Nitrobid) C Ointment, topical

2%

NITROGLYCERIN (Nitrolingual) C Spray, Sublingual

0.4mg/spray

NITROGLYCERIN (Nitro-Patch7, Transderm-Nitro®)

C Transdermal Patch, topical

0.1mg/hr, 0.2mg/hr, 0.4mg/hr, 0.6mg/hr

NITROGLYCERIN C Injection 5mg/ml, 50mg/250ml D5W

Pressors/Inotropes

DOBUTAMINE (Dobutrex®) B Injection 250mg/250ml dextrose 5% premix

DOBUTAMINE (Dobutrex®) B Injection 250mg/20ml

DOPAMINE C Injection 40mg/ml, 400mg/250ml premix

EPHEDRINE SULFATE C Injection 50mg/ml

EPINEPHRINE C Injection 1:1000 (1mg/ml), 1:10,000 (0.1mg/ml)

EPINEPHRINE (Epi-Pen, Epi-Pen Jr.) C Injection 0.15mg, 0.3mg

NOREPINEPHRINE BITARTRATE (Levophed®)

C Injection 1mg/ml

PHENYLEPHRINE C Injection 10mg/ml



VIA DOSAGE

Thrombolytics

ALTEPLASE (Activase®, Cathflo®, tPA) Restricted to use in frostbite and port/line management, for treatment of MI, Stroke or PE use Tenecteplase.

C Injection 100mg/100ml vial 2mg vial

Tenecteplase (TNKase®) Fetal risk cannot be ruled

out.

Injection 50mg vial

Volume Expanders

ALBUMIN, Normal Human Serum U.S.P. C Injection 5%, 25%


VIA DOSAGE

HETASTARCH N/A Injection 6% in 0.9% Sodium Chloride 500ml

Other

ALPROSTADIL (Prostin VR Pediatric®) C Injection 500mcg/ml

DESMOPRESSIN (DDAVP) B Injection 4mcg/ml

PENTOXIFYLLINE (Trental®) C Tablet, oral 400mg

RANOLAZINE (Ranexa®) C Tablet, oral 500mg extended release

SACUBITRIL and VALSARTAN (Entresto®) X Tablet, oral 24/26mg, 46/54mg, 97/103mg

DERMATOLOGY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Acne Preparations

ADAPALENE (Differin) C Gel, topical 0.1%

BENZOYL PEROXIDE C Gel, topical 5%, 10%

BENZOYL PEROXIDE-CLINDAMYCIN (Benzaclin®)

C Gel, topical 5%/1%

TRETINOIN (Retin-A) C Cream, topical 0.025%

Antibacterials (Topical)

BACITRACIN C Ointment, Topical

500 units/gm

CLINDAMYCIN Solution, topical

CLINDAMYCIN Solution, gel

METRONIDAZOLE B Cream, Topical Gel, Topical

0.75%

MUPIROCIN (Bactroban®) B Ointment, topical

2%

SILVER NITRATE C Applicators, topical

75% silver nitrate/25% potassium nitrate

SILVER SULFADIAZINE (Silvadene®) B Cream. topical 1%

Antifungals (Topical)

CLOTRIMAZOLE B Cream, topical 1%

GENTIAN VIOLET C Solution, topical

1%



VIA DOSAGE

KETOCONAZOLE (NIZORAL®) C Shampoo, topical

2%

KETOCONAZOLE (NIZORAL®) C Cream, topical 2%

MICONAZOLE C Powder, topical 2%

NYSTATIN C Cream, topical 100,000 units/gm

TERBINAFINE B Cream, topical 1%

Antiparasitics (Topical)

PERMETHRIN (Elimite) B Cream, topical 5%

PERMETHRIN (Nix) B Cream Rinse, topical

1%

Antipsoriatics

CALCIPOTRIENE (Dovonex®) C Cream, Ointment, and Solution, Topical

0.005%

Antivirals (Topical)

ACYCLOVIR (Zovirax®) B Ointment, topical

5%

IMIQUIMOD (Aldara®) C Cream, Topical 5%

Atopic Dermatitis Preparations

DUPILUMAB (Dupixent®) Restricted to specialist recommendation.

N/A Injection, SQ 200mg, 300mg

PIMECROLIMUS (Elidel®) Restricted to 2nd line agent, not to exceed 6 weeks, no refills, only the 30gm tube will be dispensed, will not be used in children less than 2 years of age.

C Cream, topical 1%

TACROLIMUS (Protopic®) C Ointment, topical

0.03%/0.1%

Corticosteroid/Antimicrobial Combinations

NYSTATIN/TRIAMCINOLONE (Mycolog®) C Cream, topical 100,000 units/1mg/gram

Hemorrhoid Care

HYDROCORTISONE (Anusol-HC) C Cream, rectal 2.5%

HYDROCORTISONE ACETATE C Ointment, topical

1%

HYDROCORTISONE ACETATE (Anusol HC®)

C Suppository, rectal

25mg

PHENYLEPHRINE/HARD FAT (Anusol®) C Suppository, rectal

0.25%/88.7%

PRAMOXINE HCL (Proctofoam®) C Foam 1%

WITCH HAZEL (Tucks®) N/A Medicated pads, topical

50%

Other Dermatologic Agents

ALUMINUM CHLORIDE HEXAHYDRATE (Drysol®) (HyperCare®)

N/A Solution, topical

20%

ALOE VERA N/A Gel, topical 100%



VIA DOSAGE

AQUAPHOR OINTMENT contains: petrolatum, mineral oil, mineral wax, wool wax alcohol, panthenol, glycerin & bisabolol

N/A Ointment, topical

G, L -- Therapeutic

LUBRIDERM (Lanolin free lotion) N/A Lotion, topical 473ml

BENZYL ALCOHOL (Zilactin®) C Gel, topical 10%

CALAMINE C Lotion, topical U.S.P.

CALMOSEPTINE® (Calamine/Zinc/Nabicarbetes)

N/A Ointment, topical

113g/tube

CAPSAICIN OLEORESCIN CREAM C Cream, topical 0.025%

CAVILON FOOT AND DRY SKIN N/A Lotion, topical 118ml

CETAPHIL CLEANSER® N/A Lotion, topical 473ml

CERAVE® MOISTURIZING CREAM N/A Cream, topical 453gm

COAL TAR PREPARATIONS (Ionil T Plus®) **Pharmacy will carry whichever shampoo preparation is currently available through wholesaler**

C Shampoo, topical

2% Coal Tar

COAL TAR PREPARATIONS C Emulsion, for use as bath oil or lotion (Cutar)

1.5% coal tar

COLLAGENASE (Santyl) N/A Ointment, topical

250units/g

DICLOFENAC SODIUM (Voltaren®) C Gel, topical 1%

DIMETHICONE 1.3% (Cavilon Durable Barrier Cream)

N/A Cream, topical 92gm

DIPHENHYDRAMINE WITH ZINC ACETATE

N/A Cream, topical 2%/0.1%

LACTIC ACID (Lac-Hydrin®) B Lotion, topical 12%

LANSINOH BREASTFEED OINTMENT C Ointment, topical

7gm

LIDOCAINE B Gel, topical 2%

LIDOCAINE/PRILOCAINE (EMLA®) B Cream, topical 2.5%/2.5%

MAGNESIUM SULFATE (Epsom Salt) A/C Powder, topical

METHYLSALICYLIC ACID (Bengay) N/A Cream, topical

OATMEAL, COLLOIDAL (Aveeno®) N/A Powder for bath

SAF-GEL N/A Gel, topical

SALICYLIC ACID C Powder USP

SALICYLIC ACID (Compound W) C Liquid, topical 17%

SALICYLIC ACID (Mediplast) C Patch, topical 40%

SELENIUM SULFIDE (Selsun®) C Lotion, topical 2.5%

SODIUM CHLORIDE C Irrigation, topical

0.9%

SURGILUBE GEL(Chlorhexidine Gluconate) C Jelly, topical

VITAMIN A & D (Petrolatum/Lanolin Base) B Ointment, topical



VIA DOSAGE

WATER, STERILE N/A Irrigation, topical

USP

WHITE PETROLATUM (Vaseline®) C Ointment, topical

ZINC GELATIN (Gelucast, Unna's Boot) Contains: glycerin, sorbitol, gelatin, magnesium aluminum silicate, zinc oxide and calamine,

N/A Medicated Bandage

ZINC OXIDE N/A Ointment, topical

20%, 40% (Desitin)

Corticosteroid (Topical)

BETAMETHASONE C Ointment, topical

0.05%

CLOBETASOL C Cream, topical 0.05%

CLOBETASOL C Ointment, topical

0.05%

CLOBETASOL C Shampoo, topical

0.05%

CLOBETASOL C Solution, topical

0.05%

FLUOCINONIDE (Lidex®) C Ointment, topical

0.05%

FLUOCINONIDE (Lidex®) C Cream, topical 0.05%

FLUOCINONIDE (Lidex®) C Solution, topical

0.05%

HYDROCORTISONE C Ointment, topical

1%,2.5%

HYDROCORTISONE C Cream, topical 1%, 2.5%

HYDROCORTISONE C Lotion, topical 1%, 2.5%

TRIAMCINOLONE ACETONIDE (Aristocort®)

C Cream, topical 0.1%, 0.5%


C Lotion, topical 0.1%


C Ointment, topical

0.1%

TRIAMCINOLONE ACETONIDE (Kenalog) C Spray, Topical 0.147mg/g

Other

ALUMINUM SULFATE AND CALCIUM ACETATE (Domeboro®)

N/A Packet, Effervescent

One packet/16oz of water yields 1:40

CHLORHEXIDINE GLUCONATE B Liquid, topical 4%

ENDOCRINE & METABOLIC PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Androgens/Anabolic Steroids

OXANDROLONE (Oxandrin) *Patient case must be presented to P&T for approval-only to be used in patients with Turner’s Syndrome

X Tablet, oral 2.5mg



VIA DOSAGE

TESTOSTERONE X Injection 200mg/ml

Bisphosphonates

ALENDRONATE (Fosamax®) C Tablet, oral 35mg

ALENDRONATE (Fosamax®) C Tablet, oral 70mg

DENOSUMAB (Prolia®) X Injection 60mg

ZOLEDRONIC ACID (Reclast®) D Injection 5mg

Corticosteroids

BETAMETHASONE SODIUM PHOSPHATE AND BETAMETHASONE ACETATE (Celsetone Souspan®)

C Injection 3mg/3mg

CORTISONE ACETATE (Cortone®) D Tablet, oral 25mg

DEXAMETHASONE C Tablet, oral 0.5mg, 2mg, 4mg

DEXAMETHASONE C Solution, oral 1mg/ml

DEXAMETHASONE C Elixir, oral 0.5mg/5ml

DEXAMETHASONE C Injection 4mg/1ml, 20mg/5ml, 10mg/ml

FLUDROCORTISONE (Florinef®) C Tablet, oral 0.1mg

HYDROCORTISONE C Injection 100mg/2ml, 1000mg/8ml

HYDROCORTISONE ACETATE (Cortef) C Tablet, oral 5mg, 10mg, 20mg

METHYLPREDNISOLONE (Depo-Medrol) C Injection 40mg/ml, 80mg/ml SDV

METHYLPREDNISOLONE (Solu-Medrol) C Injection 40mg/1ml SDV, 125mg/2ml SDV, 1000mg/8ml SDV

METHYLPREDNISOLONE C Injection 2grams SDV

METHYLPREDNISOLONE C Tablet, oral 2 mg, 4mg

PREDNISOLONE (Prelone) C Syrup, oral 3mg/ml

PREDNISONE (Deltasone®) D Tablet, oral 1mg, 5mg, 10mg, 20mg


C Injection 10mg/ml, 40mg/ml

Diabetes-Related

Alphagluosidase Inhibitors

Glitazones

PIOGLITAZOLE (Actos) C Tablet, oral 15mg, 30mg, 45mg

Insulins

INSULIN ASPART (Novolog Mix) B Injection 70/30 pens only

INSULIN ASPART (Novolog) INJ B Injection 100units/ml (pens and vials)

INSULIN GLARGINE INJ (Lantus®) C Injection 100units/ml (pens and vials)

INSULIN N U-100 INJ (Humulin N®) B Injection 100units/ml pens only

INSULIN R U-100 INJ (Humulin R®) B Injection 100units/ml vials only

Sulfonylureas

GLIPIZIDE C Tablet, oral 5mg, 10mg

GLIPIZIDE C Tablet, oral 2.5mg, 10mg extended release

GLYBURIDE (Diabeta®, Micronase®) ***RESTRICTED – pregnant patients only

C Tablet, oral 5mg

Other

CONTINUOUS GLUCOSE MONITORS N/A



VIA DOSAGE

DEXTROSE C Injection 10%, 25%, 50%

EMPAGLIFLOZIN (Jardiance®) N/A Tablet, oral 10 mg, 25 mg

GLUCAGON B Injection, emergency kit

1mg/ml

GLUCAGON (Baqsimi®) N/A Nasal Powder 3mg

GLUCOSE (Glutose ®) C Gel, oral 15 grams/tube

LIRAGLUTIDE (Victoza®) C Injection 6mg/ml

METFORMIN (Glucophage®) B Tablet, oral 500mg, 850mg, 1000mg, 500mg ER, 750mg ER

SAXAGLIPTIN (Onglyza®) B Tablet, oral 2.5mg

SEMAGLUTIDE (Ozempic®) N/A Injection, SQ 2mg/1.5ml

SEMEGLUTIDE (Rybelsus®) **SQ injection should remain first-line where appropriate due to proven cardiovascular benefit**

N/A Tablet 3mg, 7mg, 14mg

Diagnostic Agents

COSYNTROPIN (Cortrosyn®) C Injection 0.25mg/vial

Gout-Related

ALLOPURINOL (Zyloprim®) C Tablet, oral 100mg, 300mg

COLCHICINE C Tablet, oral 0.6mg

PROBENECID B Tablet, oral 500mg

Minerals/Electrolytes

CALCIUM ACETATE (Phos-Lo®) C Capsule, oral 667mg

CALCIUM CARBONATE C Tablet, chewable

500mg

CALCIUM CARBONATE Suspension, oral

500 mg/5 mL

CALCIUM CARBONATE/VITAMIN D C Tablet, oral 500mg/200mg

CALCIUM CARBONATE/VITAMIN D Tablet, chewable

500 mg/100 mg

CALCIUM CHLORIDE C Injection 1gm/10ml (14mEq Ca/10ml)

CALCIUM GLUCONATE C Injection 1gm/10ml vial (4.65meq Ca/10ml)

FERROUS GLUCONATE (Fergon) N/A Tablet, oral 324mg

FERROUS SULFATE N/A Tablet, oral 325mg (65mg elem iron/tab)

FERROUS SULFATE N/A Liquid 15 mg/ml elemental

FERROUS SULFATE **Restricted to patient over 12 due to alcohol content

N/A Solution, oral 220mg/5ml (15mg elem iron/0.6ml)

FLUORIDE, SODIUM Acidulated Phosphate (Phos-Flur)

Fetal risk is minimal

Oral Rinse 1mg F (2.2mg NaF)/5ml

FLUORIDE, SODIUM neutral sodium fluoride(Prevident®)

Fetal risk is minimal

Oral Rinse 2%

FLUORIDE, SODIUM (PreviDent) Fetal risk is minimal

Gel 1.1%

FLUORIDE, SODIUM Fetal risk is minimal

Tablet, oral 1mg



VIA DOSAGE

IRON POLYSACCHARIDE Solution, oral 15mg/ml (elemental iron)

IRON SUCROSE (Venofer) B Injection 100mg/vial

MAGNESIUM GLYCINATE-restricted to pediatric migraines

Solution, oral 250mg/15 mL

MAGNESIUM GLYCINATE-restricted to pediatric migraines

Tablet, oral 200 mg

MAGNESIUM OXIDE D Tablet, oral 400mg

MAGNESIUM SULFATE D Injection 50% (500mg/ml)

MAGNESIUM SULFATE (Epsom Salts) D Powder USP

MAGNESIUM SULFATE D Injection 4gm (40mg/ml in water for injection), 40gm/1000ml SWFI

MAGNESIUM SULFATE D Injection 1 gm (10mg/ml in D5)

PHOSPHATE/SODIUM/POTASSIUM (Phos-Nak®)

C Powder for oral solution

8mM (250mg)/7.1mEq (160mg)/7.1(280mg)

PHOSPHATE/SODIUM/POTASSIUM (K-Phos Neutral®)

C Tablet, oral 8mM (250mg)/13mEq (298mg)/1.1mEq (45mg)

POTASSIUM CHLORIDE C Injection 2mEq/ml

POTASSIUM CHLORIDE C Injection 10mEq/100ml (premix)

POTASSIUM CHLORIDE C Injection 20mEq/100ml (premix)

POTASSIUM CHLORIDE C Tablet, oral 10mEq

POTASSIUM CHLORIDE C Syrup, oral 20% (40mEq/15ml)

POTASSIUM CHLORIDE C Powder, oral for solution

20mEq/packet

POTASSIUM PHOSPHATE C Injection 4.4mEq/ml Potassium/ 3mM/ml Phosphorous

SODIUM BICARBONATE C Injection 4.2% (5mEq/10ml) peds 8.4% (50mg/50ml) adult

SODIUM BICARBONATE C Tablet, oral 648mg (10gr)

SODIUM CHLORIDE (Thermotabs) C Tablet, oral (Thermotabs)

250mg,1g

SODIUM CHLORIDE C Injection 0.9%, 4mEq/ml (concentrate)

ZINC SULFATE C Capsule, oral 220mg (50mg elem Zn/cap)

Nutritionals

LEVOCARNITINE (Carnitor®) B Solution, oral 1gm/10ml

LEVOCARNITINE (Carnitor®) B Injection 1gm/5ml

Thyroid Agents

IODINE (Lugols®) N/A Solution 5%

LEVOTHYROXINE (T4) (Synthroid®, Levothroid®)

A Tablet, oral 0.025mg, 0.05mg, 0.075mg, 0.1mg, 0.112mg, 0.125mg, 0.137 mg, 0.15mg, 0.175mg, 0.2mg, 0.3mg

LEVOTHYROXINE (T4) (Synthroid®, Levothroid®)

A Injection 200mcg/vial

LIOTHYRONINE (Cytomel®) A Tablet, oral 25mcg

METHIMAZOLE (Tapazole®) D Tablet, oral 5mg, 10mg

POTASSIUM IODIDE (SSKI®) Fetal Risk Demonstrated

Solution, oral U.S.P 1 gm/ml



VIA DOSAGE

PROPYLTHIOURACIL (PTU®) D Tablet, oral 50mg

Pediatric Rehydration Solution

ORAL ELECTROLYTE SOLUTION (Pedialyte®)

N/A Powder, oral 8.5g

Vitamins

ASCORBIC ACID (Vitamin C) C Tablet, oral 500mg

CALCITRIOL (Rocoltrol®) C Capsule, oral 0.25mcg

CALCITRIOL Solution, oral 1 mcg/mL

CHOLECALCIFEROL (VIT D3) N/A Tablet, oral 400 IU, 1,000 IU

CHOLECALCIFEROL (Vitamin D3) N/A Drops, oral 400 IU

CYANOCOBALAMIN (Vitamin B-12) C Injection 1000 mcg/ml

CYANOCOBALAMIN (Vitamin B-12) C Tablet, oral 100 mcg, 1000mcg

ERGOCALCIFEROL (Vitamin D2) Capsule, oral 50,000 units

FOLIC ACID A Tablet, oral Injection

1mg 5mg/ml

MULTIVITAMIN (ADULT) N/A Tablet, oral

MULTIVITAMIN (ADULT) N/A Injection

MULTIVITAMIN (CHILDRENS) N/A Tablet, chewable

MULTIVITAMIN (CHILDRENS) WITH IRON N/A Tablet, chewable

POLY-VIT N/A Solution, oral

POLY-VIT WITH FLUORIDE N/A Solution, oral

POLY-VIT WITH FLUORIDE AND IRON N/A Solution, oral

POLY-VIT WITH IRON N/A Solution, oral

NEPHROCAPS® Ascorbic Acid 100mg, Folic Acid 1mg, Niacin 20mg, Thiamine Monohydrate 1.5mg, Riboflavin 1.7mg, Pyridoxine HCL 10mg, Vitamin B 126mcg, Pantothenic Acid 5mg, Biotin 150 mcg

N/A Capsule, oral

NIACIN C Tablet, oral 100mg, 500mg

NIACIN EXTENDED RELEASE C Tablet, oral 500mg, 1000mg

Niacinamide Ascorbate, Ascorbic acid (Vit C), Thiamine (Vit B1), Riboflavin (Vit B2), Pyridoxine (Vit B6) (AllB with C)

N/A Tablet, oral

PHYTONADIONE (Vitamin K-1) (Aqua-Mephyton®)

C Injection, pediatric

1mg/0.5ml

PHYTONADIONE (Vitamin K-1) (Aqua-Mephyton®)

C Injection, adult 10mg/ml

PHYTONADIONE (Vitamin K-1) (Mephyton®)

C Tablet, oral 5mg

PRENATAL VITAMIN N/A Tablet, oral

PYRIDOXINE (Vitamin B-6) N/A Injection 100mg/ml

PYRIDOXINE (Vitamin B-6) N/A Tablet, oral 25mg, 50mg

THIAMINE (Vitamin B-1) Fetal risk minimal

Injection 100mg/ml



VIA DOSAGE

THIAMINE (Vitamin B-1) Fetal risk minimal

Tablet, oral 50mg, 100mg

TOCOPHEROL, d1-ALPHA ACETATE (Vitamin E)

A Capsule, oral 200 I.U., 400 I.U.

Other

CABERGOLINE (Dostinex®) B Tablet, oral 0.5mg

CALCITONIN C Nasal spray 200/act spray 3.7ml

CALCITONIN Injection 400 unit/2 mL

CINACALCET (Sensipar®) C Tablet, oral 30mg

DESMOPRESSIN (DDAVP) B Spray, nasal 100mcg/ml

LEUPROLIDE (Lupron®) X Injection 11.25mg/month, 22.5mg/month, 3.75mg/month, 30mg/4months, 7.5mg/month

PATIROMER (Veltassa®) N/A Soultion, oral 8.4g

SEVELAMER (Renagel®) C Tablet, oral 400mg, 800mg

SODIUM POLYSTYRENE SULFONATE (Kayexalate®)--contains sorbitol

C Injection 5mg

SOMATROPIN (Nutropin AQ®) C Injection 5mg

VASOPRESSIN (Pitressin®) C Injection 20 units/ml

ENT PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Antihistamines

CETIRIZINE (Zyrtec®) Tablet, oral 10 mg

CYPROHEPTADINE (Periactin®) B Tablet, oral 4mg

CYPROHEPTADINE (Periactin®) B Solution, oral 2mg/5ml

DIPHENHYDRAMINE (Benadryl®) B Capsule, oral 25mg, 50mg

DIPHENHYDRAMINE (Benadryl®) B Elixir, oral 12.5mg/5ml

DIPHENHYDRAMINE (Benadryl®) B Injection 50mg/ml

HYDROXYZINE (Atarax®, Vistaril®) C Tablet, oral 10mg, 25mg

HYDROXYZINE (Atarax®, Vistaril®) C Suspension, oral

10mg/5ml

LORATADINE (Claritin®) N/A Tablet, Solution, oral

10mg, 5mg/ml

MECLIZINE (Antivert®) B Tablet, oral 25mg

Antitussives/Expectorants

BENZONATATE (Tessalon Perles) C Capsule, oral 100 mg

GUAIFENESIN (Robitussin)—Should only be used in patients >6 years old

C Solution, oral 100mg/5ml

GUAIFENESIN/CODEINE (Robitussin AC) —Should only be used in patients >6 years old

C Solution, oral 100mg/10mg/5ml

GUAIFENESIN/DEXTROMETHORPHAN (Robitussin DM) —Should only be used in patients >6 years old

C Solution, oral 100mg/10mg/5ml

Decongestants



VIA DOSAGE

PSEUDOEPHEDRINE (Sudafed®)—Should only be used in patients >6 years old


PSEUDOEPHEDRINE (Sudafed®)—Should only be used in patients >6 years old

C Syrup, oral 15 mg/5 mL

Ear Preparations

ACETIC ACID/ALUMINUM ACETATE (Domeboro Otic)

N/A Solution, otic 2%/2%

CARBAMIDE PEROXIDE (Debrox®) N/A Solution, otic 6.5%

CIPROFLOXACIN/DEXAMETHASONE (Ciprodex)

C Suspension, otic

0.3%/0.1%

NEOMYCIN/POLYMYXIN B/HYDROCORTISONE (Cortisporin)

C Suspension, otic

3.5mg/10,000units/5mg/gram

Mouth and Lip Preparations

CHLORHEXIDINE GLUCONATE (Peridex®)

B Rinse, oral 0.12%

LIDOCAINE B Viscous, oral 2%

SALIVA SUBSTITUTE (Aquoral®) N/A Solution, spray

TRIAMCINOLONE ACETONIDE (Kenalog in Orabase®)

C Paste, dental 0.1%

Nasal Preparations

AZELASTINE (Astelin®) C Nasal Spray 137mcg

FLUTICASONE (Flonase®) C Nasal Spray 50mcg

MOMETASONE – restricted as 2nd line for patients >12 years

C Nasal Spray 50mcg

OXYMETAZOLINE HCL (Afrin®) C Nasal Spray 0.05%

PHENYLEPHRINE (Neo-Synephrine®) C Solution, nasal 0.25%, 0.5%

SODIUM CHLORIDE N/A Solution, nasal drops

0.65%

Other

DIPHENHYDRAMINE/ LIDOCAINE/ MAALOX 1:1:1

N/A Suspension, oral

MENTHOL (Cepacol) C Lozenge, oral 3mg

GASTROENTEROLOGY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Antidiarrheals

BISMUTH SUBSALICYLATE (Pepto-Bismol®)

N/A Suspension, oral

262mg/15ml

BISMUTH SUBSALICYLATE (Pepto-Bismol®)

N/A Tablet, oral 262mg

LOPERAMIDE (Imodium®) B Capsule, oral 2mg

LOPERAMIDE (Imodium®) B Liquid, oral 1mg/5ml

Antiemetics

APREPITANT (Emend)**Restricted to patients undergoing chemotherapy**

B Capsule, oral 80mg, 125mg



VIA DOSAGE

DOXYLAMINE – restricted to nausea/vomiting in pregnancy

Tablet, oral 25 MG

DOXYLAMINE SUCCINATE/PYRIDOXINE HCL (Diclegis®) – second line for nausea/vomiting in pregnancy

A Tablet, oral 10-10mg

DRONABINOL (Marinol®) C Capsule, oral 2.5mg, 5mg, 10mg

DROPERIDOL (Inapsine®) C Injection 2.5mg/ml

METOCLOPRAMIDE (Reglan®) B Tablet, oral 10mg

METOCLOPRAMIDE (Reglan®) B Injection 10mg/2ml

METOCLOPRAMIDE (Reglan®) B Syrup, oral 5mg/5ml

ONDANSETRON B Injection 2mg/ml

ONDANSETRON **Quantities per prescription limited by insurance coverage. Applicable limitations will be followed by pharmacy**

B Tablet, oral 4mg, 8mg

ONDANSETRON ODT B Tablet, ODT 4mg, 8mg

PROCHLORPERAZINE (Compazine®) C Tablet, oral 5mg, 10mg

PROCHLORPERAZINE (Compazine®) C Injection 10mg/2ml

PROCHLORPERAZINE (Compazine®) C Suppository, rectal

25mg

PROMETHAZINE (Phenergan®) C Injection 25mg/ml

PROMETHAZINE (Phenergan®) C Suppository, rectal

12.5mg, 25mg

PROMETHAZINE (Phenergan®) C Syrup, oral 6.25mg/5ml

PROMETHAZINE (Phenergan®) C Tablet, oral 25mg

SCOPOLAMINE HYDROBROMIDE C Patch, topical 1.5mg

Antiulcer

Antacids

ALUMINUM/MAGNESIUM/SIMETHICONE N/A Suspension, oral

200mg/200mg/20mg/5ml

H2 Antagonists

FAMOTIDINE (Pepcid®) Tablet, oral 10 mg, 20 mg, 40 mg

FAMOTIDINE (Pepcid®) Solution, Oral 40mg/5ml

FAMOTIDINE (Pepcid®) Injection 20 mg/2 mL

Proton Pump Inhibitors

LANSOPRAZOLE (PREVACID®)Restricted to peds with g-tube

B Solutab, oral 15mg, 30mg

OMEPRAZOLE C Capsule, oral 20mg

PANTOPRAZOLE (Protonix®) B Tablet, oral 40mg

PANTOPRAZOLE (Protonix) B Injection 40mg

Other

DICYCLOMINE (Bentyl®) B Tablet, oral 20mg

DICYCLOMINE (Bentyl®) B Capsule, oral 10mg

SIMETHICONE (Mylicon®, Gas-X) Fetal risk is minimal

Tablet, oral 80mg



VIA DOSAGE

SIMETHICONE (Mylicon®, Gas-X) Fetal risk is minimal

Drops, oral 40mg/0.6ml

SUCRALFATE (Carafate®) B Tablet, oral 1000mg

SUCRALFATE (Carafate®) B Suspension, oral

1gm/10ml

Laxatives

Bulk Forming

PSYLLIUM SEED (Konsyl) N/A Powder, for oral solution

100%

Osmotic

GLYCERIN N/A Suppository, rectal

infant, children, adult

LACTULOSE (Chronulac®) B Syrup, oral 10gm/15ml

MAGNESIUM CITRATE (Citrate of Magnesia)

D Solution, oral U.S.P.

MAGNESIUM HYDROXIDE (Milk of Magnesia®)

D Suspension, oral

400mg/5ml

POLYETHYLENE GLYCOL (Miralax) C Powder, oral

POLYETHYLENE GLYCOL WITH ELECTROLYTES (Colyte®, Golytely®)

C Powder for solution, oral

gallon jug

SODIUM, POTASSIUM, AND MAGNESIUM SULFATE BOWEL PREPERATION KIT (Suprep®)

C Powder for solution, oral

360 mL (two 180 mL bottles)

SODIUM PHOSPHATE (Fleets®) C Enema Adult, pediatric

Stimulant

BISACODYL (Dulcolax®) N/A Tablet, oral 5mg

BISACODYL (Dulcolax®) N/A Suppository 10mg

SENNA C Tablet, oral 8.6mg

SENNA C Liquid, oral 8.8 mg/5 ml

SENNA (Chocolate Ex-Lax®) C Oral 15 mg per piece

Stool Softener

DOCUSATE SODIUM (Colace®) N/A Capsule, oral 100mg

DOCUSATE SODIUM (Colace®) N/A Liquid, oral 10mg/ml

Other

MINERAL OIL (Fleets mineral oil) enema N/A Liquid, rectal 133ml adult

MINERAL OIL **restricted to use in OB only**

N/A Liquid, topical

NALOXEGOL (Movantik®) Tablet, oral 12.5 mg, 25 mg

Ulcerative Colitis

MESALAMINE - all branded generics will be available for prescribing

B Tablets and Capsules, oral

MESALAMINE B Enema, rectal 4gram/60ml

MESALAMINE (Canassa ®) B Suppository, rectal

1gram

SULFASALAZINE (Azulfidine®) B Tablet, oral 500mg

Other GI Agents



VIA DOSAGE

GLYCOPYRROLATE (Robinul®) C Tablet, oral 1mg

GLYCOPYRROLATE (Robinul®) C Injection 0.2mg/ml

HYOSCYAMINE (Levsin) C Tablet, oral 0.125mg SL

HYOSCYAMINE (Levsin) C Solution, oral 0.125mg/mL

LACTASE ENZYME (LactAid®) N/A Caplets, oral 3000 FCC lactase units required

LACTOBACILLUS RHAMNOSUS GG (Culturelle®)

N/A Capsule, oral 15 billion cells/capsule

OCTREOTIDE (Sandostatin) B Injection 200 mcg/mL

PANCREATIC ENZYMES (Zenpep) C Capsule, oral

RIFAXAMIN (Xifaxan®) – Restricted to specialist recommendation.

N/A Tablet 550mg

URSODIOL (Actigall®) B Capsule, oral 300mg

HEMATOLOGY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Anticoagulants

APIXABAN (Eliquis®) B Tablet, oral 2.5mg, 5mg

ENOXAPARIN (Lovenox®) B Injection 30mg/0.3ml syringe, 40mg/0.4ml syringe, 60mg/0.6mlsyringe, 80mg/0.8ml syringe, 100mg/ 1ml syringe, 120mg/0.8ml syringe, 150mg/ml syringe

HEPARIN C Injection 10 units/ml, 100 units/ml, 1000 units/ml, 5,000 units/ml, 10,000 units/ml, 25,000 units/250ml in D5W

RIVAROXABAN (Xarelto®) C Tablet, oral 10mg, 15mg, 20mg

WARFARIN, SODIUM (Coumadin®) X Tablet, oral 1mg, 2mg, 2.5mg, 3mg, 5mg

Colony Stimulating Factors

EPOETIN ALFA (Procrit®) C Injection 2,000 units/ml, 3,000 units/ml, 4,000 units/ml, 10,000 units/ml, 20,000 units/ml, 40,000 units/ml

FILGRASTIM (Neupogen®) C Injection 480mcg/0.8ml

PEGFILGRASTIM (Neulasta®) C Injection 6mg/0.6ml


VIA DOSAGE

Other Hematological Agents

AMINOCAPROIC ACID (Amicar®) C Solution, oral 250mg/ml

AMINOCAPROIC ACID (Amicar®) C Injection 250mg/ml

DESMOPRESSIN (Stimate®) B Spray, nasal 1.5mg/ml

HYDROXYUREA (Hydrea®) D Capsule, oral 500mg

PROTAMINE SULFATE C Injection 10mg/ml


PROTHROMBIN COMPLEX CONCENTRATE (Kcentra®) *Restricted to urgent reversal of coagulopathy in patients with active major bleeding or who require urgent surgical intervention.

N/A Injection 800 to 1240 unit vial 400 to 620 unit vial

TRANEXAMIC ACID (Cyklokapron®) B Solution 1000/10ml

TRANEXAMIC ACID (Lysteda®) B Tablet, oral 650 mg

IMMUNOLOGY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Immunizations

COVID 19 Vaccine N/A Injection Manufacture Specific

Diphtheria, Tetanus, acellular pertussis DTaP (Infanrix) for under 7 years old

C Injection 0.5ml IM

DTaP+HepB+IPV (Pediarix) C Injection 0.5ml IM

HEPATITIS A (peds) (Havrix or Vaqta) C Injection 0.5ml IM

HEPATITIS A VACCINE INACTIVATED adult (Havrix® or Vaqta)

C Injection 1ml IM

HEPATITIS B (peds) (Engerix or Recombivax HB)


HEPATITIS B VACCINE, RECOMBINANT (adult) (Engerix or Recombivax HB)

C Injection 1ml IM

HIB (PedvaxHib) C Injection 0.5ml IM

HPV (Gardasil) B Injection 0.5ml IM

INFLUENZA (6-35 months) B Injection 0.25ml IM

INFLUENZA (3 yrs and up) B Injection 0.5ml IM

INFLUENZA w/o preservative B Injection 0.5ml IM

Influenza (Flumist) B Intranasal 0.2ml

MCV4 (Menactra) C Injection 0.5ml IM

MEASLES, MUMPS AND RUBELLA VIRUS VACCINE, LIVE

C Injection 0.5ml SQ

MENINGOCOCCAL GROUP B (Bexsero) N/A Injection 0.5ml IM

PCV13 (Prevnar) for under 7 year olds B Injection 0.5ml IM

PPV23 (Pneumovax23) 2 years through adult


POLIO- IPV C Injection 0.5ml IM/SQ

RABIES VACCINE (Human Diploid Cell Strain)

C Injection 1 dose/vial

ROTAVIRUS (Rota Teq) C Oral Vaccine 2ml oral

Td (Decavac) for 7 year olds through adult C Injection 0.5ml IM

Tdap (Boostrix- 10-64 year olds, Adacel - 11-64 year olds)


VARICELLA (Varivax) C Injection 0.5ml SQ

ZOSTER RECOMBINANT, ADJUVANT (Shingrix)

N/A Injection 0.5ml IM

Immunoglobulins



VIA DOSAGE

HEPATITIS B IMMUNE GLOBULIN, HUMAN (Hyper-Hep®)

C Injection 100 mcg/ml

RABIES IMMUNE GLOBULIN, HUMAN (RIG, Hyperab®, Imogam Rabies®)

C Injection 1500 units/vial

TETANUS IMMUNE GLOBULIN, HUMAN (HyperTET)

C Injection 250 units

Immunosuppression

CYCLOSPORINE (Sandimmune, Neoral) C Capsule, oral 25mg, 100mg

MYCOPHENOLATE (Cellcept) D Capsule, oral 500mg

TACROLIMUS (Prograf) C Capsule, oral 0.5 mg, 1 mg

Other

PALIVIZUMAB (Synagis) C Injection 50mg, 100mg

TUBERCULIN PURIFIED PROTEIN DERIVATIVE (PPD)

C Injection

NEUROLOGY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Alzheimer's Disease

Cholinesterase Inhibitors

DONEPIZIL (Aricept) C Tablet, oral Tablet, ODT

5mg, 10mg, 23mg 5mg, 10mg

NMDA Receptor Antagonists

MEMANTINE EXTENDED RELEASE (Namenda XR®)

B Capsule, oral 7mg,14mg, 21mg, 28mg

Anticonvulsants

CARBAMAZEPINE (Tegretol®) D Suspension, oral

100mg/5ml

CARBAMAZEPINE (Tegretol®) D Tablet, oral 200mg

CARBAMAZEPINE (Tegretol®) D Tablet, chewable

100mg

CARBAMAZEPINE SUSTAINED RELEASE (Tegretol®)

D Tablet, oral 100mg, 200mg, 400mg

DIVALPROEX SODIUM (Depakote Sprinkles®)

X Sprinkle capsules, oral

125mg

DIVALPROEX SODIUM EXTENDED RELEASE (Depakote®)

X Capsule, oral 250mg, 500mg

DIVALPROEX SODIUM DELAYED RELEASE (Depakote®)

X Tablet, oral 250mg, 500mg

DIVALPROEX SODIUM (Depakote®) X Tablet, oral 250mg

FOSPHENYTOIN SODIUM (Cerebyx) D Injection 50 mg PE/ml

GABAPENTIN (Neurontin®) C Capsule, oral 100mg, 300mg, 400mg

GABAPENTIN (Neurontin®) C Solution, oral 250mg/5ml

GABAPENTIN (Neurontin®) C Tablet, oral 600mg, 800mg

LACOSAMDIE (Vimpat®) N/A Tablet, oral 50mg, 100mg, 150mg, 200mg

LACOSAMDIE (Vimpat®) N/A Solution, oral 10mg/ml



VIA DOSAGE

LAMOTRIGINE (Lamictal®) C Tablet, oral 25mg, 100mg, 200mg

LEVETIRACETAM (Keppra®) C Tablet, oral 500mg

LEVETIRACETAM (Keppra®) C Solution, oral 100mg/ml

LEVETIRACETAM (Keppra®) C Injection 100mg/mL

OXCARBAZEPINE (Trileptal) C Tablet, oral 150mg, 300mg, 600mg

OXCARBAZEPINE (Trileptal) C Suspension, oral

300mg/5ml

PHENOBARBITAL (Luminal®) D Tablet, oral 15mg, 30mg, 60mg, 100mg

PHENOBARBITAL (Luminal®) D Injection 130 mg/ml

PHENOBARBITAL (Luminal®) D Elixir, oral 20mg/5ml

PHENYTOIN (Dilantin®) D Capsule, oral 100mg

PHENYTOIN (Dilantin®) D Tablet, chewable

125mg/5ml

PHENYTOIN (Dilantin®) D Injection 250mg/5ml

PHENYTOIN (Dilantin®) D Suspension, oral

250mg/5ml

PREGABALIN (Lyrica)**Restricted to treatment of neuropathic pain

C Capsule, oral 25mg, 50mg, 75mg, 100mg

PRIMIDONE (Mysoline®) D Tablet, oral 50mg, 250mg

TOPIRAMATE (Topamax) D Sprinkle capsules, oral

15mg, 25mg

TOPIRAMATE (Topamax) D Tablet, oral 25mg, 100mg

VALPROIC ACID (Depakene®) D Syrup, oral 250mg/5ml--see Divalproex

ZONISAMIDE (Zonegran) C Capsule, oral 25mg, 100mg

Migraine Therapy

RIZATRIPTAN (Maxalt®) Tablet, oral 5 mg, 10 mg

RIZATRIPTAN (Maxalt®) Tablet, orally disintegrating

5 mg, 10 mg

SUMATRIPTAN (Imitrex®) C Tablet, oral 50mg

SUMATRIPTAN (Imitrex®) C Injection 6mg/0.5ml

Multiple sclerosis

As decided by P&T committee September 27, 2020, all medications used in the treatment of multiple sclerosis will be treated as an "open formulary items". Pharmacy will not routinely stock all multiple sclerosis medications, but will obtain upon being given notice of the specific medication needed. Myasthenia Gravis

NEOSTIGMINE C Injection 1:1000 (1mg/ml)

PYRIDOSTIGMINE (Mestinon) B Tablet, oral 60mg

Parkinsonian Agents

Anticholinergics

BENZTROPINE MESYLATE (Cogentin®) N/A Tablet, oral 1mg, 2mg

COMT Inhibitors

ENTACAPONE (Comtan) C Tablet, oral 200mg

Dopaminergic Agents & Combinations

CARBIDOPA/LEVODOPA IMMEDIATE RELEASE (Sinemet)

C Tablet, oral 10mg/100mg, 25mg/100mg, 25mg/250mg



VIA DOSAGE

CARBIDOPA/LEVODOPA SUSTAINED RELEASE (Sinemet)

C Tablet, oral 25mg/100mg, 50mg/200mg

PRAMIPEXOLE (Mirapex®) C Tablet, oral 0.125, 0.25mg, 0.5mg, 1mg, 1.5mg

Monoamine Oxidase Inhibitors

RASAGILINE (Azilect®) C Tablet, oral 1mg

SELEGILINE (Eldepryl®) C Tablet, oral 5mg

Other Agents

MANNITOL C Injection 25% (12.5gm/50ml)

MANNITOL C Injection 20% (100gm/500ml)

OB/GYN PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Oral Contraceptives

Monophasic

ETHINYL ESTRADIOL/DESOGESTREL (Ortho-cept, Desogen®)

X Tablet, oral 30mcg/0.15mg

ETHINYL ESTRADIOL/LEVONORGESTREL (Lessina, Levlite, etc)


ETHINYL ESTRADIOL/NORETHINDRONE (Norinyl, Ortho-Novum 1/35, Nortrel 1+35®)

X Tablet, oral 35mcg/1mg

ETHINYL ESTRADIOL/NORGESTREL (Lo-Ovral®)


Progestin-only

NORETHINDRONE (Nor QD, Micronor®) X Tablet, oral 0.35mg

Biphasic

Triphasic

ETHINYL ESTRADIOL/LEVONORGESTREL (Trivora®)

X Tablet, oral 30mcg/0.05mg x6 days, 40mcg/0.075mg x 5 days, 30mcg/0.125mg x 10 days

Other

DROSPIRENONE-ETHINYL ESTRADIOL (Yaz®)

X Tablet, oral 3mg/0.02mg

DROSPIRENONE-ETHINYL ESTRADIOL (Ocella®)

X Tablet, oral 3mg/0.03mg

Other Contraceptives

DIAPHRAGM N/A All-Flex Sizes 60-90 available for order upon request

ESTRADIOL (Climara, Estraderm®) X Patch, Topical No restrictions, specific strengths ordered upon request

ETHINYL ESTRADIOL/ETONOGESTREL (Nuvaring®)

X Vaginal ring 15mcg/0.12mg/day

ETHINYL ESTRADIOL/NORELGESTROMIN (Ortho Evra®)

X Patch, Topical 35 mcg/200mcg/day



VIA DOSAGE

ETONOGESTREL (Nexplanon®) X Subdermal implant

68mg

INTRAUTERINE COPPER (Paragard®) X IUD

LEVONORGESTREL (Kyleena®) X IUD

LEVONORGESTREL (Mirena®) X IUD 52 mg

LEVONORGESTREL (Plan B One-Step®) X Tablet, oral 1.5mg

MEDROXYPROGESTERONE ACETATE X Injection 150mg/ml (IM only)

ULIPRISTAL (Ella®) X Tablet, oral 30mg

Estrogens

Estrogens, Conjugated/Equine (Premarin®) X Injection 25mg

ESTRADIOL X Tablet, oral 1mg, 2mg

ESTRADIOL X Patch, topical No restrictions, all strengths will be ordered as requested

ESTRADIOL (Estrace Cream) X Cream, vaginal 0.1mg/gm

ESTRADIOL (Estring) **2nd line and restricted to diagnosis of recurrent UTI

X Ring, vaginal 7.5mcg/day

Hormone Combinations

Labor Induction/Cervical Ripening

OXYTOCIN (Pitocin®) X Injection 10units/ml

OXYTOCIN (Pitocin®) X Injection 20 units/1000ml 0.9% Sodium chloride

Ovulation Stimulants

CLOMIPHENE CITRATE (Clomid) X Tablet, oral 50mg

Progestins

HYDROXYPROGESTERONE CAPROATE (Makena®)

N/A Injection 1250 mg/5 mL

MEDROXYPROGESTERONE ACETATE (Provera®)

X Tablet, oral 2.5mg, 10mg

MEGESTROL ACETATE (Megace®)**restricted to treatment for cancer and cachexia as indicated

D Tablet, oral 40mg

MEGESTROL ACETATE (Megace®)**restricted to treatment for cancer and cachexia as indicated

D Suspension, oral

40mg/ml

NORETHINDRONE**restrict for recovery from Lupron

X Tablet, oral 5mg

PROGESTERONE (Prometrium)*2nd line agent for medroxyprogesterone failures, also approved for prevention of pre-term birth (a non-FDA approved indication)

B Capsule, oral 100mg, 200mg

Selective Estrogen Receptor Modulators

TAMOXIFEN CITRATE (Nolvadex®) D Tablet, oral 10mg

Uterotonics

CARBOPROST TROMETHAMINE (Hemabate®)

C Injection 250 mcg/ml



VIA DOSAGE

METHYLERGONOVINE MALEATE (Methergine®)

C Tablet, oral 0.2mg

METHYLERGONOVINE MALEATE (Methergine®)

C Injection 0.2mg/ml

Vaginitis Preparations

CLINDAMYCIN (Cleocin®) B Cream, vaginal 2%

CLOTRIMAZOLE B Cream, vaginal 1%

METRONIDAZOLE (Flagyl®) B Gel, vaginal 0.75%

Other OB/GYN Agents

RHO(D) IMMUNE GLOBULIN (RhoGAM, Hyper RHO) *supplied by laboratory

C Injection 50mcg/dose, 300mcg/dose

ANASTROZOLE (Arimidex)*Restricted for oncology patients

X Tablet, oral 1mg

Elagolix (Orilissa®) 3rd line behind oral hormone therapy and letrozole. Restricted to OB/GYN.

X Tablet, oral 150mg, 200mg

LETROZOLE (Femara) X Tablet, oral 2.5mg

MIFEPRISTONE (Mifeprex®) – restricted to women’s health and HROB providers only

X Tablet, oral 200 mg

MISOPROSTOL (Cytotec®) X Tablet, oral 100mcg, 200mcg

RALOXIFENE (Evista) X Tablet, oral 60mg

ONCOLOGY As decided by P&T committee July 16, 2010, all oncology items will be treated as an "open formulary items". Pharmacy will not routinely stock chemo in the pharmacy, but will obtain any requested chemotherapeutic treatment upon being given notice of the specific medication needed (P&T agreed on 2 weeks notice to allow time for acquisition of the drug).

OPHTHALMOLOGY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Antiallergy

Dual Antihistamine & Mast Cell Stabilizer

OLOPATADINE HCI (Patanol®) C Solution, ophthalmic

0.1%

Antimicrobials

Aminoglycosides

TOBRAMYCIN (Tobrex®) B Solution, ophthalmic

3mg/ml (0.3%)

TOBRAMYCIN (Tobrex®) B Ointment, ophthalmic

0.3%

Fluoroquinolones

CIPROFLOXACIN HCL (Cipro®) C Solution, Ophthalmic

0.3%

CIPROFLOXACIN HCL (Cipro®) C Ointment, Ophthalmic

0.3%

OFLOXACIN C Solution, Ophthalmic

0.3%



VIA DOSAGE

MOXIFLOXACIN (Vigamox) C Solution, Ophthalmic

0.5%

Other Antibacterials

ERYTHROMYCIN B Ointment, ophthalmic

0.5%

SULFACETAMIDE (Bleph-10®, Sulamyd®) C Solution, ophthalmic

10%

POLYMYXIN B/TRIMETHOPRIM (Polytrim) C Solution, ophthalmic

Poly 10,000 units / TMP 1mg/ml

Antifungal Agents

NATAMYCIN (Natacyn) C Suspension, Ophthalmic

5%

Antiviral Agents

GANCICLOVIR (Zirgan®) C Gel, Ophthalmic

0.15%

TRIFLURIDINE (Viroptic) C Solution, ophthalmic

1%

Corticosteroid & Antibacterial Combinations

SULFACETAMIDE-PREDNISOLONE Suspension, ophthalmic

10-0.23%

TOBRAMYCIN/DEXAMETHASONE (Tobradex)

C Suspension, ophthalamic

0.3%/0.1%

TOBRAMYCIN/DEXAMETHASONE (Tobradex)

C Ointment, ophthalmic

0.3%/0.1%

Corticosteroids

DIFLUPREDNATE (Durezol®) C Emulsion, ophthalmic

0.05%

FLUOROMETHOLONE (FML®) C Suspension, ophthalmic

0.1%

LOTEPREDNOL (LOTEMAX) C Suspension, ophthalmic

0.5%

PREDNISOLONE (Pred Forte) C Suspension, ophthalmic

1%

Diagnostic Agents

FLUORESCEIN SODIUM C Strips, ophthalmic

1mg/strip

FLUORESCEIN SODIUM/BENOXINATE HCL (Flur-Ess®)

C Solution, ophthalmic

0.25%/0.4%

Glaucoma Agents

Beta Blockers

BETAXOLOL S (Betoptic S®)**Restricted to patients with pulmonary disease

C Suspension, ophthalmic

0.25%

TIMOLOL (Timoptic XE®) C Gel solution, opthalmic

0.25%, 0.5%

Carbonic Anhydrase Inhibitors

DORZOLAMIDE (Trusopt®) C Solution, ophthalmic

2%



VIA DOSAGE

Combination products

DORZOLAMIDE AND TIMOLOL (Cosopt®) C Solution, ophthalmic

22.3-6.8mg/mL

Miotics

PILOCARPINE C Solution, ophthalmic

1%, 2%, 4%

Prostaglandin Analogs

LATANOPROST (Xalatan®) C Solution, opthalmic

0.01%

Simpathomimetics

BRIMONIDINE (Alphagan P) B Solution, opthalmic

0.15%

Mydriatics & Cycloplegics

ATROPINE B/C Solution, ophthalmic

1%

CYCLOPENTOLATE C Solution, ophthalmic

1%

HOMATROPINE HYDROBROMIDE C Solution, ophthalmic

5%

PHENYLEPHRINE C Solution, ophthalmic

2.5%, 10%

TROPICAMIDE (Mydriacyl®) C Solution, ophthalmic

1%

Nonsteroidal Anti-Inflammatories

KETOROLAC (Toradol®, Acular®) C Solution, opthalmic

0.5%

Other

APRACLONIDINE (Iopidine®) C Solution, opthalmic

0.5%

CARBOXYMETHYLCELLULOSE (Celluvisc) preservative free

N/A Solution, ophthalmic

1%

CYCLOSPORINE (Restasis®) C Emulsion, ophthalmic

0.05%

MULTIVITAMIN WITH MINERALS (ICaps AREDS2®)

N/A Tablet, oral

OCULAR LUBRICANT (Artificial Tears) N/A Solution, ophthalmic

OCULAR LUBRICANT (Artificial Tears) N/A Ointment, ophthalmic

PROPARACAINE C Solution, ophthalmic

0.5%

SODIUM CHLORIDE (Muro 128) C Ointment, ophthalmic

5%

SODIUM CHLORIDE (Muro 128) C Solution, ophthalmic

2%


PSYCHIATRY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Antidepressants

Heterocyclic Compounds

AMITRIPTYLINE (Elavil®, Endep®) C Tablet, oral 10mg, 25mg, 50mg

DOXEPIN (Sinequan®) C Capsule, oral 10mg, 25mg, 50mg

NORTRIPTYLINE (Pamelor®) N/A Capsule, oral 10mg, 25mg

Monoamine Oxidase Inhibitors

Selective Serotonin Reuptake Inhibitors

CITALOPRAM C Tablet, oral 10mg, 20mg, 40mg

ESCITALOPRAM C Tablet, oral 5mg, 10mg, 20mg

FLUOXETINE (Prozac®) C Capsule, oral 10mg, 20mg,40mg

FLUOXETINE (Prozac®) C Solution, oral 20mg/5ml

PAROXETINE (Paxil®) X Tablet, oral 10mg, 20mg, 30mg,40mg

PAROXETINE (Paxil®) X Suspension, oral

10mg/5ml

SERTRALINE (Zoloft®) C Tablet, oral 25mg, 50mg, 100mg

SERTRALINE (Zoloft®) C Solution, oral 20mg/ml

Serotonin-Norepinehprine Reuptake Inhibitors

DULOXETINE (Cymbalta®) C Capsule, oral 20mg, 30mg, 60mg

VENLAFAXINE (Effexor XR) C Capsule, oral 37.5mg, 75mg, 150mg

VENLAFAXINE (Effexor) C Tablet, oral 37.5mg

Other

BUPROPION (Wellbutrin®) C Tablet, oral 75mg, 100mg

BUPROPION (Wellbutrin SR®) C Tablet, oral 100mg,150mg, 200mg

BUPROPION (Wellbutrin XL) C Tablet, oral 300mg

BUPROPION (Zyban® ) C Tablet, oral 150mg

MIRTAZAPINE C Tablet, oral 15mg, 30mg, 45mg

TRAZODONE (Desyrel®) C Tablet, oral 50mg

Antimanic (Bipolar) Agents

LITHIUM ER (Lithobid) D Tablet, oral 300mg ER, 450mg

LITHIUM CARBONATE D Capsule, oral 300mg

LITHIUM CARBONATE D Solution, oral 8meq/5ml *equivalent to 200mg lithium carbonate/5ml

Antipsychotics

First Generation (Typical)

CHLORPROMAZINE (Thorazine®) N/A Tablet, oral 25mg, 50mg, 100mg

FLUPHENAZINE (Prolixin®) repository (Decanoate salt)

N/A Injection 25mg/ml

FLUPHENAZINE (Prolixin®) N/A Injection 2.5mg/ml

FLUPHENAZINE (Prolixin®) N/A Tablet, oral 1mg, 5mg,

HALOPERIDOL (Haldol®) lactate Injection 5mg/ml

HALOPERIDOL (Haldol®) decanoate C Injection 50mg/ml

HALOPERIDOL (Haldol®) C Tablet, oral 1mg, 2mg, 5mg, 10mg



VIA DOSAGE

HALOPERIDOL (Haldol®) C Solution, oral 2mg/ml

Second Generation (Atypical)

ARIPIPRAZOLE (Abilify®) C Tablet, oral 2 mg, 5mg, 10mg, 15mg, 20mg, 30mg

CLOZAPINE (Clozaril ®) – restricted to Bethel patients who have failed other agents or came back from another facility

B Tablet, oral 25 mg, 50 mg, 100 mg, 200 mg

LURASIDONE (Latuda®) N/A Tablet, oral 20mg, 40mg, 60mg, 80mg, 120mg

OLANZAPINE (Zyprexa Zydis®) C Tablet, orally disintegrating

5mg

OLANZAPINE (Zyprexa®) C Tablet, oral 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg

OLANZAPINE (Zyprexa®) C Injection 10 mg

PALIPERIDONE (Invega®) N/A Tablet, Extended Release

1.5mg 3mg, 6mg, 9mg

QUETIAPINE (Seroquel) C Tablet, oral 25mg, 50mg,100mg, 200mg, 300mg, 400mg

RISPERIDONE (Risperdal®) C Tablet, oral 0.5mg,1mg, 2mg, 3mg, 4mg

RISPERIDONE (Risperdal®) C Solution, oral 1mg/ml

RISPERIDONE (Risperdal Consta®) C Injection 25mg, 37.5mg, 50mg

ZIPRASIDONE (Geodon®) C Capsule, oral 20mg, 40mg, 60mg,80mg

ZIPRASIDONE (Geodon®) C Suspension, oral

10mg/ml

Anxiolytics/Hypnotics

Benzodiazepines

CHLORDIAZEPOXIDE HCL (Librium®) N/A Capsule, oral 10mg, 25mg

CLOBAZAM (Onfi®)—restricted to recommendations by neurology

C Tablet, oral 10mg

CLONAZEPAM (Klonopin®) D Tablet, oral 0.5mg, 1mg, 2mg

CLORAZEPATE (Tranxene®) N/A Tablet, oral 7.5mg

DIAZEPAM (Valium®) D Injection 10mg/2ml

DIAZEPAM (Valium®) D Tablet, oral 5mg

DIAZEPAM (Valium®) D Liquid, oral 5mg/5ml

DIAZEPAM (Valium®) D Gel, rectal 2.5mg, 10mg, 20mg/syringe

LORAZEPAM (Ativan®) D Tablet, oral 0.5mg, 1mg, 2mg

LORAZEPAM (Ativan®) D Solution, oral 2mg/ml

LORAZEPAM (Ativan®) D Injection 2mg/ml, 4mg/ml

TEMAZEPAM X Capsule, oral 15mg

ALPRAZOLAM (Xanax®) D Tablet, oral 0.25mg 0.5mg

Other

BUSPIRONE (Buspar®) B Tablet, oral 5mg, 10mg

MELATONIN **Restricted to patients 2 to less than 18 years of age diagnoses with autism, chronic headache or global developmental delay or

N/A Tablet, oral 1mg, 3mg



VIA DOSAGE

under the recommendation of pediatric neurologist or sleep specialist. Also patients at McCann treatment center**Can only be prescribed by BH provider for patients at McCann*

RAMELTEON (Rozerem®)—Restricted to use at LTC facility or in patients 65 years of age or older

C Tablet, oral 8mg

ZOLPIDEM (Ambien®) C Tablet, oral 5mg, 10mg

Drug Dependence Therapy

BUPRENORPHINE (Sublocade®) – restricted to patients approved through pain committee

Injection 100 mg/0.5 mL, 300 mg/1.5 mL

BUPRENORPHINE AND NALOXONE (Suboxone®)

Film, sublingual

2mg, 4mg, 8mg

DISULFIRAM (Antabuse®) N/A Tablet, oral 250mg

NALTREXONE C Tablet, oral 50 mg

NALTREXONE C Injection 380mg

NICOTINE D Inhaler

NICOTINE D Lozenge, oral 2mg, 4mg

NICOTINE (Nicoderm®) D Patch, transdermal

7mg/24, 14mg/24hr, 21mg/24hr

NICOTINE (Nicorette®) D Gum, oral 2mg, 4mg

VARENICLINE (Chantix®) C Tablet, oral 0.5mg, 1mg

Stimulants/ADHD/Anorexiants

ATOMOXETINE (STRATTERA) C Capsule, oral 10mg, 18mg, 25mg, 40mg, 60mg

DEXTROAMPHETAMINE/AMPHETAMINE (Adderall®)


DEXTROAMPHETAMINE/AMPHETAMINE (Adderall XR ®)

C Capsule, oral 10mg, 15mg

GUANFACINE EXTENDED RELEASE (Intuniv)

B Tablet, oral 1mg

LISDEXAMFETAMINE DIMESYLATE C Capsule 20mg, 70mg

METHYLPHENIDATE C Tablet, oral 5mg, 10mg

METHYLPHENIDATE EXTENDED RELEASE

C Tablet, oral 10mg

METHYLPHENIDATE SUSTAINED RELEASE

C Tablet, oral 20mg

METHYLPHENIDATE SUSTAINED RELEASE

C Capsule, oral 18mg, 27mg, 36mg, 54mg

PULMONARY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Beta Agonists

ALBUTEROL (Ventolin® Proair®) C Inhalation aerosol

90 mcg/metered spray



VIA DOSAGE

ALBUTEROL (Ventolin® Proair®) **concentrated albuterol restricted to inpatient/ER use only**

C Solution for inhalation

0.083%, 0.5%

LEVALBUTEROL TARTRATE (Xopenex®)**Restricted to patients with documented failure/intolerance to albuterol

C Solution for inhalation, MDI

0.63mg, 45mcg

Anticholinergics

IPRATROPIUM (Atrovent HFA®) – in pediatric patients, it is restricted to use by a pulmonologist. *Not restricted for adults*

B Inhalation aerosol

17mcg/ACT

IPRATROPIUM BROMIDE**Patient cannot have a concurrent active prescription for tiotropium

B Solution, inhalation

0.02% (500mcg/2.5ml)

TIOTROPIUM (Spiriva®)**Patient cannot have a concurrent active prescription for ipratropium

C Respimat® 1.5mcg/2.5mcg

Combinations

ALBUTEROL-IPRATROPIUM (Duoneb®) C Solution for inhalation

2.5 mg and 0.5mg per 3mL

FLUTICASONE/SALMETEROL (Wixela®) C Inhalation powder

100mcg/50mcg, 250mcg/50mcg, 500mcg/50mcg

FLUTICASONE/SALMETEROL (Advair HFA®) --restricted to use by peds pulmonology. Will not routinely keep in stock, but will order as requested.

C Inhalation aerosol

45mcg/21mcg, 115mcg/21mcg, 230mcg/21mcg

FORMOTEROL/MOMETASONE (Dulera ®) Inhalation aerosol

100mcg/5mcg 200mcg/5mcg

IPRATROPIUM BROMIDE/ALBUTEROL SULFATE (Combivent®)**Cannot have a concurrent active prescriptions for ipratropium or tiotropium


MDI 200 metered actuations, 18mcg/103 mcg

TIOTROPIUM/OLODATEROL (Stiolto®) - *restricted to patients recommended by a specialist*

Inhalation aerosol

2.5 mcg/2.5 mcg actuations

Devices

AEROCHAMBER MDI admin aid

AEROCHAMBER WITH MASK MDI admin aid Small, Medium, Large

Inhaled Steroids

BUDESONIDE (Pulmicort Respules®)**For pediatric patients < 4 years of age or for patients who have failed Asmanex

B Inhalation solution

0.5mg/2ml, 0.25mg/2ml

FLUTICASONE (Flovent®)**Restricted to patients <12 years old, or with documented failure or inability to use mometasone twisthaler


44mcg/act, 110mcg/act, 220mcg/act

MOMETASONE (Asmanex®)**First line for all patients 12 years and older

C Twisthaler, oral 110mcg, 220mcg

Leukotriene Inhibitors

MONTELUKAST SODIUM (SINGULAIR®) B Tablet, chewable

4mg, 5mg



VIA DOSAGE

MONTELUKAST SODIUM (SINGULAIR®) B Tablet, oral 10mg

Other Pulmonary Medications

ACETYLCYSTEINE B Solution for inhalation or oral administration (Mucomyst)

20%

AMMONIA INHALANT, AROMATIC C Solution, inhalation

15-22% (0.4mg)

BENRALIZUMAB (Fasenra®) *Restricted to specialist recommendation

N/A Injection 30mg

BERACTANT (SURVANTA®)**Preferred surfactant is Curosurf, use only if Curosurf not available

N/A Intratracheal suspension

25mg/ml

CAFFEINE CITRATE C Solution, oral 60mg/3ml

CAFFEINE CITRATE C Injection 60mg/3ml

DORNASE ALFA (Pulmozyme®) **Restricted to CF patients

B Solution, inhalation

2.5mg/2.5ml

PORACTANT ALFA (Curosurf®) N/A Suspension, Intratracheal

1.5ml

RACEPINEPHRINE (racemic epinephrine) C Solution, inhalation

2.25%

SODIUM CHLORIDE**3% Solution – if used as outpatient prescription, it must be recommended by pulmonologist and must be dispensed with albuterol for brochospasm

C Solution, inhalation

0.9%, 3%

TADALAFIL (Adcirca®) **Restricted to treatment of pulmonary hypertension

B Tablet, oral 20mg

TERBUTALINE (Brethine®) B Tablet, oral 2.5mg

TERBUTALINE (Brethine®) B Injection 1mg/ml

TOXICOLOGY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

ACETYLCYSTEINE (Acetadote®) B Injection 200mg/ml

BOTULISM ANTITOXIN KIT C Injection

CHARCOAL, ACTIVATED N/A Suspension, oral

50gm/240ml in Sorbitol

DEFEROXAMINE C Injection 500mg

DIMERCAPROL (Bal in Oil) C Injection 100 mg/ml

FLUMAZENIL (Romazicon®) C Injection 0.5mg/5ml

FOMEPIZOLE (Antizol) C Injection 1g/ml

IDARUCIZUMAB (Praxbind®) X Injection 2.5g/50ml

LEUCOVORIN C Injection 350 mg vial

METHYLENE BLUE X Injection 0.5%, 1% (100mg/10ml),

PHYSOSTIGMINE (Antilirium®) N/A Injection 2mg/2ml

SUGAMMADEX (Bridion®) Injection 100 mg/mL


UROLOGY PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Benign Prostatic Hyperplasia

FINASTERIDE (PROSCAR®) X Tablet, oral 5mg

TAMSULOSIN (Flomax®) B Capsule, Oral 0.4mg

Bladder Agents

Anticholinergics & Combinations

OXYBUTYNIN (Ditropan®) B Tablet, oral 5mg

OXYBUTYNIN (Ditropan®) B Syrup, oral 5mg/5ml

TOLTERODINE TARTRATE (Detrol LA®) C Capsule, oral 2mg, 4mg

Other

DESMOPRESSIN (DDAVP) B Tablet, oral 0.1mg

MIRABEGRON (Myrbetriq®) Tablet, oral 25mg, 50mg

PHENAZOPYRIDINE (Pyridium®) B Tablet, oral 100mg

Erectile Dysfunction

NONE

Nephrolithiasis

POTASSIUM CITRATE (Urocit-K®) C Tablet, oral 540mg (5mEq), 1080mg(10mEq)

SODIUM CITRATE/CITRIC ACID (Bicitra®) N/A Solution, oral 500mg/334mg/5ml

Other

INDIGO CARMINE Dye

PENTOSAN POLYSULFATE SODIUM (Elmiron ®)

Capsule, oral

IV SOLUTIONS PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Dextrose IV Solutions

DEXTROSE 5%

DEXTROSE 5% WITH 10 MEQ POTASSIUM CHLORIDE



DEXTROSE 5% AND SODIUM CHLORIDE 0.2% INJECTION

DEXTROSE 5% AND SODIUM CHLORIDE 0.2% INJECTION WITH 10 MEQ POTASSIUM CHLORIDE





VIA DOSAGE






DEXTROSE 5% AND SODIUM CHLORIDE 0.9% WITH 10 MEQ POTASSIUM CHLORIDE



VIA DOSAGE


DEXTROSE 10%

LACTATED RINGERS IV SOLUTIONS

LACTATED RINGERS

LACTATED RINGERS WITH DEXTROSE 5%

LACTATED RINGERS WITH DEXTROSE 5% AND 20 MEQ POTASSIUM CHLORIDE

Sodium Chloride IV Solutions

SODIUM CHLORIDE 0.45%

SODIUM CHLORIDE 0.9%

SODIUM CHLORIDE 3%

SODIUM CHLORIDE 0.9% WITH 20MEQ POTASSIUM CHLORIDE

SODIUM CHLORIDE 0.9% WITH 40 MEQ POTASSIUM CHLORIDE

OTHER

WATER, STERILE Injection USP, 10ml

OTHER PRODUCT PREGNANCY

CATEGORY VIA DOSAGE

Compounding Supplies

Pharmacy will order in the necessary components for compounds on an as needed basis

Other Supplies

ALCOHOL PREP PAD



VIA DOSAGE

INECTABLE SYRINGES/NEEDLES FOR SELF ADMINISTRATION

PEN NEEDLES

DIABETIC TESTING SUPPLIES

Miscellaneous

FOOD STARCH MODIFIED (ThickIt®) --**Restricted - No refills – Pharmacy only supplies first can. Refills go through Case Manager

Powder, oral 850gm

ykhc formulary

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