1. DUH intranet [click on DRH (Duke Regional Hospital), Departments and Services, Pharmacy, then Lincoln Community Health Center Formulary] (https://lincolnchc.org/?page_id=6808)
2. LCHC website (https://lincolnchc.org/?page_id=6808)
3. PADC website (http://www.projectaccessdurham.org/), then click on the Lincoln Pharmacy formulary.
4. LCHC Intranet/ Pharmacy Department/ Formulary of Drugs Use Ctrl-F to quickly search the listing for a specific item.
Patient Assistance Program Patients who meet specific eligibility requirements may receive formulary medications through manufacturer-sponsored patient assistance programs (PAPs). Medications labeled as “PAP”
are available to eligible patients through manufacturer-sponsored PAPs. These medications may not be readily available and may require up to an 8-week processing period.
HIV Patient Assistance Program EI Clinic may access medications through ADAP for qualified patients. For patients that do not qualify for ADAP, HIV medications may be obtained from manufacturer programs.
https://epi.dph.ncdhhs.gov/cd/hiv/docs/HMAPProgramManual_10252021.pdf
Project Access Durham County Project Access Durham County (PADC) serves eligible low-income, uninsured Durham residents who have specialty medical care needs. PADC enrolls members based on referrals from a primary care provider at Lincoln Community Health Center (LCHC). PADC patients are eligible for LCHC formulary medications.
Safety in Lactation Lactation safety data from American Academy of Pediatrics (www.aap.org) Medicaid Preferred Drug List https://medicaid.ncdhhs.gov/preferred-drug-list
Medicaid Prior Authorizations https://www.nctracks.nc.gov/content/public/providers/prior-approval.html
Hazardous Drugs Hazardous Drugs (HD) identified by National Institute of Occupational Safety and Health as hazardous are labeled as “HD”. Use caution when handling.
(https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016- 161.pdf?id=10.26616/NIOSHPUB2016161)
Beers List 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics
Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in
Older Adults. J Am Geriatr Soc. 2019 Jan 29. doi: 10.1111/jgs.15767.
L=Liver ALZHEIMER DISEASE Acetylcholinesterase
Inhibitor (Central) Donepezil Tablet 10mg Aricept C ? +
N-Methyl-D-Aspartate
Receptor Antagonist Memantine Extended Release Tablet 7mg, 14mg, 21mg, 28mg
(Patient Assistance Program)
Namenda XR 90 day
supply PAP B ? - K
ANALGESIC AND
ANTIPYRETICS Anticonvulsant, Analgesic Pregabalin Capsule
75mg, 150mg Lyrica C ? - K
Anticonvulsant, Neuropathic pain (unlabeled)
Gabapentin Capsule
100mg, 300mg Neurontin C ? - K
Miscellaneous Acetaminophen
Suspension 160mg/5mL Tylenol Susp 120 mL B + L
Acetaminophen Tablet
325mg Tylenol #100 tabs B + + L
Miscellaneous, Topical Capsaicin Cream 0.025% Capzasin 60 gm B +
NSAID Diclofenac Gel 1% Voltaren 100 gm
B (D in 3rd
trimester)
+ +
see p 75,76
K
Ibuprofen Suspension
100mg/5mL Motrin 120 mL B (D in 3rd
trimester) + +
See page 75,76
K
Ibuprofen Tablet 400mg Motrin B (D in 3rd
trimester) + + taste may unacceptable be
+ page See 75,76
K
Indomethacin Capsule
25mg, 50mg Indocin B (D in 3rd
trimester) + - +
See page 75,76
K
Naproxen Sodium Tablet
500mg Naprosyn B (D in 3rd
trimester) + + +
See page 75,76
K
NSAID, COX-2 Inhibitor Celecoxib Capsule
200mg Celebrex C (D in 3rd
trimester) ? - K/L
Opioid Acetaminophen/Codeine
Tablet 300mg/30mg Tylenol With
Codeine #3 C ? + L
Buprenorphine/Naloxone SL Tablet
2mg/0.5mg, 8mg/ 2mg
Zubsolv C ? + K/L
Hydrocodone/
Acetaminophen Tablet 5mg/325mg
Norco C ? + +
page See
L
ANALGESIC AND
ANTIPYRETICS Opioid (cont) Tramadol Tablet 50mg Ultram C - + K/L
ANTIANEMIA AGENTS Iron Preparations Ferrous Sulfate Drops 75mg/mL (15mg/mL elemental)
50mL + +
Ferrous Sulfate Elixer 220mg/5mL (44mg/5mL elemental)
480mL + +
Ferrous Sulfate Tablet 325mg (65mg elemental)
#100 tabs + + +
ANTICONVULSANT
AGENTS Anticonvulsant, Analgesic Pregabalin Capsule
150mg Lyrica C ? - K
Pregabalin Capsule
75mg Lyrica C ? - K
Anticonvulsant, Neuropathic pain (unlabeled)
Gabapentin Capsule
100mg, 300mg Neurontin C ? - K
Barbiturate Phenobarbital Tablet
32.4mg D - + +
page See 75
K/L
Hydantoin Phenytoin Sodium
Capsule 100mg HD Dilantin D + - L
Phenytoin Sodium
Chewable tablet 50g HD Dilantin
Infatabs D + + L
Miscellaneous Carbamazepine Tablet
200mg HD Tegretol D + + K/L
Divalproex Sodium
Tablet 250mg HD Depakote X ? - L
Lamotrigine Tablet
25mg, 100mg Lamictal C - + L
Levetiracetam Tablet
250mg, 500mg, 750mg Keppra C - + K
Topiramate Tablet
25mg, 200mgHD Topamax D ? - (taste may
be unacceptable)
K/L
ANTIDEPRESSANT
AGENTS Alpha2 Antagonist Mirtazapine Tablet 30mg Remeron C ? + K/L
Dopamine Reuptake
Inhibitor Bupropion ER (24h)
Tablet 150mg, 300mg Wellbutrin
XL C - + K/L
Selective Serotonin
Reuptake Inhibitor Fluoxetine Capsule 20mg Prozac C (- in 3rd
trimester) - - L
L=Liver ANTIDEPRESSANT
AGENTS Selective Serotonin
Reuptake Inhibitor (cont) Sertraline Tablet
50mg, 100mg Zoloft C (- in 3rd
trimester) + + L
Serotonin Reuptake
Inhibitor/Antagonist Trazodone Tablet 50mg Desyrel C - + K/L
Serotonin/Norepinephrine
Reuptake Inhibitor Duloxetine Capsule
30mg, 60mg Cymbalta C ? - may open &
mix w/
applesauce, chocolate NOT
K/L
Tricyclic Amitriptyline Tablet
25mg, 50mg Elavil D - + +
See page Doxepin Capsule 74
25mg, 50mg Sinequan C - - +
page See Imipramine Tablet 74
10mg, 25mg Tofranil D - + +
See page
74 Nortriptyline Tablet
25mg Pamelor D + + +
See page
74
K/L
ANTIDOTE 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 - - +
page See Diphenhydramine Elixer 73
12.5ml/5mL Benadryl 120 mL B - +
See page
73 Opioid Antagonist Naloxone Nasal Spray
4 mg/0.1mL Narcan 2 devices C ?
Naltrexone Tablet 50mg Revia C ? +
ANTIEMETIC/ANTI-
VERTIGO AGENTS 5-HT3 Receptor
Antagonist Ondansetron
Disintegrating Tablet 4mg
Zofran ODT B ? + L
Anticholinergic,
Antihistamine Meclizine Tablet 12.5mg Antivert B ? + +
See page
73
ANTIEMETIC/ANTI-
VERTIGO AGENTS Antidopaminergic,
Phenothiazine Promethazine
Suppository 25mg Phenergan C - +
See page
73
L
Promethazine Tablet
25mg Phenergan C - +
See page
73
L
ANTI-INFECTIVES Antifungal Nystatin Cream
100,000 units/gm Mycostatin 15 gm C ?
Nystatin Suspension
100,000 units/mL Nilstat 60 mL
bottle C ?
Fluconazole Tablet
150mg HD Diflucan C (single
dose vag candida), D
all other indications
+ + K
Griseofulvin Suspension
125mg/5mL Grifulvin C ?
Terbinafine Cream 1% Lamisil AT 15 gm B ?
Terbinafine Tablet
250mg Lamisil B - + K/L
Antihelmintic Albendazole Tablet
200mg Albenza C ? + K
Ivermectin Tablet 3 mg Stromectol C ? +
Praziquantel Tablet
600 mg Biltricide B - + L
Antimalarial Hydroxychloroquine
Tablet 200mg Plaquenil C + + K/L
Antiviral Acyclovir Suspension
200mg/5mL Zovirax B + K/L
Valacyclovir Tablet 1 gm Valtrex B + + K
Antiviral (Anti COVID-19
EUA Only) Molnupiravir 200 mg
Capsule Lagevrio 40 Capsules X - -
Nirmatrelvir 150 mg Capsule and Ritonavir 100 mg Capsule
Paxlovid 20 Capsules Nirmatrelvir 20 Capsules Ritonavir
K/L
Antiviral (Antihepaciviral) Glecaprevir-pibrentasvir Tablet 100-40mg
(Patient Assistance Program)
Mavyret 28 day
supply PAP C ? -/+ L
Sofosbuvir/ velpatasvir Tablet 400 mg/ 100 mg
(Patient Assistance Program)
Epclusa 28 day
supply PAP B ? -
(taste)
L=Liver ANTI-INFECTIVES Cephalosporin, 1st gen Cephalexin Capsule
250mg Keflex B ? - K
Cephalexin Suspension
250mg/5ml Keflex B ? K
Cephalosporin, 2nd gen Cefuroxime Tablet
250mg Ceftin B ? -
(taste) ANTI-INFECTIVES Cephalosporin, 3rd gen Cefdinir Suspension
250mg/5mL Omnicef B ? K
Macrolide Azithromycin Suspension
200mg/5mL Zithromax B ? K/L
Azithromycin Tablet
250mg Zithromax B ? + K/L
Clarithromycin Tablet
500mg Biaxin C ? + K
Miscellaneous Bismuth/Metronidazole/
Tetracycline Capsule 140mg/125mg/125mg
Pylera #120 caps D ? - K/L
Clindamycin Capsule
150mg Cleocin B ? + K
Miscellaneous Clindamycin Oral
Solution 75mg/5mL Cleocin 100 mL B ? K
Clindamycin Topical
Solution 1% Cleocin-T 60 mL B ?
Metronidazole Tablet
500mg Flagyl B ? + K/L
Penicillin Amoxicillin Capsule
500mg Amoxil B + - K
Amoxicillin Suspension
400mg/5mL Amoxil B + K
Amoxicillin/Clavulanic Acid Suspension 600mg/42.9mg
Augmentin
ES B ? + K/L
Amoxicillin/Clavulanic Acid Tablet
875mg/125mg
Augmentin
XR B ? + K/L
Penicillin VK Suspension
250mg/5mL Pen-Vee K B ? K
Penicillin VK Tablet
500mg Veetids B ? + K
Quinolone Ciprofloxacin Tablet
500mg Cipro C (but
teratogenicity unlikely)
? + K/L
Levofloxacin Tablet
500mg Levaquin C ? + K
ANTI-INFECTIVES Sulfonamide Sulfamethoxazole/
Trimethoprim Suspension 200mg- 40mg/5mL
Septra
Suspension C + +
See page
76
K/L
Sulfamethoxazole/
Trimethoprim Tablet 800mg/160mg
Septra DS C + +
See page
76
K/L
Tetracycline Doxycycline Tablet
100mg Vibramycin D ? +
Urinary Nitrofurantoin Capsule
100mg Macrobid B +? - +
page See 73
K/L
ANTINEOPLASTIC
AGENTS Aromatase Inhibitor Letrozole Tablet 2.5 mg
HD Femara X - L
Anti-estrogen Tamoxifen Tablet 10mg
HD Nolvadex D - -
ANTIPARKINSON AGENTS Anticholinergic Trihexphenidyl Tablet
2mg Artane C - + +
See page
73
K/L
Dopamine Agonist Carbidopa/Levodopa
Tablet 25mg/100mg Sinemet C - + K/L
ANTIPSYCHOTIC AGENTS Atypical, mixed serotonin-dopamine antagonist
Aripiprazole Tablet 5mg,
15mg Abilify C ? +
Lurasidone Tablet 20mg, 40mg, 60mg, 80mg, 120mg
(Patient Assistance Program)
Latuda 90 day
supply PAP B ? + K/L
Quetiapine Tablet 25mg, 50mg, 100mg, 200mg, 300mg
Seroquel C - + K
Atypical, serotonin-
dopamine antagonist Risperidone Tablet
0.5mg, 1mg, 2mg HD Risperdal C - + K/L
Bipolar Disorder Lithium Carbonate
Capsule 300mg Eskalith D - - +
See page
76
K
Typical, D2 Antagonist Haloperidol Tablet
1mg, 2mg Haldol C - +
ANXIOLYTICS,
SEDATIVES, HYPNOTICS Antianxiety Agent Buspirone Tablet 15mg Buspar B - + K/L
L=Liver ANXIOLYTICS,
SEDATIVES, HYPNOTICS Antihistamine Diphenhydramine
Capsule 25mg, 50mg Benadryl B - - +
See page
73 Diphenhydramine Elixer
12.5ml/5mL Benadryl 120 mL B - +
See page
73 Hydroxyzine HCL Syrup
10mg/5mL Atarax C - +
page See 73
K/L
Hydroxyzine HCL Tablet
25mg, 50mg Atarax C - + +
See page
73
K/L
Benzodiazepine Diazepam Tablet 5mg Valium D - + +
See page 75,76
L
Neurohormone, indole Melatonin Tablet 3mg #120 tabs - -
CARDIOVASCULAR DRUGS Antihypertensive: ACE-
Inhibitor Lisinopril Tablet 5mg,
10mg, 20mg, 40mg Zestril D ? + K
Antihypertensive: ACE- Inhibitor/ Diuretic, Thiazide
Lisinopril/HCTZ Tablet
20/12.5mg, 20/25mg Zestoretic D ? + K
Antihypertensive:
Alpha1 Blocker Doxazosin Tablet 2mg,
8mg Cardura C ? + +
See page
73
L
Antihypertensive:
Alpha2 Adrenergic Agonist
Clonidine Tablet 0.1mg,
0.2mg, 0.3mg Catapres C ? + +
See page
73
K
Antihypertensive:
Angiotensin Receptor Blocker
Losartan Tablet 25mg,
50mg, 100mg Cozaar D ? + L
Antihypertensive:
Angiotensin Receptor Blocker / Diuretic, Thiazide
Losartan/HCTZ Tablet 50/12.5mg,
100/12.5mg, 100/25mg
Hyzaar D ? + K/L
Antihypertensive:
Angiotensin Receptor Blocker/Neprilysin inhibitor
Sacubitril/Valsartan Tablet 24/26mg, 49/51mg, 97/103mg
(Patient Assistance Program)
Entresto Up to 90 day supply PAP
X - + K/L
CARDIOVASCULAR DRUGS Antihypertensive: Beta Blocker w/ alpha blocking ability,
non-cardioselective
Carvedilol Tablet 3.125mg, 6.25mg, 12.5mg, 25mg
Coreg C ? + L
Antihypertensive: Beta
Blocker, cardioselective Atenolol Tablet 50mg,
100mg Tenormin D - - K
Antihypertensive: Beta
Blocker, cardioselective Metoprolol Succinate XL Tablet 25mg, 50mg, 100mg, 200mg
Toprol XL C ? + L
Antihypertensive:
Calcium Channel Blocker, dihydropyridine
Amlodipine Tablet 5mg,
10mg Norvasc C ? + L
Antihypertensive:
Calcium Channel Blocker, dihydropyridine
Nifedipine XL Tablet
30mg, 60mg, 90mg Procardia XL C - - L
Antihypertensive:
Calcium Channel Blocker, non-dihydropyridine
Diltiazem HCl XR Capsule
180mg, 240mg Cardizem CD C + - +
Antihypertensive:
Calcium Channel Blocker, non-dihydropyridine
Verapamil SR Tablet
180mg, 240mg Calan SR C - + split/-
crush + K/L
Antihypertensive:
Calcium Channel Blocker- ACE-Inhibitor
Amlodipine-benazepril Capsule 2.5-10mg, 5- 20mg, 10-40mg
Lotrel D ? - L,K
Antihypertensive:
Diuretic, Loop Furosemide Tablet
20mg, 40mg Lasix C ? + K/L
Antihypertensive:
Diuretic, Loop Torsemide Tablet
5mg, 20mg Demedex C ? +
Antihypertensive:
Diuretic, Potassium Sparing, thiazide
Spironolactone/HCTZ
Tablet 25mg/25mg HD Aldactazide D + + K
Antihypertensive:
Diuretic, Potassium Sparing
Spironolactone Tablet
25mg HD Aldactone D + + K
Antihypertensive:
Diuretic, Thiazide Chlorthalidone Tablet
25mg Thalitone B ? + K
Antihypertensive:
Diuretic, Thiazide Hydrochlorothiazide Tablet 12.5mg, 25mg, 50mg
Hydrodiuril B (D is used
pregnancy-in induced HTN)
+ + K
L=Liver CARDIOVASCULAR DRUGS Antihypertensive:
Vasodilator Hydralazine Tablet
25mg, 50mg Apresoline C + + K
Alpha1 Blocker Prazosin Capsule
1mg, 2mg, 5mg Minipress C ? - L
Antiarrhythmic Amiodarone Tablet
200mg Cordarone D - + +
See page
74, 76
L
Digoxin Tablet
0.125mg, 0.25mg Lanoxin C + + +
See page
74
K
Anticoagulant Enoxaparin SQ Injection 30mg, 40mg, 60mg, 80mg, 100mg, 120mg, 150mg
(Patient Assistance Program)
Lovenox B + K
Warfarin Tablet 5mg Coumadin - (1st
trimester), C Use
caution + +
See page
76
K/L
Anticoagulant (Direct
Oral Anticoagulant) Apixaban Tablets 2.5mg, 5mg, 10mg
(Patient Assistance Program)
90 day supply PAP Rivaroxaban Tablet
10mg, 15mg, 20mg Xarelto C - + +
page See 74
K/L
Antihyperlipidemic, 2-
Azetidinone Ezetimibe tablet 10mg Zetia C ? + L
Antihyperlipidemic, Fibric
Acid Gemfibrozil Tablet
600mg Lopid C ? + K
Antihyperlipidemic, HMG-
CoA Reductase Inhibitor Atorvastatin Tablet 10mg, 20mg, 40mg, 80mg
Lipitor X - + L
Pravastatin Tablet 40mg Pravachol X - + K/L
CARDIOVASCULAR DRUGS Antiplatelet Aspirin Tablet (enteric
coated)81mg, 325mg Ecotrin #120 81mg
#100 100mg
D ? - K/L
Clopidogrel Tablet 75mg Plavix B ? + L
Beta Blocker, non-
selective Propranolol Tablet 10mg,
40mg Inderal C + + K/L
Carbonic Anhydrase
Inhibitor Acetazolamide Tablet
500mg ER 12 hr Diamox
Sequels C - + K/L
Vasodilator Isosorbide Mononitrate
ER Tablet 30mg, 60mg Imdur C ? +
Nitroglycerin SL Tablet
0.4mg Nitrostat #25 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
Potassium Chloride
Liquid 20mEq/15mL Klor-Con 473 mL C ? - K
ENDOCRINE AND
METABOLIC AGENTS Androgen Hormone Inhibitor, 5 Alpha- Reductase Inhibitor
Finasteride Tablet 5mg HD Proscar #30 tabs X - -
HD L
Antidiabetic, Biguanide Metformin Tablet
500mg, 1000mg Glucophage B ? + K/L
Antidiabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhibitor
Sitagliptin Tablet
25mg, 50mg, 100mg Januvia B ? - K/L
Antidiabetic, GLP-1
Agonist Liraglutide 18mg/3mL
Pen HD
Victoza C -
L=Liver ENDOCRINE AND
METABOLIC AGENTS Antidiabetic, GLP-1 Agonist and Insulin Long- Acting Combination
Insulin Glargine and Lixisenatide 100units- 33mcg/mL
(Patient Assistance Program)
Soliqua 90 day supply PAP, 3 mL pen
B/C -
Antidiabetic, Insulin
Rapid-Acting Insulin Aspart
100units/mL NovoLog,
NovoLog FlexPen
10 mL vial,
3 mL pen B/C + -
Insulin Lispro
100units/mL Humalog,
Humalog KwikPen
Insured only, 10 mL vial, 3 mL pen
B/C +
Insulin Glulisine 100units/mL
(Patient Assistance Program)
Apidra, Apidra Solostar
90 day supply PAP, 10 mL vial, 3 mL pen
B/C +
Antidiabetic, Insulin
Short-Acting Insulin Regular
100units/mL Novolin R 10 mL vial B/C +
Antidiabetic, Insulin
Combination Insulin Aspart Protamine and Insulin Aspart 100units/mL
NovoLog Mix 70/30, NovoLog Mix 70/30 FlexPen
10 mL vial,
3 mL pen B/C +
Insulin Lispro Protamine and Insulin Lispro 100units/mL
Humalog Mix
75/25 10 mL vial B/C +
Insulin NPH and Insulin
Regular 100units/mL Novolin 70/30, Humulin 70/30, Humulin 70/30 KwikPen
Humulin insured only, 10 mL vial, 3 mL pen
B/C +
Antidiabetic, Insulin
Intermediate-Acting Insulin NPH 100units/mL Novolin NPH 10 mL vial B/C + Antidiabetic, Insulin
Long-Acting Insulin Detemir
100units/mL Levemir,
Levemir FlexTouch
10 mL vial,
3 mL pen B/C +
Insulin Glargine
100units/mL Lantus,
Lantus SoloStar
10 mL vial,
3 mL pen B/C +
Antidiabetic, SGLT-2
Inhibitor Empagliflozin Tablet
10mg, 25mg Jardiance C - + K
Antidiabetic, Sulfonylurea Glipizide ER Tablet
5mg, 10mg Glucotrol XL C ? - L
Antidiabetic,
Thiazolidinedione Pioglitazone Tablet
15mg, 30mg Actos C ? + L
ENDOCRINE AND
METABOLIC AGENTS 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 - + +
page See 75
L
Contraceptive Hormone,
Combination (cont) Norethindrone acetate/
ethinyl estradiol 1 mg/
0.02 mg (21) and ferrous fumerate 75 mg (7) HD
Loestrin FE
1/20 #28 tabs X - + +
page See 75
L
Contraceptive Hormone,
Progestin Medroxyprogesterone
Acetate Tablet 10mg HD Provera X + + L
Norethindrone Tablet
0.35mg HD Nor-Q-D #28 tabs X - (may
start 6 wks after
preg)
+ L
Contraceptive, Postcoital Levonorgestrel Tablet
1.5mg HD Plan B One-
Step #1 tab X - + L
Estrogen Estradiol Tablet 2mg HD Estrace X - + +
See page
75
L
Estrogen Estrogens, conjugated
Tablet 0.625mg HD Premarin X - + +
page See 75
L
Glucocorticoids Methylprednisolone
Tablet 4mg Dose Pack Medrol #21 tabs C ? + K/L
Prednisolone Syrup
15mg/mL Prelone C + K/L
Prednisone Tablet
5mg, 20mg Deltasone C + + K/L
Gonadotropin Releasing
Hormone Agonist Leuprolide IM Injection 11.25mg, 22mg, 30mgHD
(Patient Assistance Program)
Lupron 90 day
supply PAP X -
Gout Colchicine Tablet 0.6mg
HD Colcrys C ? + K/L
Gout, Xanthine Oxidase
Inhibitors Allopurinol Tablet
100mg, 300mg Zyloprim C + + K
ENDOCRINE AND
METABOLIC AGENTS Thyroid Levothyroxine Tablet 0.025mg, 0.050mg, 0.075mg, 0.088mg, 0.1mg, 0.112mg, 0.125mg, 0.137mg.
0.15mg, 0.175mg, 0.2mg
Levoxyl A + +
L=Liver Methimazole Tablet
10mg HD Tapazole D + +
EYE, EAR, NOSE, AND
THROAT Analgesic Lidocaine (Viscous) Oral
Solution 2% Xylocaine 100 mL B +
Antiglaucoma,
Alpha2 Agonist Brimonidine Tartrate
Ophthalmic Drops 0.2% Alphagan 5 mL B ?
Antiglaucoma,
Beta-Adrenergic Blocker Timolol Maleate Ophth
Soln 0.5% Timoptic 5 mL C +
Antiglaucoma, Carbonic
Anhydrase Inhibitor Dorzolamide 2% Trusopt 10 mL C -
Antiglaucoma,
Cholinergic Agent Pilocarpine Ophth Soln
4% Pilocar 15 mL C ?
Antiglaucoma,
Prostaglandin Inhibitor Latanoprost Ophth Soln
0.005% Xalatan 2.5 mL C ?
Anti-infective Chlorhexidine Oral Rinse
0.12% Peridex 480 mL B ?
Ciprofloxacin Ophth Soln
0.3% Cipro 5 mL bottle C (but
teratogenicity unlikely)
?
Anti-infective (cont) Erythromycin Ophth
Ointment 5mg/gm Ilotycin 3.5 gm B +
Polymyxin-Trimethoprim Ophth Soln
10,000 units-1mg/mL
Polytrim 10 mL C ?
Anti-infective,
Corticosteroid Ciprofloxacin- Dexamethasone 0.3- 0.1% otic soln
Ciprodex 7.5 mL C (but
teratogenicity unlikely)
?
Cerumenolytic Carbamide Peroxide Otic
Drops 6.5% Debrox 15 mL ? ?
Corticosteroid Fluticasone Propionate Nasal Spray
50mcg/spray
Flonase 16 gm C ?
Ketorolac Ophth Soln
0.5% Acular 5 mL C ?
Prednisolone Acetate
Ophth Soln 1% Pred Forte 15 mL C ?
Decongestant (topical) Oxymetazoline Nasal
Spray 0.05% Afrin 15 mL C ?
Irrigation Saline Nose Spray Saline Spray 45 mL + +
EYE, EAR, NOSE, AND
THROAT Lubricant Artificial Tear Drops Artificial
Tears 15 mL + +
Artificial Tear Ointment Duratears 3.5 gm + + Antihistamine, Mast Cell
Stabilizer Olopatadine 0.2%
ophthalmic soln Pataday 2.5 mL C ?
Vasoconstrictor/
Antihistamine Naphazoline/Pheniramine Ophth Soln
0.025%/0.3%
Vasocon-A 15 mL C ?
GASTROINTESTINAL
DRUGS Antacid Magnesium/Aluminum/
Simethicone
400mg/400mg/40mg Soln
Maalox Max
Strength 480 mL C ? K
Anticholinergic Dicyclomine Capsule
10mg Bentyl B - - +
See page
73 Antidiarrheal Diphenoxylate/Atropine
Sulfate Tablet 2.5/0.025mg
Lomotil;
Lonox C - - K/L
Bismuth Subsalicylate
Tablet 262mg Pepto-Bismol #30 tabs D ? +
Loperamide Tablet 2mg Imodium #12 tabs C + +
Antiflatulent Simethicone Drops
40mg/0.6mL Mylicon 30 mL C but + ?
Constipation Lactulose Syrup
10gm/15mL Duphalac
Syrup B ?
Linaclotide Capsule 145
mcg, 290 mcg Linzess C ? -
Lubiprostone Capsule 24mcg
(Patient Assistance Program)
Amitiza 90 day
supply PAP C ? -
Histamine H2 Antagonist Famotidine Tablet
20mg, 40mg Pepcid
+ + + K
Famotidine Suspension
40mg/5mL Pepcid
+ + + K
Laxative,
Diphenylmethane Bisacodyl Tablet 5mg Dulcolax C ? -
Laxative, Osmotic Glycerin suppository
1 gm Pedia-Lax
Rectal A + +
Glycerin suppository
2 gm Sani-Supp
Adult Rectal A + +
Polyethylene Glycol MiraLax 238 gm C ?
Laxative, Osmotic (for
Bowel Prep) Polyethylene Glycol with
Electrolytes GoLytely 4,000 mL C ?
Laxative, Bulk Psyllium Hydrophilic
Powder Metamucil 284 gm + ?
L=Liver GASTROINTESTINAL
DRUGS 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
unacceptable) be GENITOURINARY AGENTS Alpha1 Blocker Tamsulosin Capsule
0.4mg Flomax B + -
Analgesic, Urinary Phenazopyridine Tablet
100mg, 97.5mg or 95mg Pyridium B ? + K
Anticholinergic, Urinary Tolterodine Tartrate Extended Release Tablet 4mg
Detrol LA C - - K/L
Oxybutynin Chloride
Tablet 5mg Ditropan B ? + K/L
MIGRAINE AGENTS Migraine Combinations Butalbital,
Acetaminophen and Caffeine Tablet 50mg/325mg/40mg
Note:
Fioricet changed strength April 2014 and no longer has a generic
C - + +
See page
75 K/L
Serotonin 5-HT1
Receptor Agonist Eletriptan Tablet 40mg Relpax #6 tabs C ? + L
NEPHROLOGY Alkalinizing Agent Sodium Bicarbonate
Tablet 650mg Neut C ? +
NEPHROLOGY Calcium, Phosphate
Binder Calcium Acetate Capsule
667mg PhosLo C ? -
Treatment of
Hyperkalemia Sodium Polystyrene Sulfonate Suspension 15gm/60mL
Kayexalate 60 mL per
bottle C ?
Vitamin D Analog Calcitriol Capsule 0.5mcg Rocaltrol C ? -
NUTRIENTS AND
NUTRITIONAL AGENTS Calcium Supplement Calcium (elemental)
Tablet 500mg Calcium #60 tabs
per bottle + (? 1st
trimester) ? + K
NUTRIENTS AND
NUTRITIONAL AGENTS Hypomagnesemia Magnesium Oxide Tablet 400mg (240mg
elemental)
MagOx #120 tabs A + + L
Nutritional Supplement Thiamine Tablet 100mg Various #100 tabs A + +
Vitamin Cyanocobalamin Tablet
500mcg Vitamin B12 #130 tabs C + +
Folic Acid Tablet 1mg A + +
Multivitamin Drops with
Iron Poly-vi-sol 50 mL + +
Multivitamin Tablet,
Adult Centrum #100 tabs + + +
Multivitamin Tablet,
Children Flintstones #100 tabs + + +
Omega-3 Fatty Acids
(180 EPA / 120 DHA) Fish Oil #100 caps C ? - L
Prenatal Vitamin Tablet Natalins RX #100 tabs + + +
Vitamin D3 Tablet
400 IU, 1000 IU #100 tabs C Avoid
high doses Vitamin D3 Capsule
50000 IU C Avoid
high doses Vitamin D3 Liquid
400 IU/mL D-Vi-Sol 50 mL
RESPIRATORY AGENTS Antihistamine Cetirizine Solution
1mg/mL Zyrtec 120 mL B - K
RESPIRATORY AGENTS Antihistamine (cont) Cetirizine Tablet 10mg Zyrtec #30 tabs B - + K
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 ? + +
page See Antitussive Benzonatate Capsule 73
100mg Tessalon
Perles #20 caps C ? -
Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant
budesonide/formoterol MDI 80/4.5mcg, 160/4.5mcg
Symbicort C ?
Fluticasone
Propionate/Salmeterol Diskus 100/50mcg, 250/50mcg, 500/50mcg
Advair
Diskus C ?
Bronchodilator,
Anticholinergic Ipratropium Bromide
Nebulizer Soln 0.02% Atrovent 25 vials per
box B ?
Tiotropium Bromide Capsule for inhalation 18mcg
Spiriva C - -
Bronchodilator, Beta2-
Adrenergic Agonist Albuterol MDI Proventil, Ventolin, ProAir
C ?
Bronchodilator, Beta2-
Adrenergic Agonist (cont) Albuterol Nebulizer
Solution 0.083% Proventil,
Ventolin #25 C ?
Corticosteroids, Inhalant Fluticasone Propionate MDI 44mcg/puff, 110mcg/puff, 220mcg/puff
Flovent C ?
Decongestant
(Alpha/Beta Adrenergic Agonist)
Pseudoephedrine Tablet
30mg, 60mg Sudafed #24 tabs C + + K
Expectorant Guaifenesin Tablet
200mg Humibid #100 tabs C + +
Leukotriene Inhibitor Montelukast Chewable
Tablet 4mg, 5mg Singulair B ? + L
Montelukast Tablet 10mg Singulair B ? + L
RHEUMATOLOGY Disease Modifying Antirheumatic Drug (DMARD)
Methotrexate Tablet
2.5mgHD Rheumatrex X - + K/L
RHEUMATOLOGY Disease Modifying Antirheumatic Drug (DMARD) (cont)
Sulfasalazine Tablet
500mg Sulfazine,
Azulfadine D - + K/L
Tumor Necrosis Factor
Blocking Agent Adalimumab Injection 40mg
(Patient Assistance Program)
Humira 90 day
supply PAP B - - ?
SKELETAL MUSCLE
RELAXANT Centrally Acting Cyclobenzaprine Tablet
5mg Flexeril B ? + +
See page
75
L
Methocarbamol Tablet
500mg Robaxin C ? + +
See page
75
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 20 gm D -
Antibiotic, Topical Bacitracin Ointment
500 units/gm 15 gm B ?
Mupirocin Ointment 2% Bactroban 22 gm B ?
Antifungal Ketoconazole Shampoo
2% Nizoral 120 mL C ?
Miconazole Cream 2% Micatin 30 gm + ?
Nystatin Cream 100,000
units/gm Mycostatin 15 gm C ?
Terconazole Vaginal
Cream 0.8% Terazol-3 20 gm C -
Anti-infective Silver Sulfadiazine
Cream 1% Silvadene 20 gm B -
Antiparasitic Agent,
Pediculocide Piperonyl Butoxide and
Pyrethrum Extract Kit Rid Shampoo 120 mL C ?
Permethrin Cream 5% Elimite 60 gm B ?
Anti-viral, topical
immunomodulator Imiquimod Cream 5% Aldara #12 single-
use packets C ?
Corticosteroid Clobetasol Ointment
0.05% Temovate 15 gm,60
gm C ?
Clobetasol Solution
0.05% Temovate 50 mL C ?
Fluocinonide Cream
0.05% Lidex 30 gm C -
SKIN AND MUCOUS
MEMBRANE AGENTS Corticosteroid (cont) Hydrocortisone Cream
1%, 2.5% 30gm (1%)
20gm (2.5%)
C ?
L=Liver Hydrocortisone Ointment
1%, 2.5% 30gm (1%)
20gm (2.5%) Hydrocortisone
Suppository 25mg Anusol-HC #12 per
box C ?
Triamcinolone Acetonide
Cream 0.1% Aristocort;
Kenalog 15 gm,
80 gm C ?
Triamcinolone Acetonide
Ointment 0.1% Aristocort;
Kenalog 15 gm,
80 gm C ?
Triamcinolone Acetonide
Dental Paste 0.1% Oralone 5 gm C ?
Dandruff Sulfur/Salicylic Acid
Shampoo 2%/2% Sebulex 120 mL C -
Estrogen Estrogens, conjugated
Cream 0.625mg/gm HD Premarin 30 gm X -
Miscellaneous Metronidazole Gel 0.75%
(Topical) Metrogel 45 gm B ?
Moisturizing Moisturizing Cream Eucerin 120 gm + +
Protectant Zinc Oxide Ointment
20% Desitin 30 gm + +
Psoriasis Apremilast Tablet 30 mg Otezla C - - K
Tinea Versicolor;
Dandruff; Seborrheic Dermatitis
Selenium Sulfide Lotion
2.5% Selsun 120 mL C ?
SMOKING CESSATION Dopamine Reuptake
Inhibitor Bupropion Tablet SR
(12h) 150mg Wellbutrin
SR, Zyban C - + K/L
Nicotine Product Nicotine Gum 2mg, 4mg Nicorette
Gum 110 pieces C - K/L
Nicotine Transdermal Patch 7mg/hr, 14mg/hr, 21mg/hr
Nicoderm CQ #14
patches D - K/L
Partial Nicotine Agonist Varenicline Tablet
Starter Pack Chantix C - + K
Varenicline Tablet
Continuing Pack Chantix C - + K
STIMULANT ADHD, Narcolepsy Dextroamphetamine /Amphetamine Tablet 10mg, 20mg, 30mg
Adderall C - + K
Methylphenidate HCl
Tablet 5mg Ritalin C ? +
