HealthPAC Formulary Current as of January 2014 Class I Class II Adrenals Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Misc Misc Muscle Relaxant Muscle Relaxant Muscle Relaxant Muscle Relaxant Muscle Relaxant Narcotic Narcotic Narcotic Narcotic Narcotic Analgesic Narcotic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic Narcotic NSAID NSAID NSAID NSAID NSAID NSAID NSAID NSAID NSAID NSAID Generic Name Brand Name Strength Fludrocortisone Butalbital-APAP-Caffeine Tramadol Baclofen Baclofen Cyclobenzaprine Methocarbamol Methocarbamol Acetaminophen / Oxycodone Acetaminophen/Codeine #3 Acetaminophen/Hydrocodone Acetaminophen/Hydrocodone Acetaminophen/Hydrocodone Acetaminophen/Hydrocodone bitartrate Methadone Methadone Morphine sulfate Liquid Morphine sulfate short acting Morphine sulfate SR Morphine sulfate SR Morphine sulfate SR Morphine sulfate SR Diclofenac Diclofenac Ibuprofen Ibuprofen Ibuprofen Indomethacin Indomethacin Nabumetone Naproxen Naproxen Florinef Fioricet Ultram, Rybix Lioresal Lioresal Flexeril Robaxin Robaxin Percocet Tylenol #3 Norco Norco Norco 0.2 mg 50/325/40 50 mg 10 mg 20 mg 10 mg 500 mg 750 mg 325/5 and 325/10 300 / 30 mg 325/10 mg 325/5 mg 325/7.5 mg Vicodin 500 mg - 5 mg MS MS Oramorph SR Oramorph SR Oramorph SR Oramorph SR Voltaren Voltaren Motrin Motrin Motrin Indocin Indocin Relafen Naprosyn Naprosyn 10 mg 5 mg 20mg/ 5 ml 15,30mg 100 mg 15 mg 30 mg 60 mg 50 mg 75 mg 400 mg 600 mg 800 mg 25 mg 50 mg 750 mg 250 mg 375 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 1 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Anthelmintics Antibiotic Antihistamine Anti-inflammatory Agents Anti-inflammatory Agents Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials NSAID NSAID NSAID Salicyclates Salicyclates Salicylates Naproxen Sulindac Sulindac Salsalate Salsalate Acetylsalicylic acid (ASA) Praziquantel Mupirocin Loratidine Alclometasone Cream Alclometasone Ointment Econazole Econazole Econazole Fluconazole Fluconazole Fluconazole Griseofulvin micro liquid Griseofulvin ultramicro Griseofulvin ultramicro Ketoconazole Ketoconazole Ketoconazole Ketoconazole Ketoconazole Nystatin oral suspension Ethambutol Ethambutol Isoniazid Isoniazid Isoniazid Pyrazinamide Rifampin Naprosyn Clinoril Clinoril 500 mg 150 mg 200 mg 500 mg 750 mg 81, 325 mg 600mg 2%ointment 10mg 45gm 45gm 1% crm 30 Gm (30 Gm) 1% crm 85 Gm (85 Gm) 1% crm 15 Gm (15 Gm) 100 mg 150 mg 200 mg 125 mg / 5 mL (120 ml) 125 mg 250 mg 2% crm (15 Gm) 2% crm (30 Gm) 2% crm (60 Gm) 2% shampoo 200 mg (tabs) 100,000 units/ml 100 mg 400 mg 10 mg / ml 100 mg 300 mg 500 mg 150 mg Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antifungals Antitubercular Antitubercular Antitubercular Antitubercular Antitubercular Antitubercular Antitubercular Biltricide Bactroban Claritin Aclovate Aclovate Spectazole Spectazole Spectazole Diflucan Diflucan Diflucan Grifulvin V Grisactin Fulvicin Grisactin Fulvicin Nizoral Nizoral Nizoral Nizoral Nizoral Myambutol Myambutol INH INH INH Rifadin Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 2 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antitubercular Antiviral Antiviral Antiviral Antiviral Antiviral Cephalosporins Cephalosporins Cephalosporins Cephalosporins Macrolides Macrolides Macrolides Macrolides Misc Misc Misc Misc Misc Misc Misc Misc Penicillins Penicillins Penicillins Penicillins Penicillins Penicillins Penicillins Penicillins Penicillins Penicillins Penicillins Rifampin Acyclovir Acyclovir Acyclovir Oseltamivir Oseltamivir Cephalexin Cephalexin Cephalexin Cephalexin Azithromycin Erythromycin stearate Erythromycin stearate Erythromycin stearate Clindamycin Clindamycin Metronidazole Metronidazole Metronidazole cream Nitrofurantoin macrocryst Nitrofurantoin macrocryst Nitrofurantoin monohydrate Amoxicillin Amoxicillin Amoxicillin Amoxicillin Amoxicillin Amoxicillin-clavulanate Amoxicillin-clavulanate Amoxicillin-clavulanate Dicloxacillin Dicloxacillin Penicillin VK Rifadin Zovirax Zovirax Zovirax Tamiflu Tamiflu Keflex Keflex Keflex Keflex Zithromax Ery-Tab Ery-Tab Ery-Tab Cleocin Cleocin Flagyl Flagyl Metrocream Macrodantin Macrodantin Macrobid Amoxil Amoxil Amoxil Amoxil Amoxil Augmentin Augmentin Augmentin Dynapen Dynapen 300 mg 200 mg 400 mg 800 mg 12mg/ml 75mg 125 mg / 5 ml (200 ml) 250 mg 250 mg / 5 ml (100 ml) 500 mg 250 mg 250 mg 333 mg 500 mg 150 mg 300 mg 250 mg 500 mg 0.075% 100 mg 50 mg 100 mg 125 mg / 5 cc (80 cc) 250 mg 250 mg / 5 cc (150 cc) 400 mg/ 5 cc 500 mg 200 mg / 5 cc (100 ml) 500 mg-125 mg 875 mg 250 mg 500 mg 125 mg / 5 cc (200 cc) Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 3 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Antimicrobials Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Penicillins Penicillins Penicillins Penicillins Quinolones Quinolones Sulfas Sulfas Sulfas Tetracyclines Tetracyclines Tetracyclines Tetracyclines Penicillin VK Penicillin VK Penicillin VK Penicillin VK Ciprofloxacin Ciprofloxacin Sulfamethxzl Trimethoprim Sulfamethxzl Trimethoprim Sulfamethxzl Trimethoprim DS Doxycycline Doxycycline Tetracycline Tetracycline Clarithromycin Levofloxacin Captopril Captopril Captopril Captopril Enalapril maleate Enalapril maleate Enalapril maleate Enalapril maleate Lisinopril Lisinopril Lisinopril Lisinopril Lisinopril Lisinopril Doxazosin mesylate Doxazosin mesylate Doxazosin mesylate Doxazosin mesylate Veetids 250 mg 250 mg / 5 cc (100 cc) 250 mg / 5 cc (150 cc) 500 mg 250 mg 500 mg 40mg / 5ml - 200mg / 5-ml (60 ml) 80 / 400 mg 160 / 800 mg 100 mg 50 mg 250 mg 500 mg 500 mg 500 mg 100 mg 12.5 mg 25 mg 50 mg 10 mg 2.5 mg 20 mg 5 mg 10 mg 2.5 mg 20 mg 30 mg 40 mg 5 mg 1 mg 2 mg 4 mg 8 mg ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor Alpha-1 blocker Alpha-1 blocker Alpha-1 blocker Alpha-1 blocker Cipro Cipro Bactrim Septra Septra Doryx Vibramycin Doryx Vibramycin Sumycin Sumycin Biaxin Levaquin Capoten Capoten Capoten Capoten Vasotec Vasotec Vasotec Vasotec Prinivil, Zestril Prinivil, Zestril Prinivil, Zestril Prinivil, Zestril Prinivil, Zestril Prinivil, Zestril Cardura Cardura Cardura Cardura Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 4 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Cardiovascular Cardiovascular Cardiovascular Alpha-blockers Alpha-blockers Alpha-blockers Angiotensin II Blocker Angiotensin II Blocker Angiotensin II Blocker Antiarrythmic Antiarrythmic Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Anticoagulants Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Prazosin Prazosin Prazosin Minipress Minipress Minipress 1 mg 2 mg 5 mg Losartan Cozaar 100 mg Losartan Cozaar 25 mg Losartan Cozaar 50mg Amiodarone Amiodarone Dipyridamole Dipyridamole Dipyridamole Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Warfarin sodium Atenolol Atenolol Atenolol Carvedilol Carvedilol Carvedilol Carvedilol Labetalol HCL Labetalol HCL Labetalol HCL Cordarone Cordarone Persantine Persantine Persantine Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Tenormin Tenormin Tenormin Coreg Coreg Coreg Coreg Trandate Trandate Trandate 200 mg 400 mg 25 mg 50 mg 75 mg 1 mg 10 mg 2 mg 2.5 mg 3 mg 4 mg 5 mg 6 mg 7.5 mg 100 mg 25 mg 50 mg 12.5 mg 25 mg 3.125 mg 6.25 mg 100 mg 200 mg 300 mg Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 5 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Beta Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Metoprolol succinate Metoprolol succinate Metoprolol succinate Metoprolol tartrate Metoprolol tartrate Metoprolol tartrate Propranolol HCL Propranolol HCL Propranolol HCL Propranolol HCL Propranolol HCL Toprol XL Toprol XL Toprol XL Lopressor Lopressor Lopressor Inderal Inderal Inderal Inderal Inderal 100 mg 25 mg 50 mg 100 mg 25 mg 50 mg 10 mg 20 mg 40 mg 60 mg 80 mg Amlodipine Norvasc 10 mg Amlodipine Norvasc 2.5 mg Amlodipine Norvasc 5 mg Dilitiazem HCI Cardizem LA 180 mg Diltiazem Cardizem 120 mg Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Calcium Channel Diltiazem Blockers Cardiovascular Calcium Channel Diltiazem Blockers Cardiovascular Cardiovascular Cardiovascular Calcium Channel Diltiazem SR Blockers Calcium Channel Diltiazem SR Blockers Calcium Channel Diltiazem SR Blockers Cardizem CD, Dilacor Xr, Cartia XL, Dilt-CD Cardizem CD, Dilacor Xr, Cartia XL, Dilt-CD 60 mg 90 mg Cardizem SR 120 mg Cardizem SR 180 mg Cardizem SR 240 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 6 of 22 HealthPAC Formulary Current as of January 2014 Class I Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Class II Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Calcium Channel Blockers Generic Name Brand Name Strength Diltiazem SR Cardizem SR 300 mg Diltiazem CD Cardizem CD 120 mg Diltiazem CD Cardizem CD 180 mg Diltiazem CD Cardizem CD 240 mg Diltiazem CD Cardizem CD 30 mg Diltiazem CD Cardizem CD 300 mg Diltiazem CD Cardizem CD 360mg Diltiazem CD Cardizem CD 60 mg Diltiazem CD Cardizem CD 90 mg Nifedipine SR Nifedipine SR Nifedipine SR Procardia, Adalat CC, Nifediac Procardia, Adalat CC, Nifediac Procardia, Adalat CC, Nifediac 30 mg 60 mg 90 mg Verapamil Isoptin 120 mg Verapamil LA Isoptin 180 mg Verapamil SR Calan SR 120 mg Verapamil SR Calan SR 180 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 7 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Verapamil SR Calan SR 240 mg Clonidine HCI tabs Catapres 0.1 mg Clonidine HCI tabs Catapres 0.2 mg Clonidine HCI tabs Catapres 0.3 mg Methyldopa Aldomet 250 mg Methyldopa Aldomet 500 mg Gemfibrozil Lopid 600 mg Lovastatin Mevacor 10, 20, 40 mg Pravastatin Pravachol 20, 40, 80 mg tabs Simvastatin Zocor 10 mg Simvastatin Zocor 20 mg Simvastatin Zocor 40 mg Metolazone Metolazone Zaroxolyn Zaroxolyn 10 mg 2.5 mg Cardiovascular Cardiovascular Calcium Channel Blockers Central Alpha Agonist Central Alpha Agonist Central Alpha Agonist Central Alpha Agonist Central Alpha Agonist Cholesterol Lowering Agents Cholesterol Lowering Agents Cholesterol Lowering Agents Cholesterol Lowering Agents Cholesterol Lowering Agents Cholesterol Lowering Agents Diurectics Diurectics Cardiovascular Diurectics Metolazone Zaroxolyn 5 mg Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Diuretics Diuretics Diuretics Diuretics Diuretics Chlorthalidone Chlorthalidone Furosemide Furosemide Furosemide Thalitone Thalitone Lasix Lasix Lasix 25mg 50 mg 20 mg 40 mg 80 mg Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 8 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Diuretics Diuretics Diuretics Diuretics Diuretics Diuretics Diuretics Diuretics Glycosides Glycosides Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Nitrate Vasodilators Other Vasodilators Hydrochlorothiazide Hydrochlorothiazide Hydrochlorothiazide Spironolactone Spironolactone Spironolatone Triamterene hctz Triamterene hctz Digoxin Digoxin Microzide Esidrix Esidrix Aldactone Aldactone Aldactone Maxzide Maxzide Lanoxin Lanoxin 12.5 mg cap 25 mg 50 mg 25 mg 50 mg 100 mg 37.5/25 mg 75 / 50 mg 0.125 mg 0.25 mg Isosorbide dinitrate Isordil 10 mg Isosorbide dinitrate Isordil 20 mg Isosorbide dinitrate Isordil 30 mg Isosorbide dinitrate Isordil 5 mg Isosorbide mononitrate IR, SR Imdur 10 mg Isosorbide mononitrate IR, SR Imdur 120 mg Isosorbide mononitrate IR, SR Imdur 20 mg Isosorbide mononitrate IR, SR Imdur 30 mg Isosorbide mononitrate IR, SR Imdur 60 mg Nitroglycerine SL Nitrostat 0.4 mg Hydralazine Apresoline 10 mg Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 9 of 22 HealthPAC Formulary Current as of January 2014 Class I Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Chemotherapy Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Cold, Cough, Allergy Derm Derm Derm Derm Derm Class II Other Vasodilators Other Vasodilators Other Vasodilators Potassium Supplement Potassium Supplement Potassium Supplement Potassium Supplement Antihistamine Antihistamine Antihistamine Antihistamine Antihistamine Antihistamine Antihistamine Antitussive Antitussive Nasal Steroids Acne Acne Acne Acne Acne Generic Name Brand Name Strength Hydralazine Apresoline 100 mg Hydralazine Apresoline 25 mg Hydralazine Apresoline 50 mg Potassium chloride Potassium chloride tabs Potassium chloride tabs Potassium chloride tabs Niacin IR & ER tabs only Niacin IR & ER tabs only Niacin IR & ER tabs only Methotrexate Diphenhydramine Diphenhydramine Diphenhydramine Hydroxyzine HCL Hydroxyzine HCL Hydroxyzine HCL Hydroxyzine HCL Guaifenesin + Codeine Promethazine/VC/DM Flunisolide Clindamycin topical gel, lotion Clindamycin topical solution Erythromycin gel or solution Metronidazole cream Metronidazole topical gel 10% (480 cc) K-Tab, K-Dur, Slow-K, Klor-con K-Tab, K-Dur, Slow-K, Klor-con K-Tab, K-Dur, Slow-K, Klor-con 10 mEq 20 mEq 8 mEq Rheumatrex Benadryl Benadryl Benadryl Atarax Atarax Atarax Atarax Robitussin AC 100 mg 250 mg 500 mg 2.5 mg 12.5 mg/ 5ml 25, 50 mg capsules 50 mg/cc (inj) 10 mg 10 mg / 5 cc (120 ml) 25 mg 50 mg 100 mg - 10mg / 5 ml Nasarel Cleocin Cleocin-T Erygel Metrocream Metrogel 25 mcg/spray (0.025%) 1% 1% (60 ml) 2% 0.75% 0.75% Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 10 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Derm Acne Tretinoin Retin-A 0.01%, 0.025%, 0.05%, 0.1% cream, gel Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Derm Antifungals Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Antiinflammatory Temovate Temovate Temovate Synalar Synalar Synalar Synalar Synalar Lidex Lidex Lidex Lidex Lidex Lidex Lidex HC HC HC Cortizone Cortizone 0.05% crm (15 Gms) 0.05% oint (15 Gms) 0.05% oint (30 Gms) 0.01% cream 0.01% ointment 0.025% cream 0.025% ointment 0.025%, 0.01% solution, 60 ml 0.05% solution 60ml 0.05% gel (60gm) 0.05% cream (30 gm) 0.05% cream (60 gm) 0.05% oint (15 gm) 0.05% oint (30 gm) 0.05% oint (60 gm) 10mg 2.5% lotion 20mg 2.5% 2.50% Derm Nystatin (cream or ointment) Clobetasol propionate Clobetasol propionate Clobetasol propionate Fluocinolone acetonide Fluocinolone acetonide Fluocinolone acetonide Fluocinolone acetonide Fluocinolone acetonide Fluocinonide Fluocinonide Fluocinonide Fluocinonide Fluocinonide Fluocinonide Fluocinonide Hydrocortisone Hydrocortisone Hydrocortisone Hydrocortisone cream Hydrocortisone ointment Triamcinolone cream, ointment, or Antiinflammatory lotion Triamcinolone cream, ointment, or Antiinflammatory lotion Anti-seborrhea Selenium sulfide lotion Derm Other Silver sulfadiazine Derm Scabicide and Lice Derm Derm Derm Kenalog, Aristocort 0.025% Kenalog, Aristocort 0.10% Selsun Flint SSD, Silvadene 2.50% Permethrin cream Elimite 5% (60 Gm) Clobetasol lotion Temovate 0.05% Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. 1% crm Page 11 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Derm Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Antiinflammatory Biquanides Biquanides Biquanides Insulin Product Insulin Product Insulin Product Insulin Product Insulin Product Sulfonylureas Sulfonylureas Sulfonylureas Sulfonylureas Sulfonylureas Thiazolidinedion es Thiazolidinedion es Thiazolidinedion es Hydrocortisone Metformin Metformin Metformin Insulin 70/30 Insulin glargine Insulin Lispro Insulin NPH Insulin Regular Glipizide Glipizide Glyburide Glyburide Glyburide HC Glucophage Glucophage Glucophage Humulin, Novolin Lantus Humalog Humulin N Humulin R Glucotrol Glucotrol Micronase Diabeta Micronase Diabeta Micronase Diabeta 5mg 1000 mg 500 mg 850 mg U100 (10 ml) 100 IU/mL 100U/mL U100 (10 ml) U100 (10 ml) 10 mg 5 mg 1.25 mg 2.5 mg 5 mg Pioglitazone hydrochloride Actos 15 mg Pioglitazone hydrochloride Actos 30 mg Pioglitazone hydrochloride Actos 45 mg Diabetes supplies - glucometer Diabetes supplies - lancets Diabetes supplies - syringes/needles Diabetes supplies - test strips Diabetes supplies - testing control solution Prednisolone Prednisone Prednisone Prednisone Prednisone Prednisone Prednisone Prelone Deltasone Deltasone Deltasone Deltasone Deltasone Deltasone 15mg/5ml oral sol 1 mg 10 mg 2.5 mg 20 mg 5 mg 50 mg Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Glucocorticoids Glucocorticoids Glucocorticoids Glucocorticoids Glucocorticoids Glucocorticoids Glucocorticoids Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 12 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Endocrine Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Levothyroxine Methimazole Methimazole Propylthiouracil Fludrocortisone Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Tapazole Tapazole PTU Florinef 0.025 mg 0.050 mg 0.075 mg 0.088 mg 0.1 mg 0.112 mg 0.125 mg 0.137 mg 0.15 mg 0.175 mg 0.2 mg 0.3 mg 10 mg 5 mg 50 mg 0.1 mg Finasteride Proscar 5 mg Oxybutynin Phenazopyridine HCL Phenazopyridine HCL Tamsulosin Terazosin HCL Terazosin HCL Terazosin HCL Terazosin HCL Diphenoxylate-atropine Diphenoxylate-atropine (SCH V) Metoclopramide Metoclopramide hcl Prochlorperazine Prochlorperazine Ditropan Pyridium Pyridium Flomax Hytrin Hytrin Hytrin Hytrin Lomotil Lomotil Reglan Reglan Compazine Compazine 5 mg 100 mg 200 mg 0.4 mg 1 mg 10 mg 2 mg 5 mg 2.5 mg 2.5 / .025 / 5 (60 ml) 10 mg 5 mg 10 mg 25 mg supp Genitourinary Genitourinary Genitourinary Genitourinary Genitourinary Genitourinary Genitourinary Genitourinary Genitourinary GI GI GI GI GI GI 5-alpha reductase inhibitor Alpha-blockers Antidiarrhea Antidiarrhea Antiemetic Antiemetic Antiemetic Antiemetic Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 13 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength GI GI GI GI Antiemetic Antiemetic Antiemetic Antiemetic Prochlorperazine Promethazine HCI Promethazine HCI Promethazine HCI 5 mg 12.5 mg 12.5 mg supp 25 mg GI Antiemetic Promethazine HCI GI GI GI Promethazine HCI Promethazine HCI Hydrocortisone Suppositories Mesalamine Asacol 400 mg Sulfasalazine Azulfidine 500 mg GI GI GI GI GI GI GI GI GI GI Antiemetic Antiemetic Antiinflammatory Antiinflammatory bowel Antiinflammatory bowel Antispasmodics Antispasmodics Antispasmodics H2 Antagonists H2 Antagonists H2 blockers H2 blockers H2 blockers Laxatives PPI Compazine Phenergan Phenergan Phenergan Phenergan suppositor Phenergan Phenergan syrup Cortizone Donnatal Bentyl Bentyl Pepcid Pepcid Tagamet Zantac Zantac Duphalac Prilosec 16.2 mg 10 mg 20 mg 20 mg 40 mg 400 mg 150 mg 300 mg 10g/15 ml syrup 20 mg GI Prep Belladona alkaloids, phenobarbital Dicyclomine Dicyclomine Famotidine Famotidine Cimetidine Ranitidine Ranitidine Lactulose Omeprazole Polyethylene glycol electrolyte solution Miralax Miralax Misoprostol Misoprostol Sucralfate ursodiol Allopurinol Allopurinol Mix Golytely 240g polyethylene glycol polyethylene glycol Cytotec Cytotec Carafate Actigall Zyloprim Zyloprim 238g 510g 100mg 200mg 1 Gm 300mg 100 mg 300 mg GI GI GI GI GI GI GI GI Gout Gout Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. 25 mg supp 50 mg 6.25 / 5 ml (120 ml) 25mg Page 14 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Colcrys Benemid 0.6 mg 500 mg Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Anticonvulsant Colchicine Probenecid bismuth subsalicylate-metronidazoletetracycline Pentoxifylline ER Conjugated Estrogen Cream Estradiol Estradiol Estradiol Medroxyprogesterone Medroxyprogesterone Medroxyprogesterone Tamoxifen Testosterone Inj Testosterone Inj Bromocriptine Azathioprine Carisoprodol Gabapentin Gabapentin Gabapentin Gabapentin Lamotrigine Lamotrigine Lamotrigine Lamotrigine Phenobarbital (SCH IV) Phenobarbital (SCH IV) Phenobarbital (SCH IV) Phenobarbital (SCH IV) Phenytoin Phenytoin Primidone Gout Gout Helicobacter pylori agent Hemorrheologic Agents Hormone Replacement Hormone Replacement Hormone Replacement Hormone Replacement Hormone Replacement Hormone Replacement Hormone Replacement Hormone Replacement Hormone Replacement Hormone Replacement Hypoprolactinemic Immunosupressive muscle relaxant Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Helidac Trental Premarin Estrace Estrace Estrace Provera Provera Provera Soltamox Depo Testosterone Depo Testosterone Parlodel Imuran Soma Neurontin Neurontin Neurontin Neurontin Lamictal Lamictal Lamictal Lamictal Dilantin Dilantin Mysoline Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. 400 mg 0.625 mg/g crm (43 Gm) 0.5 mg 1 mg 2 mg 10 mg 2.5 mg 5 mg 10mg 100 mg/ml 200mg/ml 2.5mg 50mg 250mg 100 mg 300 mg 400 mg 600 mg 100 mg tab 150 mg tab 200 mg tab 25 mg tab 100 mg 15 mg 30 mg 60 mg 100 mg 50 mg 250 mg Page 15 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Neurologic Anticonvulsant Migraine Migraine Migraine Misc Parkinson Parkinson Parkinson Parkinson Parkinson Parkinson Parkinson Parkinson Parkinson Parkinson Primidone Sumatriptan Sumatriptan Sumatriptan Meclizine Amantadine Amantadine Benztropine mesylate Benztropine mesylate Benztropine mesylate Benztropine mesylate Carbidopa - levodopa Carbidopa - levodopa Carbidopa - levodopa Carbidopa - levodopa LA Mysoline Imitrex Imitrex Imitrex Antivert Symmetrel Symmetrel Cogentin Cogentin Cogentin Cogentin Sinemet Sinemet Sinemet Sinemet CR 50 mg 100 mg 25 mg 50 mg 25mg tabs 100 mg 50 mg / 5 ml (120 ml) 0.5 mg 1 mg 1 mg/cc (inj) 2 mg 10 - 100 mg 25 - 100 mg 25 - 250 mg 25 - 100 mg Neurologic Parkinson Carbidopa - levodopa LA Sinemet CR 50 - 200 mg Neurologic Neurologic Parkinson Parkinson Trihexyphenidyl Trihexyphenidyl Artane Artane 2 mg 2 mg / 5 cc Neurologic Parkinson Trihexyphenidyl Artane 5 mg Levetiracetam Levetiracetam Levetiracetam Brimonidine tartrate solution Brimonidine tartrate solution Brinzolamide Timolol Maleate eye drops Timolol Maleate eye drops Ciprofloxacin eye drop Erythromycin eye ointment Gentamicin eye drops Ketotifen Keppra Keppra Keppra Alphagan Alphagan Azopt 1000 mg 500 mg 750 mg 0.2% 0.2% 1% solution 0.25% 0.5% 0.3% 5 mg / Gm (3.5 Gm) 0.3% (5 ml) 0.025% Neurologic Neurologic Neurologic Ophthalmic Ophthalmic Ophthalmic Ophthalmic Ophthalmic Ophthalmic Ophthalmic Ophthalmic Ophthalmic Glaucoma Glaucoma Glaucoma Glaucoma Glaucoma Ciloxan Garamycin Alaway Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 16 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Xalatan Polytrim Polytrim Fosamax Fosamax Vosol Vosol HC 0.005% 10 mL drops 3.5 gm ointment 1% 10% 10% 0.30% 35 mg 70 mg 15 ml drops 2%-1% Auralgan 10 ml drops Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Latanoprost Polymyxin b- trimethoprim Polymyxin b- trimethoprim Prednisolone ophth solu or susp Sulfacetamide sodium eye drop sol Sulfacetamide sodium eye ointment Tobramycin ophthal soln. Alendronate Alendronate Acetic acid Acetic acid/Hydrocortisone Antipyrene, Benzodine, Glycerine dehyd Cortisporin otic soln Cortisporin otic susp Calcium acetate Clopidogrel Ticlopidine Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Bupropion XL Buproprion IR, SR Buproprion IR, SR Buproprion IR, SR Buproprion IR, SR Buproprion IR, SR Citalopram Hydrobromide Citalopram Hydrobromide Citalopram Hydrobromide Citalopram Hydrobromide Phoslo Plavix Ticlid Elavil Elavil Elavil Elavil Elavil Wellbutrin XL Wellbutrin SR Wellbutrin SR Wellbutrin SR Wellbutrin SR Wellbutrin SR Celexa Celexa Celexa Celexa 1%-0.35%-10000u/mL (10 ml) drops (10 ml) 667mg 75 mg 250mg 10 mg 100 mg 25 mg 50 mg 75 mg 150 mg, 300 mg 100 mg 150 mg 200 mg 300 mg 75 mg 10 mg 10 mg / 5 cc 20 mg 40 mg Ophthalmic Ophthalmic Ophthalmic Ophthalmic Ophthalmic Ophthalmic Ophthalmic Osteoporosis Osteoporosis Otic Otic Otic Otic Otic phosphate binder platelet aggregation inhibitoraggregation platelet inhibitor Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Sulamyd Sulamyd Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 17 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Clomipramine Clomipramine Clomipramine Doxepin HCL Doxepin HCL Doxepin HCL Doxepin HCL Doxepin HCL Doxepin HCL Fluoxetine Fluoxetine Fluoxetine Fluoxetine Imipramine Imipramine Imipramine Mirtazapine Mirtazapine Mirtazapine Nortriptyline Nortriptyline Nortriptyline Nortriptyline Paroxetine Paroxetine Paroxetine Paroxetine Paroxetine Sertraline Sertraline Sertraline Sertraline Trazodone Anafranil Anafranil Anafranil Sinequan Sinequan Sinequan Sinequan Sinequan Sinequan Prozac Prozac Prozac Prozac Tofranil Tofranil Tofranil Remeron Remeron Remeron Pamelor Pamelor Pamelor Pamelor Paxil Paxil Paxil Paxil Paxil Zoloft Zoloft Zoloft Zoloft Desyrel 25 mg 50 mg 75 mg 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg 10 mg 20 mg 20 mg / 5 ml 40 mg 10 mg 25 mg 50 mg 15 mg 30 mg 45 mg 10 mg 25 mg 50 mg 75 mg 10 mg 10 mg / 5 ml 20 mg 30 mg 40 mg 100 mg 20 mg/ml 25 mg 50 mg 100 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 18 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antidepressant Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Trazodone Trazodone Venlafaxine Venlafaxine XR Venlafaxine XR Venlafaxine XR Chlorpromazine Chlorpromazine Chlorpromazine Chlorpromazine Chlorpromazine Chlorpromazine Chlorpromazine Fluphenazine Fluphenazine Fluphenazine Fluphenazine Fluphenazine Fluphenazine decanoate Haloperidol Haloperidol Haloperidol Haloperidol Haloperidol Haloperidol Haloperidol Haloperidol Haloperidol decanoate Haloperidol decanoate Loxapin Olanzapine Olanzapine Perphenazine Desyrel Desyrel Effexor IR Effexor XR Effexor XR Effexor XR Thorazine Thorazine Thorazine Thorazine Thorazine Thorazine Thorazine Prolixin Prolixin Prolixin Prolixin Prolixin Prolixin Haldol Haldol Haldol Haldol Haldol Haldol Haldol Haldol Haldol Haldol Loxitane Zyprexa Zyprexa Trilafon 150 mg 50 mg 25 mg 100 mg 37.5 mg 75 mg 10 mg 100 mg 100 mg/ml 200 mg 25 mg 30 mg/ml 50 mg 0.5 mg/ml 1 mg 10 mg 2.5 mg 5 mg / cc 25 mg/cc (inj) 0.5 mg 1 mg 10 mg 2 mg 2 mg / cc (120 cc) 2 mg / cc (15 cc) 20 mg 5 mg 100 mg/cc (inj) 50 mg/cc (inj) 5, 10, 25, 50 mg 2.5mg 5 mg 16 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 19 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Perphenazine Perphenazine Perphenazine Perphenazine Quetiapine fumarate Quetiapine fumarate Quetiapine fumarate Quetiapine fumarate Quetiapine fumarate Quetiapine fumarate Risperidone Risperidone Risperidone Trilafon Trilafon Trilafon Trilafon Seroquel Seroquel Seroquel Seroquel Seroquel Seroquel Risperdal Risperdal Risperdal 16 mg / 5 cc (120 ml) 2 mg 4 mg 8 mg 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg 0.5 mg 1 mg 1 mg/ml solution Psychiatric Antipsychotic Risperidone Risperdal 2 mg Psychiatric Psychiatric Psychiatric Psychiatric Antipsychotic Antipsychotic Antipsychotic Antipsychotic Risperidone Risperidone Thiothixene Thiothixene Risperdal Risperdal Navane Navane 3 mg 4 mg 1 mg 10 mg Psychiatric Antipsychotic Thiothixene Navane 2 mg Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Antipsychotic Benzos Benzos Benzos Benzos Benzos Benzos Thiothixene Thiothixene Thiothixene Trifluoperazine Trifluoperazine Trifluoperazine Clonazepam (SCH IV) Clonazepam (SCH IV) Clonazepam (SCH IV) Diazepam (SCH IV) Diazepam (SCH IV) Diazepam (SCH IV) Navane Navane Navane Stelazine Stelazine Stelazine Klonopin Klonopin Klonopin Valium Valium Valium 20 mg 5 mg 5 mg/ml 10 mg 2 mg 5 mg 0.5 mg 1 mg 2 mg 10 mg 2 mg 5 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 20 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Psychiatric Benzos Benzos Benzos Hypnotic Hypnotic Hypnotic Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Mood Stabilizer Other Other Other Other Stimulant Stimulant Stimulant Stimulant Stimulant Stimulant Stimulant Stimulant Stimulant Stimulant Stimulant Lorazepam (SCH IV) Lorazepam (SCH IV) Lorazepam (SCH IV) Temazepam (SCH IV) Temazepam (SCH IV) Zolpidem Carbamazepine Carbamazepine Carbamazepine Divalproex sodium Divalproex sodium Divalproex sodium Divalproex sodium Divalproex sodium Lithium carbonate Lithium carbonate Lithium carbonate Lithium carbonate Buspirone HCI Buspirone HCI Buspirone HCI Buspirone HCI Dextroamphetamine/amphetamine Dextroamphetamine/amphetamine Dextroamphetamine/amphetamine Dextroamphetamine/amphetamine Methylphenidate long-acting Methylphenidate long-acting Methylphenidate long-acting Methylphenidate long-acting Methylphenidate short acting Methylphenidate short acting Methylphenidate short acting Ativan Ativan Ativan Restoril Restoril Ambien Tegretol Tegretol Tegretol Depakote DR Depakote DR Depakote ER Depakote DR Depakote ER Eskalith CR Eskalith CR Eskalith SR Eskalith SR BuSpar BuSpar BuSpar BuSpar Adderall XR Adderall XR Adderall XR Adderall XR Ritalin LA Ritalin LA Ritalin LA Ritalin LA Ritalin Ritalin Ritalin 0.5 mg 1.0 mg 2.0 mg 15 mg 30 mg 5, 10 mg tabs 100 mg 100 mg / 5 cc 200 mg 125 mg 250 mg 250 mg 500 mg 500 mg 150 mg 300 mg 300 mg 450 mg 10 mg 15 mg 30 mg 5 mg 10mg 15mg 20mg 30mg 10mg 20mg 30mg 40mg 10mg 20mg 30mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 21 of 22 HealthPAC Formulary Current as of January 2014 Class I Class II Generic Name Brand Name Strength Respiratory Respiratory Asthma Asthma Inhaler Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Respiratory Rheumatology Smoking deterrents Smoking deterrents Smoking deterrents Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin Nasal Inhaler Nebulizer soln Nebulizer soln Steroid inhaler Steroid inhaler Atrovent Serevent Diskus Proventil HFA (IDP) Flonase Proventil Atrovent Inh Sol Qvar Qvar Ventolin, Proventil Proventil Combivent MDI Intal Singulair Singulair Theo-Dur Theo-Dur Plaquenil NicoDerm NicoDerm NicoDerm Rocaltrol Rocaltrol 18mcg/dose MDI (14gm) 50 mcg Respiratory Ipratropium MDI Salmeterol xinafoate Albuterol HFA (IDP) tablet, MDI, solution, UD Fluticasone propionate Albuterol solution neb Ipratropium bromide 0.02% Beclomethasone dipropinate Beclomethasone dipropinate Albuterol liquid Albuterol Unit Dose Albuterol-ipratropium Inhaler Cromolyn inhaler Montelukast Montelukast Theophylline Theophylline Hydroxychloroquine Nicotine Patches- 28 weeks Nicotine Patches- 28 weeks Nicotine Patches- 28 weeks Calcitriol Calcitriol Folic Acid Pyridoxine Pyridoxine Vitamin B6 Vitamin D Vitamin K Vitamin B6 Vitamin B5 Calciferol Phytonadione Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. 90 mcg 50 mcg/spray 5 mg/ml (20 ml bottle) 500 mcg (3 cc/amp) 40 mcg 80 mcg 2 mg / 5 cc (120 ml) 0.83 mg/ml 14.2 Gm 10 mg 5 mg chew 200 mg 300 mg 200 mg 14mg 21mg 7mg 0.25 mcg 0.5mcg 800 MicorGrams 100mg 25mg 50 mg 50,000 units 5mg tab Page 22 of 22
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