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Southern California Kaiser Permanente Commercial Consumer FormularyImportant Points About Our Drug Formulary:

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms Tier5-Alpha-Reductase Inhibitor Finasteride Propecia Proscar ● Tablet: 5 mg 1Abortifacient Antineoplastic Agent, Hormone Antagonist Antiprogestin

Mifepristone Mifeprex ● Tablet: 200 mg 1

Abortifacient Prostaglandin Carboprost Tromethamine Hemabate ● Injection: Carboprost 250 mcg and tromethamine 83 mcg per mL (1 mL)

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● There are two Kaiser Permanente Commercial drug Formularies within California, one for Northern California and one for Southern California. In addition, Kaiser Permanente maintains a National Formulary for members who are covered by the Medicare Part D Outpatient Prescription Drug Benefit. Please note that injectable Formulary medications administered in the medical office or hospital setting may not appear on this Consumer Formulary list. The Medicare Part D Formulary is posted on the Kaiser Permanente Internet site: http://kp.org/seniormedrx

● The drug Formulary is revised periodically; therefore, the drugs on this list are subject to change.

● Plan physicians determine whether to prescribe a particular drug based upon their clinical judgment, and the presence of a drug on the formulary does not mean that your Plan physician will prescribe that drug for your condition.

● If a drug is included on this list, it does not mean that all strengths or dosage forms are on the Formulary. Please refer to the "Formulary Dosage Forms" column to view covered products.● The Formulary is comprised of the drugs in the column titled "Generic Name". Some of the most commonly recognized brand names of these drugs are listed in the column titled "Brand Name." The brand names are provided only as a reference to help you identify the formulary drug. Listing of the brand name does not mean that the brand name product is on the Formulary. A generic version may be the preferred product on the Formulary.

● Plan physicians are not required to obtain prior authorization from Kaiser Foundation Health Plan, Inc. for coverage of any drug included on the Formulary.

● Not all Kaiser Permanente benefit plans include coverage for prescription drugs and some drugs are excluded from coverage. Please read your Evidence of Coverage booklet or call our Member Service Call Center (1-800-464-4000) for more information about your coverage or any specific limitations or exclusions to your drug benefit.

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAbortifacient Prostaglandin Dinoprostone Cervidil Vaginal Insert Cervidil

Prepidil Vaginal Gel Prostin E2 Vaginal Suppository

● Gel, endocervical: 0.5 mg per 3 g● Insert, vaginal (Cervidil): 10 mg● Suppository, vaginal: 20 mg

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Acetylcholinesterase Inhibitor (Central)

Donepezil Aricept ● Tablet: 5 mg, 10 mg● Tablet, orally-disintegrating, as hydrochloride: 5 mg, 10 mg

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Acetylcholinesterase Inhibitor (Central)

Galantamine Razadyne ● Tablet: 4 mg, 8 mg, 12 mg● Capsules, extended release: 8 mg, 16 mg, 24 mg

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Acetylcholinesterase Inhibitor Neostigmine Prostigmin Bloxiverz ● Injection, as methylsulfate: 0.5 mg/mL = 1:2000 (10 mL); 1 mg/mL = 1:1000 (10 mL)● Tablet, as bromide: 15 mg

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Acetylcholinesterase Inhibitor Physostigmine ● Injection, as salicylate: 1 mg/mL (2 mL) [contains benzyl alcohol]

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Acetylcholinesterase Inhibitor Pyridostigmine Bromide Mestinon Regonol ● Injection: 5 mg/mL (2 mL)● Syrup: 60 mg/5 mL with alcohol 5% (480 mL)● Tablet: 60 mg● Tablet, sustained release: 180 mg

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Acetylcholinesterase Inhibitor Ophthalmic Agent, Antiglaucoma Ophthalmic Agent, Miotic

Echothiophate Iodide Phospholine Iodide ● Powder for reconstitution, ophthalmic: 6.25 mg [0.125%]

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Acne Products Antibiotic, Macrolide Antibiotic, Ophthalmic Antibiotic, Topical Topical Skin ProductTopical Skin Product, Acne

Erythromycin E-Mycin E.E.S. Ery-Tab EryPed ● Injection: 500 mg (30 mL); 1 g (30 mL)● Tablet (E.E.S.): 400 mg (30s, 40s, 100s)● Gel: 2% (27 g)● Ointment, ophthalmic: 5 mg/g (3.5 g) [OF]● Solution, topical: 1.5% (60 mL); 2% (60 mL)

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAcne ProductsTopical Skin Product, Acne

Erythromycin and Benzoyl peroxide

Benzamycin ● Erythromycin 30 mg and benzoyl peroxide 50 mg per g

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Antibiotic, Ophthalmic Antibiotic, Sulfonamide Derivative

Sodium Sulfacetamide Sodium Sulamyd ● Solution, ophthalmic: 10% [OF] 1

Acne Products Antibiotic, Sulfonamide Derivative AntiseborrheicAgent, Topical Topical Skin Product, Acne

Sulfur and Sodium Sulfacetamide

Novacet Sulfacet-R ● Cleanser, topical: Sulfur colloid 5% and sodium sulfacetamide 10%● Suspension, topical: Sulfur colloid 4% and sodium sulfacetamide 8%

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Acne Products Antiseborrheic Agent, Topical

Sulfur ● Powder, precipitated (for compounding use only)

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAcne Products Keratolytic AgentTopical Skin Product, Acne

Salicylic Acid Compound W One Step Wart Remover [OTC] DHS Sal [OTC]Dr. Scholl's Callus Remover [OTC] Dr. Scholl's Clear Away [OTC] DuoFilm [OTC]DuoPlant [DSC] [OTC] Freezone [OTC]Fung-O [OTC]Gordofilm [OTC] Hydrisalic [OTC] Ionax Astringent SkinCleanser Ionil Plus [OTC] Ionil [OTC] Keralyt [OTC] LupiCare Dandruff [OTC] LupiCare II Psoriasis [OTC] LupiCare Psoriasis [OTC] Mediplast [OTC] MG217 Sal-Acid [OTC]Mosco Corn and Callus Remover [OTC] NeoCeuticals Acne Spot Treatment [OTC] Neutrogena Acne Wash [OTC] Neutrogena Body Clear [OTC] Neutrogena

● Crystal (bulk) (for compounding use only)● Powder (bulk) (for compounding use only)● Skin cleanser, astringent (Ionax): Salicylic acid, allantoin, acetone, polyoxyethylene ethers and 48% isopropyl alcohol (240 mL) (for compounding use only)● Solution (Paplex Ultra): 26% in flexible collodion (15 mL with brush applicator)

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Acne Products Keratolytic AgentTopical Skin Product, Acne

Tazarotene Tazorac ● Cream, topical: 0.05%; 0.1% (15 g, 30 g, 60 g)● Gel, topical: 0.05% (30 g, 100 g), 0.1% (30g, 100 g)

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Acne ProductsRetinoic Acid Derivative

Isotretinoin Accutane, Sotret ● Capsule: 10 mg, 20 mg, 30 mg 40 mg

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAcne ProductsRetinoic Acid Derivative Topical Skin Product, Acne

Tretinoin, Topical Avita Retin-A ● Cream:● Tretinoin 0.025% (20 g, 45 g); 0.05% (20 g,45 g); 0.1% (20g, 45 g)● Gel:● Tretinoin: 0.01% (15 g, 45 g), 0.025% (15g, 45 g)● Retin-A Micro [microsphere gel]: 0.04% (20 g, 45 g); 0.1% (20 g, 45 g)

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Acne ProductsTopical Skin Product, Acne

Adapalene Differin ● Cream, topical: 0.1%● Gel, topical: 0.1%, 0.3%

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Acne ProductsTopical Skin Product, Acne

Adapalene and Benzoyl peroxide

Epiduo Epiduo Forte ● Gel, topical: Gel, topical: Epiduo: Adapalene 0.1% and benzoyl peroxide 2.5%● Gel, topical: Epiduo Forte: Adapalene 0.3% and benzoyl peroxide 2.5%

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Adjuvant, Chemoprotective Agent (Cytoprotective) Antidote

Amifostine Ethyol ● Injection, powder for reconstitution: 500 mg

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Adrenergic Agonist Agent Dobutamine Hydrochloride Dobutrex ● Injection: 12.5 mg/mL (20 mL)● Infusion, premix: 1 mg/ mL

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Adrenergic Agonist Agent Dopamine Hydrochloride ● Injection: 40 mg/mL (5 mL); 80 mg/mL (5 mL)● Infusion, premix: 1.6 mg/ mL

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Adrenergic Agonist Agent Ritodrine Hydrochloride Yutopar ● Injection: 10 mg/mL (5 mL) 1Adrenergic Agonist Agent Imidazoline Derivative Ophthalmic Agent, Vasoconstrictor

Tetrahydrozoline Hydrochloride

Tyzine Nasal ● Solution, nasal: 0.1% (15 mL) 1

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAldehyde Dehydrogenase Inhibitor Disulfiram Antabuse ● Tablet: 250 mg, 500 mg 1

Alkalinizing Agent Antacid Electrolyte Supplement, Oral Electrolyte Supplement, Parenteral

Sodium Bicarbonate Brioschi [OTC] Neut ● 7.5% (50 mL)● Tablet: 325 mg, 600 mg (100s each)● Infusion, premix: 5% (500 mL)

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Alkalinizing Agent, Oral Potassium Citrate Urocit-K ● Tablet: 540 mg [5 mEq], 1080 mg [10 mEq]

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Alkalinizing Agent, Oral Potassium Citrate and Citric Acid

Cytra-K Polycitra-K ● Powder:● Polycitra-K: Potassium citrate 3300 mg and citric acid 1002 mg per packet (100s) [sugar free]● Solution:● Polycitra-K: Potassium citrate 1100 mg and citric acid monohydrate 334 mg per 5 mL (480 mL) [alcohol free, sugar free]

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Alkalinizing Agent, Parenteral Sodium Lactate ● Injection: 1.87 g/100 mL = 16.7 mEq sodium and 16.7 mEq lactate per 100 mL (500 mL)

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Alkalinizing Agent, Parenteral Tromethamine THAM-E THAM ● Injection:● THAM: 36 mg/mL (500 mL)● THAM-E: 36 mg/mL with electrolytes, sodium 15 mEq, potassium 2.5 mEq, chloride17.5 mEq (500 mL)

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Allergen-Specific Immunotherapy Grass Pollen Allergen Extract (Timothy Grass)

Grastek ● Tablet Sublingual: Grastek: 2800 bau

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Alpha/Beta Agonist Ephedrine Sulfate Pretz-D [OTC] ● Injection: 50 mg/mL (1 mL) 1Alpha/Beta Agonist Norepinephrine Bitartrate Levophed ● Injection: 1 mg/mL (4 mL) 1

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAlpha/Beta Agonist Antidote Epinephrine Adrenalin Epifrin

EpiPen Injector EpiPen Jr Injector

● Auto-injector:● Adrenaclick™ (generic): 0.15 mg/0.15 mL (1.1 mL) [contains chlorobutanol, sodium bisulfite; 1:1000 solution; delivers 0.15 mg per injection]● Adrenaclick™ (generic): 0.3 mg/0.3 mL (1.1 mL) [contains chlorobutanol, sodium bisulfite; 1:1000 solution; delivers 0.3 mg per injection]● EpiPen: Delivers 0.3 mg I.M. of epinephrine 1:1000 (2 mL)● EpiPen Jr: Delivers 0.15 mg I.M. of epinephrine 1:2000 (2 mL)● Injection: 1 mg/mL = 1:1000 (1 mL, 30 mL); 0.1 mg/mL =1:10,000 (10 mL)● Inhalation solution: Racephinephrine 2.25% single unit-of- use vial (0.5 ml)● Ophthalmic, as borate: 1% (7.5 mL); 2% (7.5 mL)● Ophthalmic, as hydrochloride: 0.25% (15 mL); 0.5% (15 mL); 1% (15 mL)

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Alpha/Beta Agonist Ophthalmic Agent, Antiglaucoma Ophthalmic Agent, Mydriatic

Phenylephrine Hydrochloride

Isopto Frin Ophthalmic Solution Mydfrin Ophthalmic Solution Neo-Synephrine Ophthalmic Solution Prefrin Ophthalmic Solution

● Injection: 10 mg/mL (1 mL)● Solution:● Ophthalmic: 2.5% (5 mL) [OF]; 10% (Neo- Synephrine Plain) (5 mL) (prescription required) [OF] o

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Alpha1 Agonist Midodrine Hydrochloride ProAmatine ● Tablet: 2.5 mg, 5 mg (100s) 1

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAlpha1 Agonist Imidazoline DerivativeOphthalmic Agent, Vasoconstrictor

Naphazoline Hydrochloride Albalon Liquifilm Vasocon Regular

● Solution, ophthalmic: 0.1% (15 mL) [OF]

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Alpha1 Blocker Doxazosin Cardura ● Tablet: 1 mg, 2 mg, 4 mg, 8 mg 1Alpha1 Blocker Phenoxybenzamine

HydrochlorideDibenzyline ● Capsule: 10 mg (100s) 1

Alpha1 Blocker Phentolamine Mesylate Regitine ● Injection: 5 mg/mL (1 mL) 1Alpha1 Blocker Prazosin Hydrochloride Minipress ● Capsule: 1 mg (prazosin starter pack

#50 for titrating from 1 mg/day to 2 mg twice daily over 21 days) (100s); 2 mg5 mg (100s each)

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Alpha1 Blocker Tamsulosin Flomax ● Capsules (Geneva brand only): 0.4 mg

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Alpha1 Blocker Terazosin Hytrin ● Capsules (Geneva brand only): 1 mg, 2 mg, 5 mg, 10 mg (100s each)

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Alpha2 Agonist, Ophthalmic Apraclonidine Hydrochloride

Iopidine ● Solution, ophthalmic: 0.5% (5 mL) 1

Alpha2 Agonist, Ophthalmic Ophthalmic Agent, Antiglaucoma

Brimonidine Alphagan P ● Solution, ophthalmic (Generic): 0.2% (5 mL, 10 mL, 15 mL) [contains benzalkonium chloride]

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Alpha2-Adrenergic Agonist Clonidine Catapres-TTS Catapres ● Patch, transdermal: (Catapres-TTS-1) 0.1 mg/24 hours (12s); (Catapres-TTS-2) 0.2 mg/24 hours (12s); (Catapres- TTS-3) 0.3 mg/24 hours (4s)● Tablet, as hydrochloride: 0.1 mg, 0.2 mg,0.3 mg (100s each)

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Alpha2-Adrenergic Agonist Guanfacine Tenex (Generic) ● Tablet: 1 mg, 2 mg 1Alpha2-Adrenergic Agonist Tizanidine Zanaflex ● Tablet: 2 mg, 4 mg (150s) 1

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAlpha-Adrenergic Inhibitor Alpha2-Adrenergic Agonist

Methyldopa Aldomet ● Injection, as methyldopate hydrochloride: 50 mg/mL (5 mL)● Tablet: 125 mg, 250 mg, 500 mg (100s each)

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Amebicide Iodoquinol Yodoxin ● Tablet: 210 mg, 650 mg (100s each) 1

Amebicide Paromomycin Sulfate Humatin ● Capsule: 250 mg 1AmebicideAntibiotic, Miscellaneous Antibiotic, Topical Antiprotozoal, Nitroimidazole

Metronidazole Flagyl MetroCream MetroGel-Vaginal MetroGel

● Cream, topical: 0.75%● Gel, topical: 0.75% (30 g, 45g)● Gel, vaginal: 0.75% (70 g)● Tablet: 250 mg (100s); 500 mg (14s, 100s)● Injection, ready to use: 5 mg/mL (100 mL)● Infusion, premix 500 mg

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Aminoquinoline (Antimalarial) Chloroquine Phosphate Aralen Phosphate ● Tablet: 250 mg = 150 mg base; 500 mg = 300 mg base (100s each)

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Aminoquinoline (Antimalarial) Hydroxychloroquine Sulfate

Plaquenil ● Tablet: 200 mg (100s) 1

Aminoquinoline (Antimalarial) Primaquine Phosphate ● Tablet: 26.3 mg = base 15 mg 1Ammonium Detoxicant Antibiotic, Aminoglycoside Antibiotic, Topical

Neomycin Sulfate Mycifradin Sulfate ● Solution, oral: 125 mg/5 mL (480 mL)● Tablet: 500 mg (100s)

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Ammonium Detoxicant Laxative, Osmotic

Lactulose Cephulac ● Syrup: 10 g/15 mL (480 mL) 1

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnalgesic Combination (Opioid) Hydrocodone and

AcetaminophenNorco Vicodin ● Tablet:

● Hydrocodone bitartrate 5 mg and acetaminophen 325 m● Hydrocodone bitartrate 5 mg and acetaminophen 500 mg● Hydrocodone bitartrate 7.5 mg and acetaminophen 325 mg● Hydrocodone bitartrate 10 mg and acetaminophen 325 mg● Solution, oral: Hydrocodone bitartrate 7.5 mg and acetaminophen 325 mg per 15 mL (480 mL)● Solution, oral: Hydrocodone bitartrate 10 mg and acetaminophen 325 mg per 15 mL (480 mL)● Elixir: Hydrocodone bitartrate 10 mg and acetaminophen 300 mg per 15 mL

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Analgesic Combination (Opioid) Antispasmodic Agent, Urinary

Belladonna and Opium B&O Supprettes ● Suppository, rectal:● #15 A: Belladonna 16.2 mg and opium 30 mg (12s)● #16 A: Belladonna 16.2 mg and opium 60 mg (12s)

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Analgesic, Miscellaneous Acetaminophen Ofirmev ● Injection, solution [preservative free]: 10 mg/mL

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Analgesic, Miscellaneous Acetaminophen, Isometheptene Mucate, and Dichloralphenazone

Midrin ● Capsule: Acetaminophen 325 mg and isometheptene mucate 65 mg with dichloralphenazone 100 mg (30s, 50s, 100s)

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Analgesic, Nonopioid Tramadol Ultram ● Tablet, as hydrochloride: 50 mg 1

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnalgesic Combination (Opioid) Tramdol and

AcetaminophenUltracet ● Tablet: Acetaminophen 325 mg and

tramadol hydrochloride37.5 mg

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Analgesic, Opioid Acetaminophen and Codeine

Tylenol With Codeine ● Elixir (C-V): Acetaminophen 120 mg and codeine phosphate 12 mg per 5 mL with alcohol 7% (120 mL)● Tablet (C-III):● #2: Acetaminophen 300 mg and codeine phosphate 15 mg (100s)● #3: Acetaminophen 300 mg and codeine phosphate 30 mg (20s, 30s, 50s, 100s)● #4: Acetaminophen 300 mg and codeine phosphate 60 mg (100s)

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Analgesic, Opioid Buprenorphine and Naloxone

Suboxone ● Tablet, sublingual: Buprenorphine 2 mg and naloxone 0.5 mg; buprenorphine 8 mg and naloxone 2 mg [lemon-lime flavor]

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Analgesic, Opioid Butorphanol Tartrate Stadol ● Injection: 1 mg/mL (1 mL); 2 mg/mL (1 mL, 2 mL, 10 mL)

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Analgesic, Opioid Hydromorphone Hydrochloride

Dilaudid ● Injection: 2 mg/mL (1 mL); 4 mg/mL (1 mL)● Suppository, rectal: 3 mg (6s)● Tablet: 2 mg, 4 mg (100s each)● Solution, oral: 1 mg/mL

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Analgesic, Opioid Meperidine Hydrochloride Demerol ● Injection: Single dose: 25 mg/dose (1 mL); 50 mg/dose (1 mL); 100 mg/dose (1 mL)

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Analgesic, Opioid Methadone Hydrochloride Dolophine ● Injection: 10 mg/mL (1 mL, 10 mL, 20 mL)● Tablet: 5 mg, 10 mg

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnalgesic, Opioid Morphine Sulfate RMS ● Injection: 10 mg/mL (1 mL); 15

mg/mL (1 mL)● Injection, preservative free: 0.5 mg/mL (10 mL); 1 mg/mL (10 mL)● Solution, oral: 10 mg/5 mL (100 mL, 120 mL, 500 mL); 20mg/5 mL (100 mL, 120 mL, 500 mL); 20mg/mL (30 mL, 120 mL)● Suppository, rectal: 5 mg, 10 mg, 20 mg (12s each)● Tablet: 15 mg, 30 mg● Tablet, soluble: 10mg, 15 mg, 30 mg● Tablet, controlled release: 15 mg, 30 mg, 60 mg, 100 mg (50s, 100s each)● Tablet, extended release: 200 mg

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Analgesic, Opioid Nalbuphine Hydrochloride Nubain ● Injection: 10 mg/mL (1 mL, 10 mL); 20 mg/mL (1 mL, 10 mL)

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Analgesic, Opioid Oxycodone Endocodone OxyIR Percolone Roxicodone Intensol Roxicodone

● Tablet, immediate-release: 5 mg 1

Analgesic, Opioid Oxycodone and Acetaminophen

Percocet ● Tablet : Oxycodone hydrochloride 5 mg and acetaminophen 325 mg (100s)● Tablet : Oxycodone hydrochloride 7.5 mg and acetaminophen 325 mg (100s)● Tablet : Oxycodone hydrochloride 10 mg and acetaminophen 325 mg (100s)

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnalgesic, Opioid Oxymorphone

HydrochlorideNumorphan ● Injection: 1 mg (1 mL) 1

Analgesic, Opioid Paregoric ● Liquid: 2 mg morphine equivalent/5 mL (120 mL)

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Analgesic, Opioid Pentazocine Talwin Nx ● Tablet: Pentazocine hydrochloride 50 mg and naloxone hydrochloride 0.5 mg (100s)

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Analgesic, Opioid Anilidopiperidine Opioid

Alfentanil Hydrochloride Alfenta ● Injection, preservative free: 500 mcg/mL (2 mL, 5 mL, 10 mL, 20 mL)

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Analgesic, Opioid Anilidopiperidine Opioid General Anesthetic

Fentanyl Citrate Duragesic Sublimaze ● Injection: 0.05 mg/mL (2 mL, 5 mL, 20 mL)● Transdermal system: 12.5 mcg/hour (3.13 cm2); 12.5 mcg/hour (5 cm2); 25 mcg/hour (10 cm2); 50 mcg/hour (20 cm2); 75 mcg/hour (30 cm2); 100 mcg/hour (40 cm2)

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Analgesic, Opioid Antitussive Codeine ● Injection, as phosphate: 15 mg/mL, 30 mg/mL (2 mL) [contains sodium metabisulfite]● Tablet, as sulfate: 15 mg, 30 mg, 60 mg (30s, 100s each)

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Analgesic, Topical Dichlorodifluorometha ne and Trichloromonofluorom ethane

Fluori-Methane Topical Spray ● Spray, topical: Dichlorodifluoromethane 15% and trichloromonofluoromethane 85%

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnalgesic, Topical Antiarrhythmic Agent, Class Ib Local Anesthetic

Lidocaine Hydrochloride Xylocaine ● Injection: 1% (30 mL, 50 mL); 2% (30 mL,50 mL)● Injection, solution, as hydrochloride [preservative free]: 1% [10 mg/mL] (2 mL)● Infusion: 40 mg/mL (25 mL, 50 mL)● Infusion: 2 gm in 500 mL● Solution, viscous topical: 2% (30 mL)● Ointment, topical: 2.5% (35 g); 5% (37 g)● Solution, topical: 2% (50 mL); 4% (5 mL, 50 mL)

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Analgesic, Urinary Pentosan Polysulfate Sodium

Elmiron ● Capsule: 100 mg (100s) 1

Androgen Danazol Danocrine ● Capsule: 50 mg, 100 mg, 200 mg (100s each)

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Androgen Fluoxymesterone Halotestin ● Tablet: 10 mg (100s each) 1Androgen Methyltestosterone Metandren Oreton ● Tablet: 10 mg 1Androgen Oxandrolone Oxandrin ● Tablet: 2.5 mg (100s) 1

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAndrogen Testosterone Androderm AndroGel

DelatestrylDepo-Testosterone Oreton Propionate Testim Vogelxo

● Injection, in oil, as cypionate: 50 mg/mL (10 mL); 100 mg/mL (10 mL); 200 mg/mL (10 mL)● Injection, in oil, as enanthate: 200 mg/mL (5 mL)● Injection, in oil, as cypionate (Depo Testosterone): 200 mg/mL (1 mL, 10 mL) [contains benzyl alcohol, benzyl benzoate, and cottonseed oil]● Testosterone transdermal system (Androderm): 2 mg/day; 4 mg/ day (30)● Gel, topical: 1%

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Anesthetic, Topical Diagnostic Agent Ophthalmic Agent

Fluorescein and Benoxinate EyeFlur Fluress Flurox ● Solution, ophthalmic: 0.25% with benoxinate 0.4% (5 mL) [OF]

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Anesthetic/Corticosteroid Pramoxine and Hydrocortisone

Analpram-HC Proctofoam- HC ● Lotion, topical: Pramosone®: Pramoxine hydrochloride 1% and hydrocortisone acetate 2.5% Cream, topical● Analpram-HC®: Pramoxine hydrochloride 1% and hydrocortisone acetate 1%● Analpram-HC®: pramoxine hydrochloride 1% and hydrocortisone acetate 2.5%● Foam, rectal (ProctoFoam-HC): Pramoxine hydrochloride 1% and hydrocortisone acetate 1% (10 g)

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAngiogenesis Inhibitor Antineoplastic Agent Immunosuppressant Agent Tumor Necrosis Factor (TNF) Blocking Agent

Lenalidomide Revlimid ● Capsule: 2.5 mg, 5 mg, 10 mg, 15 mg, 20mg, 25 mg

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Angiogenesis Inhibitor Antineoplastic Agent Immunomodulator

Pomalidomide Pomalyst ● Capsule, Oral: Pomalyst: 1 mg, 2 mg, 3 mg, and 4 mg

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Angiogenesis Inhibitor Immunosuppressant Agent Tumor Necrosis Factor (TNF) Blocking Agent

Thalidomide Thalomid® ● Capsule: 50 mg, 100 mg, 150 mg, 200 mg

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Angiotensin II Receptor Blocker Losartan Potassium Cozaar ● Tablet, film coated, as potassium salt: 25 mg, 50 mg, 100 mg

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Angiotensin II Receptor Blocker; Neprilysin Inhibitor

Sacubitril and valsartan

Entresto

● Tablet, Oral: Entresto: Sacubitril 24 mg and valsartan 26 mg, Sacubitril 49 mg and valsartan 51 mg, Sacubitril 97 mg and valsartan 103

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Angiotensin II Receptor Blocker Valsartan generic Diovan ● Tablet, oral: 40 mg, 80 mg, 160 mg, 320 mg

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Angiotensin II Receptor Blocker Diuretic, thiazide

Valsartan Hydrochlorothiazide

Generic Diovan-HCT ● Tablet, oral: 80 mg/12.5 mg, 160 mg/12.5 mg, 160 mg/25 mg, and 320 mg/12.5 mg

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Angiotensin-Converting Enzyme (ACE) Inhibitor

Benazapril Lotensin ● Tablet, oral, as hydrochloride: 5 mg, 10 mg, 20 mg, 40 mg

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Captopril Capoten ● Tablet: 12.5 mg, 25 mg, 50 mg (100s, 200s each), 100 mg (100s)

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Enalapril Vasotec I.V. ● Injection: as enalaprilat: 1.25 mg/mL (1 mL, 2 mL)

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Lisinopril Prinivil ● Tablet: 2.5 mg, 5 mg, 20 mg (30s, 50s, 100s); 10 mg (100s); 40 mg (50s, 100s)

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Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntacid Antidote Protectant, Topical

Aluminum Hydroxide AlternaGEL [OTC] Alu- Cap [OTC] Alu-Tab [OTC] Amphojel [OTC]

● Gel: 600 mg/5 mL (360 mL) 1

Antacid Antiflatulent Aluminum Hydroxide, Magnesium Hydroxide, and Simethicone

Alamag Plus [OTC] Aldroxicon I [OTC] Aldroxicon II [OTC] Almacone Double Strength [OTC] Almacone [OTC] Gelusil [OTC] Maalox Max [OTC] Maalox [OTC]Mi-Acid Maximum Strength [OTC] Mi-Acid [OTC]Mintox Extra Strength [OTC] Mintox Plus [OTC] Mylanta Liquid [OTC] Mylanta Maximum Strength Liquid [OTC]

● Liquid:● Aluminum hydroxide 200 mg, magnesium hydroxide 200 mg and simethicone 20 mg per 5 mL● Suspension: Aluminum hydroxide 225 mg, magnesium hydroxide 200 mg and simethicone 25 mg per 5 mL (360 mL)● Aluminum hydroxide 400 mg, magnesium hydroxide 400 mg and simethicone 40 mg per 5 mL (360 mL)● Tablet, chewable: Aluminum hydroxide 200, magnesium hydroxide 200 mg and simethicone 25 mg

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Antacid Laxative Magnesium Salt Magnesium Hydroxide Phillips' Milk of Magnesia [OTC]

● Liquid: 400 mg/5 mL (480 mL) 1

Antacid Protectant, Topical Aluminum Hydroxide, Magnesium Trisilicate, Sodium Bicarbonate, and Alginic Acid

Gaviscon [OTC] ● Tablet, chewable: Aluminum hydroxide 80 mg, magnesium trisilicate 20 mg, sodium bicarbonate 70 mg, and alginic acid 200 mg (100s)

1

Anthelmintic Albendazole Albenza ● Tablet: 200 mg 1Antianxiety Agent, Miscellaneous Buspirone Hydrochloride BuSpar ● Tablet: 5 mg, 10 mg, 30 mg 1Antiarrhythmic Agent, Class Ia Disopyramide Phosphate Norpace CR Norpace ● Capsule: 100 mg (100s), 150 mg

(30s,100s)● Capsule, sustained action: 100 mg, 150 mg (100s each)

1

17

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiarrhythmic Agent, Class Ia Procainamide

HydrochlorideProcanbid Pronestyl ● Injection: 100 mg /m L (10 m L);

500 mg/m L (2 m L) D

1

Antiarrhythmic Agent, Class Ia Quinidine Quinaglute Dura-Tabs Quinidex Extentabs

● Injection, as gluconate: 80 mg/mL (10 mL)● Tablet, as sulfate: 200 mg, 300 mg (100s)● Tablet:● Extended release, as sulfate: 300 mg (100s)● Extended release, as gluconate: 324 mg (100s)

1

Antiarrhythmic Agent, Class Ib Mexiletine Hydrochloride Mexitil ● Capsule: 150 mg, 200 mg, 250 mg (100s each)

1

Antiarrhythmic Agent, Class Ib Anticonvulsant, Hydantoin

Phenytoin Dilantin ● Capsule, as sodium, extended: 30 mg (100s); 100 mg (100s, 200s)● Injection, as sodium: 50 mg/mL (2 mL, 5 mL)● Suspension, oral: 125 mg/5 mL (240 mL)● Tablet, chewable: 50 mg (100s)

1

Antiarrhythmic Agent, Class Ic Flecainide Acetate Tambocor ● Tablet: 50 mg, 100 mg and 150 mg (100s)

1

Antiarrhythmic Agent, Class Ic Propafenone Hydrochloride Rythmol ● Tablet: 150 mg, 225 mg, 300 mg 1

Antiarrhythmic Agent, Class II Antiarrhythmic Agent, Class IIIBeta-Adrenergic Blocker, Nonselective

Sotalol Hydrochloride Betapace ● Tablet (generic only): 80 mg, 120 mg, 160 mg, 240 mg

1

Antiarrhythmic Agent, Class II Beta Blocker, Beta1 Selective

Esmolol Hydrochloride Brevibloc ● Injection: 10 mg/mL, 20 mg/mL● Infusion, premix: 2,500 mg in 250 mL, 10 mg/ mL

1

18

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiarrhythmic Agent, Class II Beta-Adrenergic Blocker, Nonselective

Propranolol Hydrochloride ● Injection: 1 mg/mL (1 mL)● Tablet: 10 mg; 20 mg (100s, 200s each); 40 mg (100s); 60 mg (100s); 80 mg (100s, 200s)

1

Antiarrhythmic Agent, Class III Amiodarone Hydrochloride Cordarone ● Injection: 50 mg/mL (3 mL)● Tablet (generic only): 200 mg (60s)

1

Antiarrhythmic Agent, Class III Dofetilide Tikosyn ● Capsule: 125 mcg, 250 mcg, 500 mcg (14s, 60s)

1

Antiarrhythmic Agent, Class III Ibutilide Corvert ● Injection, as fumarate: 0.1 mg/mL (10 mL)

1

Antiarrhythmic Agent, Class IV Calcium Channel Blocker

Verapamil Hydrochloride Calan SR Calan ● Injection: 2.5 mg/mL (2 mL)● Tablet: 40 mg, 80 mg, 120 mg (100s each)● Tablet, sustained release: 120 mg, 180 mg, 240 mg (100s each)

1

Antiarrhythmic Agent, Class IV Cardiac Glycoside

Digoxin Lanoxin ● Elixir, pediatric: 50 mcg/mL (60 mL) [contains alcohol 10%; lime flavor]● Injection: 250 mcg/mL (2 mL) [contains alcohol 10%]● Injection, pediatric: 100 mcg/mL (1 mL) [contains alcohol 10%]● Tablet: 125 mcg, 250 mcg

1

Antiarrhythmic Agent, Class IV Diagnostic Agent

Adenosine Adenocard Adenoscan ● Injection:● Adenocard: 3 mg/mL (2 mL)● Adenoscan: 3 mg/mL (30 mL)

1

Antibiotic, Aminoglycoside Amikacin Sulfate Amikin ● Injection: 50 mg/mL (2 mL); 250 mg/mL (2 mL, 4 mL)

1

Antibiotic, Aminoglycoside Antibiotic, Ophthalmic

Tobramycin Nebcin o Injection, as sulfate: 10 mg/mL (2 mL); 40 mg/mL (2 mL) o

1

19

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Aminoglycoside Antibiotic, Ophthalmic

Tobramycin Inhalation Solution

TOBITOBI Podhaler

● Solution for inhalation (TOBI): 300 mg/5 mL● Capsules, powder for inhalation (TOBI Podhaler): 28 mg

1

Antibiotic, Aminoglycoside Antibiotic, Ophthalmic Antibiotic, Topical

Gentamicin Sulfate Garamycin ● Cream: 0.1% (15 g)● Ointment: Ophthalmic: 0.3% [3 mg/g] (3.5g) [OF]● Topical: 0.1% (15 g)● Solution, ophthalmic: 0.3% (5 mL) [OF]● Injection: 10 mg/mL (2 mL); 40 mg/mL (2 mL)● Infusion, premix: 40 mg (50 mL), 60 mg (100 mL), 80 mg (100 mL), 100 mg (100 mL), 120 mg (100 mL)● Infusion, as sulfate: 90 mg (100 mL), 70 mg (50 mL), 60 mg/mL; 80 mg/ mL

1

Antibiotic, Aminoglycoside Antitubercular Agent

Streptomycin Sulfate ● Injection, powder for reconstitution: 1 g

1

Antibiotic, Carbapenem Ertapenem Invanz ● Injection, powder for reconstitution: 1 g [contains sodium 137 mg/g]

1

Antibiotic, Carbapenem Meropenem Merrem I.V. ● Injection: 500 mg (15 mL; ADD-Vantage, 20 mL, 100 mL); 1 g (15 mL; ADD-Vantage, 30 mL, 100 mL)

1

Antibiotic, Cephalosporin (First Generation)

Cefazolin Sodium Ancef Kefzol ● Injection: 500 mg, 1 g● Infusion, premix: 1 g

1

20

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Cephalosporin (First Generation)

Cephalexin Monohydrate Keflex ● Capsule: 250 mg (40s, 100s); 500 mg (40s, 100s)● Suspension, oral: 125 mg/5 mL (100 mL, 200 mL); 250 mg/5 mL (100 mL, 200 mL)

1

Antibiotic, Cephalosporin (First Generation)

Cephradine Velosef ● Suspension, oral: 250 mg/5 mL (100 mL)

1

Antibiotic, Cephalosporin (Fourth Generation)

Cefepime Maxipime ● Powder for injection, as hydrochloride: 500 mg, 1 g, 2 g

1

Antibiotic, Cephalosporin (Second Generation)

Cefaclor Ceclor ● Capsules: 250 mg (15s, 100s); 500 mg (15s, 100s)

1


Cefoxitin Mefoxin ● Injection, powder for reconstitution, as sodium: 1 g, 2 g, 10 g [contains sodium 53.8 mg/g (2.3 mEq/g)]● Infusion, premix: 1 g, 2 g

1


Cefuroxime Ceftin Zinacef ● Suspension Reconstituted, Oral, as axetil [strength expressed as base]:125 mg/5 mL (100 mL)● Injection, as sodium: 750 mg, 1.5 g● Infusion, premix: 750 mg, 1.5 g● Tablet, as axetil: 250 mg, 500 mg● Infusion [premixed iso-osmotic diluent solution]: 1.5g

1

Antibiotic, Cephalosporin (Third Generation)

Cefdinir Omnicef ● Suspension, oral: 125 mg/5 mL , 250 mg/5 mL (60 mL, 100 mL)

1


Cefixime Suprax ● Powder for oral suspension: 100 mg/5 mL● Tablet: 400 mg

1

21

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Cephalosporin (Third Generation)

Cefotaxime Sodium Claforan ● Infusion, as sodium [premixed in D5W]: 1 g (50 mL); 2 g (50 mL)● Injection, powder for reconstitution, as sodium: 500 mg, 1 g, 2 g, 10 g, 20 g● Claforan: 500 mg, 1 g, 2 g, 10 g [contains sodium 50.5 mg (2.2 mEq) per cefotaxime 1 g]

1


Cefotetan ●Injection, powder for reconstitution: 1 g, 2 g [contains sodium 80 mg/g (3.5 mEq/g)]● Infusion, premix: 1 g, 2 g

1


Cefpodoxime Vantin ● Tablet, film coated, as proxetil: 100 mg (20s), 200 mg (20s)

1


Ceftazidime Ceptaz Fortaz Tazicef Tazidime ● Injection, powder for reconstitution:● 500 mg, 1 g, 2 g [contains sodium carbonate]● Infusion, premix: 1 g, 2 g

1


Ceftriaxone Sodium Rocephin ● Powder for injection: 250 mg, 500 mg, 1 g, 2 g, 10 g● Infusion [premixed in dextrose]: 1 g, 2 g● Injection [iso-osmotic dextrose]: 1 g, 2 g

1

Antibiotic, Cephalosporin (Fourth Generation)

Cefepime Maxipime ● Injection, powder for reconstitution: 500 mg, 1 g, 2 g

1

Antibiotic, Cyclic Lipopeptide Daptomycin Cubicin ● Injection, powder for reconstitution: 500 mg

1

22

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Lincosamide Topical Skin Product, Acne

Clindamycin Cleocin Pediatric Cleocin T Cleocin Vaginal

● Capsule, as hydrochloride: 150 mg, 300 mg● Lotion, topical: 1% (60 mL)● Solution, topical: 1% (60 mL)● Cream, vaginal, as phosphate: 2% (40 g)● Granules for oral suspension, as palmitate: 75 mg/5 mL (100 mL, 200 mL)● Injection, as phosphate: 150 mg/mL (2 mL, 4 mL)● Infusion, premix: 300 mg, 600 mg, 900 mg

1

Antibiotic, Macrolide Clarithromycin Biaxin Filmtabs ● Granules for oral suspension: 125 mg/5 mL (after reconstitution) (50 mL, 100 mL), 250 mg/5 mL (after reconstitution) (50 mL, 100 mL)● Tablet: 250 mg, 500 mg (60s each)

1

Antibiotic, Macrolide Antibiotic, Macrolide Combination Antibiotic, Sulfonamide Derivative

Erythromycin and Sulfisoxazole

Pediazole ● Suspension, oral: Erythromycin ethylsuccinate 200 mg and sulfisoxazole acetyl 600 mg per 5 mL (100 mL, 150 mL, 200 mL)

1

23

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Macrolide Antibiotic, Ophthalmic

Azithromycin Zithromax ● Injection, powder for reconstitution, as dihydrate: 500 mg● Powder for oral suspension: 1 g (single dose packet); 100 mg/5 mL after reconstitution (300 mg bottle); 200 mg/5 mL after reconstitution (600 mg, 900 mg bottles)● Tablet, as dihydrate: 250 mg (30s), (unit dose 50s); 500 mg [contains sodium 1.8 mg per tablet]; 600 mg (30s)

1

Antibiotic, Miscellaneous Aztreonam Azactam ● Injection: 500 mg (15 mL, 100 mL); 1 g (15mL, 50 mLViaflex, 100 mL bottle); 2 g (15 mL, 50 mL Viaflex, 100 mL bottle)●Infusion, premix: 1 g, 2 g

1

Antibiotic, Miscellaneous Chloramphenicol Chloromycetin ● Injection, powder for reconstitution (Chloromycetin Sodium Succinate): 1 g [contains sodium ~52 mg/g (2.25 mEq/g)]

1

Antibiotic, Miscellaneous Methenamine Hiprex ● Tablet, as hippurate (Hiprex): 1 g (100s)

1

Antibiotic, Miscellaneous Nitrofurantoin Furadantin Macrobid Macrodantin

● Capsule, as monohydrate, macrocrystal (Macrobid): 100 mg (100s)● Capsule, macrocrystal (Macrodantin): 25 mg, 50 mg, 100 mg (100s each)● Suspension, oral (Furadantin): 25 mg/5 mL (60 mL, 470 mL)

1

Antibiotic, Miscellaneous Pentamidine Isethionate NebuPent Pentam-300 ● Aerosol: 300 mg● Injection: 300 mg

1

24

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Miscellaneous Rifampin and Isoniazid Rifamate ● Capsule: Isoniazid 150 mg and

rifampin 300 mg (100s)1

Antibiotic, Miscellaneous Spectinomycin Hydrochloride

Trobicin ● Powder for injection: 2 g 1

Antibiotic, Miscellaneous Trimethoprim Proloprim Trimpex ● Tablet: 100 mg 1Antibiotic, Miscellaneous Vancomycin Hydrochloride Vancocin ● Capsule: 125 mg, 250 mg

● Powder for oral solution: 1 g● Powder for injection: 500 mg, 1 g● Infusion, premix: 500 mg, 1 g

1

Antibiotic, Miscellaneous Rifaximin Xifaxan ● Tablet, oral: 550 mg 1Antibiotic, Miscellaneous Antibiotic, Ophthalmic Antibiotic, Topical

Bacitracin AK-Tracin [DSC] Baciguent [OTC] BaciiM

● Injection: 50,000 units● Ointment, ophthalmic: 500 units/g (3.5 g) [OF]● Ointment, topical: 500 units/g (0.9 g, 15 g, 30 g, 120 g, 454 g)

1

Antibiotic, Miscellaneous Antibiotic, Sulfonamide Derivative

Co-trimoxazole Bactrim DS Bactrim Septra DS Septra

● Injection: Sulfamethoxazole 80 mg and trimethoprim 16 mg per mL (5 mL, 10 mL)● Suspension, oral: Sulfamethoxazole 200 mg and trimethoprim 40 mg per 5 mL (150 mL, 100 mL, 200 mL)● Tablet: Sulfamethoxazole 400 mg and trimethoprim 80 mg (100s)● Tablet, double strength: Sulfamethoxazole 800 mg and trimethoprim 160 mg (10s, 14s, 20s, 28s, 30s, 100s)

1

Antibiotic, Miscellaneous Antitubercular Agent

Cycloserine Seromycin Pulvules ● Capsule: 250 mg (100s) 1

Antibiotic, Miscellaneous Antitubercular Agent

Rifabutin Mycobutin ● Capsule: 150 mg 1

25

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Miscellaneous Antitubercular Agent

Rifampin Rifadin Rimactane ● Capsule: 150 mg (100s), 300 mg (100s)● Injection, powder for reconstitution: 600 mg

1

Antibiotic, Miscellaneous Topical Skin Product, Acne

Dapsone Aczone ● Tablet: 25 mg, 100 mg (100s each) 1

Antibiotic, Ophthalmic Neomycin, Polymyxin B, and Gramicidin

Neosporin Ophthalmic Solution ● Solution, ophthalmic: Neomycin sulfate1.75 mg, polymyxin B sulfate 10,000 units, and gramicidin 0.025 mg per mL (10 mL) [OF]

1

Antibiotic, Ophthalmic Trimethoprim and Polymyxin B

Polytrim Ophthalmic ● Solution, ophthalmic: Trimethoprim sulfate 1 mg and polymyxin B sulfate 10,000 units per mL (10 mL) [OF]

1

Antibiotic, Ophthalmic Antibiotic, Otic Antibiotic, TopicalCorticosteroid, Ophthalmic Corticosteroid, Otic Corticosteroid, Topical

Neomycin, Polymyxin B, and Hydrocortisone

Cortisporin Cream Cortisporin Otic

● Solution, otic: Neomycin sulfate 3.5 mg, polymyxin B sulfate 10,000 units, and hydrocortisone 10 mg per mL (10 mL)● Suspension, otic: Neomycin sulfate 3.5 mg, polymyxin B sulfate 10,000 units, and hydrocortisone 10 mg per mL (10 mL)

1

26

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Ophthalmic Antibiotic, Quinolone

Ciprofloxacin Hydrochloride

Ciloxan Ophthalmic Cipro ● Injection: 200 mg (20 mL); 400 mg (40 mL)● Infusion, premix: 200 mg, 400 mg● Microcapsules for oral suspension (Cipro): 250 mg/5 mL (100 mL); 500 mg/5 mL (100 mL) [strawberry flavor]● Solution, ophthalmic, generic: 3.5 mg/mL (2.5 mL, 5 mL) [OF]● Tablet: 250 mg (50s, 100s); 500 mg (14s, 20s, 50s, 100s); 750 mg (50s)

1

Antibiotic, Ophthalmic Antibiotic, Quinolone

Gatifloxacin ZymaxidR) ● Solution, ophthalmic: 0.5% [OF] [contains benzalkonium chloride]

1

Antibiotic, Quinolone Levofloxacin Levaquin ● Tablet: 250 mg, 500 mg, 750 mg● Infusion, premixed in D5W [preservative free]: 250 mg (50 mL); 500 mg (100 mL); 750 mg (150 mL)● Solution, oral: 25 mg/mL

1

Antibiotic, Ophthalmic Antibiotic, Quinolone

Moxifloxacin Avelox ● Solution for infusion: 400 mg/250 mL premixed bag● Tablet: 400 mg

1

Antibiotic, Ophthalmic Antibiotic, Topical

Bacitracin and Polymyxin B

Polysporin ● Ointment, ophthalmic: Bacitracin 500 units and polymyxin B sulfate 10,000 units per g (3.5 g) [OF]

1

Antibiotic, Ophthalmic Antibiotic, Topical

Bacitracin, Neomycin, and Polymyxin B

Neosporin Ophthalmic Ointment ● Ointment, ophthalmic: Bacitracin 400 units, neomycin sulfate 3.5 mg and polymyxin B sulfate 10,000 units per g (3.75 g) [OF]

1

Antibiotic, Oral Rinse Antibiotic, Topical

Chlorhexidine Gluconate Peridex Oral Rinse PerioGard ● Rinse: Oral (mint flavor) (Peridex, PerioGard): 0.12% with alcohol 11.6% (480 mL)

1

27

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Oxazolidinone Linezolid Zyvox ● Infusion: 200 mg (100 mL); 600 mg

(300 mL)● Suspension, oral (orange-flavored): 20 mg/mL (150 mL)● Tablet: 600 mg (20s, 100s)

1

Antibiotic, Penicillin Amoxicillin and Clavulanic Acid

Augmentin ● Suspension, oral:● 125: Amoxicillin trihydrate 125 mg and clavulanic acid 31.25 mg per 5 mL (75 mL, 100 mL, 150 mL)● 200: Amoxicillin trihydrate 200 mg and clavulanic acid 28.5 mg per 5 mL (50 mL, 75 mL, 150 mL)● 400: Amoxicillin trihydrate 400 mg and clavulanic acid 57 mg per 5 mL (50 mL, 75 mL, 100 mL)● 600: Amoxicillin trihydrate 600 mg and clavulanic acid 42.9 mg per 5 mL (50 mL, 75 mL, 100 mL)● Tablet:● 500: Amoxicillin trihydrate 500 mg and clavulanic acid 125 mg (20s)● 875: Amoxicillin trihydrate 875 mg and clavulanic acid 125 mg (20s)● Tablet, chewable:● 200: Amoxicillin trihydrate 200 mg and clavulanic acid 28.5 mg (20s)● 400: Amoxicillin trihydrate 400 mg and clavulanic acid 57 mg (20s)

1

28

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Penicillin Amoxicillin Trihydrate Amoxil ● Capsule: 250 mg (30s, 100s); 500

mg (20s, 30s, 40s, 50s, 100s)● Drops, oral: 50 mg/mL (30 mL)● Suspension, oral: 125 mg/5 mL (80 mL, 150 mL); 250 mg/5 mL (80 mL, 150 mL); 200 mg/5 mL (50 mL, 75 mL, 100 mL); 400 mg/5 mL (50 mL, 75 mL, 100 mL)● Tablet, chewable: 125 mg, 200 mg, 250 mg, 400 mg

1

Antibiotic, Penicillin Ampicillin Principen ● Capsule: 250 mg (40s, 100s); 500 mg (40s, 100s)● Injection, as sodium: 125 mg, 250 mg, 500 mg, 1 g, 2 g● Suspension, oral, as trihydrate: 125 mg/5 mL (100 mL, 200 mL); 250 mg/5 mL (100 mL, 200 mL)

1

Antibiotic, Penicillin Ampicillin Sodium and Sulbactam Sodium

Unasyn ● Powder for injection:● 1.5 g: Ampicillin sodium 1 g and sulbactam sodium 0.5 g● 3 g: Ampicillin sodium 2 g and sulbactam sodium 1 g

1

Antibiotic, Penicillin Dicloxacillin Sodium Dynapen Pathocil® ● Capsule: 250 mg, 500 mg (40s, 100s each)

1

Antibiotic, Penicillin Nafcillin Sodium ● Injection, powder for reconstitution, as sodium: 1 g, 2 g● Infusion, premix [iso-osmotic in dextrose]: 1 g, 2 g

1

Antibiotic, Penicillin Oxacillin Sodium Prostaphlin ● Powder for injection: 1 g, 2 g● Infusion, premix: 1g 2 g

1

29

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Penicillin Penicillin G

(Parenteral/Aqueous)● Injection, as sodium:5 million units● Powder for injection, as potassium: 1 million units, 5 million units, 20 million units● Infusion, premix: 1 million units, 2 million units, 3 million units

1

Antibiotic, Penicillin Penicillin G Benzathine, Parenteral

Bicillin L-A Permapen ● Injection: 600,000 units/mL (1 mL, 2 mL, 4 mL)

1

Antibiotic, Penicillin Penicillin G Procaine Crysticillin A.S. Pfizerpen- AS Wycillin

● Injection: 600,000 units (1 mL, 2 mL, 4 mL)

1

Antibiotic, Penicillin Penicillin V Potassium ● Powder for oral solution: (when reconstituted) 125 mg/5 mL (100 mL, 200 mL); 250 mg/5 mL (100 mL, 200 mL)● Tablet: 250 mg (30s, 40s, 100s); 500 mg (40s, 100s)

1

Antibiotic, Penicillin Piperacillin and Tazobactam Sodium

Zosyn ● Injection: Piperacillin sodium 2 g and tazobactam sodium0.25 g; piperacillin sodium 3 g and tazobactam sodium 0.375 g; piperacillin sodium 4 g and tazobactam sodium 0.5 g (vials at an 8:1 ratio of piperacillin sodium/tazobactam sodium)● Infusion, premix: Piperacillin sodium 2 g and tazobactam sodium 0.25 g; piperacillin sodium 3 g and tazobactam sodium 0.375 g; piperacillin sodium 4 g and tazobactam sodium 0.5 g

1

Antibiotic, Penicillin Piperacillin Sodium Pipracil ● Powder for injection: 2 g, 3 g, 4 g● Infusion, premix: 2 g, 4 g

1

30

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Quinolone Ofloxacin Floxin Otic

Ocuflox Ophthalmic● Solution, ophthalmic, generic: 0.3% [3 mg/mL] (1 mL, 5 mL) [OF: 5 mL]● Solution, otic: 0.3% (5 mL, 10 mL)

1

Antibiotic, Streptogramin Quinupristin and Dalfopristin

Synercid ● Injection, powder for reconstitution:● 500 mg: Quinupristin 150 mg and dalfopristin 350 mg● 600 mg: Quinupristin 180 mg and dalfopristin 420 mg

1

Antibiotic, Sulfonamide Derivative Sulfadiazine ● Tablet: 500 mg (100s) 1

Antibiotic, Sulfonamide Derivative Sulfamethoxazole ● Tablet, (Gantanol): 500 mg 1

Antibiotic, Tetracycline Derivative Doxycycline Periostat Vibra-Tabs Vibramycin

● Tablet, as hyclate: 20 mg (100s)● Tablet monohydrate 50 mg , 100 mg● Injection, as hyclate: 100 mg● Powder for oral suspension, as monohydrate: 25 mg/5 mL (60 mL)

1

Antibiotic, Tetracycline Derivative Minocycline Hydrochloride Minocin IV Minocin ● Capsule, as hydrochloride, pellet-filled: 50 mg (100s); 75 mg; 100 mg (50s)

1

Antibiotic, Topical Hexachlorophene pHisoHex ● Liquid: 3% (473 mL) 1Antibiotic, Topical Mafenide Acetate Sulfamylon ● Cream, topical: 85 mg/g (60 g, 120

g, 435 g)1

Antibiotic, Topical Mupirocin Bactroban ● Ointment, topical: 2% (15 g, 22 g) 1

Antibiotic, Topical Silver Sulfadiazine Silvadene ● Cream, topical: 10 mg/g (50 g, 400 g)

1

Antibiotic, Topical Antifungal Agent, Topical

Gentian Violet ● Solution, topical: 1%, 2% 1

31

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic, Topical Genitourinary Irrigant

Neomycin and Polymyxin B

Neosporin G.U. Irrigant ● Solution, irrigant: Neomycin sulfate 40 mg and polymyxin B sulfate 200,000 units per mL (1 mL)

1

Antibiotic, Topical Topical Skin Product

Benzoin Benz-Protect Swabs [OTC] Sprayzoin [OTC]

● Spray, as compound tincture: 40% (120 mL)● Tincture, as compound tincture: 20% (60 mL)

1

Antibiotic/Corticosteroid, Ophthalmic

Neomycin, Polymyxin B, and Dexamethasone

Maxitrol ● Ointment, ophthalmic: Neomycin sulfate3.5 mg, polymyxin B sulfate 10,000 units, and dexamethasone 0.1% per g (3.5g) [OF]● Suspension, ophthalmic: Neomycin sulfate3.5 mg, polymyxin B sulfate 10,000 units, and dexamethasone 0.1% per mL (5 mL) [OF]

1


Sodium Sulfacetamide and Prednisolone

Blephamide Vasocidin ● Ointment, ophthalmic: (Blephamide ): Sodium sulfacetamide 10% and prednisolone acetate 0.2% (3.5 g) [OF]● Solution, ophthalmic: (generic Vasocidin): Sodium sulfacetamide 10% and prednisolone acetate 0.25% (5 mL, 10 mL) [OF]

1


Tobramycin and Dexamethasone

TobraDex Ophthalmic ● Ointment, ophthalmic: Tobramycin 0.3% and dexamethasone 0.1% (3.5 g) [OF]

1

Antibiotic/Corticosteroid, Otic Ciprofloxacin and Dexamethasone

Ciprodex ● Suspension, otic: Ciprofloxacin 0.3% and dexamethasone 0.1%

1

32

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntibiotic/Corticosteroid, Otic Neomycin, Colistin,

Hydrocortisone, and Thonzonium

Coly-Mycin S Cortisporin- TC ● Coly-Mycin S: Neomycin 0.33%, colistin 0.3%, hydrocortisone acetate 1%, and thonzonium bromide 0.05% (5 mL) [contains thimerosal; packaged with dropper]

1

Anticholinergic Agent Dicyclomine Hydrochloride Bentyl Hydrochloride ● Capsule: 10 mg (100s)● Syrup: 10 mg/5 mL (120 mL)● Tablet: 20 mg (100s)

1

Anticholinergic Agent Glycopyrrolate Robinul Forte Robinul ● Injection: 0.2 mg/mL (1 mL, 2 mL, 5 mL, 20 mL)● Tablet: 1 mg, 2 mg (100s each)

1

Anticholinergic Agent Hyoscyamine Sulfate Anaspaz Cystospaz Levbid Levsin SL Levsin

● Drops, oral solution (Levsin): 0.125 mg/mL (15 mL)● Elixir (Levsin): 0.125 mg/5 mL with alcohol 20% (480 mL)● Tablet (Anaspaz, Levsin): 0.125 mg● Tablet sublingual (Levsin SL): 0.125 mg● Tablet SR 12 HR: 0.375 mg

1

Anticholinergic Agent Ipratropium Bromide Atrovent ● Solution for oral inhalation, as bromide (Atrovent HFA): 17 mcg/actuation (12.9 g)● Solution, intranasal spray, as bromide (Atrovent): 0.03% (30 mL)● Solution for nebulization, as bromide: 0.02% (2.5 mL per unit dose vial, 25 vials/box)

1

Anticholinergic Agent Propantheline Bromide ● Tablet: 15 mg (100s) 1

33

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnticholinergic Agent Scopolamine Scopace Transderm Scop ● Disc, transdermal: 1.5 mg/disc (4s)

● Injection, as hydrobromide: 0.4 mg/mL● Tablet, soluble, as hydrobromide (Scopace):0.4 mg

1

Anticholinergic Agent Tiotropium Spiriva Respimat ● Capsule, Inhalation: Spiriva HandiHaler: 18 mcg

1

Anticholinergic Agent Trospium Sanctura ● Tablets, immediate release: 20 mg● Capsule, extended release, oral, as chloride (generic Sanctura): 60 mg

1

Anticholinergic Agent; Anticholinergic Agent, Long- Acting; Beta2 Agonist; Beta2 Agonist, Long- Acting

Tiotropium and olodaterol Stiolto Respimat ● Aerosol Solution, Inhalation: Stiolto Respimat: Tiotropium2.5 mcg and olodaterol 2.5 mcg per actuation

1

Anticholinergic Agent AtroPen Atropine-Care ● Injection: 0.4 mg/mL (1 mL); 1 mg/mL (1

1

Anticholinergic Agent, mL) 1Ophthalmic Antidote ● Ointment, ophthalmic: 1% (3.5 g)

[OF]1

Antispasmodic Agent, 1Gastrointestinal Ophthalmic 1Agent, Mydriatic 1Anticholinergic Agent Antidote Atropine and Pralidoxime ATNAA

Duodote● Duodote: Atropine 2.1 mg/0.7 mL and pralidoxime chloride 600 mg/2 mL [contains benzyl alcohol; prefilled autoinjector]

1

Atropine Sulfate

Isopto Atropine Sal-Tropine

● Solution, ophthalmic: 1% (15 mL) [OF]

34

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnticholinergic Agent Antispasmodic Agent, Gastrointestinal

Hyoscyamine, Atropine, Scopolamine, and Phenobarbital

Donnatal ● Elixir: Hyoscyamine sulfate 0.1037 mg, atropine sulfate 0.0194 mg, scopolamine hydrobromide 0.0065 mg, and phenobarbital16.2 mg per 5 mL with alcohol 23% (120 mL, 240 mL)● Tablet: Hyoscyamine sulfate 0.1037 mg, atropine sulfate 0.0194 mg, scopolamine hydrobromide 0.0065 mg, and phenobarbital 16.2 mg (30s, 50s, 100s)

1

Anticholinergic Agent, Ophthalmic Cyclopentolate Hydrochloride

Cyclogyl ● Solution, ophthalmic: 0.5% (15 mL) [OF]; 1% (5 mL) [OF]; 2% (5 mL) [OF]

1

Anticholinergic Agent, Ophthalmic Ophthalmic Agent, Mydriatic

Homatropine Hydrobromide

Isopto Homatropine ● Solution, ophthalmic: 2% (5 mL) [OF]; 5% (15 mL) [OF]

1

Anticoagulant Heparin Hep-Lock HepFlush Liquaemin ● Injection, as sodium: 10 units/mL (1 mL); 100 units/mL (1 mL); 1000 units/mL (10 mL); 5000 units/mL (1 mL); 20,000 units/mL (1 mL, 2 mL, 5 mL, 10 mL); 40,000 units/mL (2 mL)●Injection, preservative free: 10 units/mL (1 mL)●Infusion, premix: 25, 000 units/ 500 mL

1

AnticoagulantBlood Product Derivative

Antithrombin, human Antithrombin III ● Solution Reconstituted, Intravenous: Thrombate III: 500 units (1 ea); 1000 units (1 ea)

1

AnticoagulantBlood Product Derivative

Antithrombin, recombinate Atryn ● Solution Reconstituted, Intravenous: 1

35

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnticoagulant, Coumarin Derivative Argatroban ● Injection, solution: 100 mg/mL (2.5

mL) [contains dehydrated alcohol 1000 mg/mL]

1

Anticoagulant, Coumarin Derivative Warfarin Sodium Coumadin ● Tablet: 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5mg, 10 mg

1

Anticoagulant, Direct thrombin Inhibitor

Dabigatran Pradaxa ● Capsule, Oral: 75 mg, 110mg, 150 mg

1

Anticoagulant, Thrombin Inhibitor Bivalirudin Angiomax ● Injection, powder for reconstitution: 250 mg

1

Anticonvulsant Paraldehyde Paral ● Liquid, oral or rectal: 1 g/mL (30 mL)

1

Anticonvulsant, Barbiturate Barbiturate

Phenobarbital Luminal ● Elixir: 20 mg/5 mL (473 mL)● Injection, as sodium: 65 mg/mL (1 mL); 130 mg/mL (1 mL)● Tablet: 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60mg, 65 mg,97.2 mg, 100 mg

1

Anticonvulsant, Barbiturate BarbiturateGeneral Anesthetic

Thiopental Sodium Pentothal Sodium ● Injection: 500 mg, 1 g 1

Anticonvulsant, Hydantoin Fosphenytoin Sodium Cerebyx ● Injection, solution, as sodium: 75 mg/mL (2 mL, 10 mL) [equivalent to phenytoin sodium 50 mg/mL]

1

Anticonvulsant, Miscellaneous Carbamazepine Carbatrol Tegretol-XR Tegretol ● Capsule, extended release: 100 mg, 200 mg, 300 mg (120s)● Suspension, oral: 100 mg/5 mL (450 mL)● Tablet: 200 mg (100s)● Tablet, chewable: 100 mg (100s)● Tablet, sustained release: 100 mg, 200 mg, 400 mg (100s)

1

36

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnticonvulsant, Miscellaneous Gabapentin Neurontin ● Capsule: 100 mg, 300 mg, 400 mg

● Tablet: 600 mg, 800 mg1

Anticonvulsant, Miscellaneous Lamotrigine Lamictal ● Tablet: 25 mg, 100 mg (100s) 150 mg (60s); 200 mg (30s, 60s)● Tablet, chewable, dispersible: 5 mg (100s); 25 mg (100s)● Tablet, combination package [each unit- dose starter kit contains]:● 42 x 25 mg + 7 x 100 mg tablets (NDC 0173-0594-02, Orange Kit) - for patients with bipolar I disorder only, and who are not taking carbamazepine, phenytoin, Phenobarbital, primidone, rifampin, or valproate.● 84 x 25 mg + 14 x 100 mg tablets (NDC 0173-0594-01, Green Kit) - for patients with epilepsy or bipolar I disorder, and not taking valproate.● 35 x 25 mg tablets (NDC 01730633-10, Blue Kit) - for patients with epilepsy or bipolar I disorder, and who are taking valproate

1

37

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnticonvulsant, Miscellaneous Levetiracetam Keppra Keppra XR ● Injection: 100 mg/mL

● Solution: 100 mg/mL● Tablet: 250 mg, 500 mg, 750 mg, 1000 mg● Tablet, extended release: 500 mg, 750 mg ● Infusion, premixed in sodium chloride: 500 mg, 1000 mg, 1500 mg

1

Anticonvulsant, Miscellaneous Oxcarbazepine Trileptal ● Suspension, oral: 300 mg/5 mL (250 mL)● Tablet: 150 mg, 300 mg, 600 mg

1

Anticonvulsant, Miscellaneous Topiramate Topamax ● Capsule, sprinkle: 15 mg, 25 mg● Tablet: 25 mg, 50 mg, 100 mg, 200 mg

1

Anticonvulsant, Miscellaneous Valproic Acid and Derivatives

Depacon Depakene Depakote Divalproex

● Capsule, as valproic acid (Depakene): 250 mg● Capsule, sprinkle, as divalproex sodium (Depakote Sprinkle): 125 mg (100s)● Injection, as valproic acid (Depacon): 100 mg/mL (5 mL vials)● Syrup, as sodium valproate (Depakene): 250 mg/5 mL (480 mL)● Tablet, delayed release, as divalproex sodium (Generic): 125 mg, 250 mg, 500 mg (100s each)

1

Anticonvulsant, Miscellaneous Vigabatrin Sabril® ● Powder for solution, oral: 500 mg/packet

1

Anticonvulsant, Miscellaneous Barbiturate

Primidone Mysoline ● Tablet: 50 mg, 250 mg (100s each) 1

38

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnticonvulsant, Miscellaneous Carbonic Anhydrase Inhibitor Diuretic, Carbonic Anhydrase Inhibitor Ophthalmic Agent, Antiglaucoma

Acetazolamide Diamox ● Capsule, sustained release: 500 mg (100s)● Injection, as sodium: 500 mg● Tablet: 125 mg (100s); 250 mg (100s)

1

Anticonvulsant, Miscellaneous Electrolyte Supplement, Parenteral Laxative, Saline Magnesium Salt

Magnesium Sulfate ● Injection: 100 mg/mL (20 mL); 125 mg/mL (8 mL); 250mg/mL (150 mL); 500 mg/mL (2 mL, 5 mL,10 mL, 50 mL)● Infusion, premix 10 mg/ mL, 40 mg/ mL

1

Anticonvulsant, Succinimide Ethosuximide Zarontin ● Capsule: 250 mg● Syrup: 250 mg/5 mL (473 mL)

1

Anticonvulsant, Succinimide Methsuximide Celontin ● Capsule: 150 mg, 300 mg 1Anticonvulsant, Triazole Derivative Rufinamide Banzel ● Tableta: 200 mg, 400 mg

● Suspension, oral: 40 mg/mL1

Anticystine Agent Urinary Tract Product

Cysteamine Cystagon ● Capsule, as cysteamine bitartrate: 50 mg, 150 mg

1

Antidepressant, Alpha-2 Antagonist Mirtazapine Remeron SolTab Remeron ● Tablet: 15 mg, 30 mg, 45 mg 1

Antidepressant, Dopamine- Reuptake Inhibitor Smoking Cessation Aid

Bupropion Budeprion XL Budeprion SR Buproban Wellbutrin SR Wellbutrin XL Wellbutrin Zyban

● Tablet: 75 mg, 100 mg● Tablet, sustained release: 100 mg, 150 mg, 200mg● Tablet, extended release (XL), as hydrochloride: 150 mg, 300 mg

1

Antidepressant, Monoamine Oxidase Inhibitor

Phenelzine Sulfate Nardil 15 mg 1

Antidepressant, Monoamine Oxidase Inhibitor

Tranylcypromine Sulfate Parnate ● Tablet: 10 mg 1

39

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntidepressant, Selective Serotonin Reuptake Inhibitor

Citalopram Celexa ● Solution, oral: 10 mg/5 mL [alcohol free; peppermint flavor; sugar free]● Tablet, as hydrobromide: 10 mg, 20 mg, 40 mg

1

Antidepressant, Selective Serotonin Reuptake Inhibitor

Escitalopram Lexapro ● Tablet, oral: 5 mg, 10 mg, 20 mg 1


Fluoxetine Hydrochloride Prozac Sarafem ● Capsule (Sarafem brand is NonFormulary): 10 mg, 20 mg, 40 mg (30s, 60s, 100s, 200s)● Solution: 20 mg/5 mL

1


Fluvoxamine Luvox ● Tablet: 25 mg, 50 mg, 100 mg (100s, 1000s)

1


Paroxetine Paxil ● Tablet: 10 mg, 20 mg (30s, 100s), 30 mg (100s), 40 (30s)

1


Sertraline Zoloft ● Tablet: 25 mg, 50 mg, 100 mg 1

Antidepressant, Serotonin Reuptake Inhibitor/Antagonist

Nefazodone Serzone ● Tablet, as hydrochloride: 50 mg, 100 mg, 150 mg, 200 mg (60s, 100s each); 250 mg (60s)

1

Antidepressant, Serotonin Reuptake Inhibitor/Antagonist

Trazodone Hydrochloride Desyrel ● Tablet: 50 mg (30s, 50s, 100s); 100 mg; 150 mg (100s each)

1

Antidepressant, Serotonin/Norepinephrine Reuptake Inhibitor

Duloxetine Cymbalta ● Capsule Delayed Release Particles, Oral: 20 mg, 30 mg, 60 mg

1

Antidepressant, Serotonin/Norepinephrine Reuptake Inhibitor

Venlafaxine Effexor ● Tablets: extended-release: 37.5 mg, 75 mg, 150 mg, 225 mg● Tablet: 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg

1

Antidepressant, Tetracyclic Maprotiline Hydrochloride Ludiomil ● Tablet: 25 mg, 50 mg, 75 mg 1

Antidepressant, Tricyclic (Secondary Amine)

Amoxapine Asendin ● Tablet: 25 mg, 50 mg, 100 mg, 150 mg (100s each)

1

40

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntidepressant, Tricyclic (Secondary Amine)

Desipramine Hydrochloride Norpramin ● Tablet: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg (100s each)

1


Nortriptyline Pamelor ● Capsule, as hydrochloride: 10 mg, 25 mg, 50 mg, 75 mg● Solution, as hydrochloride (Pamelor): 10 mg/5 mL (473 mL) [contains alcohol 4% and benzoic acid]

1


Protriptyline Hydrochloride Vivactil ● Tablet: 5 mg, 10 mg 1

Antidepressant, Tricyclic (Tertiary Amine)

Amitriptyline Hydrochloride

Elavil Endep ● Tablet: 10 mg (30s, 100s); 25 mg (30s, 50s, 100s); 50 mg (100s); 75 mg (100s); 100 mg (100s); 150 mg (100s)

1


Clomipramine Hydrochloride

Anafranil ● Capsule: 25 mg, 50 mg, 75 mg (100s each)

1


Imipramine Tofranil ● Tablet, as hydrochloride: 10 mg, 25 mg, 50 mg (100s each)

1

Antidepressant, Tricyclic (Tertiary Amine) Topical Skin Product

Doxepin Hydrochloride Sinequan ● Capsule: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg (100s each)● Concentrate, oral: 10 mg/mL (120 mL)

1

Antidiabetic Agent, Alpha- Glucosidase Inhibitor

Acarbose Precose ● Tablet (generic), oral: 25 mg, 50 mg, 100 mg

1

Antidiabetic Agent, Biguanide Metformin Glucophage ● Tablet: 500 mg (100s), 850 mg (100s), 1000 (100s) mg● Tablet, extended release (generic) 500 mg, 750 mg

1

41

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntidiabetic Agent, Biguanide Antidiabetic Agent, Sulfonylurea

Glipizide and Metformin Metaglip ● Tablet:● 2.5/250: Glipizide 2.5 mg and metformin 250 mg● 2.5/500: Glipizide 2.5 mg and metformin 500 mg● 5/500: Glipizide 5 mg and metformin 500 gm

1

Antidiabetic Agent, Dipeptidyl Peptidase IV (DPP-IV) Inhibitor

Linagliptin Tradjenta ● Tablet, Oral: 5 mg 1

Antidiabetic Agent, Glucagon- Like Peptide-1 (GLP-1) Receptor Agonist

Exenatide Bydureon ● Pen-injector, Subcutaneous: Bydureon: 2 mg (1 ea)

1

Antidiabetic Agent, Insulin Insulin Aspart ● Injection, solution:● 100 units/mL (10 mL) [vial]

1

Antidiabetic Agent, Insulin Insulin Glargine Lantus ● Injection, solution (Lantus): 100 units/mL (10 mL) [vial]

1

Antidiabetic Agent, Insulin Insulin NPH Humulin NHumuLIN N KwikPen

● 100 units/mL (10 mL) [vial]● HumuLIN N KwikPen: 100 units/mL

1

Antidiabetic Agent, Insulin Insulin NPH and Insulin Regular

Humulin 70/30HumuLIN 70/30 KwikPen

● Insulin NPH suspension 70% [intermediate acting] and insulin regular solution 30% [short acting]: (10 mL) [vial]● HumuLIN 70/30 KwikPen: Insulin NPH suspension 70% [intermediate acting] and insulin regular solution 30% [short acting]: 100 units/mL (3 mL)

1

Antidiabetic Agent, Insulin Antidote Insulin Regular Humulin R (Concentrated) U-500 Humulin R

● Injection, solution:● Injection, solution [concentrate]:● Humulin R U-500: 500 units/mL (20 mL vial)

1

42

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntidiabetic Agent, Sodium- Glucose Cotransporter 2 (SGLT2) Inhibitor; Sodium- Glucose Cotransporter 2 (SGLT2) Inhibitor

Empagliflozin Jardiance ● Tablet, Oral: 10 mg, 25 mg 1

Antidiabetic Agent, Sulfonylurea Glimepiride Amaryl ● Tablet, Oral: 1 mg, 2 mg, 4 mg 1Antidiabetic Agent, Sulfonylurea Glipizide Glucotrol ● Tablet: 5 mg, 10 mg (100s each) 1Antidiabetic Agent, Sulfonylurea Glyburide Dia&Beta eta Micronase ● Tablet: 1.25 mg, 2.5 mg, 5 mg 1Antidiabetic Agent, Sulfonylurea Tolbutamide Orinase ● Tablet: 500 mg (100s) 1Antidiabetic Agent, Thiazolidinedione

Pioglitazone Actos ● Tablet: 15 mg, 30 mg, 45 mg 1

Antidiarrheal Diphenoxylate and Atropine

Lomotil ● Solution, oral: Diphenoxylate hydrochloride2.5 mg and atropine sulfate 0.025 mg per 5 mL (60 mL)● Tablet: Diphenoxylate hydrochloride 2.5 mg and atropine sulfate 0.025 mg (20s, 30s, 100s, 1000s)

1

Antidiarrheal Somatostatin Analog Octreotide Acetate Sandostatin LAR Sandostatin ● Injection, solution: 0.05 mg (1 mL); 0.1 mg (1 mL); 0.5 mg (1 mL), 0.2 mg/mL (5 mL), 1 mg/mL (5 mL)● Injection, microspheres for suspension, as acetate [depot formulation] (Sandostatin LAR): 10 mg, 20 mg, 30 mg [with diluent and syringe]

1

Antidiuretic Hormone Analog Hormone, Posterior Pituitary

Vasopressin Pitressin ● Injection: 20 units/mL (0.5 mL, 1 mL)

1

43

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntidote Mark 1 Kit ● Contents:

● Atropine-injector: 2 mg total dose per injection● 2-PAM (2-PAM CL; pralidoxime chloride): 600 mg total dose per injection

1

Antidote Diethylene Triamine Penta-Acetic Acid

● Injection, solution:● Ca-DTPA: 200 mg/mL (5 mL)● Zn-DTPA: 200 mg/mL (5 mL)

1

Antidote Digoxin Immune Fab (Ovine)

DigiFab ● DigiFab: 40 mg● Powder for injection, lyophilized: 40 mg

1

Antidote Dimercaprol BAL in Oil ● Injection: 100 mg/mL (3 mL) 1Antidote Flumazenil Romazicon ● Injection: 0.1 mg/mL (5 mL, 10 mL) 1

Antidote Mesna Mesnex ● Injection: 100 mg/mL (2 mL, 4 mL, 10 mL)● Tablet: 400 mg

1

Antidote Methylene Blue Urolene Blue ● Injection: 10 mg/mL (10 mL)● Tablet: 65 mg

1

Antidote Naloxone Hydrochloride Evzio Narcan ● Injection: 0.4 mg/mL (1 mL); 1 mg/mL (1 mL, 10 mL)● Injection, neonatal: 0.02 mg/mL (2 mL)Solution● Auto-injector, Injection, as hydrochloride: Evzio: 0.4 mg/0.4 mL● Liquid, Nasal: Narcan: 4 mg/0.1 mL

1

Antidote Naltrexone Hydrochloride Depade: ReVia Oral Vivitrol ● Tablet: 50 mg (50s) 1

44

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntidote Pralidoxime Chloride Protopam Chloride ● Injection: 20 mL vial containing 1 g

each pralidoxime chloride with one 20 mL ampul diluent, disposable syringe, needle, and alcohol swab

1

Antidote Protamine Sulfate ● Injection: 10 mg/mL (5 mL) 1Antidote Sodium Polystyrene

SulfonateKayexalate ● Powder for suspension, oral or

rectal: 454 g● Suspension, oral or rectal: 1.25 g/5 mL with sorbitol 33% and alcohol 0.3% (60 mL)

1

Antidote Sodium Thiosulfate Versiclear ● Injection: 100 mg/mL (10 mL); 250 mg/mL (50 mL)

1

Antidote Succimer Chemet ● Capsule: 100 mg 1Antidote Anticholinesterase inhibitor

Edrophonium Enlon ● Injection, solution, as chloride:10 mg/mL

1

AntidoteBisphosphonate Derivative

Pamidronate Disodium Aredia ● Powder for injection, lyophilized: (30 mg, 60 mg, 90 mg vials)

1

AntidoteBisphosphonate Derivative

Zoledronic Acid Reclast Zometa ● Powder for injection: 4 mg (as monohydrate4.264 mg)● Intravenous, solution: 5 mg

1

Antidote Calcium Salt Phosphate Binder

Calcium Acetate PhosLo Eliphos Phoslyra ● Gelcap: 667 mg● Tablet: 667 mg● Oral solution: 667 mg/ 5 mL

1

Antidote Chelating Agent Deferasirox Exjade Jadenu ● Tablet Soluble, Oral: Exjade: 125 mg, 250 mg, 500 mg● Tablet, Oral: Jadenu: 90 mg, 180 mg, 360 mg

1

Antidote Chelating Agent Deferoxamine Mesylate Desferal Mesylate ● Powder for injection: 500 mg, 2 g 1Antidote Diagnostic Agent Glucagon GlucaGen HypoKit ● GlucaGen HypoKit: 1 mg 1

45

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntidote, Enzyme Glucarpidase Voraxaze ● Injection, powder for reconstitution:

1000 units [contains lactose 10 mg/vial]

1

Antidote Hormone Calcitonin Calcimar Fortical Miacalcin ● Injection, salmon (Miacalcin®): 200 units/mL (2 mL)●Solution, intranasal [spray, calcitonin-salmon]: 200 int. units/0.09 mL (3.7 mL) [rDNA origin; contains benzyl alcohol; delivers 30 doses, 200 units/actuation]

1

Antidote, Monoclonal Antibody Idarucizumab Praxbind ● Solution, Intravenous [preservative free]: Praxbind: 2.5 g/50 mL

1

Antidote Mucolytic Agent Acetylcysteine Acetadote Mucomyst ● Injection, solution (Acetadote): 20% [200 mg/mL] (30 mL) [contains disodium edetate]● Solution: 10% (10 mL, 30 mL); 20% (10mL, 30 mL)

1

Antidote Pharmaceutical Aid Alcohol, Ethyl EpiClenz [OTC] Gel-Stat [OTC] GelRite [OTC]Isagel [OTC] Lavacol [OTC] Prevacare [OTC] Protection Plus [OTC] Purell 2 in 1 [OTC] Purell with Aloe [OTC] Purell [OTC]

● Liquid, topical, denatured: 70% (473 mL) [OTC] (for compounding use only)

1

Antidote, Selective Relaxant Binding Agent

Sugammadex Bridion ● Solution, Intravenous: Bridion: 200 mg/2 mL; 500 mg/5 mL

1

Antidote Vasodilator Amyl Nitrite ● Inhalant: 0.3 mL crushable glass perles

1

46

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntidoteVitamin, Water Soluble

Hydroxocobalamin Cyanokit ● Injection, powder for reconstitution:● Cyanokit: 2.5 g (2 vials) [provided in a kit which also contains one I.V. infusion set]

1

AntidoteVitamin, Water Soluble

Leucovorin Calcium Wellcovorin ● Injection: 10 mg/mL, 50 mg● Tablet: 5 mg, 25 mg (100s)

1

Antidote, Hypoglycemia Intravenous Nutritional Therapy

Dextrose in Water B-D Glucose [OTC] Dex4 Glucose [OTC] Enfamil Glucose Glutol [OTC] Glutose [OTC]Insta-Glucose [OTC] Similac Glucose

● Injection: 5% (1000 mL); 10% (1000 mL);50% (50 mL)

1

Antiemetic Antihistamine Hydroxyzine Atarax Vistaril ● Capsule, as pamoate: 25 mg, 50 mg, 100 mg (100s each)● Injection, as pamoate: 50 mg/mL (2 mL)● Syrup, as hydrochloride: 10 mg/5 mL with alcohol 0.5% (120 mL, 240 mL, 480 mL)● Tablet, as hydrochloride: 10 mg, 25 mg (30s, 50s, 100s each); 50 mg, 100 mg (100s each)

1

Antiemetic Antihistamine Phenothiazine Derivative Sedative

Promethazine Hydrochloride

Phenergan ● Injection: 25 mg/mL (1 mL)● Suppository, rectal: 12.5 mg, 25 mg● Tablet: 12.5 mg, 25 mg

1

AntiemeticAntipsychotic Agent, Typical

Droperidol Inapsine ● Injection: 2.5 mg/mL (2 mL, 5 mL) 1

AntiemeticAntipsychotic Agent, Typical, Phenothiazine

Perphenazine Trilafon ● Tablet: 2 mg, 4 mg, 8 mg, 16 mg (100s each)

1

47

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiemeticAntipsychotic Agent, Typical, Phenothiazine

Prochlorperazine Compazine ● Injection, as edisylate: 5 mg/mL (2 mL, 10 mL)● Suppository, rectal: 2.5 mg, 25 mg (12s each)● Tablet, as maleate: 5 mg, 10 mg(100s each)

1

Antiemetic Gastrointestinal Agent, Prokinetic

Metoclopramide Reglan ● Injection: 5 mg/mL (2 mL, 10 mL, 20 mL, 30 mL vials) (2 mL, 30 mL amps)● Syrup: 5 mg/5 mL● Tablet: 5 mg, 10 mg (100s each)

1

AntiemeticSelective 5-HT3 Receptor Antagonist

Ondansetron Hydrochloride Zofran ● Injection: 2 mg/mL (20 mL)● Tablet: 4 mg, 8 mg (30s each)

1

AntiemeticSubstance P/Neurokinin 1 Receptor Antagonist

Fosaprepitant Emend ● Injection: 150 mg 1

Antifungal Agent, Oral Nonabsorbed Antifungal Agent, TopicalAntifungal Agent, Vaginal

Clotrimazole Lotrimin Mycelex ● Troche, oral: 10 mg (70s, 140s) 1

Antifungal Agent, Oral Nonabsorbed Antifungal Agent, TopicalAntifungal Agent, Vaginal

Nystatin Mycostatin ● Powder, topical: 100,000 units/g (15 g)● Suspension, oral: 100,000 units/mL (60 mL)● Tablet, oral: 500,000 units (100s)

1

Antifungal Agent, Oral Flucytosine Ancobon ● Capsule: 250 mg, 500 mg (100s each)

1

48

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntifungal Agent, Oral Griseofulvin Grifulvin V Gris-PEG ● Microsize:

● Suspension, oral: 125 mg/5 mL with alcohol 0.2% (120 mL)● Tablet: 500 mg (60s each)● Ultramicrosize: Tablet : 125 mg, 250 mg (100s)

1

Antifungal Agent, Oral Itraconazole Sporanox ● Capsule: 100 mg (30s) 1Antifungal Agent, Oral Antifungal Agent, Parenteral

Fluconazole Diflucan ● Suspension Reconstituted, Oral: Generic: 10 mg/mL (35 mL); 40 mg/mL (35 mL)tituted, Oral, as axetil [strength expressed as base]:125 mg/5 mL (100 mL)ed Release 24 Hour, Oral: Generic: 2.5 mg, 5 mg, 10 mgmg and velpatasvir 100 mg● Injection: 2 mg/mL (100 mL, 200 mL)● Infusion, premix: 200 mg, 400 mg● Tablet: 50 mg, 100 mg, 150 mg, 200 mg (30s each)

1

Antifungal Agent, Oral Antifungal Agent, Parenteral

Voriconazole VFEND ● Injection, powder for reconstitution: 200 mg [contains SBECD 3200 mg]● Powder for oral suspension: 200 mg/5 mL (70 mL) [contains sodium benzoate and sucrose; orange flavor]● Tablet: 50 mg, 200 mg [contains lactose]

1

Antifungal Agent, Oral Antifungal Agent, Topical

Ketoconazole Nizoral ● Shampoo: 2% (120 mL)● Tablet: 200 mg (100s)

1

Antifungal Agent, Oral Antifungal Agent, Topical

Terbinafine Lamisil AT [OTC] Lamisil ● Tablet: 250 mg 1

49

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntifungal Agent, Parenteral Amphotericin B Fungizone ● Powder for injection, lyophilized: 50

mg1

Antifungal Agent, Parenteral Amphotericin B (Liposomal)

AmBisome ● AmBisome: 50 mg [contains soy and sucrose]

1

Antifungal Agent, Topical Corticosteroid, Topical

Iodoquinol and Hydrocortisone

Vytone ● Cream: Iodoquinol 1% and hydrocortisone 1% (30 g)

1

Antihemophilic Agent, Antifibrinolytic Agent, Hemostatic Agent, Lysine Agent

Tranexamic acid Lysteda™ Cyklokapron® ● Injection, solution: 100 mg/mL● Tablets: 650 mg

1

Antihemophilic Agent Antihemophilic Factor, Recombinant

Bioclate Helixate Kogenate FS Kogenate Recombinate ReFacto®Koate DVI

● Injection, recombinant 1

Antihemophilic Agent Antihemophilic Agent, Recombinant

BeneFIX Solution Reconstituted, Intravenous [preservative free]: BeneFIX: 250 units; 500units; 1000 units ; 2000 units

1

Antihemophilic Agent Blood Product Derivative

Antihemophilic Factor, Human

Hemofil M ● Injection: 10 mL, 20 mL, 30 mL 1


Factor IX (Human) AlphaNine SD Mononine ● Injection (vials):● AlphaNine SD: 500 units, 1000 units, 1500 units● Mononine: 250 units, 500 units, 1000 units

1


Factor IX Complex (Human)

Proplex T Profilnine® SD ● Injection: Single dose vials with varied units

1


Factor VIIa (Recombinant) NovoSevenRT ● Injection, powder for reconstitution [preservative free]: 1 mg, 2 mg, 5 mg, 8 mg.

1

50

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntihemophilic Agent Hemostatic Agent Vasopressin Analog, Synthetic

Desmopressin Acetate DDAVP ● Injection: 4 mcg/mL (10 mL)● Solution, nasal: 0.1 mg/mL (2 mL intranasal pipettes containing 20 mcg/0.2 mL, 2.5 mL vials with applicator tubes● Solution, nasal spray: 5 mL pump spray bottle containing 10 mcg/dose) (50 doses/bottle)● Tablet : 0.1 mg, 0.2 mg (100s)

1

Antihemophilic Factor/von Willebrand Factor Complex (Human)

Factor VIII Alphanate Humate-P® Wilate Injection, powder for reconstitution [human derived]:● 250 int. units, 500 int. units, 1000 int. units, 1500 int. units[Factor VIII and vWF:RCof ratio varies by lot; contains sodium ≥10 mEq/vial, albumin and polysorbate 80; packaged with diluent]● FVIII 250 int. units, FVIII 500 int. units, FVIII 1000 int. units and vWF:RCof 600 int. units [contains albumin; packaged with diluent [Factor VIII and vWF:RCof ratio varies by lot]

1

Antihepaciviral, NS5A Inhibitor; Antihepaciviral, Polymerase Inhibitor (Anti- HCV)

Ledipasvir and sofosbuvir Harvoni ● Tablet, oral: Ledipasvir 90 mg and sofosbuvir 400 mg

1

Antihepaciviral, NS5A Inhibitor Daclatasvir Daklinza ● Tablet, Oral: 30 mg, 60 mg 1Antihepaciviral, Polymerase Inhibitor (Anti-HCV)

Sofosbuvir Sovaldi ● Tablet, oral: 400 mg 1

Antihepaciviral, NS5A Inhibitor; Polymerase Inhibitor (Anti-HCV); NS5B RNAPolymerase Inhibitor

Sofosbuvir and Velpatasvir Epclusa ● Tablet, Oral:Epclusa: Sofosbuvir 400 mg and velpatasvir 100 mg

1

51

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntihistamine Cyproheptadine

HydrochloridePeriactin ● Syrup: 2 mg/5 mL with alcohol 5%

(120 mL)● Tablet: 4 mg (100s)

1

Antihistamine Diphenhydramine Hydrochloride

Benadryl Allergy Liquid Benadryl

● Capsule: 25 mg, 50 mg (30s, 50s, 100s each)● Injection: 50 mg/mL● Liquid: 12.5 mg/5 mL (120 mL)

1

Antihistamine/Antitussive Bromodiphenhydramin e and Codeine

● Liquid: Bromodiphenhydramine 12.5 mg and codeine phosphate 10 mg per 5 mL with alcohol 5% (120 mL)

1

Antihistamine/Antitussive Promethazine and Codeine Phenergan With Codeine Pherazine With Codeine

● Syrup: Promethazine hydrochloride 6.25 mg and codeine phosphate 10 mg per 5 mL (120 mL, 240 mL, 473 mL)

1

Antihistamine/Decongestant/A nticholinergic

Chlorpheniramine, Phenylephrine, and Methscopolamine

AH-CHEWD.A. Chewable Drihist SR OMNIhist LA

● Tablet, chewable (AH-CHEW, D.A. Chewable, Chlorpheniramine maleate 2 mg, phenylephrine 10 mg, methscopolamine 1.25 mg

1

Antihistamine/Decongestant/A ntitussive

Chlorpheniramine, Pseudoephedrine, and Codeine

Dihistine DH ● Liquid: Chlorpheniramine maleate 2 mg, pseudoephedrine hydrochloride 30 mg, and codeine phosphate 10 mg per 5 mL (120 mL)

1

Antihistamine/Decongestant/A ntitussive

Promethazine, Phenylephrine, and Codeine

Phenergan VC With Codeine ● Liquid: Promethazine hydrochloride 6.25 mg, phenylephrine hydrochloride 5 mg, and codeine phosphate 10 mg per 5 mL with alcohol 7% (120 mL, 480 mL)

1

52

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntihypertensive Agent, Combination

Atenolol and Chlorthalidone

Tenoretic ● Tablet: Atenolol 50 mg and chlorthalidone 25 mg● Atenolol 100 mg and chlorthalidone 25 mg

1

Antihypertensive Agent, Combination

Bisoprolol and Hydrochlorothiazide

Ziac ● Tablet:● Bisoprolol fumarate 2.5 mg and hydrochlorothiazide 6.25 mg● Bisoprolol fumarate 5 mg and hydrochlorothiazide 6.25 mg● Bisoprolol fumarate 10 mg and hydrochlorothiazide 6.25 mg

1


Hydrochlorothiazide and Losartan

Hyzaar (generic) ● Tablet:●Losartan 100 mg and hydrochlorothiazide12.5 mg●Losartan 50 mg and hydrochlorothiazide12.5 mg

1


Hydrochlorothiazide and Spironolactone

Aldactazide ● Tablet:● Hydrochlorothiazide 25 mg and spironolactone 25 mg

1


Lisinopril and Hydrochlorothiazide

Prinzide ● Tablet: Lisinopril 10 mg and hydrochlorothiazide 12.5 mg; lisinopril 20 mg and hydrochlorothiazide 12.5 mg; lisinopril 20 mg and hydrochlorothiazide 25 mg

1

53

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntihypertensive Agent, Combination Diuretic, Potassium-Sparing Diuretic, Thiazide

Hydrochlorothiazide and Triamterene

Maxzide ● Tablet:● Maxzide-25, generics: Hydrochlorothiazide 25 mg and triamterene 37.5 mg (100s)● Maxzide, generics: Hydrochlorothiazide 50 mg and triamterene 75 mg (50s, 100s)

1

Antihypertensive; Diuretic, Loop Torsemide Dermadex ● Tablet, Oral: 5 mg, 10 mg, 20 mg, 100 mg

1

Antihypertensive Antihypoglycemic Agent

Diazoxide Hyperstat I.V. Proglycem ● Capsule: 50 mg (100s)● Injection: 15 mg/mL (20 mL)● Suspension, oral: 50 mg/mL (30 mL)

1

Anti-inflammatory Agent Anti-inflammatory Agent, Ophthalmic Antiemetic Corticosteroid, Ophthalmic Corticosteroid, Otic Corticosteroid, Systemic

Dexamethasone Decadron-LA Decadron Hexadrol Maxidex Ozurdex

● Elixir: 0.5 mg/5 mL (120 mL)● Solution, oral: Intensol 1 mg/mL● Injection, as sodium phosphate: 4 mg/mL (1 mL), 10 mg/mL (10 mL)● Tablet: 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2mg, 4 mg, 6 mg● Solution, ophthalmic, as sodium phosphate [drops]: 0.1% [OF]● Implant, Intraocular [preservative free]: Ozurdex: 0.7 mg

1

Antilipemic Agent, Bile Acid Sequestrant

Cholestyramine Resin Questran Light Questran ● Powder: 4 g of resin/9 g of powder (9 g, 378 g)● Powder, for oral suspension, with aspartame: 4 g of resin/5 g of powder (239.4 grams/can)

1

54

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntilipemic Agent, Bile Acid Sequestrant

Colestipol Hydrochloride Colestid ● Granules:● Unflavored: 5 g packet (30s, 90s); 500 g bottle● Flavored: 7.5 g packet (60s) (contains 5 g of colestipol hydrochloride); 450 g bottle● Tablet: 1 g

1

Antilipemic Agent, Fibric Acid Fenofibrate Antara Lipofen Lofibra TriCor Triglide

● Tablet: 54 mg, 160 mg (90s) 1

Antilipemic Agent, Fibric Acid Gemfibrozil Lopid ● Tablet: 600 mg (60s, 100s) 1Antilipemic Agent, HMG-CoA Reductase Inhibitor

Lovastatin Mevacor ● Tablet: 10 mg, 20 mg, 40 mg 1

Antilipemic Agent, HMG-CoA Reductase Inhibitor

Pravastatin Pravachol ● Tablet: 10 mg, 20 mg, 40 mg, 80 mg 1


Atorvastatin Lipitor ● Tablet (generic): 10 mg, 20 mg, 40 mg, 80 mg

1


Simvastatin Zocor ● Tablet, generic: 5 mg, 10 mg, 20 mg, 40 mg, 80 mg (50s, 60s)

1


Rosuvastatin Crestor (generic) ● Tablet: 5 mg, 10 mg, 20 mg, 40 mg 1

Antilipemic Agent, Miscellaneous Vitamin, Water Soluble

Niacin Nicobid [OTC] Nicolar Nicotinex [OTC]Slo-Niacin [OTC]

● Capsule, timed release: 125 mg, 250 mg, 500 mg (100s each)● Tablet: 50 mg, 100 mg, 500 mg (100s each)● Tablet, timed release: 250 mg, 500 mg, 750 mg (100s)● Tablet, extended release: 500 mg, 750 mg, 100 mg (100s)

1

Antimalarial Agent Artemether and Lumefantrine

Coartem® ● Tablet: Artemether 20 mg and lumefantrine 120 mg

1

55

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntimalarial Agent Atovaquone and Proguanil Malarone ● Tablet: Atovaquone 250 mg and

proguanil hydrochloride 100 mg● Tablet, pediatric: Atovaquone 62.5 mg and proguanil hydrochloride 25 mg

1

Antimalarial Agent Mefloquine Hydrochloride Lariam ● Tablet: 250 mg (25s) 1

Antimalarial Agent Pyrimethamine Daraprim ● Tablet: 25 mg (100s) 1Antimigraine Agent Ergot Derivative

Dihydroergotamine Mesylate

D.H.E. 45 Migranal ● Injection: 1 mg/mL (1 mL)● Spray, nasal: 4 mg/mL [0.5 mg/spray] (1 mL)

1

Antimigraine Agent Ergot Derivative

Ergotamine Ergomar ● Tablet, sublingual: 2 mg (20s) 1

Antimigraine Agent Ergot Derivative Stimulant

Ergotamine and Caffeine Cafergot Migergot ● Suppository, rectal (Cafergot): Ergotamine tartrate 2 mg and caffeine 100 mg● Tablet (Cafergot): Ergotamine tartrate 1 mg and caffeine 100 mg

1

Antimigraine Agent Serotonin 5-HT1B, 1D Receptor Agonist

Naratriptan Hydrochloride Amerge ● Tablet: 1 mg, 2.5 mg 1


Rizatriptan Maxalt, Maxalt MLT ● Tablet, oral: 5 mg, 10 mg● Tablet, orally disintegrating, oral: 5 mg, 10 mg

1


Sumatriptan Succinate Imitrex ● Injection: 6 mg/0.5 mL [unit-of-use syringes (2s) (STAT dose), single dose vial (5s)]● Nasal spray: 20 mg● Tablet: 25 mg, 50 mg, 100 mg (9s)

1

Antineoplastic Agent, Anaplastic Lymphoma Kinase Inhibitor; Antineoplastic Agent, Tyrosine Kinase Inhibitor

Alectinib Alecensa ● Capsule: 150 mg 1

56

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent Antineoplastic Agent, Alkylating Agent (Nitrosourea) Antineoplastic Agent, DNA Adduct-Forming Agent Antineoplastic Agent, DNA Binding Agent

Carmustine BiCNUGliadel

● Powder for injection: 100 mg 1

Antineoplastic Agent Proteasome Inhibitor

Bortezomib Velcade ● Injection, powder for reconstitution [preservative free]: 3.5 mg [contains mannitol 35 mg]

1

Antineoplastic Agent Proteasome Inhibitor

Carfilzomib Kyprolis ● Injection, powder for reconstitution: 60 mg [contains cyclodextrin]

1

Antineoplastic Agent, Alkylating Agent

Bendamustine Treanda® Injection, powder for reconstitution: Treanda: 100 mg DSolution, Intravenous, as hydrochloride: Bendeka: 100 mg /4 m L

1

Antineoplastic Agent, Alkylating Agent (Nitrogen Mustard)

Mechlorethamine Hydrochloride

Mustargen ● Powder for injection: 10 mg 1

Antineoplastic Agent, Alkylating Agent (Nitrosourea)

Polifeprosan 20 With Carmustine

Gliadel Wafer ● Implant: 7.7 mg carmustine wafer (8s)

1

Antineoplastic Agent, Alkylating Agent (Triazene)

Dacarbazine DTIC-Dome ● Injection: 10 mg/mL (10 mL, 20mL) 1

Antineoplastic Agent, Alkylating Agent (Triazene)

Temozolomide Temodar ● Capsule: 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, 250 mg (5s and 20s)

1


Busulfan Busulfex Myleran ● Tablet: 2 mg (100s) 1


Chlorambucil Leukeran ● Tablet, 2 mg (100s) 1

57

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Alkylating Agent

Cyclophosphamide Cytoxan ● Injection, powder for reconstitution: 500 mg,1g, 2g● Capsule: 25 mg, 50 mg

1


Lomustine Gleostine ● Capsule: 5 mg, 10 mg, 40 mg, 100 mg (100s each)

1


Melphalan Alkeran ● Tablet: 2 mg (100s) 1


Procarbazine Hydrochloride Matulane ● Capsule: 50 mg 1


Streptozocin Zanosar ● Powder for injection: 1 g 1


Thiotepa ● Powder for injection: 15 mg 1

Antineoplastic Agent, Alkylating Agent Antineoplastic Agent, Alkylating Agent (Nitrogen Mustard)

Ifosfamide Ifex ● Powder for injection: 1 g with mesna 200 mg per ampul

1

Antineoplastic Agent, Alkylating Agent Antineoplastic Agent, Hormone Antineoplastic Agent, Hormone (Estrogen/Nitrogen Mustard)

Estramustine Phosphate Sodium

Emcyt ● Capsule: 140 mg (100s) 1

Antineoplastic Agent, Alkylating Agent Antineoplastic Agent, Platinum Analog

Carboplatin Paraplatin [DSC] ● Powder for injection, lyophilized: 50 mg, 150 mg, 450 mg

1


Cisplatin Platinol ● Injection, solution: 1 mg/mL (50 mL, 100 mL, 200 mL)

1


Oxaliplatin Eloxatin ● Injection, solution [preservative free]: 5 mg/mL (10 mL, 20 mL, 40 mL)

1

Antineoplastic Agent, Anthracenedione

Mitoxantrone Hydrochloride

Novantrone ● Injection: 2 mg/mL (10 mL, 12.5 mL, 15 mL)

1

58

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Anthracycline

Daunorubicin Hydrochloride

Cerubidine ● Injection, powder for reconstitution: 20 mg● Injection, solution (preservative free): 5 mg/mL

1

Antineoplastic Agent, Anthracycline

Doxorubicin (Liposomal) Doxil ● Injection, as hydrochloride: 2 mg/mL (10 mL)

1

Antineoplastic Agent, Anthracycline

Doxorubicin Hydrochloride Adriamycin ● Powder for injection: 10 mg, 50 mg 1

Antineoplastic Agent, Anthracycline Antineoplastic Agent, Antibiotic

Idarubicin Hydrochloride Idamycin ● Powder for injection, lyophilized: 5 mg, 10 mg

1

Antineoplastic Agent, Antiandrogen Abiraterone Zytiga™ ● Tablet, oral: 250 mg 1

Antineoplastic Agent, Antiandrogen Bicalutamide Casodex ● Tablet: 50 mg 1

Antineoplastic Agent, Antiandrogen Enzalutamide Xtandi ● Capsule, liquid filled, oral: 40 mg 1

Antineoplastic Agent, Antiandrogen Flutamide Eulexin ● Capsule: 125 mg 1

Antineoplastic Agent, Antibiotic Bleomycin Sulfate Blenoxane ● Injection, powder for reconstitution, as sulfate: 15 units

1

Antineoplastic Agent, Antibiotic Dactinomycin Cosmegen ● Powder for injection, lyophilized: 0.5 mg/3 mL

1

Antineoplastic Agent, Antibiotic Mitomycin Mutamycin ● Powder for injection: 5 mg, 20 mg 1

59

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Antimetabolite (Antifolate) Antirheumatic, Disease Modifying

Methotrexate Folex Mexate Rheumatrex Rasuvo

● Injection, as sodium: 25 mg/mL (2 mL)● Tablet: 2.5 mg (100s)● Tablet, dose pack: 5 mg/card, 7.5 mg/card, 10 mg/card,12.5 mg/card, 15 mg/card● Rasuvo: 7.5 mg/0.15 mL; 10 mg/0.2 mL; 12.5 mg/0.25 mL; 15 mg/0.3 mL; 17.5mg/0.35 mL; 20 mg/0.4 mL; 22.5 mg/0.45 mL; 25 mg/0.5 mL; 27.5 mg/0.55 mL; 30 mg/0.6 mL

1

Antineoplastic Agent, Antimetabolite (Purine Antagonist)

Fludarabine Phosphate Fludara ● Injection, lyophilized: 50 mg 1

Antineoplastic Agent, Antimetabolite (Purine Antagonist)

Thioguanine Tabloid ● Tablet: 40 mg (25s) 1

Antineoplastic Agent, Antimetabolite (Pyrimidine Analog)

Floxuridine FUDR ● Powder for injection, preservative free: 100 mg/mL (5 mL)

1


Fluorouracil Efudex Fluoroplex ● Cream, topical: 1%, 5%● Injection: 50 mg/mL (10 mL)● Solution, topical: 2% (10 mL); 5% (10 mL)

1


Gemcitabine Gemzar ● Injection, powder for reconstitution: 200 mg, 1 g

1

Antineoplastic Agent, Antimetabolite (Pyrimidine Antagonist)

Cytarabine (Liposomal) DepoCyt ● Injection: 10 mg per mL 1

Antineoplastic Agent, Antimetabolite

Hydroxyurea Hydrea ● Capsule: 500 mg (30s, 100s) 1

60

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Antimetabolite

Nelarabine Arranon ● Injection, solution: 5 mg/mL (50 mL)

1

Antineoplastic Agent, Antimetabolite Antineoplastic Agent, Antimetabolite (Antifolate)

Pemetrexed Alimta ● Injection, powder for reconstitution: 500 mg

1

Antineoplastic Agent, Antimetabolite Antineoplastic Agent, Antimetabolite (Purine Antagonist)

Cladribine Leustatin ● Injection, preservative free: 1 mg/mL (10 mL)

1

Antineoplastic Agent, Antimetabolite Antineoplastic Agent, Antimetabolite (Pyrimidine Analog)

Capecitabine Xeloda ● Tablet: 150 mg, 500 mg 1

Antineoplastic Agent, Antimetabolite Antineoplastic Agent, Antimetabolite (Pyrimidine Analog)

Cytarabine Hydrochloride Cytosar-U ● Injection, powder for reconstitution: 100 mg, 500 mg

1

Antineoplastic Agent, Antimetabolite Antineoplastic Agent, Antimetabolite (Pyrimidine Analog), Thymidine Phosphorylase Inhibitor

Trifluridine and Tipiracil Lonsurf ● Tablets, oral Trifluridine 15 mg and tipiracil6.14 mg, Trifluridine 20 mg and tipiracil 8.19 mg

1

Antineoplastic Agent, Antimetabolite Immunosuppressant Agent

Mercaptopurine Purinethol Purixan ● Tablet: 50 mg (100s)● Oral suspension: 20 mg/mL

1

Antineoplastic Agent, Antimicrotubular

Eribulin Halaven ● Injection, solution, as mesylate: 0.5 mg/mL

1

Antineoplastic Agent, Antimicrotubular Antineoplastic Agent, Epothilone B Analog

Ixabepilone Ixempra ● Injection, powder for reconstitution: Ixempra™: 15 mg, 45 mg

1

Antineoplastic Agent, Antimicrotubular Antineoplastic Agent, Taxane Derivative

Cabazitaxel o Jetvana® ● Injection, solution: Jevtana®: 40 mg/mL (1.5mL)

1

61

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Antimicrotubular Antineoplastic Agent, Natural Source (Plant) Derivative Antineoplastic Agent, Taxane Derivative

Docetaxel Taxotere ● Injection, solution [concentrate]: 20 mg/mL; 80 mg/4 mL; 160 mg/8 mL

1

Antineoplastic Agent, Antimicrotubular Antineoplastic Agent, Natural Source (Plant) Derivative Antineoplastic Agent, Taxane Derivative

Paclitaxel Taxol ● Injection: 30 mg/5 mL 1

Antineoplastic Agent, Anti-PD- L1 Monoclonal Antibody; Antineoplastic Agent, Monoclonal Antibody

Atezolizumab Tecentriq ● Solution, Intravenous [preservative free]: Tecentriq: 1200 mg/20 mL

1

Antineoplastic Agent, Anti-PD- 1 Monoclonal Antibody; Antineoplastic Agent, Monoclonal Antibody

Nivolumab Opdivo ● Solution, Intravenous [preservative free]: Opdivo: 40 mg/4 mL (4 mL); 100 mg/10 mL (10 mL)

1

Antineoplastic Agent, Aromatase Inactivator

Exemestane Aromasin ● Tablet: 25 mg (30s) 1

Antineoplastic Agent, Aromatase Inhibitor

Anastrozole Arimidex ● Tablet: 1 mg 1

Antineoplastic Agent, Aromatase Inhibitor

Letrozole Femara ● Tablet: 2.5 mg 1

Antineoplastic Agent, BRAF Kinase Inhibitor

Dabrafenib Tafinlar ● Capsule, oral: 50 mg, 75 mg 1

Antineoplastic Agent, BRAF Kinase Inhibitor

Vemurafenib Zelboraf ● Tablet: 240 mg 1

Antineoplastic Agent, Camptothecin Antineoplastic Agent, Natural Source (Plant) Derivative

Irinotecan Camptosar ● Injection: 100 mg/5 mL vial 1

62

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Camptothecin Antineoplastic Agent, Natural Source (Plant) Derivative

Topotecan Hycamtin ● Capsules: 0.25 mg and 1 mg● Injection: 4 mg single dose vial as free base

1

Antineoplastic Agent, Cyclin- Dependent Kinase Inhibitor

Palbociclib Ibrance ● Powder for injection, as hydrochloride, lyophilized: 4 mg (base)

1

Antineoplastic Agent, DNA Methylation Inhibitor

Azacitidine Vidaza ● Injection, powder for suspension: 100 mg [contains mannitol 100 mg]

1

Antineoplastic Agent, Epidermal Growth Factor Receptor (EGFR) Inhibitor; Antineoplastic Agent, Tyrosine Kinase Inhibitor

Osimetrtinib Tagrisso ● Tablet: 40 mg, 80 mg 1

Antineoplastic Agent, Estrogen Receptor Antagonist

Fulvestrant Faslodex ● Injection, solution: 50 mg/mL (2.5 mL, 5 mL) [[prefilled syringe; contains alcohol, benzyl alcohol, benzyl stearate, castor oil]

1

Antineoplastic Agent, Estrogen Receptor AntagonistSelective Estrogen Receptor Modulator (SERM)

Tamoxifen Citrate Nolvadex ● Tablet: 10 mg, 20 mg 1

Antineoplastic Agent, Gonadotropin-Releasing Hormone Agonist Gonadotropin Releasing Hormone Agonist

Leuprolide Acetate Lupron Depot-3 Month Lupron Depot-Ped Lupron DepotLupron

● Powder for injection:● Depot: 3.75 mg, 7.5 mg● Depot-Ped: 7.5 mg, 11.25 mg, 15 mg, 30 mg● Depot-3 Month: 11.25 mg, 22.5 mg

1

Antineoplastic Agent, Hedgehog Pathway Inhibitor

Vismodegib Erivedge ● Capsule: Erivedge: 150 mg 1

63

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Histone Deacetylase Inhibitor

Romidepsin Istodax ● Injection, powder for reconstitution: 10 mg [contains dehydrated ethanol (in diluent), propylene glycol (in diluent); supplied with diluent]

1

Antineoplastic Agent, Interleukin-6 Receptor Antagonist

Situximab Sylvant ● Solution Reconstituted, Intravenous [preservative free]: 100 mg; 400 mg

1

Antineoplastic Agent, MEK Inhibitor

Cobimetinib Cotellic ● Tablet, oral: 20 mg 1

Antineoplastic Agent, MEK Inhibitor

Trametinib Mekinist ● Tablet, oral: 0.5 mg, 1 mg, 2 mg 1

Antineoplastic Agent, Hormone Appetite Stimulant Progestin

Megestrol Acetate Megace ● Suspension, oral: 40 mg/mL with alcohol 0.06% (240 mL)● Tablet: 20 mg, 40 mg (100s each)

1

Antineoplastic Agent, Miscellaneous

Altretamine Hexalen ● Gelcap: 50 mg (100s) 1


Arsenic Trioxide Trisenox ● Injection: 1 mg/mL (10 mL) 1


Asparaginase (E. coli) Elspar ● Injection: 10,000 units/mL (10 mL) 1


Asparaginase(Erwinia)

Erwinaze ● Injection: 10,000 units/mL (10 mL) 1


Bexarotene Targretin ● Capsule: 75 mg (100s)● Gel, topical: 1% (60 g)

1


Mitotane Lysodren ● Tablet: 500 mg (100s) 1


Pegaspargase Oncaspar ● Injection, preservative free: 750 units/mL

1


Teniposide Vumon ● Injection: 10 mg/mL (5 mL) 1

64

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Miscellaneous

Tretinoin, Oral Vesanoid ● Capsule: 10 mg (100s) 1


Trimetrexate Glucuronate Neutrexin ● Injection: 25 mg 1

Antineoplastic Agent, Miscellaneous Biological Response Modulator

Aldesleukin Proleukin ● Powder for injection, lyophilized: 22 x 106 units [18 million units/mL = 1.1 mg/mL]

1

Antineoplastic Agent, Monoclonal Antibody

Alemtuzumab Campath ● Injection: 30 mg/mL (1 mL) 1

Antineoplastic Agent, Monoclonal Antibody

Brentuximab Adcetris ● Injection: 50 mg 1

Antineoplastic Agent, Monoclonal Antibody Epidermal Growth Factor Receptor (EGFR) Inhibitor

Cetuximab Erbitux ● Injection, solution [preservative free]: 2 mg/mL (50 mL)

1

Antineoplastic Agent, Monoclonal Antibody Monoclonal Antibody, Anti CD-20

Obinutuzumab Gazyva ● Solution, Intravenous [preservative free]: Gazyva: 1000 mg/40 mL (40 mL)

1

Antineoplastic Agent, Anti- GD2; Antineoplastic Agent, Monoclonal Antibody

Dinutuximab Unituxin ● Solution, Intravenous [preservative free]:17.5 mg/5 mL (5 mL)

1

Antineoplastic Agent, Monoclonal Antibody Monoclonal Antibody, Anti PD- 1

Pembrolizumab Keytruda ● Solution Reconstituted, Intravenous [preservative free]: Keytruda: 50 mg

1

Antineoplastic Agent, Monoclonal Antibody Monoclonal Antibody

Rituximab Rituxan ● Injection: 100 mg (preservative free) (10 mL); 500 mg (10 mL)

1

Antineoplastic Agent, Monoclonal Antibody Monoclonal Antibody

Ipilimumab Yervoy ● Injection: 50 mg/ 10 mL; 200 mg/ 40 mL

1

65

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Monoclonal Antibody, Anti- HER2 o

Pertuzumab Perjeta ● Injection, solution [preservative free]: 30 mg/mL (14 mL)

1

Antineoplastic Agent, Monoclonal AntibodyAnti-HER2, Antineoplastic Agent, Antimicrotubular

Ado-tratuzumab emtansine Kadcyla ● Injection, Solution, Intravenous [preservative free]; 100 mg, 160 mg

1

Antineoplastic Agent, Monoclonal Antibody Anti- HER2 o

Trastuzumab Herceptin ● Injection, powder for reconstitution: 440 mg

1

Antineoplastic Agent, Monoclonal Antibody Radiopharmaceutical

Ibritumomab Zevalin ● Each kit contains 4 vials for preparation of either In-111 or Y- 90 conjugate (as indicated on container label)● Injection: 1.6 mg/mL (2 mL) [supplied with sodium acetate solution, formulation buffer vial (includes albumin 750 mg), and an empty reaction vial]

1

Antineoplastic Agent, Monoclonal Antibody Vascular Endothelial Growth Factor (VEGF) Inhibitor

Bevacizumab Avastin ● Injection, solution [preservative free]: 25 mg/mL (4 mL, 16 mL)

1

Antineoplastic Agent, Monoclonal Antibody Vascular Endothelial Growth Factor (VEGF) Inhibitor; Agent, Vascular Endothelial Growth Factor Receptor 2 (VEGFR2) Inhibitor

Ramucirumab Cyramza ● Solution, Intravenous [preservative free]: Cyramza: 100 mg/10 mL; 500 mg/50 mL

1

Antineoplastic Agent, mTOR Kinase Inhibitor

Everolimus Afinitor ● Tablet: 2.5 mg, 5 mg, 7.5 mg, 10 mg 1

66

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, mTOR Kinase Inhibitor

Temsirolimus Torisel ● Injection, solution [concentrate]:● Torisel: 25 mg/mL

1

Antineoplastic Agent, Natural Source (Plant) Derivative Antineoplastic Agent, Vinca Alkaloid

Vinblastine Sulfate Alkaban-AQ Velban Velsar ● Injection: 1 mg/mL (10 mL) 1


Vincristine Sulfate Oncovin ● Injection: 1 mg/mL (1 mL, 2 mL) 1


Vinorelbine Tartrate Navelbine ● Injection: 10 mg/mL (1 mL, 5 mL) 1

Antineoplastic Agent, Phosphatidylinositol 3- Kinase Inhibitor

Idelalisib Zydelig ● Tablet: 100 mg, 150 mg 1

Antineoplastic Agent, Podophyllotoxin Derivative

Etoposide VePesid ● Injection: 20 mg/mL (5 mL)● Capsules: 50 mg

1

Antineoplastic Agent, Anaplastic Lymphoma Kinase Inhibitor; Antineoplastic Agent, Tyrosine Kinase Inhibitor

Crizotinib Xalkori ● Capsule, oral: Xalkori®: 200 mg, 250 mg

1

Antineoplastic Agent, Janus Associated Kinase Inhibitor; Antineoplastic Agent, Tyrosine Kinase Inhibitor; Janus Associated Kinase Inhibitor

Ruxolitinib Jakafi ● Tablet, oral: Jakafi™: 5 mg, 10 mg, 15 mg, 20 mg, 25 mg

1

Antineoplastic Agent, Proteasome Inhibitor

Ixazomib Ninlaro ● Capsule, Oral: Ninlaro: 2.3 mg, 3 mg, 4 mg

1

Antineoplastic Agent, Tyrosine Kinase Inhibitor

Dasatinib Sprycel ● Tablets, Sprycel: 20 mg, 50 mg, 70 mg, 80 mg,100mg, 140 mg

1

67

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Tyrosine Kinase Inhibitor

Imatinib Mesylate Gleevec ● Tablet: 100 mg, 400 mg 1


Ibrutinib Imbruvica ● Capsule, Oral: Imbruvica: 140 mg 1


Nilotinib Tasigna ● Capsule, oral: 150 mg, 200 mg 1

Antineoplastic Agent, Tyrosine Kinase Inhibitor Epidermal Growth Factor Receptor (EGFR) Inhibitor

Erlotinib Tarceva ● Tablet: 25 mg, 100 mg, 150 mg 1

Antineoplastic Agent, Tyrosine Kinase Inhibitor Epidermal Growth Factor Receptor (EGFR) Inhibitor

Lapatinib Tykerb ● Tablet: 250 mg 1

Antineoplastic Agent, Tyrosine Kinase Inhibitor Vascular Endothelial Growth Factor (VEGF) Inhibitor

Cabozantinib Cometriq ● Capsule, oral [each package contains four blister cards; each card contains the following]:● Cometriq™: 60 mg daily-dose: 20 mg (21s)● Cometriq™: 100 mg daily-dose: 80 mg (7s) and 20 mg (7s)● Cometriq™: 140 mg daily-dose: 80 mg (7s) and 20 mg (21s)

1


Levatinib Lenvima Capsule Therapy Pack, Oral:● Lenvima 10 MG Daily Dose: 10 mg● Lenvima 14 MG Daily Dose: 10 mg & 4 mg● Lenvima 20 MG Daily Dose: 2x10 mg● Lenvima 24 MG Daily Dose: 2x10 mg & 4 mg

1

68

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntineoplastic Agent, Tyrosine Kinase Inhibitor Vascular Endothelial Growth Factor (VEGF) Inhibitor

Pazopanib Votrient ● Tablet: 200 mg 1


Regorafenib Stivarga ● Tablet, oral: Stivarga®: 40 mg [contains soy lecithin]

1


Sorafenib Nexavar ● Tablet, as tosylate: 200 mg 1


Sunitinib Sutent ● Capsule: 12.5 mg, 25 mg, 37.5 mg, 50 mg

1

Antineoplastic Agent, Tyrosine Kinase Inhibitor Vascular Endothelial Growth Factor (VEGF) InhibitorEpidermal Growth Factor Receptor (EGFR) Inhibitor

Vandetanib Caprelsa ● Tablet: 100 mg, 300 mg 1

Antiparasitic Agent, Topical PediculocideScabicidal Agent

Malathion Ovide Topical ● Lotion: 0.5% (2 oz) 1

Antiparasitic Agent, Topical Scabicidal Agent

Permethrin Elimite ● Cream: 5% (60 g) 1

Anti-Parkinson's Agent, Anticholinergic Anticholinergic Agent

Benztropine Mesylate Cogentin ● Injection: 1 mg/mL (2 mL)● Tablet: 0.5 mg, 1 mg, 2 mg (100s each)

1

Anti-Parkinson's Agent, Anticholinergic Anticholinergic Agent

Trihexyphenidyl Hydrochloride

● Elixir: 2 mg/5 mL (480 mL)● Tablet: 2 mg, 5 mg (100s each)

1

69

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnti-Parkinson's Agent, COMT Inhibitor

Entacapone Comtan ● Tablet: 200 mg (90s) 1

Anti-Parkinson's Agent, COMT Inhibitor Anti- Parkinson's Agent, Dopamine Agonist

Levodopa, Carbidopa, and Entacapone

Stalevo Stalevo 75Stalevo 125

● Tablet:● 50: Carbidopa 18.75 mg, levodopa 75 mg, and entacapone 200 mg● 50: Carbidopa 31.25 mg, levodopa 125 mg, and entacapone 200 mg● 50: Carbidopa 12.5 mg, levodopa 50 mg, and entacapone 200 mg● 100: Carbidopa 25 mg, levodopa 100 mg, and entacapone 200 mg● 150: Carbidopa 37.5 mg, levodopa 150 mg, and entacapone 200 mg● 200: Carbidopa 50 mg, levodopa 200 mg, and entacapone 200 mg

1

Anti-Parkinson's Agent, Dopamine Agonist

Apomorphine Apokyn ● Injection, solution, as hydrochloride: 10 mg/mL (3 mL) [multidose cartridge; contains sodium metabisulfite and benzyl alcohol]

1


Carbidopa Lodosyn ● Tablet: 25 mg (100s) 1

70

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnti-Parkinson's Agent, Dopamine Agonist

Levodopa and Carbidopa Sinemet CR Sinemet Duopa ● Tablet:● 10/100: Carbidopa 10 mg and levodopa 100 mg (100s)● 25/100: Carbidopa 25 mg and levodopa 100 mg (100s)● 25/250: Carbidopa 25 mg and levodopa 250 mg (100s)● Sustained release:● Sinemet CR 25-100: Carbidopa 25 mg and levodopa 100 mg (100s)● Sinemet CR 50-200: Carbidopa 50 mg and levodopa 200 mg (100s)Suspension, Enteral: Carbidopa 4.63 mg and levodopa 20 mg per 1 mL

1


Pramipexole Mirapex ● Tablet: 0.125 mg (63s); 0.25 mg, 0.5 mg,0.75 mg, 1 mg,1.5 mg (90s each)

1


Ropinirole Hydrochloride Requip ● Tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg,4 mg, 5 mg (30s, 100s)

1

Anti-Parkinson's Agent, Dopamine Agonist Antiviral Agent, Adamantane

Amantadine Hydrochloride Symmetrel ● Capsule: 100 mg (100s)● Solution, oral: 50 mg/5 mL (473 mL)● Tablet, as hydrochloride: 100 mg

1

Anti-Parkinson's Agent, Dopamine Agonist Ergot Derivative

Bromocriptine Mesylate Parlodel 1

71

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAnti-Parkinson's Agent, MAO Type B Inhibitor Antidepressant, Monoamine Oxidase Inhibitor

Selegiline Hydrochloride Eldepryl ● Tablet: 5 mg● Capsule: 5 mg

1

Antiplatelet Agent Aspirin and Extended- Release Dipyridamole

Aggrenox ● Capsule: Dipyridamole (extended release) 200 mg and aspirin 25 mg

1

Antiplatelet Agent Clopidogrel Bisulfate Plavix ● Tablet (generic): 75 mg 1Antiplatelet Agent Vasodilator Dipyridamole Persantine ● Tablet: 25 mg, 50 mg, 75 mg (100s

each)1

Antiplatelet Agent, Cyclopentyltriazolopyrimidine

Ticagrelor Brilinta™ ● Tablet, oral: 90 mg 1

Antiplatelet Agent, Glycoprotein IIb/IIIa Inhibitor

Abciximab ReoPro ● Injection: 2 mg/mL (5 mL) 1

Antiplatelet Agent, Glycoprotein IIb/IIIa Inhibitor

Eptifibatide Integrilin ● Injection: 2 mg/mL (10 mL vial); 0.75 mg/mL (100 mL vial)

1

Antiplatelet Agent, Thienopyridine Prasurgel Effient ● Tablet: 5 mg, 10 mg 1

Antiprotozoal Atovaquone Mepron ● Suspension: 750 mg/5 mL (210 mL) 1

Antiprotozoal Nitazoxanide Alinia ● Powder for oral suspension: 100 mg/5 mL (60 mL) [contains sucrose 1.48 g/5 mL, sodium benzoate; strawberry flavor]● Tablet: 500 mg

1

Antipsoriatic Agent; Interleukin-17A Receptor Antagonist; Monoclonal Antibody

Secukinumab Cosentyx ● Solution Auto-injector, Subcutaneous [preservative free]: Cosentyx: 150 mg/mL● Solution Prefilled Syringe, Subcutaneous [preservative free]: Cosentyx: 150 mg/mL

1

Antipsoriatic Agent; Interleukin-12 Inhibitor; Interleukin-23 Inhibitor; Monoclonal Antibody

Ustekinumab Stelara ● Solution, Subcutaneous [preservative free]: Stelara: 45 mg/0.5 mL; 90 mg/mL

1

72

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntipsoriatic Agent Keratolytic Agent

Anthralin Dritho-Scalp Psoriatec ● Cream, topical: 0.5% (50 g); 1% (50 g)

1

Antipsychotic Agent, Atypical Aripiprazole Abilify (generic) ● Tablet: 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg

1

Antipsychotic Agent, Atypical Clozapine Clozaril ● Tablet: 25 mg, 50 mg, 100 mg, 200 mg

1

Antipsychotic Agent, Atypical Olanzapine Zyprexa ● Tablet: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg (60s, 100s)

1

Antipsychotic Agent, Atypical Quetiapine Seroquel ● Tablet, as fumarate: 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg

1

Antipsychotic Agent, Atypical Risperidone Risperdal Oral ● Solution, oral: 1 mg/mL (30 mL)● Tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg,4 mg

1

Antipsychotic Agent, Atypical Ziprasidone Geodon ● Capsule (generic), as hydrochloride: 20 mg, 40 mg, 60 mg, 80 mg

1

Antipsychotic Agent, Typical Haloperidol Haldol Decanoate Haldol ● Concentrate, oral: 2 mg/mL (120 mL)● Injection, as decanoate: 50 mg (as 70.5 mg decanoate)/mL (1 mL); 100 mg (as 141.04 mg decanoate) /mL (1 mL)● Injection, as lactate: 5 mg/mL (1 mL)● Tablet: 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mg (100s each)

1

Antipsychotic Agent, Typical Loxapine Loxitane ● Capsule: 5 mg, 10 mg, 25 mg, 50 mg (100s each)

1

Antipsychotic Agent, Typical Pimozide Orap ● Tablet: 1 mg, 2 mg (100s) 1Antipsychotic Agent, Typical Thiothixene Navane ● Capsule: 1 mg, 2 mg, 5 mg, 10 mg,

20 mg (100s each)1

73

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntipsychotic Agent, Typical, Phenothiazine

Chlorpromazine Hydrochloride

Thorazine ● Injection: 25 mg/mL (1 mL, 2 mL, 10 mL)● Tablet: 10 mg, 25 mg, 50 mg, 100 mg, 200 mg (100s each)

1

Antipsychotic Agent, Typical, Phenothiazine

Fluphenazine Prolixin Decanoate Prolixin ● Concentrate, as hydrochloride: 5 mg/mL with alcohol 14% (120 mL)● Elixir, as hydrochloride: 2.5 mg/5 mL with alcohol 14% (60 mL)● Injection, as decanoate ester: 25 mg/mL (1 mL, 5 mL)● Injection, as hydrochloride: 2.5 mg/mL (10 mL)● Tablet, as hydrochloride: 1 mg, 2.5 mg, 5 mg, 10 mg (100s each)

1


Thioridazine Mellaril-S Mellaril ● Tablet: 10 mg, 25 mg, 50 mg, 100 mg

1


Trifluoperazine Hydrochloride

Stelazine ● Tablet: 1 mg, 2 mg, 5 mg, 10 mg (100s each)

1

Antiretroviral Agent, CCR5 Antagonist

Maraviroc Selzentry ● Tablet: Selzentry: 150 mg, 300 mg 1

Antiretroviral Agent, Fusion Protein Inhibitor

Enfuvirtide Fuzeon ● Injection, powder for reconstitution [single- use vial]: 108 mg [90 mg/mL following reconstitution; available in convenience kit of 60 vials, SWFI, syringes, syringes, alcohol wipes, patient instructions

1

Antiretroviral Agent,Integrase Inhibitor

Raltegravir Isentress ● Tablet: 25 mg, 100 mg, 400 mg 1

Antiretroviral, Integrase Inhibitor (Anti-HIV)

Dolutegravir Tivicay ● Tablet, Oral: 10 mg, 25 mg, 50 mg 1

74

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiretroviral, Integrase Inhibitor (Anti-HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Nucleoside (Anti-HIV)

Abacavir 600 mg,dolutegravir 50 mg,and lamivudine 300 mg

Triumeq ● Tablet, Oral: Abacavir 600 mg, dolutegravir 50 mg, and lamivudine 300 mg

1

Antiretroviral, Integrase Inhibitor (Anti-HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Nucleoside (Anti-HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Nucleotide (Anti-HIV); Cytochrome P-450 Inhibitor

Elvitegravir, Cobicistat, Emtricitabine, and Tenofovir Alafenamide

Genvoya

● Tablet, Oral: Genvoya: Elvitegravir 150 mg, cobicistat 150 mg, emtricitabine 200 mg, and tenofovir alafenamide 10 mg

1

Antiretroviral Agent,Integrase Inhibitor

Atazanavir Reyataz ● Capsules, as sulfate: 150 mg, 200 mg, 300 mg

1

Antiretroviral Agent, Protease Inhibitor

Darunavir Prezista ● Tablet: 75 mg, 150 mg, 600 mg, 800 mg

1


Darunavir and Cobicistat Prezcobix ● Tablet, Oral: Darunavir 800 mg and cobicistat 150 mg

1


Fosamprenavir Lexiva ● Tablet, as calcium: 700 mg 1


Indinavir Crixivan ● Capsule: 200 mg, 400 mg 1


Lopinavir and Ritonavir Kaletra ● Solution, oral: Lopinavir 80 mg and ritonavir 20 mg per mL● Tablet: Lopinavir 100 mg and ritonavir 25 mg● Tablet: Lopinavir 200 mg and ritonavir 50 mg

1


Nelfinavir Viracept ● Powder, oral: 50 mg/g [powder contains 50 mg as nelfinavir free base in each level scoopful (1 g)] (144 g of powder with scoop)● Tablet: 250 mg (270s), 625 mg

1

75

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiretroviral Agent, Protease Inhibitor

Ritonavir Norvir ● Tablet: 100 mg● Capsule: 100 mg● Solution: 80 mg/mL (240 mL)

1


Saquinavir Mesylate Fortovase Invirase ● Capsule, as mesylate: Invirase: 200 mg [contains lactose63.3 mg/capsule]● Tablet, as base (Invirase): 500 mg

1


Tipranavir Aptivus ● Capsule, gelatin: 250 mg [contains dehydrated ethanol 7% per capsule]

1

Antiretroviral Agent, Reverse Transcriptase Inhibitor (Non- nucleoside)

Delavirdine Rescriptor ● Tablet: 100 mg (360s) 1


Efavirenz Sustiva ● Capsule: 50 mg (30s), 100 mg (30s), 200 mg (90s)● Tablet: 600 mg (30s,100s)

1


Nevirapine Viramune Viramune XR ● Suspension, oral: 50 mg/5 mL (240 mL)● Tablet: 200 mg (100s)● Tablet, extended release: 400 mg (100s)

1


Rilpivirine Edurant ● Tablet, oral: Edurant: 25 mg 1


Etravirine Intelence ● Tablet: 25 mg, 100 mg, 200 mg 1

76

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiretroviral Agent, Reverse Transcriptase Inhibitor (Non- nucleoside)Antiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleoside)Antiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleotide)

Efavirenz, Emtricitabine, and Tenofovir

Atripla ● Tablet: Efavirenz 600 mg, emtricitabine 200 mg, and tenofovir disoproxil fumarate 300 mg

1

Antiretroviral Agent, Reverse Transcriptase Inhibitor (Non- nucleoside); Antiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleoside); Antiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleotide)

Emtricitabine, Rilpivirine, and Tenofovir

Complera™ ● Tablet, oral: Complera™: Emtricitabine 200 mg, rilpivirine 25 mg, and tenofovir disoproxil fumarate 300 mg

1

Antiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleoside)

Abacavir and Lamivudine Epzicom ● Tablet, film-coated: Abacavir 600 mg and lamivudine 300 mg

1


Abacavir Sulfate Ziagen ● Solution: 20 mg/mL (240 mL)● Tablet: 300 mg

1


Abacavir, Lamivudine, and Zidovudine

Trizivir ● Tablet: Abacavir 300 mg, lamivudine 150 mg, and zidovudine 300

1


Adefovir Dipivoxil Hepsera ● Tablet: 10 mg (30s) 1

77

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleoside)

Didanosine Videx EC Videx ● Capsule (Videx EC): 125 mg, 200 mg, 250 mg, 400 mg ● Powder for oral solution, pediatric (Videx®) 10 mg/ mL (final reconstituted concentration): 2 gram, and 4 gram

1


Emtricitabine Emtriva ● Capsule: 200 mg● Solution: 10 mg/mL

1


Entecavir Baraclude ● Oral solution: 0.05 mg/mL (210 mL) [orange flavor]● Tablet: 0.5 mg, 1 mg

1


Lamivudine Epivir-HBV Epivir ● Solution, oral: 10 mg/mL (240 mL)● Tablet (generic): 150 mg, 300 mg● Solution, oral: 5 mg/mL (240 mL)● Tablet: 100 mg (60s)

1


Stavudine Zerit ● Capsule: 15 mg, 20 mg, 30 mg, 40 mg● Powder, for oral solution: 1 mg/mL

1


Zidovudine Retrovir ● Capsule: 100 mg (100s)● Injection: 10 mg/mL (20 mL)● Syrup: 50 mg/5 mL (240 mL)● Tablet: 300 mg

1


Zidovudine and Lamivudine

Combivir ● Tablet, generic: Zidovudine 300 mg and lamivudine 150 mg

1

78

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleoside)Antiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleotide)

Elvitegravir, Cobicistat, Emtricitabine, and Tenofovir

Stribild ● Tablet, oral: Stribild™: Elvitegravir 150 mg, cobicistat 150 mg, emtricitabine 200 mg, and tenofovir disoproxil fumarate 300 mg

1

Antiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleoside)Antiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleotide)

Emtricitabine and Tenofovir

Truvada ● Tablet, Oral: Truvada:Emtricitabine 100 mg and tenofovir disoproxil fumarate 150 mg,Emtricitabine 133 mg and tenofovir disoproxil fumarate 200 mg,Emtricitabine 167 mg and tenofovir disoproxil fumarate 250 mg,Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg

1

Antiretroviral, Reverse Transcriptase Inhibitor, Nucleoside (Anti-HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Nucleotide (Anti-HIV)

Emtricitabine and Tenofovir alafenamide

Descovy

● Tablet, Oral: Descovy: Emtricitabine 200 mg and tenofovir alafenamide 25 mg

1

Antiretroviral, Reverse Transcriptase Inhibitor, Non- nucleoside (Anti-HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Nucleoside (Anti- HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Nucleotide (Anti-HIV)

Emtricitabine, rilpivirine, and tenofovir alafenamide

Odefsey

● Tablet, Oral: Odefsey: Emtricitabine 200 mg, rilpivirine 25 mg, and tenofovir alafenamide 25 mg

1

Antiretroviral Agent, Reverse Transcriptase Inhibitor (Nucleotide)

Tenofovir Viread ● Tablet, as disoproxil fumarate: 300 mg [equivalent to 245 mg tenofovir disoproxil]

1

79

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntirheumatic, Disease Modifying Abatacept Orencia ● Injection, powder for reconstitution

[preservative free]: 250 mg● Injection, solution [preservative free]: Orencia®: 125 mg/mL● Solution Auto-injector, Subcutaneous: Orencia ClickJect: 125 mg/mL (1 mL)

1

Antirheumatic, Disease Modifying Leflunomide Arava ● Tablet: 10 mg, 20 mg (30s, 100s); 100 mg

1

Antirheumatic, Disease Modifying, Janus Kinase Inhibitor

Tofacitinib Xeljanz ● Tablet, Oral: Xeljanz: 5 mg● Tablet Extended Release 24 Hour, Oral: Xeljanz XR: 11 mg

1

Antirheumatic, Disease Modifying Gastrointestinal Agent, Miscellaneous Monoclonal AntibodyTumor Necrosis Factor (TNF) Blocking Agent

Infliximab Remicade ● Injection: 100 mg/vial 1

Antirheumatic, Disease Modifying Interleukin-1 Receptor Antagonist

Anakinra Kineret ● Injection [prefilled glass syringe; preservative free]: 100 mg/0.67 mL (1 mL)

1

Antirheumatic, Disease Modifying Monoclonal AntibodyTumor Necrosis Factor (TNF) Blocking Agent

Adalimumab Humira ● Pen-injector Kit, Subcutaneous [preservative free]:● Humira Pen: 40 mg/0.8 mL (1 ea)● Humira Pen-Crohns Starter: 40 mg/0.8 mL● Humira Pen-Psoriasis Starter: 40 mg/0.8 mL● Prefilled Syringe Kit, Subcutaneous [preservative free]: 10 mg/0.2 mL; 20 mg/0.4 mL; 40 mg/0.8 mL

1

80

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntirheumatic, Disease ModifyingTumor Necrosis Factor (TNF) Blocking Agent

Etanercept Enbrel ● Injection: 25 mg single-use vials with diluent (4s)● Injection 25 mg/0.5 mL prefilled syringe● Enbrel: 50 mg/mL (0.51 mL, 0.98 mL) [contains sucrose; packaging may contain dry natural rubber (latex)]● ENBREL SureClick autoinjector, Single- use, prefilled, 50 mg/mL,

1

Antiseptic, Topical Iodine Iodex [OTC] Iodoflex Iodosorb ● Solution:● Dilute (Schiller's): 0.0033% with potassium iodide 0.0066%

1

Antispasmodic Agent, Gastrointestinal Benzodiazepine

Clidinium and Chlordiazepoxide

Librax ● Capsule: Clidinium bromide 2.5 mg and chlordiazepoxide hydrochloride 5 mg (30s, 100s)

1

Antispasmodic Agent, Urinary Oxybutynin Chloride Ditropan Oxytrol ● Syrup: 5 mg/5 mL● Tablet: 5 mg (100s)● Tablet, extended release, as chloride: 5 mg, 10 mg, 15 mg● Transdermal system (Oxytrol): 3.9 mg/day (8s) [39 cm2; total oxybutynin 36 mg]

1

Antithyroid Agent Sodium Iodide ● Injection: 10% (10 mL) 1Antithyroid Agent Expectorant Potassium Iodide SSKI ● Solution, oral: 1 g/mL (30 mL) 1Antithyroid Agent Thioamide Methimazole Tapazole ● Tablet: 5 mg, 10 mg (100s each) 1Antithyroid Agent Thioamide Propylthiouracil ● Tablet: 50 mg (100s) 1Antitoxin Diphtheria Antitoxin ● Injection: 20,000 units 1Antitrypsin Deficiency Agent Alpha1-Proteinase Inhibitor Prolastin-C ● Prolastin-C Injection: ~ 1000 mg

[contains sodium 100-210 mEq/vial; supplied with diluent]

1

Antitubercular Agent Ethambutol Hydrochloride Myambutol ● Tablet: 100 mg, 400 mg (100s each) 1

81

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntitubercular Agent Ethionamide Trecator-SC ● Tablet: 250 mg (100s) 1Antitubercular Agent Isoniazid Nydrazid ● Injection: 100 mg/mL (10 mL)

● Syrup: 50 mg/5 mL (473 mL)● Tablet: 100 mg, 300 mg (100s each)

1

Antitubercular Agent Pyrazinamide ● Tablet: 500 mg 1Antitubercular Agent Rifapentine Priftin ● Tablet, oral: 150 mg 1Antitussive Benzonatate Tessalon Perles ● Capsule: 100 mg (30s, 100s) 1Antitussive Hydrocodone and

HomatropineHycodan ● Syrup: Hydrocodone bitartrate 5 mg

and homatropine methylbromide 1.5 mg per 5 mL (120 mL) [NP, PA in 4 oz, 8 oz]● Tablet: Hydrocodone bitartrate 5 mg and homatropine methylbromide 1.5 mg (100s)

1

AntitussiveCough Preparation Expectorant

Guaifenesin and Codeine Robitussin A-C ● Syrup: Guaifenesin 100 mg and codeine phosphate 10 mg per 5 mL with alcohol 3.5% (120 mL, 240 mL) [NP, PA in 4 oz, 8 oz]

1

Antitussive/Decongestant/Expe ctorant

Guaifenesin, Pseudoephedrine, and Codeine

Novahistine Expectorant ● Liquid: Guaifenesin 100 mg, pseudoephedrine hydrochloride 30 mg, and codeine phosphate 10 mg per 5 mL with alcohol 7.5% (120 mL, 480 mL)

1

Antivenin Antivenin (Crotalidae) Polyvalent

CroFab ● Injection: 10 mL 1

Antivenin Antivenin, Black Widow Spider (Equine)

● Injection, powder for reconstitution: 6000 antivenin units [equine origin; contains thimerosal; packaged with diluent and normal horse serum for sensitivity testing]

1

Antiviral Agent Cidofovir Vistide ● Injection: 75 mg/mL (5 mL) 1

82

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiviral Agent Foscarnet Foscavir ● Injection: 24 mg/mL (250 mL, 500

mL)1

Antiviral Agent Ganciclovir Cytovene Vitrasert ● Intravitreal implant: 4.5 mg of ganciclovir designed to release over 5-8 months. Following depletion of ganciclovir from the implant, as evidenced by progression of retinitis, the implant may be removed and replaced.● Powder for injection, lyophilized: 500 mg (10 mL)

1

Antiviral Agent Ribavirin Copegus Rebetol Virazole ● Capsule (generic): 200 mg● Powder for aerosol (Virazole): 6 g

1

Antiviral Agent Rimantadine Flumadine ● Syrup, as hydrochloride: Flumadine®: 50 mg/5 mL● Tablet, as hydrochloride: 100 mg

1

Antiviral Agent Valganciclovir Valcyte ● Tablet, as hydrochloride: 450 mg [496.3 mg valganciclovir hydrochloride equivalent to 450 mg valganciclovir]● Powder for oral solution 50 mg/ mL

1

Antiviral Agent Antiviral Agent, Topical

Acyclovir Zovirax ● Capsule: 200 mg (30s, 50s, 100s)● Injection: 500 mg (10 mL)● Suspension, oral: 200 mg/5 mL (480 mL)● Tablet: 400 mg, 800 mg (100s)

1

Antiviral Agent; Antiviral Agent, Oral

Valcyclovir Valtrex ● Caplet, oral: 500 mg, 1 g 1

83

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierAntiviral Agent Neuraminidase Inhibitor

Oseltamivir Tamiflu ● Capsule, as phosphate: 30 mg, 45 mg, 75 mg● Powder for oral suspension: 6 mg/ mL

1

Antiviral Agent Neuraminidase Inhibitor

Zanamivir Relenza® ● Powder for oral inhalation: 5 mg/blister (20s) [4 blisters per Rotadisk® foil pack, 5 Rotadisk® per package; packaged with Diskhaler® inhalation device; contains lactose]

1

Antiviral Agent, Ophthalmic Trifluridine Viroptic ● Solution, ophthalmic: 1% (7.5 mL) 1

Barbiturate Amobarbital Amytal ● Injection, as sodium: 500 mg 1Barbiturate Methohexital Sodium Brevital Sodium ● Injection: 50 mg/mL (50 mL) 1Benzodiazepine Alprazolam Alprazolam Intensol Niravam

Xanax XR Xanax● Tablet: 0.25 mg (30s, 50s, 100s); 0.5 mg (30s, 50s, 100s); 1 mg (100s), 2 mg

1

Benzodiazepine Chlordiazepoxide Librium ● Capsule, as hydrochloride: 5 mg, 10 mg, 25 mg (30s, 100s each)● Powder for injection: 100 mg

1

Benzodiazepine Clonazepam Klonopin ● Tablet: 0.5 mg, 1 mg, 2 mg (100s each)

1

Benzodiazepine Clorazepate Dipotassium Tranxene ● Tablet: 3.75 mg, 7.5 mg, 15 mg (100s each)

1

84

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierBenzodiazepine Diazepam Diastat Valium ● Diastat: Pediatric rectal tip [4.4 cm]:

(2.5 mg) [contains ethyl alcohol 10%, sodium benzoate, benzyl alcohol 1.5%; twin pack]● AcuDial delivery system:● 10 mg: Pediatric/adult rectal tip [4.4 cm]: 5 mg/mL (delivers set doses of 5 mg, 7.5 mg, and 10 mg) [contains ethyl alcohol 10%, sodium benzoate, benzyl alcohol 1.5%; twin pack]● 20 mg: Adult rectal tip [6 cm]: 5 mg/mL (delivers set doses of 10 mg, 12.5 mg, 15 mg,17.5 mg, and 20 mg) [contains ethyl alcohol 10%, sodium benzoate, benzyl alcohol 1.5%; twin pack]● Injection: 5 mg/mL (2 mL, 10 mL)● Solution, oral: 5 mg/mL (30 mL with dropper); 5 mg/5 mL (500 mL)● Tablet: 2 mg, 5 mg, 10 mg (30s, 100s each)

1

Benzodiazepine Lorazepam Ativan ● Injection: 2 mg/mL (1 mL, 10 mL); 4 mg/mL (10 mL)● Solution, concentrated, oral: 2 mg/mL (30 mL)● Tablets: 0.5 mg, 1 mg, 2 mg (30s, 100s, 250s, 500s, 1000s)

1

85

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierBenzodiazepine Midazolam Hydrochloride Versed ● Injection: 5 mg/mL (1 mL, 2 mL, 2

mL Tel- E-Ject syringe, 10 mL)● Injection, solution: 1 mg/mL (2 mL, 5 mL, 10 mL); 5 mg/mL (1 mL, 2 mL, 5 mL, 10 mL) [contains benzyl alcohol 1%]● Syrup, oral: 2 mg/mL (118 mL)

1

Benzodiazepine Oxazepam Serax ● Capsule: 10 mg (30s, 100s), 15 mg, 30 mg (100s each)

1

Beta Blocker With Alpha- Blocking Activity

Carvedilol Coreg ● Tablet: 3.125 mg, 6.25 mg, 12.5 mg, 25 mg (100s each)

1

Beta Blocker With Alpha- Blocking Activity

Labetalol Hydrochloride Normodyne Trandate ● Injection: 5 mg/mL (20 mL)● Tablet: 100 mg, 200 mg, 300 mg (100s)

1

Beta Blocker, Beta1 Selective Atenolol Tenormin ● Tablet: 25 mg (100s); 50 mg (30s, 50s, 100s); 100 mg (100s)

1

Beta Blocker, Beta1 Selective Bisoprolol Zebeta ● Tablet, as fumarate: 5 mg, 10 mg 1Beta Blocker, Beta1 Selective Metoprolol Lopressor Toprol generic ● Injection, as tartrate: 1 mg/mL (5

mL)● Tablet, as tartrate: 25 mg, 50 mg, 100 mg (100s each)● Tablet Extended Release 24 Hour, Oral, as succinate: Generic: 25 mg, 50 mg, 100 mg, 200 mg

1

Beta Blocker, Beta1 Selective Ophthalmic Agent, Antiglaucoma

Betaxolol Hydrochloride Betoptic S Kerlone ● Solution, ophthalmic, as hydrochloride: 0.5% (5 mL, 10 mL, 15 mL) [contains benzalkonium chloride]● Tablet: 10 mg, 20 mg

1

Beta1- & Beta2-Adrenergic Agonist Agent

Isoproterenol Isuprel Medihaler-Iso ● Injection: 0.2 mg/mL (1 mL, 5 mL) 1

86

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierBeta2-Adrenergic Agonist Albuterol Ventolin AccuNeb ● Aerosol, for oral inhalation

(Ventolin HFA): 90 mcg/metered inhalation● Solution: Inhalation: 0.5% (Unit dose and 20 mL)●Solution, for nebulization: 0.021% [0.63 mg/3 mL] (25s); 0.042% [1.25 mg/3 mL]● Nebulization: 0.083% (3 mL)● Syrup, as sulfate: 2 mg/5 mL● Tablet, as sulfate: 2 mg; 4 mg

1

Beta2-Adrenergic Agonist Metaproterenol Sulfate Alupent Metaprel ● Solution, inhalation: 0.6% (2.5 mL)● Syrup: 10 mg/5 mL (240 mL, 480 mL)● Tablet: 10 mg, 20 mg (100s each)

1

Beta2 Agonist; Beta2- Adrenergic Agonist, Long- Acting

Olodaterol Striverdi Respimat ● Aerosol Solution, Inhalation: Striverdi Respimat: 2.5 mcg/actuation (4 g)

1

Beta2-Adrenergic Agonist Salmeterol Xinafoate Serevent Diskus Serevent ● Powder for inhalation (Serevent Diskus): 50 mcg (28s, 60s) [delivers 47 mcg/inhalation]

1

Beta2-Adrenergic Agonist Terbutaline Sulfate Brethine ● Injection: 1 mg/mL (1 mL)● Tablet: 2.5 mg, 5 mg (100s each)

1

87

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierBeta2-Adrenergic Agonist Corticosteroid, Inhalant (Oral)

Mometasone and Formoterol

Dulera® ● Aerosol, for oral inhalation:● Mometasone furoate 100 mcg and formoterol fumarate dihydrate 5 mcg per inhalation (13 g) [120 metered actuations]● Mometasone furoate 200 mcg and formoterol fumarate dihydrate 5 mcg per inhalation (13 g) [120 metered actuations]

1

Beta2-Adrenergic Agonist Corticosteroid, Inhalant (Oral)

Fluticasone and Salmeterol Advair Diskus ● Powder, for oral inhalation: Advair Diskus● 100/50: Fluticasone propionate 100 mcg and salmeterol xinafoate 50 mcg (28s, 60s) [contains lactose; chlorofluorocarbon free]● 250/50: Fluticasone propionate 250 mcg and salmeterol xinafoate 50 mcg (28s, 60s) [contains lactose; chlorofluorocarbon free]● 500/50: Fluticasone propionate 500 mcg and salmeterol xinafoate 50 mcg (28s, 60s) [contains lactose; chlorofluorocarbon free]

1

Beta-Adrenergic Blocker, Nonselective

Nadolol Corgard ● Tablet: 20 mg, 40 mg, 80 mg 1

Beta-Adrenergic Blocker, Nonselective Ophthalmic Agent, Antiglaucoma

Levobunolol Hydrochloride Betagan ● Solution, ophthalmic: 0.25% (5 mL, 10 mL); 0.5% (5 mL, 10 mL, 15 mL)

1

Beta-Adrenergic Blocker, Nonselective Ophthalmic Agent, Antiglaucoma

Timolol Betimol Ophthalmic Timoptic Ophthalmic

● Solution, ophthalmic, as maleate: 0.25% (5 mL, 10 mL, 15 mL); 0.5% (2.5 mL, 5 mL, 10 mL, 15 mL)

1

88

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierBiological Response Modulator Human Growth Factor

Oprelvekin Neumega ● Powder for injection, lyophilized: 5 mg

1

Biological Response Modulator Vaccine

BCG TheraCys TICE ● Injection (TICE): 50 mg (2 mL)● Injection, intravesical (TheraCys): 81 mg [with diluent]

1

Biological, Miscellaneous Glatiramer Copaxone (generic) ● Injection: Glatiramer acetate 20 mg vials with diluent (32s)

1

Bisphosphonate Derivative Alendronate Sodium Fosamax ● Tablet: 10 mg (30s, 100s); 40 mg (For Paget's only) (30s); 70 mg

1

Bisphosphonate Derivative Etidronate Disodium Didronel ● Tablet: 200 mg, 400 mg (60s each) 1

Bisphosphonate Derivative Risedronate Actonel ● Tablet: 30 mg (Formulary for Paget's only)

1

Blood Product Derivative Plasma Protein Fraction Plasmanate ● Injection: 5% (250 mL) 1Blood Product Derivative C1 Esterase Inhibitor

C1 Inhibitor (Human) Cinryze ● Solution Reconstituted, Intravenous [preservative free]: Cinryze: 500 units

1

Blood Product Derivative; Hemostatic Agent; Prothrombin Complex Concentrate (PCC)

Prothrombin Complex Concentrate [Human]

Kcentra ● Injection, powder for reconstitution [preservative free]: Kcentra: 500 units [contains albumin (human)

1

Blood Product Derivative Plasma Volume Expander, Colloid

Albumin Human Albumisol ● Injection: 5% (50 mL, 250 mL, 500 mL);25% (50 mL)

1

Blood Viscosity Reducer Agent Pentoxifylline Trental ● Tablet, controlled release: 400 mg (100s)

1

89

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierBronchodilator Ipratropium Bromide and

Albuterol SulfateCombivent ● Aerosol, oral inhalation: 103 mcg

albuterol and 18 mcg ipratropium per actuation (200 doses per inhaler [14.7 g])● Solution, for oral inhalation [spray]: Ipratropium bromide 20 mcg and albuterol (base) 100 mcg per inhalation (4 g) [contains benzalkonium chloride; 120 metered actuations]

1

Calcimimetic Cinacalcet Sensipar ● Tablet [film coated]: 30 mg, 60 mg, 90 mg

1

Calcium Channel Blocker Amlodipine Norvasc ● Tablet: (generic) 2.5 mg, 5 mg, 10 mg

1

Calcium Channel Blocker; Calcium Channel Blocker, Dihydropyridine

Clevidipine Cleviprex ● Emulsion, Intravenous: Cleviprex: 0.5 mg/mL

1

Calcium Channel Blocker Diltiazem Hydrochloride Cardizem SR Cardizem Cartia XT Cardia XT

● Cardizem SR (Capsule Extended Release 12 Hour): 60 mg, 90 mg, 120 mg● Cardia XT (Capsule Extended Release 24 Hour): 180 mg, 120 mg, 240 mg● Injection: 5 mg/mL (5 mL, 10 mL)● Tablet: 30 mg, 60 mg, 90 mg, 120 mg

1

Calcium Channel Blocker, Antianginal Agent; Antihypertensive; Calcium Channel Blocker; Dihydropyridine

Nicardipine Cardene Solution, Intravenous: 2.5 mg/mL (10 mL)Solution, Intravenous: Cardene: 20 mg (200mL); 40 mg (200 mL)

1

90

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierCalcium Channel Blocker Nifedipine Nifedical XL ● Capsule, liquid-filled: 10 mg, 20 mg

(100s each)● Tablet, extended release; (generic): 30 mg, 60 mg, 90 mg (100s)

1

Calcium Channel Blocker Nimodipine Nimotop ● Capsule, liquid-filled: 30 mg 1Calcium SaltElectrolyte Supplement, Oral Electrolyte Supplement, Parenteral

Calcium Gluconate ● Injection: 10% [100 mg/mL] (10 mL, 50mL, 100 mL, 200 mL)

1

Calcium Salt Electrolyte Supplement, Parenteral

Calcium Chloride ● Injection: 100 mg/mL (10 mL) 1

Calcium-Lowering Agent Gallium Nitrate Ganite ● Injection: 25 mg/mL (20 mL) 1Caloric Agent Fat Emulsion Intralipid Liposyn ● Injection: 10%, 20% (100 mL, 500

mL)1

Caloric Agent Intravenous Nutritional Therapy

Total Parenteral Nutrition Clinimix E Clinimix ● Injection System (Clinimix, Clinimix E): 2000 mL● See tables

1

Carbonic Anhydrase Inhibitor Diuretic, Carbonic Anhydrase Inhibitor Ophthalmic Agent, Antiglaucoma

Methazolamide Neptazane ● Tablet: 25 mg, 50 mg (100s each) 1

Carbonic Anhydrase Inhibitor Ophthalmic Agent, Antiglaucoma

Dorzolamide Trusopt ● Solution, ophthalmic: 2% 1

Carbonic Anhydrase Inhibitor Ophthalmic Agent and Beta adrenergic blocking agent, ophthalmic, Antiglaucoma

Dorzolamide / Timolol Cosopt ● Dorzolamide 2% solution, ophthalmic: 2% with timolol maleate 0.5% ophthalmic solutions

1

91

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierCatharticElectrolyte Supplement, Oral Electrolyte Supplement, Parenteral Laxative, Bowel Evacuant

Sodium Phosphate Fleet Enema Extra [OTC] Fleet Enema for Children [OTC] Fleet Enema [OTC] Fleet Phospho-soda EZ- Prep [OTC] Fleet Phospho- soda [OTC] OsmoPrep Visicol

● Injection: Phosphate 3 mmol and sodium 4 mEq per mL (15 mL)

1

Central Monoamine-Depleting Agent Rauwolfia Alkaloid

Reserpine ● Tablet: 0.1 mg, 0.25 mg (100s each) 1

Central Nervous System Stimulant Lisdexamfetamine Vyvanse ● Capsule, oral, as dimesylate: 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg capsules

1

Central Nervous System Stimulant Dexmethylphenidate Focalin (generic) Focalin XR (generic)

● Tablet, immediate release: 2.5 mg, 5 mg, 10 mg● Capsule Extended Release 24 Hour, Oral: 5 mg, 10 mg, 15 mg, 20 mg, 30 mg, 40 mg

1

Central Nervous System Stimulant Methylphenidate Hydrochloride

Concerta Daytrana Metadate ER Methylphenidate ER Ritalin-SR Ritalin

● Tablet: 5 mg, 10 mg, 20 mg (100s each)● Metadate ™ CD generic: Capsule, extended release: 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg● Capsule, extended release, as hydrochloride (Aptensio XR): 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg● Methylphenidate ER: 10 mg, 20 mg● Concerta (generic ER tablets): 18 mg (100s), 27 mg, 36 mg (100s), 54 mg (100s)

1

Chelating Agent Edetate Calcium Disodium Calcium Disodium Versenate ● Injection: 200 mg/mL (5 mL) 1

92

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierChelating Agent Edetate Disodium Sodium Versenate ● Injection: 150 mg/mL (20 mL) 1Cholinergic Agonist Bethanechol Chloride Urecholine ● Tablet: 5 mg, 10 mg, 25 mg, 50 mg 1

Cholinergic Agonist Ophthalmic Agent, Antiglaucoma Ophthalmic Agent, Miotic

Carbachol Isopto Carbachol Miostat ●Solution, intraocular: (Miostat®): 0.01%

1

Cholinergic Agonist Ophthalmic Agent, Antiglaucoma Ophthalmic Agent, Miotic

Pilocarpine Salagen ● Tablet: 5 mg● Solution, ophthalmic, as hydrochloride 1% (15 mL); 2% (15 mL); 4% (15 mL)

1

Cholinergic Agonist Ophthalmic Agent, Miotic

Acetylcholine Chloride Miochol ● Powder, intraocular ophthalmic: 20 mg (2 mL)

1

Colchicine Colchicine Colcrys ● Capsule: 0.6 mg 1Colony Stimulating Factor Epoetin Alfa Procrit ● (Epogen brand is NonFormulary)

● Injection, preservative free: 2000 units (1 mL); 3000 units (1 mL); 4000 units (1 mL); 10,000 units (1 mL); 20,000 units (1 mL), 40,000 units (1 mL)● Injection, solution [with preservative]: 10,000 units/mL (2 mL); [contains human albumin and benzyl alcohol]

1

Colony Stimulating Factor Filgrastim Neupogen Zarxio ● Solution, Injection: Neupogen: 300 mcg/mL; 480 mcg/1.6 mL● Solution Prefilled Syringe [preservative free]: Zarxio: 300 mcg/0.5 mL; 480 mcg/0.8 mL

1

Colony Stimulating Factor Sargramostim Leukine ● Injection, powder for reconstitution: 250 mcg

1

93

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierColony Stimulating Factor, Thrombopoietic

Eltrombopag Promacta ● Tablet: Promacta: 25 mg, 50 mg, 75 mg● Powder for Oral Suspension: 25 mg

1

Contraceptive Intrauterine Copper Contraceptive

Paragard ● ParaGard T380A 1

Contraceptive Estrogen and Progestin Combination

Ethinyl Estradiol and Desogestrel

Reclipsen ● Tablet, monophasic: Ethinyl estradiol 0.03 mg and desogestrel 0.15 mg (28s) [21 white tablets and 7 green inactive tablets]

1


Ethinyl Estradiol and Drospirenone

Ocella ● Tablet: Ethinyl estradiol 0.03 mg and drospirenone 3 mg [21 yellow round active tablets and 7 white inert round tablets] (28s)]

1


Ethinyl Estradiol and Ethynodiol Diacetate

Demulen 1/35 Demulen1/50 Zovia 1/35 Zovia 1/50

● Tablet:● 1/35: Ethinyl estradiol 0.035 mg and ethynodiol diacetate 1 mg● 1/50: Ethinyl estradiol 0.050 mg and ethynodiol diacetate 1 mg

1


Ethinyl Estradiol and Etonogestrel

NuvaRing ● Ring, vaginal: Ethinyl estradiol 0.015 mg/day and etonogestrel 0.12 mg/day (1s) [3- week duration]

1

94

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierContraceptive Estrogen and Progestin Combination

Ethinyl Estradiol and Levonorgestrel

Aviane LevlenLevora , Trivora Tri-Levlen

● Tablet:● Levora 28: Ethinyl estradiol 0.03 mg and levonorgestrel0.15 mg [21 white tablets and 7 peach inactive tablets] (28s)● Trivora 28:● Day 1-6: Ethinyl estradiol 0.03 mg and levonorgestrel 0.05 mg [6 blue tablets]● Day 7-11: Ethinyl estradiol 0.04 mg and levonorgestrel0.075 mg [5 white tablets]● Day 12-21: Ethinyl estradiol 0.03 mg and levonorgestrel0.125 mg [10 pink tablets]● Day 22-28: 7 peach inactive tablets (28s)

1


Ethinyl Estradiol and Norelgestromin

Xulane ● Patch, transdermal: Xulane: Ethinyl estradiol 0.53 mg and norelgestromin 4.86 mg

1

95


Ethinyl Estradiol and Norethindrone

Aranelle Microgestin Microgestin Fe Necon 0.5/35 Necon 10/11: Norinyl 1+35 Nortrel 7/7/7

Tablet:● Microgestin™ Fe 1/20: Ethinyl estradiol0.020 mg and norethindrone acetate 1 mg (ferrous fumarate 75 mg in 7 otherwise inert tablets)● Microgestin™ Fe 1.5/30: Ethinyl estradiol0.030 mg and norethindrone acetate 1.5 mg (ferrous fumarate 75 mg in 7 otherwise inert tablets)● Necon® 0.5/35: Ethinyl estradiol 0.035 mg and norethindrone 0.5 mg (28s) [21 light yellow tablets and 7 white inactive tablets] Necon® 1/35: Ethinyl estradiol 0.035 mg and norethindrone 1 mg (28s) [21 dark yellow tablets and 7 white inactive tablets]● Aranelle:Day 1-7: Ethinyl estradiol 0.035 mg and norethindrone 0.5mg Day 8-16: Ethinyl estradiol 0.035 mg and norethindrone 1 mg Day 17-21: Ethinyl estradiol 0.035 mg and norethindrone 0.5 mgDay 22-28: 7 peach inactive tablets

1

96


Ethinyl Estradiol and Norgestrel

Lo/OvralLow-Ogestrel Ogestrel

● Tablet:● Ethinyl estradiol 0.03 mg and norgestrel 0.3 mg● Ethinyl estradiol 0.05 mg and norgestrel 0.5 mg● Low-Ogestrel 28: Ethinyl estradiol 0.03 mg and norgestrel0.3 mg [21 white tablets and 7 peach inactive tablets] (28s)

1


Mestranol and Norethindrone

Norinyl 1+50 ● Tablet: Mestranol 0.05 mg and norethindrone 1 mg (28 tablet blister)

1

97


Norgestimate and Ethinyl Estradiol

Ortho Tri-Cyclen Ortho- Cyclen SprintecTri-Sprintec Tri-Lo- Sprintec

Tablet, monophasic formulation:● Sprintec: Ethinyl estradiol 0.035 mg and norgestimate 0.25 mg [21 blue tablets and 7 white inactive tablets] (28s) Tablet, triphasic formulation:● Tri-Sprintec:Day 1-7: Ethinyl estradiol 0.035 mg and norgestimate 0.18 mg [7 gray tablets]Day 8-14: Ethinyl estradiol 0.035 mg and norgestimate 0.215 mg [7 light blue tablets] Day 15-21: Ethinyl estradiol 0.035 mg and norgestimate 0.25 mg [7 blue tablets]Day 22-28: 7 white inactive tablets (28s)● Tri-Lo-Sprintec:Day 1 to 7: Ethinyl estradiol 0.025 mg andnorgestimate 0.18 mg [7 gray tablets]Day 8 to 14: Ethinyl estradiol 0.025 mg and norgestimate0.215 mg [7 light blue tablets]Day 15 to 21: Ethinyl estradiol 0.025 mg and norgestimate0.25 mg [7 blue tablets]Day 22 to 28: 7 white inactive tablets

1

Contraceptive Progestin Etonogestrel Nexplanon ● Rod, subdermal [radiopaque]: Nexplanon®: 68 mg [contains barium sulfate 15 mg]

1

98

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierContraceptive Progestin Levonorgestrel Mirena EContra EZ Tablet: EContra EZ: Levonorgestrel

1.5 mg tablet Intrauterine device: Mirena: T-shaped unit containing a reservoir of 52 mg levonorgestrel covered by a silicone membrane

1

Contraceptive Progestin Medroxyprogesterone Acetate

Depo-Provera Provera ● Injection, suspension: 150 mg/mL (1 mL single dose vial, 1 mL prefilled syringe); 400 mg/mL (10 mL)● Injection, suspension, as acetate:● 400 mg/mL (2.5 mL, 10 mL)● Prefilled syringe or vial: 150 mg/mL (1 mL)● Tablet: 2.5 mg (100s); 5 mg (100s); 10 mg (30s, 40s, 100s)

1

Contraceptive Progestin Norethindrone Aygestin Micronor Nor-QD ● Tablet (Nor-QD): 0.35 mg (28s)● Tablet, as acetate: 5 mg

1

ContraceptiveProgestin receptor modulator

Ulipristal Ella ● Tablet, oral, as acetate: 30 mg 1

Contraceptive, Barrier Diaphragms Koroflex Koromex Ortho All-Flex

● Ortho All-Flex 1

Corticosteroid, AdrenalCorticosteroid, OralCorticosteroid, SystemicCorticosteroid, Topical

Aristocort Aristocort ● Cream, as acetonide: 0.025% (15 g, 80 g);

0.1% (15 g, 80g); 0.5% (15 g)● Injection, as acetonide: 40 mg/mL (5 mL)● Injection, as hexacetonide, intralesional: 5mg/mL (5 mL)

1Triamcinolone

Aristospan Kenalog

99

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms Tier● Injection as hexacetonide, intra-articular: 20mg/mL (5 mL)● Paste, oral, topical, as acetonide: 0.1% (5 g)● Ointment, topical, as acetonide: 0.025% (15g, 80 g); 0.1% (15 g, 80 g); 0.5% (15 g)● Tablet: 1 mg, 4 mg, 8 mg, 16 mg (100seach)

Corticosteroid, Inhalant (Oral) Corticosteroid, Nasal

Beclomethasone Dipropionate

QVAR Oral Inhaler ● Oral inhalation (QVAR), as beclomethasone dipropionate hydrofluoroalkane: 40 mcg/inhalation (100 metered doses, 8.7 g), 80 mcg/inhalation (100 metered doses, 8.7 g)

1

Corticosteroid, Inhalant (Oral) Corticosteroid, Nasal

Flunisolide Nasalide ● Inhalant: Nasal (Nasalide): 25 mcg/actuation (25 mL)

1

Corticosteroid, Inhalant (Oral) Corticosteroid, Nasal Corticosteroid, Systemic

Budesonide Pulmicort Turbuhaler ● Pulmicort Flexhaler: 180 mcg/inhalation (225 mg) [delivers~160 mcg/inhalation; 120 actuations]

1

Corticosteroid, Inhalant (Oral) Mometasone Furoate Asmanex HFA ● Aerosol, Inhalation: Asmanex HFA: 100 mcg/actuation; 200 mcg/actuation

1

100

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierCorticosteroid, Inhalant (Oral) Corticosteroid, Nasal Corticosteroid, Topical Corticosteroid, Topical (Medium Potency)

Fluticasone Propionate Flonase Flovent ● Spray, intranasal: 50 mcg/actuation (9 g = 60 actuations, 16 g = 120 actuations)● Aerosol for oral inhalation, as propionate [CFC free] (Flovent HFA): 44 mcg/inhalation (10.6 g) [120 metered doses]

1

Corticosteroid, Ophthalmic Fluorometholone FML ● Suspension, ophthalmic: 0.1% (5 mL, 10 mL) [OF]● Ointment, ophthalmic: 0.1% (3.5 g) [OF]

1

Corticosteroid, Ophthalmic Corticosteroid, Systemic

Prednisolone Hydeltra-T.B.A. Inflamase Forte Inflamase Mild Orapred PediapredPred Mild

● Solution, ophthalmic, as sodium phosphate: 1% (5 mL, 10 mL, 15 mL) [OF]● Suspension, ophthalmic, as acetate: 0.12%, 1% (5 mL, 10 mL) [OF]● Tablet: 5 mg (100s)● Solution, oral, alcohol free: 5 mg/5 mL (120 mL, 480 mL)● Solution, oral, 20 mg/5 mL (240 mL) [equivalent to prednisolone base 15 mg/5 mL; dye free; contains alcohol 2%, sodium benzoate; grape flavor]

1

Corticosteroid, Ophthalmic Corticosteroid, Topical

Rimexolone Vexol ● Suspension, Ophthalmic: Vexol: 1% 1

Corticosteroid, Topical Fluocinolone Acetonide Derma-Smoothe/FS Synalar ● Oil, as acetonide:● Derma-Smoothe/FS [scalp oil] and [body oil]: 0.01%● Solution, topical: 0.01% (60 mL)

1

101

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierCorticosteroid, Rectal Corticosteroid, Systemic Corticosteroid, Topical

Hydrocortisone Cortef Cortenema Cortifoam Cortril Solu-Cortef

● Cream: 2.5% (30 g)● Cream, rectal: 2.5%● Enema: 100 mg/60 mL each unit (7 units/box)● Injection, as acetate: 25 mg/mL (5 mL); 50 mg/mL (5 mL)● Injection, as sodium succinate: 100 mg, 250 mg, 500 mg, 1,000 mg● Lotion: 2.5% (60 mL, 120 mL)● Ointment, topical: 2.5% (30 g)● Suppository, as acetate: 25 mg (12s)● Suspension, as cypionate, oral: 10 mg/5 mL (120 mL)● Tablet: 5 mg (50s); 10 mg (100s); 20 mg (100s)

1

Corticosteroid, Systemic Corticotropin Cortrophin-Zinc ● Injection, repository: 80 units/mL (1 mL, 5 mL)

1

Corticosteroid, Systemic Cortisone Acetate Cortone Acetate ● Tablet: 25 mg (100s) 1Corticosteroid, Systemic Fludrocortisone Acetate Florinef Acetate ● Tablet: 0.1 mg (100s) 1Corticosteroid, Systemic Methylprednisolone Depo-Medrol Medrol Solu-

Medrol● Injection, as acetate: 40 mg/mL (1 mL); 80 mg/mL (1 mL)● Injection, as sodium succinate: 40 mg (1 mL); 125 mg (2 mL); 500 mg; 1000 mg (16 mL)● Tablet: 2 mg, 4 mg, 8 mg, 16 mg, 32 mg (100s each)● Tablet, dose-pack (Medrol Dosepack): 4 mg (21s)

1

102

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierCorticosteroid, Systemic Prednisone Deltasone Meticorten ● Solution, concentrate: 5 mg/mL with

alcohol 30% (30 mL)● Tablet: 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg (100s each)

1

Corticosteroid, Systemic Corticosteroid, Topical

Betamethasone Beta-ValCelestone Soluspan Celestone Diprolene AF DiproleneLuxiq

● Base (Celestone):● Syrup: 0.6 mg/5 mL (120 mL) Dipropionate salt● Diprolene (generic):● Gel, augmented topical: 0.05% (15 g, 45 g)● Lotion, augmented: 0.05% (30 mL, 60 mL) Valerate salt● Valisone (generic):● Cream: 0.1% (15 g, 45 g)● Ointment, topical: 0.1% (15 g, 45 g) .● Sodium phosphate and acetate salt (Celestone Soluspan):● Injection, suspension: 6 mg/mL (3 mg of betamethasone sodium phosphate and 3 mg of betamethasone acetate per mL) (5 ml)

1

Corticosteroid, Topical Clobetasol Propionate Temovate® ● Cream: 0.05% (15 g, 30 g, 45 g)● Solution as propionate: 0.05%● Gel as propionate: 0.05%● Lotion: 0.05%● Spray 0.05%

1

Corticosteroid, Topical Desonide DesOwen Tridesilon Otic ● Solution, otic: 0.05% with acetic acid 2% in propylene glycol (10 mL)

1

Corticosteroid, Topical Desoximetasone Topicort ● Cream, topical: 0.25% 1

103

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierCorticosteroid, Topical Fluocinonide Lidex ● Ointment, topical: 0.05% (15 g, 30

g, 60 g) D1

Corticosteroid, Topical Flurandrenolide Cordran ● Tape, topical: 4 mcg/cm2 (7.5 cm x 60 cm and 7.5 cm x 200 cm roll)

1

Cystic Fibrosis Transmembrane Conductance Regulator Potentiator

Ivacaftor Kalydeco ● Tablet, oral: 150 mg 1

Cystic Fibrosis Transmembrane Conductance Regulator Potentiator

Lumacaftor and Ivacaftor Orkambi ● Tablet, Oral: Orkambi: Lumacaftor 100 mg and ivacaftor 125 mg, Lumacaftor 200 mg and ivacaftor 125 mg

1

Diagnostic Agent Arginine Hydrochloride R-Gene ● Injection: 10% (300 mL)● Granules, packets: 50 mg, 75 mg

1

Diagnostic Agent Benzylpenicilloyl- polylysine

Pre-Pen ● Solution: 0.25 mL 1

Diagnostic Agent Candida Albicans (Monilia) Candin ● Injection, solution: 0.1 mL/dose (1 mL)

1

Diagnostic Agent Coccidioidin Skin Test Spherulin ● Injection: 1:10 (0.5 mL); 1:100 (1 mL)

1

Diagnostic Agent Congo Red ● Injection: 1% (10 mL) 1Diagnostic Agent Cosyntropin Cortrosyn ● Powder for injection: 0.25 mg/mL (1

mL)1

Diagnostic Agent d-Xylose Xylo-Pfan [OTC] ● Powder, for oral solution: 25 g 1Diagnostic Agent Evans's Blue ● Injection: 22.6 mg/5 mL 1Diagnostic Agent Fluorescein Fluor-I-Strips Fluorescite

Fluress● Injection, 10% (5 mL)● Strip, ophthalmic: 9 mg [OF]

1

Diagnostic Agent Indocyanine Green Cardio-Green ● Injection: 25 mg 1Diagnostic Agent Pentagastrin Peptavlon ● Injection: 0.25 mg/mL (2 mL) 1Diagnostic Agent Phenolsulfonphthalein ● Injection: 6 mg/mL (1 mL) 1Diagnostic Agent Protirelin Relefact TRH Thypinone ● Injection: 500 mcg/mL (1 mL) 1Diagnostic Agent Regadenoscan Lexiscan ● Injection: 0.08 mg/mL ( mL) 1Diagnostic Agent Secretin Secretin-Kabi ● Powder for injection: 16 mcg 1

104

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierDiagnostic Agent Thyrotropin Alpha Thyrogen ● Kits containing two 1.1 mg vials

(>=4 int. units) of Thyrogen and two 10 mL vials of sterile water for injection

1

Diagnostic Agent Tuberculin Tests Aplisol Tubersol ● Injection, purified protein derivative: 1 TU/0.1 mL (1 mL); 5 TU/0.1 mL (1 mL); 250 TU/0.1 mL (1 mL)

1

Diagnostic Agent, Kidney Function Indigotindisulfonate Sodium

● Injection: 8 mg/mL (5 mL) 1

Diagnostic Agent, Radiologic Examination of GI Tract

Ethiodized Oil Ethiodol ● Injection: 10 mL 1

Dietary Supplement Amino Acid Mix, Essential Nephramine ● Injection: 5.4% (250 mL) 1

Dietary Supplement Levocarnitine Carnitor ● Tablet: 333 mg 1Diuretic, Loop Ethacrynic Acid Edecrin ● Injection, as ethacrynate sodium: 50

mg (50 mL)● Tablet: 25 mg, 50 mg (100s each)

1

Diuretic, Loop Furosemide Lasix ● Injection: 10 mg/mL (2 mL, 4 mL, 10 mL)● Solution, oral: 10 mg/mL (60 mL)● Tablet: 20 mg, 40 mg, 80 mg (100s each)

1

Diuretic, Osmotic Genitourinary Irrigant

Mannitol Osmitrol Resectisol ● Injection: 10% (500 mL); 20% (500 mL);25% (50 mL)

1

Diuretic, Potassium-Sparing Triamterene Dyrenium ● Capsule: 50 mg, 100 mg (100s each) 1

Diuretic, Potassium-Sparing Selective Aldosterone Blocker

Spironolactone Aldactone ● Tablet: 25 mg, 50 mg, 100 mg (100s each)

1

Diuretic, Thiazide Chlorthalidone Thalitone ● Tablet: 25 mg, 50 mg 1Diuretic, Thiazide Hydrochlorothiazide Esidrix HydroDIURIL ● Tablet: 12.5 mg, 25 mg, 50 mg 1

105

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierDiuretic, Thiazide-Related Indapamide Lozol o ● Tablet: 1.25 mg, 2.5 mg 1Diuretic, Thiazide-Related Metolazone Diulo Mykrox Zaroxolyn ● Tablet: 2.5 mg, 5 mg, 10 mg 1Electrolyte Supplement, Oral Electrolyte Supplement, Parenteral

Potassium Chloride K-Tab Klor-Con Slow-K ● Injection, concentrate: 2 mEq/mL (5 mL, 10 mL, 15 mL, 20 mL, 30 mL)●Premix: 10 mEq in 100 mL, 20 mEq in 100 mL, 20 mEq in1000 mL, 40 mEq in 1000 mL● Liquid, oral, sugar free: 10% [20 mEq/15 mL] (480 mL); 20% [40 mEq/15 mL] (480 mL)● Powder (Klor-Con): 20 mEq per packet (30s, 100s)● Tablet:● Controlled release : 750 mg = 10 mEq (100s, 200s)● Wax matrix (Slow-K): 600 mg = 8 mEq (100s)

1

Electrolyte Supplement, Oral Electrolyte Supplement, Parenteral

Potassium Phosphate Neutra-Phos-K [OTC] ● Injection: Potassium phosphate 224 mg and potassium phosphate dibasic anhydrous 236 mg per mL = phosphate 3 mmol and potassium 4.4 mEq per mL (15 mL)

1

Electrolyte Supplement, Parenteral Ammonium Chloride ● Injection: 5 mEq/mL (20 mL) 1

Electrolyte Supplement, Parenteral Potassium Acetate ● Injection: 2 mEq/mL (20 mL) 1

Electrolyte Supplement, Parenteral Sodium Acetate ● Injection: 2 mEq/mL (20 mL) 1

106

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierElectrolyte Supplement, Parenteral Genitourinary IrrigantIrrigant Lubricant, Ocular Sodium Salt

Sodium Chloride Adsorbonac [OTC] Ophthalmic Muro 128 [OTC] Ophthalmic

● Injection: 0.45% ; 3% ; 5% ; 23.4%● Solution:● Inhalation: 0.9% (50 mL)● Irrigation: 0.9% (1000 mL, 2000 mL)● Nebulizer : 7% , 4 mL/vial● Tablet: 1 g (100s)

1

Endothelin Antagonist Ambrisentan Letairis ● Tablet: 5 mg; 10 mg 1Endothelin Antagonist Bosentan Tracleer ● Tablet: 62.5 mg, 125 mg 1Endothelin Receptor Antagonist; Vasodilator

Macitentan Opsumit ● Tablet, Oral: 10 mg 1

Enzyme Agalsidase Beta Fabrazyme ● Injection, powder for reconstitution: 5 mg, 35 mg

1

Enzyme Alglucosidase Alfa Myozyme Lumizyme ● Injection, powder for reconstitution [preservative free]:● Myozyme: 50 mg [contains mannitol 210 mg; polysorbate 80; derived from Chinese hamster ovary cells]● Lumizyme®: 50 mg [contains mannitol, polysorbate 80; derived from or manufactured using Chinese hamster ovary cells]

1

Enzyme Asfotase Strensiq ● Solution, Subcutaneous [preservative free]: Strensiq: 18 mg/0.45 mL (0.45 mL); 28 mg/0.7 mL (0.7 mL); 40 mg/mL (1 mL); 80 mg/0.8 mL (0.8 mL)

1

Enzyme Dornase Alfa Pulmozyme ● Solution, inhalation: 1 mg/mL (2.5 mL)

1

Enzyme Elosulfase Alfa Vimizim ● Solution, Intravenous [preservative free]: 5 mg/5 mL

1

107

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierEnzyme Galsulfase Naglazyme ● Injection, solution [preservative

free]: 5 mg/5 mL (5 mL)1

Enzyme Hyaluronidase Amphadase Vitrase ● Sterile 6200 USP units of lyophilized ovine hyaluronidase nonpreserved in a single-use 5 mL vial with a rubber stopper and aluminum seal; 1 mL sterile polycarbonate syringe; and one 5 micrometer sterile filter needle● Injection, solution (Amphadase): 150 units/mL (2 mL) [bovine derived; contains edetate disodium 1 mg, thimerosal<=0.1 mg]● Injection, solution [preservative free] (Vitrase): 200 units/mL (2 mL) [ovine derived; contains lactulose]

1

Enzyme Idursulfase Elaprase ● Elaprase: 2 mg/mL (5 mL) [extractable volume: 3 mL]

1

Enzyme Imiglucerase Cerezyme ● Powder for injection, preservative free (lyophilized): 200 units per vial, 400 units per vial

1

Enzyme Laronidase Aldurazyme ● Injection, solution [preservative free]: 2.9 mg/5 mL (5 mL)

1

108

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierEnzymeEnzyme

PancrelipasePegademase Bovine

ZenPep X-Gen Creon oGengraf Neoral Restasis Sandimmune

Zenpep™: Lipase 5000 units, protease 17,000 units, amylase 27,000 unitsZenpep™: Lipase 10,000 units, protease 34,000 units, amylase 55,000 units Zenpep™: Lipase 15,000 units, protease 51,000 units, amylase 82,000 units Zenpep™: Lipase 20,000 units, protease 68,000 units, amylase 109,000 units Zenpep: Lipase 25,000 USP units, protease85,000 USP units, and amylase 136,000 USP unitsZenpep: Lipase 40,000 USP units, protease 136,000 USP units, and amylase 218,000 USP unitsPancrelipase™ (X-Gen): Lipase 5000 units, protease 17,000 units, amylase 27,000 unitsCreon®: Lipase 6000 units, protease 19,000 units, and amylase 30,000 unitsCreon®: Lipase 12000 units, protease 38,000 units, and amylase 60,000 unitsCreon®: Lipase 24,000 units, protease 76,000 units, and amylase 120,000 unitsCreon®: Lipase 36,000 units, protease 114,000 units, amylase 180,000 units

1

Enzyme Velaglucerase VPRIV® ● Injection, powder for reconstitution: 400 units [contains sucrose 200 mg/vial]

1

Enzyme Inhibitor; Glucosylceramide Synthase Inhibitor

Eliglustat Cerdelga ● Capsule: 84 mg 1

109

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierEnzyme, Topical Debridement Collagenase Santyl ● Ointment: 250 units/g (15 g, 30 g) 1

Ergot Derivative Cabergoline Dostinex ● Tablet: 0.5 mg (8s) 1Ergot Derivative Methylergonovine Maleate Methergine ● Injection: 0.2 mg/mL (1 mL)

● Tablet: 0.2 mg (100s)1

Estrogen and Progestin Combination

Estrogens With Methyltestosterone

Syntest DS Syntest HS ● Tablet:● Syntest DS: Esterified estrogen 1.25 mg and methyltestosterone 2.5 mg● Syntest HS: Esterified estrogen 0.625 mg and methyltestosterone 1.25 mg

1

Estrogen Derivative Estradiol Climara Transdermal DelestrogenDepo-Estradiol Estrace Estraderm Estring

● Injection, as cypionate: 5 mg/mL (5 mL)● Injection, oil, as valerate: 10 mg/mL, 20 mg/mL ; 40 mg/mL● Ring, vaginal (Estring): 2 mg● Tablet, micronized: 0.5 mg, 1 mg, 2 mg (100s each) Patch● Weekly, Transdermal: 0.025 mg/24 hr (4 ea); 0.0375 mg/24 hr (4 ea); 0.05 mg/24 hr (1 ea, 4 ea); 0.06 mg/24 hr (4 ea); 0.075 mg/24 hr (4 ea); 0.1 mg/24 hr (1 ea, 4 ea)● Estraderm:● 0.05 mg/24 hours [10 cm2], total estradiol 4 mg (8s, 24s)● 0.1 mg/24 hours [20 cm2], total estradiol 8 mg (8s, 24s)●Cream, vaginal: 0.1 mg/g

1

Estrogen Derivative Estrogens, Conjugated Premarin ● Cream, vaginal: 0.625 mg/g● Injection: 25 mg (5 mL)

1

110

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierFactor Xa Inhibitor Fondaparinux Arixtra ● Injection, solution, as sodium

[preservative free]: 2.5 mg/0.5 mL (0.5 mL); 5 mg/0.4 mL (0.4 mL); 7.5 mg/0.6 mL (0.6 mL); 10 mg/0.8 mL (0.8 mL) [prefilled syringe]

1

GABA Agonist/Glutamate Antagonist

Acamprosate Campral ● Tablet, enteric coated, delayed release, as calcium: 333 mg [contains calcium 33 mg and sulfites]

1

Gallstone Dissolution Agent Ursodiol Actigall ● Capsule: 250 mg● Tablet:500 mg

1

Gastrointestinal Agent, Miscellaneous

Balsalazide Colazal® ● Capsule, as disodium 750 mg 1


Hydrochloric Acid ● Liquid: 500 mL, 2500 mL● Liquid, diluted: 500 mL, 2500 mL

1


Mesalamine Asacol Canasa Pentasa Rowasa Lialda

● Capsule, controlled release: 250 mg, 500 mg● Suppository, rectal: 1000 mg● Suspension, rectal: 4 g/60 mL (7s)● Tablet, delayed release: 1.2 g

1


Sucralfate Carafate ● Liquid: 1 g/10 mL (420 mL)● Tablet: 1 g (100s)

1


Sulfasalazine Azulfidine EN-tabs Azulfidine ● Tablet: 500 mg● Tablet, enteric coated: 500 mg

1

General Anesthetic Etomidate Amidate ● Injection: 2 mg/mL (10 mL, 20 mL) 1

General Anesthetic Ketamine Hydrochloride Ketalar ● Injection: 10 mg/mL (20 mL, 50 mL); 100 mg/mL (5 mL)

1

General Anesthetic Propofol Diprivan ● Injection: 10 mg/mL (20 mL) 1General Anesthetic, Inhalation Enflurane Ethrane ● Liquid: 125 mL 1

111

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierGeneral Anesthetic, Inhalation Halothane Fluothane ● Liquid: 250 mL 1General Anesthetic, Inhalation Isoflurane Forane ● Solution: 100 mL 1General Anesthetic, Inhalation Sevoflurane Ultane ● Volatile liquid for inhalation: 250

mL1

Genitourinary Irrigant Laxative, Osmotic

Sorbitol ● Solution, irrigation: 3% (3000 mL) 1

Glutamate Inhibitor Riluzole Rilutek ● Tablet: 50 mg 1Gold Compound Auranofin Ridaura ● Capsule: 3 mg = gold 29% (60s) 1Gold Compound Gold Sodium Thiomalate Myochrysine ● Injection: 50 mg/mL (1 mL, 10 mL) 1

Gonadotropin Releasing Hormone Agonist

Nafarelin Acetate Synarel® ● Solution, nasal: 2 mg/mL (8 mL) 1

Gonadotropin Ovulation Stimulator Menotropins Menopur Repronex ● Powder for injection: Follicle-stimulating hormone activity 75 units and luteinizing hormone activity 75 units per 2 mL● Menopur: Follicle stimulating hormone activity 75 int. units and luteinizing hormone activity 75 int. units [packaged with diluent; contains lactose 21 mg]

1

Gonadotropin Ovulation Stimulator Urofollitropin Bravelle ● Injection, powder for reconstitution [human origin]:● Bravelle: 75 int. units [contains lactose; packaged with diluent]

1

112

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierGrowth Hormone Human Growth Hormone

(Somatropin)Humatrope Norditropin Serostim® Omnitrope

● Injection:● Norditropin FlexPro®: 15 mg/1.5 mL (1.5 mL) [prefilled pen]● Serostim: 4 mg, 5 mg, 6 mg● Omnitrope: powder for injection: 5.8 mg [~17.4 int. units; packaged with diluent containing benzyl alcohol]● Omnitrope Injection solution: 5 mg/1.5 mL (1.5 mL); 10 mg/1.5 mL

1

Hemostatic Agent Aminocaproic Acid Amicar Injection: 250 mg/mL (20 mL)Syrup: 1.25 g/5 mL (480 mL)Tablet: 500 mg

1

Hemostatic Agent Thrombin, Topical Evithrom Recothrom ● Thrombin, topical, recombinant vials and kits: 5000 units, 20,000 units

1

Histamine H1 Antagonist Azelastine Astelin ● Solution, intranasal, as hydrochloride [spray] (generic): 0.1% [137 mcg/spray]

1

Histamine H1 Antagonist, Second Generation

Olopatadine Patanol ● Solution, Ophthalmic: Generic: 0.1%

1

Histamine H2 Antagonist Cimetidine Tagamet ● Liquid, oral: 300 mg/5 mL (240 mL) 1

Histamine H2 Antagonist Famotidine Pepcid ● Injectable Formulations:● Single-dose vial: 10 mg/mL (2 mL, 4 mL)● Tablet: 20 mg, 40 mg● Infusion [premixed in NS]: 20 mg (50 mL)

1

113

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierHistamine H2 Antagonist Ranitidine Hydrochloride Zantac 150 [OTC] Zantac 75

[OTC] Zantac EFFERdose Zantac

● Injection: 25 mg/mL (2 mL)● Infusion [premixed in NaCl 0.45%; preservative free]: 50 mg● Syrup: 15 mg/mL with alcohol 7.5% (480 mL)● Tablet (generic only): 150 mg ; 300 mg

1

Homocystinuria, Treatment Agent Betaine Anhydrous Cystadane ● Powder, Oral, as anhydrous: Cystadane: 1 g/scoop (180g)

1

Hypnotic, Benzodiazepine Temazepam Restoril ● Capsule: 15 mg (30s, 100s); 30 mg (100s)

1

Hypnotic, Nonbenzodiazepine Zolpidem Ambien ● Tablet: 5 mg 1Immune Globulin Cytomegalovirus Immune

Globulin Intravenous, Human

CytoGam ● Powder for injection, lyophilized: 2500 mg± 250 mg (50 mL)

1

Immune Globulin Hepatitis B Immune Globulin

Nabi-HB ● Injection: 5 mL● Injection (Nabi-HB): 1 mL, 5 mL

1

114

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierImmune Globulin Immune Globulin

(Intravenous) Immune Globulin (Intramuscular)

Carimune® NF Flebogamma® DIF Gammagard Liquid Gammaplex Gamunex®-C GamaSTAN™ S/D Gammaked Hizentra Iveegam EN Octagam Privigen

Injection, solution [preservative free]:● Gammaked™: 10% [100 mg/mL] (10 mL,25 mL, 50 mL,100 mL, 200 mL)● GamaSTAN™ S/D: 15% to 18% [150 to 180 mg/mL] (2 mL,10 mL)● Gammagard® Liquid: 10% [100 mg/mL] (2.5 g, 10 g, 20 g,30 g)● Gammaplex®: 5% [50 mg/mL] (2.5 g, 5 g,10 g)● Flebogamma® DIF: 5% [50 mg/mL] (0.5 g, 2.5 g, 5 g, 10 g,20 g); 10% [100 mg/mL] (5 g, 10 g, 20 g)● Octagam®: 5% [50 mg/mL] (1 g, 2.5 g, 5 g,10 g, 25 g)● Privigen®: 10% [100 mg/mL] (5 g, 10 g, 20 g)● Gamunex®-C: 10% [100 mg/mL] 1 gram/10mL, 2.5 gram/25 mL, 5 gram/50 mL, 10 gram/100 mL, and 20 gram/200 mL Injection, powder for

1

Immune Globulin Rabies Immune Globulin, Human

Hyperab Imogam-HT ● Injection: 150 units/mL (2 mL, 10 mL)

1

115

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierImmune Globulin Rho(D) Immune Globulin HyperRHO S/D Full Dose

HyperRHO S/D Mini Dose MICRhoGAMMini-Gamulin Rh RhoGAM Rhophylac

● Injection: Each package contains one single dose 300 mcg of Rho(D) immune globulin● Injection, microdose: Each package contains one single dose of microdose, 50 mcg of Rho(D) immune globulin●Rhophylac®: 300 mcg/2 mL (2 mL) [1500 int. units; for I.M. or I.V. use; contains human albumin]

1

Immune Globulin Tetanus Immune Globulin, Human

BayTet ● Injection: 250 units (single dose vial, prefilled syringes)

1

Immune Globulin Varicella-Zoster Immune Globulin (Human)

VariZig ● Injection: 125 units of antibody in single dose vials

1

Immunosuppressant Agent Azathioprine Imuran ● Tablet: 50 mg (100s) 1Immunosuppressant Agent Cyclosporine Gengraf Neoral Restasis

Sandimmune● Capsule, soft gel, modified: (Gengraf): 25 mg, 100 mg (30s each)● Capsule, soft gel, non-modified (Sandimmune): 25 mg, 100 mg (30s each)● Emulsion, ophthalmic [preservative free, single-use vial] (Restasis): 0.05% (0.4 mL) [contains glycerin, castor oil, polysorbate 80, carbomer 1342; 32 vials/box]● Injection (Sandimmune): 50 mg/mL (5 mL)● Solution, oral (Sandimmune): 100 mg/mL (50 mL)● Solution, oral for microemulsion (Neoral): 100 mg/mL (50 mL)

1

116

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierImmunosuppressant Agent Mycophenolate Mofetil CellCept® generic ● Capsule: 250 mg

● Tablet, as mofetil: 500 mg [may contain ethyl alcohol]● Suspension, Oral: 200 mg/mL

1

Immunosuppressant Agent mTOR Kinase Inhibitor

Sirolimus Rapamune ● Solution, oral: 1 mg/mL (1 mL, 2 mL, 5 mL, 60 mL, 150 mL)● Tablet: 0.5 mg, 1 mg, 2 mg

1

Immunosuppressant Agent Topical Skin Product

Pimecrolimus Elidel ● Cream, topical: 1% (30 g, 100 g) 1

Immunosuppressant Agent Topical Skin Product

Tacrolimus Prograf ● Capsule: 0.5 mg; 1 mg, 5 mg● Ointment: 0.03%; 0.1%● Injection, with alcohol and surfactant: 5 mg/mL (1 mL)

1

Inhalation, Miscellaneous Inhalation Devices Aerochamber MAX Spacer AeroChamber Z-Stat Plus AeroChamberEZ Spacer w/mask EZ Spacer Optihaler

● Aerochamber MAX Spacer VHC with small, medium and large mask● AeroChamber Z-Stat Plus VHC with mouthpiece

1

Interferon Interferon Alfa-2b Intron A ● Powder for injection, lyophilized: 10 million int. units, 18 million int. units, 50 million int. units● Solution for injection: 3 million int. units, 5 million int. units, 6 million int. units, 10 million int. units, 18 million int. units● Solution for injection, with syringe: 3 million int. units, 5 million int. units, 10 million int. units● Solution for injection, preloaded multidose injection pen: 3 million int. units, 5 million int. units, 10 million int. units

1

117

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierInterferon Interferon Alfacon-1 Infergen ● Injection: 9 mcg (0.3 mL) vials, 15

mcg (0.5 mL) vials (6 vials per package)

1

Interferon Interferon Beta-1a Avonex ● Injection: Powder for injection, lyophilized: 33 mcg [6.6 million int. units] and syringe kit● Injection: Avonex®: 30 mcg/0.5 mL (0.5 mL) [albumin free; prefilled syringe]

1

Interferon Interferon Beta-1b Extavia® ● Powder for injection, lyophilized: 0.3 mg [9.6 million int. units]

1

Interferon Interferon Gamma-1B Actimmune ● Injection: 100 mcg = 3 million units = 2 million IU (0.5 mL)

1

Interferon Peginterferon Alfa-2a Pegasys® Proclick ● Injection, solution: 180 mcg/mL (1 mL) [contains benzyl alcohol]● Pegasys® Proclick: 180 mcg/0.5 mL Autoinjector for single use : 135 mcg/0.5 mL Autoinjector for single use

1

Intravenous Nutritional Therapy Amino Acid Injection Travasol TrophAmine ● Injection (TrophAmine): 6% 500 mL; 10% 500 mL

1

Intravenous Nutritional Therapy Dextrose and Sodium Chloride

● Injection:● Dextrose 5% in sodium chloride 0.2% (500 mL, 1000 mL)● Dextrose 5% in sodium chloride 0.45% (500 mL, 1000 mL)● Dextrose 5% in sodium chloride 0.9% (500 mL, 1000 mL)

1

Intravenous Nutritional Therapy Ringer's Injection ● Injection: 1000 mL 1Intravenous Nutritional Therapy Ringer's Injection, Lactated ● Injection: 1000 mL 1

118

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierIntravenous Nutritional Therapy Ringer's Injection, Lactated

With Dextrose● Calcium 3 mEq, chloride 109 mEq, lactate 28 mEq, potassium 4 mEq, sodium 130 mEq, dextrose 50 g/liter (250 mL, 500 mL, 1000 mL)

1

Iron Salt Iron Dextran Complex INFeD ● INFeD Injection: 50 mg/mL (2 mL)● (Dexferrum is not on the Formulary and should not be substituted for INFeD.)

1

Iron Salt Iron Sucrose Venofer ● Injection: 20 mg of elemental iron/mL (5 mL vial)

1

Irrigating Solution Ophthalmic Agent, Miscellaneous

Balanced Salt Solution BSS PlusBSS Ophthalmic

● Ophthalmic:● Drops (BSS)● Solution, sterile (BSS)● Two part solution (BSS Plus)

1

Keratinocyte Growth Factor Palifermin Kepivance ● Injection, powder for reconstitution [preservative free]: 6.25 mg [contains mannitol 50 mg, sucrose 25 mg]

1

Keratolytic Agent Podophyllum Resin Podocon-25 ● Liquid, topical: 25% in benzoin tincture (15 mL)

1

Keratolytic Agent Salicylic Acid and Propylene Glycol

Keralyt ● Gel, topical: Salicylic acid 6% and propylene glycol 60% in ethyl alcohol 19.4%, hydroxypropyl methylcellulose and water (30 g)

1

Keratolytic Agent Trichloroacetic Acid Tri-ChlorTrichlor Fresh Pac

● Powder for reconstitution, topical (Trichlor Fresh Pac): 10% (28 mL); 15% (28 mL); 20% (28 mL); 25% (28 mL); 30% (28 mL); 35% (28 mL); 40% (28 mL); 50% (28 mL) [supplied with diluent]

1

119

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierKeratolytic Agent Topical Skin Product

Podofilox Condylox ● Gel, topical: 0.5% (3.5 mL)● Solution, topical: 0.5% (3.5 mL)

1

Laxative, Osmotic Polyethylene Glycol- Electrolyte Solution

CoLyte ● PEG 3350/Electrolyte, powder for oral solution: PEG 3350 240 g, sodium sulfate22.72 g, sodium bicarbonate 6.72 g, sodium chloride 5.84 g, and potassium chloride 2.98 g (4000 mL)

1

Leukotriene-Receptor Antagonist Montelukast Singulair ● Tablet:10 mg ●Tablet, chewable, oral:4 mg; 5 mg ●Granules, oral: 4 mg

1

Lithium Lithium Eskalith CR Eskalith Lithane Lithobid Lithotabs

● Capsule, as carbonate: 150 mg, 300 mg, 600 mg (100s each)● Capsule, extended release: Lithium carbonate ER: 300 mg● Syrup, as citrate (Cibalith-S): 300 mg/5 mL (480 mL)● Tablet, as carbonate: 300 mg● Tablet, controlled release, as carbonate: 450 mg (100s)● Tablet, extended release, as carbonate: 300 mg

1

Local Anesthetic Bupivacaine Hydrochloride Marcaine Spinal Marcaine Sensorcaine-MPF Sensorcaine

● Injection, with dextrose 8.25% (Spinal): 0.75% (2 mL) Injection: 0.25%; 0.5%; 0.75%● Injection, solution, as hydrochloride [preservative free]: Spinal: 0.75% (2 mL) [in dextrose 8.25%]

1

120

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierLocal Anesthetic Benzocaine, Butamben, and

TetracaineExactacain ● Aerosol, topical [spray]:

Exactacain™: Benzocaine 14%, butamben 2%, and tetracaine hydrochloride 2%

1

Local Anesthetic Chloroprocaine Hydrochloride

Nesacaine-MPF Nesacaine ● Injection: 1% (30 mL); 2% (30 mL) 1

Local Anesthetic Cocaine Hydrochloride ● Solution, topical: 4% (4 mL) 1Local Anesthetic Ethyl Chloride and

Dichlorotetrafluoroeth aneFluro-Ethyl ● Aerosol: Ethyl chloride 25% and

dichlorotetrafluoroethane 75% (225 g)1

Local Anesthetic Lidocaine and Epinephrine Xylocaine With Epinephrine ● Injection with epinephrine:● 1:200,000: Lidocaine hydrochloride 1% (30 mL)● 1:200,000: Lidocaine hydrochloride 1.5% (30 mL)● 1:200,000: Lidocaine hydrochloride 2% (20 mL)

1

Local Anesthetic Lidocaine and Prilocaine EMLA ● Cream: Lidocaine 2.5% and prilocaine 2.5% [2 Tegaderm dressings] (5 g, 30 g)

1

Local Anesthetic Mepivacaine Hydrochloride Carbocaine Isocaine HCl Polocaine

● Injection: 1% (30 mL); 1.5% (30 mL); 2%(20 mL)

1

Local Anesthetic Procaine Hydrochloride Novocain ● Injection: 1%, 10% 1Local Anesthetic Ropivacaine Naropin ● Injection, as hydrochloride (single

dose): 2 mg/mL (20 mL); 5 mg/mL (30 mL); 7.5 mg/mL (10 mL, 20 mL); 10 mg/mL (10 mL, 20 mL)

1

121

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierLocal Anesthetic Tetracaine Hydrochloride Pontocaine ● Injection: 1% (2 mL)

● Solution:● Ophthalmic:● 0.5% (15 mL) [OF]● TetraVisc: 0.5% viscous soln. 5 mL● Topical: 2% (30 mL, 118 mL)

1

Local Anesthetic, Ophthalmic Proparacaine Hydrochloride Alcaine Ophthaine Ophthetic ● Solution, ophthalmic: 0.5% (15 mL) [OF]

1

Low Molecular Weight Heparin Enoxaparin Sodium Lovenox ● Injection: 30 mg vial, 300 mg vial● Injection, prefilled syringes: 30 mg/0.3 mL, 40 mg/0.4 mL, 60 mg/0.6 mL, 80 mg/0.8 mL, 100 mg/1 mL, 120 mg/0.8 mL, 150 mg/1 mL

1

Lung Surfactant Beractant Survanta ● Suspension for inhalation: 25 mg/mL (4 mL, 8 mL)

1

Lung Surfactant Poractant Alfa Curosurf ● Suspension, intratracheal [preservative free; porcine derived]:● Curosurf: 80 mg/mL (1.5 mL, 3 mL)

1

Mast Cell Stabilizer Cromolyn Sodium Crolom Intal ● Inhalation, oral (Intal): 800 mcg/spray (8.1 g, 14.2 g)● Solution for nebulization: 20 mg/2 mL● Solution, oral, as sodium 100 mg/5 mL● Ophthalmic (Generic): 4% (10 mL) [OF]

1

Miscellaneous Product Yohimbine Hydrochloride Yocon ● Tablet: 5.4 mg (100s) 1

122

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierMonoclonal Antibody Palivizumab Synagis ● Injection, solution [preservative

free]: 100 mg/mL (1 mL)● Injection, solution [preservative free]: 50 mg/0.5 mL

1

Monoclonal Antibody Monoclonal Antibody, Complement Inhibitor

Eculizumab Soliris ● Injection, solution [preservative free]:● Soliris: 10 mg/ml (30 mL) [contains polysorbate 80]

1

Monoclonal Antibody Ophthalmic AgentVascular Endothelial Growth Factor (VEGF) Inhibitor

Ranibizumab Lucentis ● Injection, solution: 0.3 mg/ 0.05 mL 1

Monoclonal Antibody, Anti- Asthmatic

Omalizumab Xolair ● Injection, powder for reconstitution [preservative free]: 150 mg

1

Monoclonal Antibody, Selective Adhesion- Molecule Inhibitor

Natalizumab Tysabri ● Injection, solution [preservative free]: 300 mg/15 mL (15 mL)

1

Neuromuscular Blocker Agent, Depolarizing

Succinylcholine Chloride Anectine Chloride Anectine Flo-Pack Quelicin

● Injection: 20 mg/mL (10 mL) 1

Neuromuscular Blocker Agent, Nondepolarizing

Atracurium Besylate Tracrium ● Injection: 10 mg/mL (5 mL, 10 mL) 1


Cisatracurium Nimbex ● Injection: 2 mg/mL (5 mL, 10 mL); 10 mg/mL (20 mL)

1


Pancuronium Bromide Pavulon ● Injection: 1 mg/mL (10 mL); 2 mg/mL (2 mL)

1


Rocuronium Bromide Zemuron ● Injection: 10 mg/mL 1


Vecuronium Norcuron ● Injection: 1 mg/ mL, 20 mg vial 1

Neuromuscular Blocker Agent, Toxin

Botulinum Toxin Type B Myobloc ● Injection: Myobloc®: 5000 units/mL (0.5 mL, 1 mL, 2 mL) [contains albumin 0.05%]

1

123

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierNeuromuscular Blocker Agent, Toxin Ophthalmic Agent, Toxin

Botulinum Toxin Type A Botox ● Powder for injection, lyophilized: 100 units

1

N-Methyl-D-Aspartate Receptor Antagonist

Memantine Namenda (generic) ● Solution, oral: 2 mg/mL (360 mL) [alcohol free, dye free, sugar free; peppermint flavor]● Tablet, as hydrochloride (Namenda): 5 mg, 10 mg● Combination package (Namenda) [titration pack contains 2 separate tablet formulations]: Memantine hydrochloride 5 mg (28s) and memantine hydrochloride 10 mg (21s)

1

Nonsteroidal Anti- inflammatory Drug (NSAID)

Aminosalicylate Sodium ● Tablet: 500 mg (100s) 1

Nonsteroidal Anti- inflammatory Drug (NSAID) Nonsteroidal Anti- inflammatory Drug (NSAID), OphthalmicNonsteroidal Anti- inflammatory Drug (NSAID), Oral

Diclofenac Voltaren Ophthalmic ● Solution, ophthalmic, as sodium (Generic): 0.1% (5 mL) [OF]● Gel, Transdermal, as sodium: Generic: 1% (100 g)● Solution, Transdermal, as sodium: Generic: 1.5% (150 mL)

1

Nonsteroidal Anti- inflammatory Drug (NSAID), OphthalmicNonsteroidal Anti- inflammatory Drug (NSAID), Oral

Flurbiprofen Sodium Ocufen ● Solution, ophthalmic: 0.03% (2.5 mL, 5 mL, 10 mL) [OF]:2.5 mL]

1

Nonsteroidal Anti- inflammatory Drug (NSAID), OphthalmicNonsteroidal Anti- inflammatory Drug (NSAID), OralNonsteroidal Anti- inflammatory Drug (NSAID), Parenteral

Ketorolac Tromethamine Acular LS Acular PF Acular Toradol

● Solution, ophthalmic, as tromethamine: Ketorolac: 0.4%, 0.5%● Injection solution as tromethamine (generic Toradol): 15 mg/ml and 30 mg/ml, 1 mL, 2 mL, 10 mL

1

124

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierNonsteroidal Anti- inflammatory Drug (NSAID), Oral

Etodolac Lodine ● Capsule: 200 mg (100s), 300 mg (100s)● Tablet: 400 mg (100s), 500 mg (100s)

1

Nonsteroidal Anti- inflammatory Drug (NSAID), Oral

Meclofenamate Sodium Meclomen ● Capsule: 50 mg, 100 mg (100s each) 1


Mefenamic Acid Ponstel ● Capsule: 250 mg (100s) 1


Meloxicam Mobic ● Tablet (generic): 7.5 mg, 15 mg 1


Nabumetone Relafen ● Tablet: 500 mg, 750 mg 1


Naproxen Naprosyn ● Tablet: 250 mg, 375 mg, 500 mg 1


Sulindac Clinoril ● Tablet: 150 mg, 200 mg (30s, 50s, 100s each)

1

Nonsteroidal Anti- inflammatory Drug (NSAID), OralNonsteroidal Anti- inflammatory Drug (NSAID), Parenteral

Ibuprofen Motrin PediaProfen ● Injection, solution, as lysine [preservative free]: NeoProfen:17.1 mg/mL (2 mL)● Suspension, oral: 100 mg/5 mL (120 mL)● Tablet: 400 mg, 600 mg, 800 mg (30s, 50s, 100s each)

1

Nonsteroidal Anti- inflammatory Drug (NSAID), OralNonsteroidal Anti- inflammatory Drug (NSAID), Parenteral

Indomethacin Indocin I.V. Indocin SR Indocin ● Capsule: 25 mg, 50 mg (30s, 50s, 100s each)● Capsule, sustained release: 75 mg (60s)● Powder for injection, as sodium trihydrate: 1 mg (3 mL)● Suppository, rectal: 50 mg (30s)

1

125

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierNutritional Supplement Fluoride Florical [OTC] Luride Pediaflor

Prevident● Drops, oral (Pediaflor): 0.5 mg (1.1 mg sodium fluoride)/mL (50 mL)● Gel: 0.5% (from 1.1% sodium fluoride) (30 mL, 130 mL, 250 mL)● Tablet, chewable: 0.25 mg (0.55 mg sodium fluoride), 0.5 mg (1.1 mg sodium fluoride), 1 mg (2.2 mg sodium fluoride) (120s each)

1

Ophthalmic Agent Trypan Blue VisionBlue ● Solution, ophthalmic: 0.06% (0.5 mL)

1

Ophthalmic Agent Verteporfin Visudyne ● Injection, powder for reconstitution: 15 mg

1

Ophthalmic Agent, Mydriatic Cyclopentolate and Phenylephrine

Cyclomydril ● Solution, ophthalmic: Cyclopentolate hydrochloride 0.2% and phenylephrine hydrochloride 1% (5 mL) [OF]

1

Ophthalmic Agent, Antiglaucoma Prostaglandin, Ophthalmic

Bimatoprost Lumigan ● Solution, ophthalmic: 0.01% 1

Ophthalmic Agent, Antiglaucoma Prostaglandin, Ophthalmic

Latanoprost Xalatan ● Solution, ophthalmic: 0.005% [with benzalkonium chloride] (2.5 mL)

1

Ophthalmic Agent, Miscellaneous Hydroxypropyl Cellulose Lacrisert ● Insert, ophthalmic [preservative free]: 5 mg [OF]

1

Ophthalmic Agent, Mydriatic Tropicamide Mydriacyl ● Solution, ophthalmic: 0.5% (15 mL) [OF]; 1% (15 mL) [OF]

1

Ophthalmic AgentVascular Endothelial Growth Factor (VEGF) Inhibitor

Aflibercept Eylea ● Injection, solution, intravitreal [preservative free]: Eylea™: 40 mg/mL (0.05 mL)

1

Ophthalmic Agent, Vitreolytic Ocriplasmin Jetrea ● Injection, solution, intravitreal [preservative free]: Jetrea®:2.5 mg/mL

1

126

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierOtic Agent, Anti-infective Acetic Acid Vosol o ● Solution, otic: Acetic acid 2% in

propylene glycol (10 mL)1

Otic Agent, Anti-infective Topical Skin Product

Acetic Acid Aci-jel ● It is recommended to NOT stock glacial acetic acid (95% to 100%) in the Pharmacy● Solution, irrigation: 0.25% (500 mL, 1000 mL); 3% (500 mL,1000 mL); 5% (480 mL, 1000 mL)

1

Ovulation Stimulator Selective Estrogen Receptor Modulator (SERM)

Clomiphene Citrate Clomid ● Tablet: 50 mg (30s) 1

Oxytocic Agent Oxytocin Pitocin Syntocinon ● Injection: 10 units/mL (1 mL)● Solution, nasal, synthetic: 40 units/mL (5 mL)

1

Parathyroid Hormone Analog Teriparatide Forteo ● Injection: 600 mcg/2.4 mL 1Pharmaceutical Aid Boric Acid ● Ointment: 10% (for compounding

use only)1

Pharmaceutical Aid Gelatin Capsules, Empty ● Capsule: Size: #000, #00, #0, #1, #2, #3, #4

1

Pharmaceutical Aid Menthol ● Crystals 1Pharmaceutical Aid Propylene Glycol ● Liquid: 10%, 100% 1Pharmaceutical Aid Water for Injection, Sterile ● Injection: 10 mL, 20 mL, 50 mL,

100 mL, 250 mL, 1000 mL1

Pharmaceutical Aid Water for Irrigation ● Solution: 1000 mL, 2000 mL 1Phosphate Binder Sevelamer Hydrochloride

Sevelamer CarbonateRenagel Renvela ● Tablet, as hydrochloride: 400 mg,

800 mg● Tablet, as carbonate: 800 mg● Powder for oral suspension: 2.4 gram

1

Phosphodiesterase Enzyme Inhibitor Milrinone Primacor ● Injection, as lactate: 1 mg/mL (5 mL, 10 mL, 20 mL)● Infusion, premix: 200 mcg/ mL (100 mL, 200 mL)

1

127

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierPhosphodiesterase-4 Enzyme Inhibitor

Apremilast Otezla ● Tablet: 10 mg, 20 mg, 30 mg 1

Phosphodiesterase-5 Enzyme Inhibitor

Sildenafil Revatio ● Tablet, generic: 20 mg 1

Phosphodiesterase-5 Enzyme Inhibitor

Vardenafil Levitra ● Tablet, as hydrochloride [film-coated]: 2.5 mg, 5 mg, 10 mg, 20 mg

1

Phospholipase A2 Inhibitor Anagrelide Hydrochloride Agrylin ● Capsules: 0.5 mg, 1 mg (generic 1Photosensitizing Agent, Topical Topical Skin Product

Aminolevulinic Acid Levulan Kerastick ● Levulan Kerastick: 20% (6s) [2-component system containing aminolevulinic acid hydrochloride 354 mg (powder) and diluent containing ethanol 48% (1.5 mL) packaged together in an applicator tube]

1

Plasma Volume Expander Dextran ●Infusion [premixed in D5W]: 10% Dextran 40●Infusion [premixed in NS]: 10% Dextran 40

1

Plasma Volume Expander, Colloid Hetastarch Hespan Hextend ● Injection, in NS (Hextend): 6% (500 mL) (6% hetastarch in lactated electrolyte injection) supplied in sterile and nonpyrogenic in 500 mL and 1000 mL single-dose flexible plastic infusion containers

1

128

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierPolypeptide Hormone Radiological/Contrast Media, Nonionic

Iohexol Omnipaque ● Injection: 180 mg (10 mL, 20 mL); 240 mg (10 mL, 100 mL);300 mg (50 mL, 100 mL); 350 mg/mL (50mL, 100 mL, 150mL, 200 mL)● Iohexol DS injection: 300 mg/mL (10 x 100 mL, 10 x 125 mL, 10 x 150 mL)● Iohexol DS injection: 350 mg/mL (10 x 100 mL, 10 x 125 mL)

1

Progestin Hydroxyprogesterone caproate

Makena ● Oil, Intramuscular: 250 mg/mL 1

Progestin Progesterone Prometrium Endometrin ● Injection, in oil: 50 mg/mL (10 mL); 100 mg/mL (10 mL)● Tablet, vaginal: 100 mg (with applicators)

1

Prostacyclin Prostaglandin Vasodilator

Epoprostenol Sodium Flolan Injection ● Injection: 0.5 mg, 1.5 mg 1


Iloprost Ventavis ● Solution, for oral inhalation [preservative free]: Ventavis: 10 mcg/mL (1 mL); 20 mcg/mL (1 mL)

1


Treprostinil Tyvaso Solution, Inhalation: Tyvaso: 0.6 mg/mL (2.9 mL)

1

Prostaglandin Misoprostol Cytotec ● Tablet: 100 mcg (60s, 120s); 200 mcg (60s, 100s)

1

129

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierProstaglandin Vasodilator Alprostadil Caverject Impulse Caverject

Edex MuseProstin VR Pediatric

● Injection (Prostin VR Pediatric): 500 mcg/mL (1 mL)● Injection, powder for reconstitution:● Caverject: 10 mcg, 20 mcg, 40 mcg [diluent contains benzyl alcohol]● Caverject Impulse: 10 mcg, 20 mcg [prefilled injection system; diluent contains benzyl alcohol]● Edex: 10 mcg, 20 mcg, 40 mcg

1

Proton Pump Inhibitor Substituted Benzimidazole

Omeprazole Prilosec ● Capsule, delayed release: 10 mg, 20 mg

1

Proton Pump Inhibitor Substituted Benzimidazole

Pantoprazole Protonix ● Injection, powder for reconstitution: 40 mg● Tablet, Delayed release: 20 mg, 40 mg

1

Psoralen Methoxsalen Oxsoralen ● Capsule: 10 mg● Lotion: 1% (30 mL)

1

Respiratory Stimulant Stimulant Doxapram Hydrochloride Dopram ● Injection: 20 mg/mL (20 mL) 1Retinoid-Like Compound Acitretin Soriatane ● Capsule: 10 mg, 25 mg ] D 1Salicylate Choline Magnesium

TrisalicylateTrilisate ● Tablet: 500 mg, 750 mg, 1000 mg 1

Salicylate Salsalate Disalcid ● Tablet: 500 mg (100s), 750 mg (50s, 100s)

1

Sclerosing Agent Ethanolamine Oleate Ethamolin ● Injection: 5% (2 mL) 1Sclerosing Agent Sodium Tetradecyl Sulfate Sotradecol ● Injection, as sulfate: 1% [10 mg/mL]

(2 mL); 3% [30 mg/mL] (2 mL)1

Selective Bradykinin Beta 2 Receptor Antagonist

Icatibant Firazyr ●Injection, solution [preservative free]: 10 mg/mL (3 mL)

1

Selective Estrogen Receptor Modulator (SERM)

Raloxifene Evista ● Tablet, as hydrochloride: 60 mg 1

130

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierSkeletal Muscle Relaxant Baclofen Gablofen ● Solution, Intrathecal: Gablofen: 50

mcg/mL (1 mL); 10,000 mcg/20 mL (20 mL); 20,000 mcg/20 mL (20 mL); 40,000 mcg/20 mL (20 mL)

1

Skeletal Muscle Relaxant Baclofen Lioresal ● Tablet: 10 mg, 20 mg (100s each) 1

Skeletal Muscle Relaxant Cyclobenzaprine Hydrochloride

Flexeril ● Tablet: 5 mg, 10 mg (30s, 100s) 1

Skeletal Muscle Relaxant Dantrolene Sodium Dantrium Revonto Ryanodex ● Capsule: 25 mg, 50 mg, 100 mg (100s each)● Suspension, powder for injection: 250 mg

1

Skeletal Muscle Relaxant Methocarbamol Robaxin ● Injection: 100 mg/mL in polyethylene glycol 50% (10 mL)● Tablet: 500 mg, 750 mg (30s, 50s, 100s each)

1

Skin and Mucous Membrane Agent Topical Skin Product

Imiquimod Aldara ● Cream: 5% (0.25g each; 12s) [contains benzyl alcohol; single-dose packets]

1

Smoking Cessation Aid Nicotine Commit [OTC] NicoDerm CQ [OTC] Nicorette [OTC] Nicotrol Inhaler Nicotrol NS

● 3 Step patch, transdermal: 21 mg/day (7s- OTC, 14s, 30s); 14 mg/day (7s-OTC, 14s, 30s); 7 mg/day (7s-OTC, 30s)● Lozenge, as polacrilex: Nicorette (OTC): 2 mg, 4 mg● Gum, chewing, as polacrilex: Nicorette (OTC): 2 mg, 4 mg

1

Smoking Cessation Aid, Partial Nicotine Agonist

Varenicline Chantix

● Tablet, Oral: Chantix: 0.5 mg, 1 mg Chantix Continuing Month Pak: 1 mg Chantix Starting Month Pak: 0.5 mg x 11 & 1 mg x 42

1

131

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierStimulant Caffeine Cafcit

Enerjets [OTC]No Doz Maximum Strength [OTC] Vivarin [OTC]

● Injection, solution, as citrate [preservative free] (Cafcit): 20 mg/mL (3 mL) [equivalent to 10 mg/mL caffeine base]● Solution, oral, as citrate [preservative free]: Cafcit: 20 mg/mL (3 mL) [equivalent to 10 mg/mL caffeine base]

1

132

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierStimulant Dextroamphetamine and

AmphetamineAdderall XR Adderall ● Tablet (Adderall):

● 5 mg [dextroamphetamine sulfate 1.25 mg, dextroamphetamine saccharate 1.25 mg and amphetamine aspartate 1.25 mg, amphetamine sulfate 1.25 mg] (100s)● 10 mg [dextroamphetamine sulfate 2.5 mg, dextroamphetamine saccharate 2.5 mg and amphetamine aspartate 2.5 mg, amphetamine sulfate 2.5 mg] (100s)● Tablet (generic):● 7.5 mg [dextroamphetamine 1.875 mg, dextroamphetamine saccharate 1.875 mg, amphetamine aspartate 1.875 mg, amphetamine sulfate 1.875 mg] (equivalent to amphetamine base 4.7 mg)● 12.5 mg [dextroamphetamine sulfate 3.125 mg, dextroamphetamine saccharate 3.125 mg, amphetamine aspartate 3.125 mg, amphetamine sulfate 3.125 mg] (equivalent to amphetamine base 7.8 mg)● 15 mg [dextroamphetamine sulfate 3.75 mg, dextroamphetamine saccharate 3.75 mg, amphetamine

1

Stimulant Lisdexamfetamine Vyvanse ● Capsule, oral, as dimesylate: 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg

1

Stimulant Dextroamphetamine Sulfate Dexedrine Dextrostat ● Capsule, sustained release: 5 mg, 10 mg, 15 mg (50s each)● Tablet: 5 mg, 10 mg

1

133

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierTheophylline Derivative Aminophylline ● Injection: 25 mg/mL (10 mL, 20

mL)1

Theophylline Derivative Theophylline Elixophyllin [DSC] Theo- 24 TheoCap Theochron Uniphyl

● Elixir, oral: 80 mg/15 mL● Tablet, timed release: 12hours, theophylline sustained release: 100 mg, 200 mg, 300 mg, 400 mg, 450 mg

1

Thrombolytic Agent Alteplase, Recombinant Activase Cathflo Activase Injection, powder for reconstitution, recombinant:● Activase®: 50 mg [29 million int. units; contains polysorbate 80; packaged with diluent]; 100 mg [58 million int. units; contains polysorbate 80; packaged with diluent and transfer device]● Cathflo® Acti

1

Thrombolytic Agent Streptokinase Streptase ● Injection, powder for reconstitution: 250,000 units; 750,000 units

1

Thrombolytic Agent Tenecteplase TNKase ● Powder for injection, lyophilized (recombinant): 50 mg

1

Thrombolytic Agent Urokinase Abbokinase Open-Cath Abbokinase

● Powder for injection: 250,000 units (5 mL)

1

134

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierThyroid Product Levothyroxine Sodium Levothroid Synthroid ● Injection: 0.2 mg/vial (6 mL, 10

mL); 0.5 mg/vial (6 mL, 10 mL)● Tablet: 0.025 mg, 0.05 mg, 0.075 mg, 0.088mg, 0.1 mg,0.112 mg, 0.125 mg, 0.137 mg, 0.15 mg,0.175 mg, 0.2 mg,0.3 mg (100s each)● Levothroid: 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg

1

Thyroid Product Liothyronine Sodium Cytomel Triostat ● Tablet: 5 mcg, 25 mcg, 50 mcg (100s each)

1

Topical Skin Product Aluminum Chloride Hexahydrate

Drysol Xerac AC ● Crystals (for compounding use only)● Xerac AC: 6.25% aluminum chloride hexahydrate in 96% anhydrous ethyl alcohol (35 mL, 60 mL)● Drysol: 20% aluminum chloride hexahydrate in 93% SD alcohol 40 (35 mL with Dab-o-matic applicator, 37.5 mL)

1

Topical Skin Product Camphor and Menthol Men-Phor [OTC] Mentholatum [OTC] Sarna [OTC]Soltice Quick-Rub [OTC]

● Cream, topical (Soltice Quick-Rub): Camphor 5.1% and menthol 5.1% (40 g, 90 g)● Lotion, topical (Sarna): Camphor 0.5% and menthol 0.5% (222 mL)● Ointment, topical (Mentholatum): Camphor 9% and menthol 1.35% (30 g, 90 g)

1

135

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierTopical Skin Product Coal Tar Doak Tar Zetar [OTC] ● Coal tar, crude

● Ointment: 1%● Shampoo, topical (Zetar ): Whole coal tar: 1%● Solution, coal tar: 20%

1

Topical Skin Product Lactic Acid LactiCare [OTC] Lactinol- E Lactinol

● Lotion 10%, for compounding 1

Topical Skin Product Lactic Acid With Ammonium Hydroxide

Lac-Hydrin ● Cream: 12% (280 g) 1

Topical Skin Product Potassium Permanganate ● Solution, topical: 5%● Tablet, for topical solution: 300 mg

1

Pharmaceutical agent Thymol ● Crystals (for compounding use only) 1

Vasodilator Minoxidil Loniten ● Tablet: 2.5 mg, 10 mg (100s each) 1

Topical Skin Product Vitamin D Analog

Calcitriol Vectical ● Oinment, topical: 3 mcg/g 1

Topical Skin Product Vitamin D Analog

Calcipotriene Dovonex ● Scalp solution, topical: 0.005% (60 mL)

1

Toxoid Diphtheria and Tetanus Toxoid

Tenivac ● Injection, pediatric use: (Pediatric DT): Diphtheria 25 Lf units and tetanus 5 Lf units per 0.5 mL (0.5 mL)● Injection, adult use: (Adult Td) Diphtheria and tetanus toxoids 2 Lf diphtheria, 5 Lf tetanus

1

136

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierToxoid Diphtheria, Tetanus

Toxoids, and Acellular Pertussis Vaccine

Adacel Infanrix Tripedia ● Adacel: Diphtheria 2 Lf units, tetanus 5 Lf units, and acellular pertussis 2.5 mcg per 0.5 mL (0.5 mL) [prefilled syringe and vial stopper is latex free]● Infanrix: Diphtheria 25 Lf units, tetanus 10 Lf units, and acellular pertussis 25 mcg per0.5 mL (0.5 mL) [available in vial and prefilled syringe; syringe cap and rubber plunger contain natural latex rubber]● Tripedia: Diphtheria 6.7 Lf units, tetanus 5 Lf units, and acellular pertussis 46.8 mcg per0.5 mL (7.5 mL) [contains trace amounts of thimerosal; vial stopper contains natural latex rubber]● Note: Tripedia vaccine is also used to reconstitute ActHIB to prepare TriHIBit vaccine (diphtheria, tetanus toxoids, and acellular pertussis and Haemophilus influenzae b conjugate vaccine combination)

1

Trace Element, Parenteral Copper Sulfate ● Injection: 0.8% = 0.4 mg/mL (10 mL)

1

Urea Cycle Disorder (UCD) Treatment Agent

Phenylbutyrate Sodium Buphenyl ● Powder: 3.2 g [sodium phenylbutyrate 3 g] per teaspoon (500 mL, 950 mL)● Tablet: 500 mg (250s, 500s)

1

Uricosuric Agent Probenecid Benemid ● Tablet: 500 mg (100s) 1Urinary Tract Product Acetohydroxamic Acid Lithostat ● Tablet: 250 mg (120s) 1

137

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierUrinary Tract Product Dimethyl Sulfoxide Rimso-50 ● Solution: 50% (50 mL) 1Urinary Tract Product Tiopronin Thiola ● Tablet: 100 mg 1Vaccine Diphtheria and Tetanus

Toxoids, Acellular Pertussis, and Poliovirus (Inactivated) Vaccine

KinrixR) ● Injection suspension: Diphtheria toxoid 25 Lf, tetanus toxoid 10 Lf, acellular pertussis antigens [inactivated pertussis toxin 25 mcg, filamentous hemagglutinin 25 mcg, pertactin 8 mcg], type 1 poliovirus 40 D-antigen units, type 2 poliovirus 8 D- antigen units, and type 3 poliovirus 32 D-antigen units per 0.5 mL (0.5 mL) [contains aluminum, neomycin sulfate, polymyxin B, polysorbate 80, natural rubber/natural latex in packaging]

1

Vaccine Haemophilus influenzae Type b (Hib) Vaccine

Hiberix ● Injection:● Hiberix®: Haemophilus b capsular polysaccharide 10 mcg (bound to tetanus toxoid 25 mcg) per 0.5 mL [contains lactose12.6 mg]● ActHIB® Haemophilus b capsular polysaccharide 10 mcg per 0.5 mL

1

138

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierVaccine Hepatitis A Inactivated and

Hepatitis B (Recombinant) Vaccine

Twinrix ● Injection [single-dose vial]: Inactivated hepatitis A virus 720 ELISA units and hepatitis B surface antigen 20 mcg per mL (1 mL)● Injection, prefilled syringe [single-dose]: Inactivated hepatitis A virus 720 ELISA units and hepatitis B surface antigen 20 mcg per mL (1 mL)

1

Vaccine Hepatitis A Vaccine Vaqta ● Injection: 0.5 mL (25 units/0.5 mL, 50 units/0.5 mL)● Injection, suspension [pediatric formulation; preservative free]:● Havrix: Viral antigen 720 ELISA units/0.5 mL (0.5 mL) [contains trace amounts of neomycin; syringe plunger contains latex rubber; available in prefilled syringe or single- dose vial]● Injection, suspension [adult formulation; preservative free]:● Havrix: Viral antigen 1440 ELISA units/mL (1 mL) [contains trace amounts of neomycin; syringe plunger contains latex rubber; available in prefilled syringe or single-dose vial]

1

Vaccine Hepatitis B Vaccine Engerix-B ● Injection:● Pediatric (Engerix-B): Hepatitis B surface antigen 10 mcg/mL● Adult (Engerix-B): Hepatitis B surface antigen 20 mcg/mL tip-lok syringe

1

139

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierVaccine Influenza Virus Vaccine Fluarix Flublok Flucelvax Flu-

Shield FluMist Fluogen Fluzone Fluvirin Fluarix Afluria

Injection, suspension [purified split-virus]: FluLaval®: Hemagglutinin 45 mcg/0.5 mL (5 mL) [contains chicken egg protein, thimerosal; TIV]Fluvirin®: Hemagglutinin 45 mcg/0.5 mL (5 mL) [contains thimerosal; TIV]Fluzone®: Hemagglutinin 45 mcg/0.5 mL (5 mL) [contains chicken egg protein, thimerosal; TIV]Injection, suspension [purified split-virus, preservative free]: Afluria®: Hemagglutinin 45 mcg/0.5 mL (0.5 mL) [contains chicken egg protein, neomycin (may have trace amounts), polymyxin B (may have trace amounts), thimerosal (may have trace amounts); TIV]Fluarix®: Hemagglutinin 45 mcg/0.5 mL (0.5 mL) [contains chicken egg protein, gentamicin (may have trace amounts), hydrocortisone (may have trace amounts), may contain natural rubber/natural latex in packaging, polysorbate 80; TIV] Fluvirin®: Hemagglutinin 45 mcg/0.5 mL (0.5 mL) [contains may contain natural rubber/natural latex in packaging,

1

Vaccine Influenza A (H1N1) Virus Vaccine

Influenza A (H1N1) Virus Vaccine

● Injection suspension (Inactivated) : 0.5 mL● Suspension, intranasal (Live, preservative free spray)

1

Vaccine Japanese Encephalitis Virus Vaccine, Inactivated

Ixiaro ● Injection suspension 1

140

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierVaccine Meningococcal

Polysaccharide (Groups A/C/Y and W-135) Diphtheria Toxoid Conjugate Vaccine

Menveo ● Injection, solution: Menveo: MenA oligosaccharide 10 mcg, MenC oligosaccharide 5 mcg, MenY oligosaccharide 5 mcg, and MenW-135 oligosaccharide 5 mcg [bound to CRM197 protein 32.7-64.1 mcg] per 0.5 mL (0.5 mL) [MenACWY- CRM; supplied in two vials, one containing MenA powder and one containing MenCYW-135 liquid]

1

Vaccine Meningococcal Polysaccharide Vaccine, Groups A, C, Y, and W- 135

Menomune-A/C/Y/W-135 ● Injection: Single dose, 10 dose, 50 dose

1

Vaccine Meningococcal Group B Vaccine injection

Bexsero ● Suspension Prefilled Syringe, intramuscular: (0.5 mL)

1

Vaccine Mumps Virus Vaccine, Live, Attenuated

Mumpsvax ● Injection: Single dose 1

Vaccine Pneumococcal Conjugate Vaccine, 7- Valent and 13-Valent

Prevnar™ Prevnar 13™ ● Injection: Prevnar™: 0.5 mL in single-use vials (5 per package)● Injection: Prevnar 13™: 0.5 mL (0.5 mL)

1

Vaccine Pneumococcal Vaccine, Polyvalent

Pneumovax 23Pnu-Imune 23

● Injection: 25 mcg each of 23 polysaccharide isolates/0.5 mL dose (0.5 mL, 2.5 mL)

1

Vaccine Poliovirus Vaccine, Inactivated

IPOL ● Injection: Suspension of three types of poliovirus (Types 1, 2 and 3) grown in monkey kidney cell culture (1 mL)

1

141

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierVaccine Quadrivalent Human

Papillomavirus (Types 6, 11, 16,18) Recombinant Vaccine

Gardasil ● Injection, suspension [preservative free]:● Gardasil: HPV 6 L1 protein 20 mcg, HPV 11 L1 protein 40 mcg, HPV 16 L1 protein 40 mcg, and HPV 18 L1 protein 20 mcg per 0.5 mL (0.5 mL) [contains polysorbate 80; packaged in vials]

1

Vaccine Papillomavirus (9- valent) Recombinant Vaccine

Gardasil 9 ● Injection, suspension vial and pre-filled syringe

1

Vaccine Rabies Virus Vaccine, Human Diploid

Imovax ● Injection: 2.5 units rabies antigen/mL (1 mL)

1

Vaccine Rotavirus Vaccine RotaTeq® Rotarix® ● Suspension, oral [preservative free] (RotaTeq): G1 >=2.2 106 infectious units, G2>=2.8 106 infectious units, G3 >=2.2 106infectious units, G4 >=2.0 106 infectious units, and P1 [8]>=2.3 106 infectious units (2 mL) [bovine and human derived; available in a prefilled, ready- to-use dosing tube]●Powder, for suspension, oral [preservative free; human derived]: Rotarix®: G1P[8] ≥106 infectious units per 1 mL [oral applicator contains natural latex/natural rubber]

1

Vaccine Rubella Virus Vaccine, Live

Meruvax II ● Injection: 1000 TCID5O (Wistar RA 27/3 Strain) single dose

1

142

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierVaccine Typhoid Vaccine Live Typhim Vi Vivotif Berna ● Capsule, enteric coated (Vivotif

Berna): Viable S. typhi Ty21a colony-forming units 2- 6 x 109 and nonviable S. typhi Ty21a colony- forming units 50 x 109 [also contains sucrose, ascorbic acid, amino acid mixture, lactose, and magnesium stearate]● Injection, solution (Typhim Vi): Purified Vi capsular polysaccharide 25 mcg/0.5 mL (0.5 mL, 10 mL)

1

Vaccine Varicella Virus Vaccine Varivax ● Powder for injection, lyophilized powder, preservative free: 1350 plaque forming units (PFU)/0.5 mL (0.5 mL single-dose vials)

1

Vaccine Zoster Vaccine Zostavax ● Injection, powder for reconstitution [preservative free]● Zostavax: 19,400 plaque-forming units (PFU) [contains gelatin, sucrose, and trace amounts of neomycin]

1

Vaccine, Live Virus Measles Virus Vaccine, Live, Attenuated

Attenuvax ● Injection: 1000 TCID50 per dose 1

Vaccine, Live Virus Measles, Mumps, and Rubella Vaccines, Combined

M-M-R II ● Injection: 1000 TCID50 each of measles virus vaccine and rubella virus vaccine, 5000 TCID50 mumps virus vaccine

1

143

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierVaccine, Live Virus Measles, Mumps, Rubella,

and Varicella Virus VaccineProQuad ● Injection, powder for reconstitution

[preservative free]: ProQuad: Measles virus>=3.00 log10 TCID50, mumps virus>=4.3 log10 TCID50, rubella virus >=3.0 log10 TCID50, and varicella virus >=3.99 log10 plaque-forming units [contains neomycin, sucrose, gelatin, human albumin, and bovine serum; produced in chick embryo cell culture]

1

Vaccine, Live Virus Yellow Fever Vaccine YF-VAX ● Injection: Distribution is limited to physicians certified by the State Department of Health

1

Vasodilator Hydralazine Hydrochloride Apresoline ● Injection: 20 mg/mL (1 mL)● Tablet: 10 mg (100s), 25 mg, 50 mg (100s); 100 mg (100s each)

1

Vasodilator Isosorbide Dinitrate Isordil Sorbitrate ● Tablet:● Oral: 5 mg, 10 mg, 20 mg, 30 mg (100s each)● Sublingual: 2.5 mg, 5 mg (100s each)● Sustained release: 40 mg (100s)

1

Vasodilator Isosorbide Mononitrate Imdur ● Tablet, 10 mg● Tablet, extended release : 30 mg, 60 mg, 120 mg

1

144

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierVasodilator Nitroglycerin Minitran Nitro-Bid Nitro- Dur

Nitrodisc Nitrol NitrostatTransderm-Nitro Tridil

● Capsule, sustained release: 2.5 mg, 6.5 mg, 9 mg● Injection: 5 mg/mL● Ointment, topical: 2%● Tablet, sublingual: 0.3 mg, 0.4 mg, 0.6 mg● Patch, transdermal, topical: Systems designed to deliver0.1 mg/hour, 0.2 mg/hour, 0.3 mg/hour, 0.4 mg/hour, 0.6 mg/hour● Infusion, premix: 50 mg (250 mL) [0.2 mg/ mL]

1

Vasodilator Nitroprusside Sodium Nipride Nitropress ● Powder for injection: 50 mg 1Vasodilator Papaverine Hydrochloride Para-Time SR ● Capsule, sustained release: 150 mg

(100s)● Injection: 30 mg/mL (2 mL, 10 mL)

1

Vasodilator Tolazoline Hydrochloride Priscoline ● Injection: 25 mg/mL (4 mL) 1Vitamin D Analog Calcitriol Rocaltrol ● Capsule: 0.25 mcg, 0.5 mcg (30s,

100s each)1

Vitamin D Analog Ergocalciferol Calciferol Drisdol ● Capsule: 50,000 units = 1.25 mg (100s)● Injection: 500,000 units/mL = 12.5 mg/mL (1 mL)

1

145

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierVitamin Vitamin B Complex

CombinationsAllbee C-800 + Iron [OTC] Allbee C-800 [OTC] Allbee with C [OTC] Apatate [OTC]DexFol DiatxGevrabon [OTC] Kobee [OTC] NephPlex Rx Nephro-Vite Rx Nephro- Vite Nephrocaps Nephron FA NephronexQuin B Strong [OTC] Rena- Vite RXRena-Vite [OTC] Renalcaps Rhenaphro SenilezolStresstabs High Potency Advanced [OTC] Stresstabs High Potency Energy [OTC] Stresstabs High Potency Weight [OTC] StroviteSuper Quints 50 [OTC] Surbex-T [OTC] Trinsicon [DSC]VitafolZ-Bec [OTC]

● Soft Gels: Renal Caps 1

Vitamin Vitamin, Multiple (Pediatric)

Poly-Vi-Flor With Iron Poly-Vi-FlorTri-Vi-Flor With Iron Tri- Vi-Flor

● Multiple 1

Vitamin, Fat Soluble Phytonadione AquaMEPHYTONMephyton

● Injection: 2 mg/mL (0.5 mL); 10 mg/mL (1 mL, 5 mL)● Tablet: 5 mg (100s)

1

Vitamin, Fat Soluble Vitamin A Aquasol A [OTC] Del-Vi-A Aquasol A Palmitate-A [OTC]

● Capsule: 25,000 units, 50,000 units● Injection: 50,000 units/mL (5 mL)

1

146

Pharmacologic Category Generic Name Brand Name Formulary Dosage Forms TierVitamin, Water Soluble Ascorbic Acid Acerola [OTC] Asco-Caps

[OTC] Asco-Tabs [OTC] Ascocid [OTC]C-Gel [OTC] C-Gram [OTC] C-Time [OTC]Cecon [OTC] Cemill [OTC] Cenolate Chew-C [OTC] Dull-C [OTC] Mild- C [OTC]One Gram C [OTC] Time- C [OTC]Time-C-Bio [OTC] Vicks Vitamin C [OTC] Vita-C [OTC]

● Injection: 500 mg/mL 1

Vitamin, Water Soluble Cyanocobalamin Redisol Rubramin-PC ● Injection: 100 mcg/mL (10 mL); 1000 mcg/mL (1 mL, 10 mL)

1

Vitamin, Water Soluble Folic Acid Folvite ● Injection, as sodium folate: 5 mg/mL (10 mL)

1

Vitamin, Water Soluble Pyridoxine Hydrochloride Aminoxin [OTC] Pyri-500 [OTC]

● Injection: 100 mg/mL 1

Vitamin, Water Soluble Thiamine Hydrochloride ● Injection: 100 mg/mL 1Xanthine Oxidase Inhibitor Allopurinol Zyloprim ● Tablet: 100 mg, 300 mg (100s each) 1

147

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