HealthPAC Formulary Current as of April 2014

Transcription

1 Adrenals Fludrocortisone Florinef 0.2 mg Analgesic Misc Butalbital-APAP-Caffeine Fioricet 50/325/40 Analgesic Misc Tramadol Ultram, Rybix 50 mg Analgesic Muscle Relaxant Baclofen Lioresal 10 mg Analgesic Muscle Relaxant Baclofen Lioresal 20 mg Analgesic Muscle Relaxant Cyclobenzaprine Flexeril 10 mg Analgesic Muscle Relaxant Methocarbamol Robaxin 500 mg Analgesic Muscle Relaxant Methocarbamol Robaxin 750 mg Analgesic Narcotic Acetaminophen/Oxycodone Percocet 325/5 and 325/10 Analgesic Narcotic Acetaminophen/Codeine #3 Tylenol #3 300 / 30 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325/10 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325/5 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325/7.5 mg Analgesic Narcotic Acetaminophen/Hydrocodone bitartrate Vicodin 500 mg - 5 mg Analgesic Narcotic Methadone 10 mg Analgesic Narcotic Methadone 5 mg Analgesic Narcotic Morphine sulfate Liquid MS 20mg/ 5 ml Analgesic Narcotic Morphine sulfate short acting MS 15,30mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 100 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 15 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 30 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 60 mg Analgesic NSAID Diclofenac Voltaren 50 mg Analgesic NSAID Diclofenac Voltaren 75 mg Analgesic NSAID Ibuprofen Motrin 400 mg Analgesic NSAID Ibuprofen Motrin 600 mg Analgesic NSAID Ibuprofen Motrin 800 mg Analgesic NSAID Indomethacin Indocin 25 mg Analgesic NSAID Indomethacin Indocin 50 mg Analgesic NSAID Nabumetone Relafen 750 mg Analgesic NSAID Naproxen Naprosyn 250 mg Analgesic NSAID Naproxen Naprosyn 375 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 1 of 23

2 Analgesic NSAID Naproxen Naprosyn 500 mg Analgesic NSAID Sulindac Clinoril 150 mg Analgesic NSAID Sulindac Clinoril 200 mg Analgesic Salicyclates Salsalate 500 mg Analgesic Salicyclates Salsalate 750 mg Analgesic Salicylates Acetylsalicylic acid (ASA) 81, 325 mg Anthelmintics Praziquantel Biltricide 600mg Antibiotic Mupirocin Bactroban 2%ointment Antihistamine Loratidine Claritin 10mg Anti-inflammatory Agents Alclometasone Cream Aclovate 45gm Anti-inflammatory Agents Alclometasone Ointment Aclovate 45gm Antimicrobials Antifungals Econazole Spectazole 1% crm 30 Gm (30 Gm) Antimicrobials Antifungals Econazole Spectazole 1% crm 85 Gm (85 Gm) Antimicrobials Antifungals Econazole Spectazole 1% crm 15 Gm (15 Gm) Antimicrobials Antifungals Fluconazole Diflucan 100 mg Antimicrobials Antifungals Fluconazole Diflucan 150 mg Antimicrobials Antifungals Fluconazole Diflucan 200 mg Antimicrobials Antifungals Griseofulvin micro liquid Grifulvin V 125 mg / 5 ml (120 ml) Antimicrobials Antifungals Griseofulvin ultramicro Grisactin Fulvicin 125 mg Antimicrobials Antifungals Griseofulvin ultramicro Grisactin Fulvicin 250 mg Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (15 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (30 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (60 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% shampoo Antimicrobials Antifungals Ketoconazole Nizoral 200 mg (tabs) Antimicrobials Antifungals Nystatin oral suspension 100,000 units/ml Antimicrobials Antitubercular Ethambutol Myambutol 100 mg Antimicrobials Antitubercular Ethambutol Myambutol 400 mg Antimicrobials Antitubercular Isoniazid INH 10 mg / ml Antimicrobials Antitubercular Isoniazid INH 100 mg Antimicrobials Antitubercular Isoniazid INH 300 mg Antimicrobials Antitubercular Pyrazinamide 500 mg Antimicrobials Antitubercular Rifampin Rifadin 150 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 2 of 23

3 Antimicrobials Antitubercular Rifampin Rifadin 300 mg Antimicrobials Antiviral Acyclovir Zovirax 200 mg Antimicrobials Antiviral Acyclovir Zovirax 400 mg Antimicrobials Antiviral Acyclovir Zovirax 800 mg Antimicrobials Antiviral Oseltamivir Tamiflu 12mg/ml Antimicrobials Antiviral Oseltamivir Tamiflu 75mg Antimicrobials Cephalosporins Cephalexin Keflex 125 mg / 5 ml (200 ml) Antimicrobials Cephalosporins Cephalexin Keflex 250 mg Antimicrobials Cephalosporins Cephalexin Keflex 250 mg / 5 ml (100 ml) Antimicrobials Cephalosporins Cephalexin Keflex 500 mg Antimicrobials Macrolides Azithromycin Zithromax 250 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 250 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 333 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 500 mg Antimicrobials Misc Clindamycin Cleocin 150 mg Antimicrobials Misc Clindamycin Cleocin 300 mg Antimicrobials Misc Metronidazole Flagyl 250 mg Antimicrobials Misc Metronidazole Flagyl 500 mg Antimicrobials Misc Metronidazole cream Metrocream 0.075% Antimicrobials Misc Nitrofurantoin macrocryst Macrodantin 100 mg Antimicrobials Misc Nitrofurantoin macrocryst Macrodantin 50 mg Antimicrobials Misc Nitrofurantoin monohydrate Macrobid 100 mg Antimicrobials Penicillins Amoxicillin Amoxil 125 mg / 5 cc (80 cc) Antimicrobials Penicillins Amoxicillin Amoxil 250 mg Antimicrobials Penicillins Amoxicillin Amoxil 250 mg / 5 cc (150 cc) Antimicrobials Penicillins Amoxicillin Amoxil 400 mg/ 5 cc Antimicrobials Penicillins Amoxicillin Amoxil 500 mg Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 200 mg / 5 cc (100 ml) Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 500 mg-125 mg Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 875 mg Antimicrobials Penicillins Dicloxacillin Dynapen 250 mg Antimicrobials Penicillins Dicloxacillin Dynapen 500 mg Antimicrobials Penicillins Penicillin VK 125 mg / 5 cc (200 cc) Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 3 of 23

4 Antimicrobials Penicillins Penicillin VK Veetids 250 mg Antimicrobials Penicillins Penicillin VK 250 mg / 5 cc (100 cc) Antimicrobials Penicillins Penicillin VK 250 mg / 5 cc (150 cc) Antimicrobials Penicillins Penicillin VK 500 mg Antimicrobials Quinolones Ciprofloxacin Cipro 250 mg Antimicrobials Quinolones Ciprofloxacin Cipro 500 mg Antimicrobials Sulfas Sulfamethxzl Trimethoprim Bactrim 40mg / 5ml - 200mg / 5-ml (60 ml) Antimicrobials Sulfas Sulfamethxzl Trimethoprim Septra 80 / 400 mg Antimicrobials Sulfas Sulfamethxzl Trimethoprim DS Septra 160 / 800 mg Antimicrobials Tetracyclines Doxycycline Doryx Vibramycin 100 mg Antimicrobials Tetracyclines Doxycycline Doryx Vibramycin 50 mg Antimicrobials Tetracyclines Tetracycline Sumycin 250 mg Antimicrobials Tetracyclines Tetracycline Sumycin 500 mg Antimicrobials Clarithromycin Biaxin 500 mg Antimicrobials Levofloxacin Levaquin 500 mg ACE Inhibitor Captopril Capoten 100 mg ACE Inhibitor Captopril Capoten 12.5 mg ACE Inhibitor Captopril Capoten 25 mg ACE Inhibitor Captopril Capoten 50 mg ACE Inhibitor Enalapril maleate Vasotec 10 mg ACE Inhibitor Enalapril maleate Vasotec 2.5 mg ACE Inhibitor Enalapril maleate Vasotec 20 mg ACE Inhibitor Enalapril maleate Vasotec 5 mg ACE Inhibitor Lisinopril Prinivil, Zestril 10 mg ACE Inhibitor Lisinopril Prinivil, Zestril 2.5 mg ACE Inhibitor Lisinopril Prinivil, Zestril 20 mg ACE Inhibitor Lisinopril Prinivil, Zestril 30 mg ACE Inhibitor Lisinopril Prinivil, Zestril 40 mg ACE Inhibitor Lisinopril Prinivil, Zestril 5 mg Alpha-1 blocker Doxazosin mesylate Cardura 1 mg Alpha-1 blocker Doxazosin mesylate Cardura 2 mg Alpha-1 blocker Doxazosin mesylate Cardura 4 mg Alpha-1 blocker Doxazosin mesylate Cardura 8 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 4 of 23

5 Alpha-blockers Prazosin Minipress 1 mg Alpha-blockers Prazosin Minipress 2 mg Alpha-blockers Prazosin Minipress 5 mg Angiotensin II Blocker Losartan Cozaar 100 mg Angiotensin II Blocker Losartan Cozaar 25 mg Angiotensin II Blocker Losartan Cozaar 50mg Antiarrythmic Amiodarone Cordarone 200 mg Antiarrythmic Amiodarone Cordarone 400 mg Anticoagulants Dipyridamole Persantine 25 mg Anticoagulants Dipyridamole Persantine 50 mg Anticoagulants Dipyridamole Persantine 75 mg Anticoagulants Warfarin sodium Coumadin 1 mg Anticoagulants Warfarin sodium Coumadin 10 mg Anticoagulants Warfarin sodium Coumadin 2 mg Anticoagulants Warfarin sodium Coumadin 2.5 mg Anticoagulants Warfarin sodium Coumadin 3 mg Anticoagulants Warfarin sodium Coumadin 4 mg Anticoagulants Warfarin sodium Coumadin 5 mg Anticoagulants Warfarin sodium Coumadin 6 mg Anticoagulants Warfarin sodium Coumadin 7.5 mg Beta Atenolol Tenormin 100 mg Beta Atenolol Tenormin 25 mg Beta Atenolol Tenormin 50 mg Beta Carvedilol Coreg 12.5 mg Beta Carvedilol Coreg 25 mg Beta Carvedilol Coreg mg Beta Carvedilol Coreg 6.25 mg Beta Labetalol HCL Trandate 100 mg Beta Labetalol HCL Trandate 200 mg Beta Labetalol HCL Trandate 300 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 5 of 23

6 Beta Metoprolol succinate Toprol XL 100 mg Beta Metoprolol succinate Toprol XL 25 mg Beta Metoprolol succinate Toprol XL 50 mg Beta Metoprolol tartrate Lopressor 100 mg Beta Metoprolol tartrate Lopressor 25 mg Beta Metoprolol tartrate Lopressor 50 mg Beta Propranolol HCL Inderal 10 mg Beta Propranolol HCL Inderal 20 mg Beta Propranolol HCL Inderal 40 mg Beta Propranolol HCL Inderal 60 mg Beta Propranolol HCL Inderal 80 mg Amlodipine Norvasc 10 mg Amlodipine Norvasc 2.5 mg Amlodipine Norvasc 5 mg Dilitiazem HCI Cardizem LA 180 mg Diltiazem Cardizem 120 mg Cardizem CD, Diltiazem Dilacor Xr, Cartia XL, Dilt-CD 60 mg Diltiazem Cardizem CD, Dilacor Xr, Cartia XL, Dilt-CD 90 mg Diltiazem SR Cardizem SR 120 mg Diltiazem SR Cardizem SR 180 mg Diltiazem SR Cardizem SR 240 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 6 of 23

7 Diltiazem SR Cardizem SR 300 mg Diltiazem CD Cardizem CD 120 mg Diltiazem CD Cardizem CD 180 mg Diltiazem CD Cardizem CD 240 mg Diltiazem CD Cardizem CD 30 mg Diltiazem CD Cardizem CD 300 mg Diltiazem CD Cardizem CD 360mg Diltiazem CD Cardizem CD 60 mg Diltiazem CD Cardizem CD 90 mg Procardia, Adalat Nifedipine SR CC, Nifediac 30 mg Procardia, Adalat Nifedipine SR CC, Nifediac 60 mg Procardia, Adalat Nifedipine SR CC, Nifediac 90 mg Verapamil Isoptin 120 mg Verapamil LA Isoptin 180 mg Verapamil SR Calan SR 120 mg Verapamil SR Calan SR 180 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 7 of 23

8 Verapamil SR Calan SR 240 mg Central Alpha Agonist Clonidine HCI tabs Catapres 0.1 mg Central Alpha Agonist Clonidine HCI tabs Catapres 0.2 mg Central Alpha Agonist Clonidine HCI tabs Catapres 0.3 mg Central Alpha Agonist Methyldopa Aldomet 250 mg Central Alpha Agonist Methyldopa Aldomet 500 mg Cholesterol Gemfibrozil Lowering Agents Lopid 600 mg Cholesterol Lovastatin Lowering Agents Mevacor 10, 20, 40 mg Cholesterol Pravastatin Lowering Agents Pravachol 20, 40, 80 mg tabs Cholesterol Simvastatin Lowering Agents Zocor 10 mg Cholesterol Simvastatin Lowering Agents Zocor 20 mg Cholesterol Simvastatin Lowering Agents Zocor 40 mg Diurectics Metolazone Zaroxolyn 10 mg Diurectics Metolazone Zaroxolyn 2.5 mg Diurectics Metolazone Zaroxolyn 5 mg Diuretics Chlorthalidone Thalitone 25mg Diuretics Chlorthalidone Thalitone 50 mg Diuretics Furosemide Lasix 20 mg Diuretics Furosemide Lasix 40 mg Diuretics Furosemide Lasix 80 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 8 of 23

9 Diuretics Hydrochlorothiazide Microzide 12.5 mg cap Diuretics Hydrochlorothiazide Esidrix 25 mg Diuretics Hydrochlorothiazide Esidrix 50 mg Diuretics Spironolactone Aldactone 25 mg Diuretics Spironolactone Aldactone 50 mg Diuretics Spironolatone Aldactone 100 mg Diuretics Triamterene hctz Maxzide 37.5/25 mg Diuretics Triamterene hctz Maxzide 75 / 50 mg Glycosides Digoxin Lanoxin mg Glycosides Digoxin Lanoxin 0.25 mg Nitrate Isosorbide dinitrate Isordil 10 mg Nitrate Isosorbide dinitrate Isordil 20 mg Nitrate Isosorbide dinitrate Isordil 30 mg Nitrate Isosorbide dinitrate Isordil 5 mg Nitrate Isosorbide mononitrate IR, SR Imdur 10 mg Nitrate Isosorbide mononitrate IR, SR Imdur 120 mg Nitrate Isosorbide mononitrate IR, SR Imdur 20 mg Nitrate Isosorbide mononitrate IR, SR Imdur 30 mg Nitrate Isosorbide mononitrate IR, SR Imdur 60 mg Nitrate Nitroglycerine SL Nitrostat 0.4 mg Other Hydralazine Apresoline 10 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 9 of 23

10 Other Hydralazine Apresoline 100 mg Other Hydralazine Apresoline 25 mg Other Hydralazine Apresoline 50 mg Potassium Supplement Potassium chloride 10% (480 cc) Potassium K-Tab, K-Dur, Potassium chloride tabs Supplement Slow-K, Klor-con 10 meq Potassium K-Tab, K-Dur, Potassium chloride tabs Supplement Slow-K, Klor-con 20 meq Potassium K-Tab, K-Dur, Potassium chloride tabs Supplement Slow-K, Klor-con 8 meq Niacin IR & ER tabs only 100 mg Niacin IR & ER tabs only 250 mg Niacin IR & ER tabs only 500 mg Chemotherapy Methotrexate Rheumatrex 2.5 mg Cold, Cough, Allergy Antihistamine Diphenhydramine Benadryl 12.5 mg/ 5ml Cold, Cough, Allergy Antihistamine Diphenhydramine Benadryl 25, 50 mg capsules Cold, Cough, Allergy Antihistamine Diphenhydramine Benadryl 50 mg/cc (inj) Cold, Cough, Allergy Antihistamine Hydroxyzine HCL Atarax 10 mg Cold, Cough, Allergy Antihistamine Hydroxyzine HCL Atarax 10 mg / 5 cc (120 ml) Cold, Cough, Allergy Antihistamine Hydroxyzine HCL Atarax 25 mg Cold, Cough, Allergy Antihistamine Hydroxyzine HCL Atarax 50 mg Cold, Cough, Allergy Antitussive Guaifenesin + Codeine Robitussin AC 100 mg - 10mg / 5 ml Cold, Cough, Allergy Antitussive Promethazine/VC/DM Cold, Cough, Allergy Nasal Steroids Flunisolide Nasarel 25 mcg/spray (0.025%) Derm Acne Clindamycin topical gel, lotion Cleocin 1% Derm Acne Clindamycin topical solution Cleocin-T 1% (60 ml) Derm Acne Erythromycin gel or solution Erygel 2% Derm Acne Metronidazole cream Metrocream 0.75% Derm Acne Metronidazole topical gel Metrogel 0.75% Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 10 of 23

11 Derm Acne Tretinoin Retin-A 0.01%, 0.025%, 0.05%, 0.1% cream, gel Derm Antifungals Nystatin (cream or ointment) Derm Antiinflammatory Clobetasol propionate Temovate 0.05% crm (15 Gms) Derm Antiinflammatory Clobetasol propionate Temovate 0.05% oint (15 Gms) Derm Antiinflammatory Clobetasol propionate Temovate 0.05% oint (30 Gms) Derm Antiinflammatory Fluocinolone acetonide Synalar 0.01% cream Derm Antiinflammatory Fluocinolone acetonide Synalar 0.01% ointment Derm Antiinflammatory Fluocinolone acetonide Synalar 0.025% cream Derm Antiinflammatory Fluocinolone acetonide Synalar 0.025% ointment Derm Antiinflammatory Fluocinolone acetonide Synalar 0.025%, 0.01% solution, 60 ml Derm Antiinflammatory Fluocinonide Lidex 0.05% solution 60ml Derm Antiinflammatory Fluocinonide Lidex 0.05% gel (60gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% cream (30 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% cream (60 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% oint (15 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% oint (30 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% oint (60 gm) Derm Antiinflammatory Hydrocortisone HC 10mg Derm Antiinflammatory Hydrocortisone HC 2.5% lotion Derm Antiinflammatory Hydrocortisone HC 20mg Derm Antiinflammatory Hydrocortisone cream Cortizone 2.5% Derm Antiinflammatory Hydrocortisone ointment Cortizone 2.50% Derm Triamcinolone cream, ointment, or Antiinflammatory lotion Kenalog, Aristocort 0.025% Derm Triamcinolone cream, ointment, or Antiinflammatory lotion Kenalog, Aristocort 0.10% Derm Anti-seborrhea Selenium sulfide lotion Selsun 2.50% Derm Other Silver sulfadiazine Flint SSD, Silvadene 1% crm Derm Scabicide and Lice Permethrin cream Elimite 5% (60 Gm) Derm Clobetasol lotion Temovate 0.05% Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 11 of 23

12 Derm Antiinflammatory Hydrocortisone HC 5mg Diabetes Biguanides Metformin Glucophage 1000 mg Diabetes Biguanides Metformin Glucophage 500 mg Diabetes Biguanides Metformin Glucophage 850 mg Diabetes Biguanides Metformin ER Glucophage XR 1000 mg Diabetes Biguanides Metformin ER Glucophage XR 750 mg Diabetes Biguanides Metformin ER Glucophage XR 500 mg Diabetes Insulin Product Insulin 70/30 Humulin, Novolin U100 (10 ml) Diabetes Insulin Product Insulin glargine Lantus 100 IU/mL Diabetes Insulin Product Insulin Lispro Humalog 100U/mL Diabetes Insulin Product Insulin NPH Humulin N U100 (10 ml) Diabetes Insulin Product Insulin Regular Humulin R U100 (10 ml) Diabetes Sulfonylureas Glipizide Glucotrol 10 mg Diabetes Sulfonylureas Glipizide Glucotrol 5 mg Diabetes Sulfonylureas Glyburide Micronase Diabeta 1.25 mg Diabetes Sulfonylureas Glyburide Micronase Diabeta 2.5 mg Diabetes Sulfonylureas Glyburide Micronase Diabeta 5 mg Diabetes Thiazolidinedion es Pioglitazone hydrochloride Actos 15 mg Diabetes Thiazolidinedion es Pioglitazone hydrochloride Actos 30 mg Diabetes Thiazolidinedion es Pioglitazone hydrochloride Actos 45 mg Diabetes Diabetes supplies - glucometer Diabetes Diabetes supplies - lancets Diabetes Diabetes supplies - syringes/needles Diabetes Diabetes supplies - test strips Diabetes Diabetes supplies - testing control solution Endocrine Glucocorticoids Prednisolone Prelone 15mg/5ml oral sol Endocrine Glucocorticoids Prednisone Deltasone 1 mg Endocrine Glucocorticoids Prednisone Deltasone 10 mg Endocrine Glucocorticoids Prednisone Deltasone 2.5 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 12 of 23

13 Endocrine Glucocorticoids Prednisone Deltasone 20 mg Endocrine Glucocorticoids Prednisone Deltasone 5 mg Endocrine Glucocorticoids Prednisone Deltasone 50 mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl 0.1 mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl 0.15 mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl 0.2 mg Endocrine Thyroid Levothyroxine Levoxyl 0.3 mg Endocrine Thyroid Methimazole Tapazole 10 mg Endocrine Thyroid Methimazole Tapazole 5 mg Endocrine Thyroid Propylthiouracil PTU 50 mg Endocrine Fludrocortisone Florinef 0.1 mg Genitourinary 5-alpha reductase Finasteride Proscar 5 mg inhibitor Genitourinary Oxybutynin Ditropan 5 mg Genitourinary Phenazopyridine HCL Pyridium 100 mg Genitourinary Phenazopyridine HCL Pyridium 200 mg Genitourinary Alpha-blockers Tamsulosin Flomax 0.4 mg Genitourinary Terazosin HCL Hytrin 1 mg Genitourinary Terazosin HCL Hytrin 10 mg Genitourinary Terazosin HCL Hytrin 2 mg Genitourinary Terazosin HCL Hytrin 5 mg GI Antidiarrhea Diphenoxylate-atropine Lomotil 2.5 mg GI Antidiarrhea Diphenoxylate-atropine (SCH V) Lomotil 2.5 /.025 / 5 (60 ml) GI Antiemetic Metoclopramide Reglan 10 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 13 of 23

14 GI Antiemetic Metoclopramide hcl Reglan 5 mg GI Antiemetic Prochlorperazine Compazine 10 mg GI Antiemetic Prochlorperazine Compazine 25 mg supp GI Antiemetic Prochlorperazine Compazine 5 mg GI Antiemetic Promethazine HCI Phenergan 12.5 mg GI Antiemetic Promethazine HCI Phenergan 12.5 mg supp GI Antiemetic Promethazine HCI Phenergan 25 mg GI Antiemetic Promethazine HCI Phenergan suppositor 25 mg supp GI Antiemetic Promethazine HCI Phenergan 50 mg GI Antiemetic Promethazine HCI Phenergan syrup 6.25 / 5 ml (120 ml) GI Antiinflammatory Hydrocortisone Suppositories Antiinflammatory Cortizone 25mg GI Mesalamine Asacol 400 mg GI bowel Antiinflammatory Sulfasalazine Azulfidine 500 mg GI bowel Antispasmodics Belladona alkaloids, phenobarbital Donnatal 16.2 mg GI Antispasmodics Dicyclomine Bentyl 10 mg GI Antispasmodics Dicyclomine Bentyl 20 mg GI H2 Antagonists Famotidine Pepcid 20 mg GI H2 Antagonists Famotidine Pepcid 40 mg GI H2 blockers Cimetidine Tagamet 400 mg GI H2 blockers Ranitidine Zantac 150 mg GI H2 blockers Ranitidine Zantac 300 mg GI Laxatives Lactulose Duphalac 10g/15 ml syrup GI PPI Omeprazole Prilosec 20 mg GI Prep Polyethylene glycol electrolyte solution Mix Golytely 240g GI Miralax polyethylene glycol 238g GI Miralax polyethylene glycol 510g GI Misoprostol Cytotec 100mg GI Misoprostol Cytotec 200mg GI Sucralfate Carafate 1 Gm Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 14 of 23

15 GI ursodiol Actigall 300mg Gout Allopurinol Zyloprim 100 mg Gout Allopurinol Zyloprim 300 mg Gout Colchicine Colcrys 0.6 mg Gout Probenecid Benemid 500 mg Helicobacter pylori agent bismuth subsalicylate-metronidazoletetracycline Helidac Hemorrheologic Agents Pentoxifylline ER Trental 400 mg Hormone Replacement Conjugated Estrogen Cream Premarin mg/g crm (43 Gm) Hormone Replacement Estradiol Estrace 0.5 mg Hormone Replacement Estradiol Estrace 1 mg Hormone Replacement Estradiol Estrace 2 mg Hormone Replacement Medroxyprogesterone Provera 10 mg Hormone Replacement Medroxyprogesterone Provera 2.5 mg Hormone Replacement Medroxyprogesterone Provera 5 mg Hormone Replacement Tamoxifen Soltamox 10mg Hormone Replacement Testosterone Inj Depo Testosterone 100 mg/ml Hormone Replacement Testosterone Inj Depo Testosterone 200mg/ml Hypoprolactinemic Bromocriptine Parlodel 2.5mg Immunosupressive Azathioprine Imuran 50mg muscle relaxant Carisoprodol Soma 250mg Neurologic Anticonvulsant Gabapentin Neurontin 100 mg Neurologic Anticonvulsant Gabapentin Neurontin 300 mg Neurologic Anticonvulsant Gabapentin Neurontin 400 mg Neurologic Anticonvulsant Gabapentin Neurontin 600 mg Neurologic Anticonvulsant Lamotrigine Lamictal 100 mg tab Neurologic Anticonvulsant Lamotrigine Lamictal 150 mg tab Neurologic Anticonvulsant Lamotrigine Lamictal 200 mg tab Neurologic Anticonvulsant Lamotrigine Lamictal 25 mg tab Neurologic Anticonvulsant Phenobarbital (SCH IV) 100 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 15 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 30 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 60 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 15 of 23

16 Neurologic Anticonvulsant Phenytoin Dilantin 100 mg Neurologic Anticonvulsant Phenytoin Dilantin 50 mg Neurologic Anticonvulsant Primidone Mysoline 250 mg Neurologic Anticonvulsant Primidone Mysoline 50 mg Neurologic Migraine Sumatriptan Imitrex 100 mg Neurologic Migraine Sumatriptan Imitrex 25 mg Neurologic Migraine Sumatriptan Imitrex 50 mg Neurologic Misc Meclizine Antivert 25mg tabs Neurologic Parkinson Amantadine Symmetrel 100 mg Neurologic Parkinson Amantadine Symmetrel 50 mg / 5 ml (120 ml) Neurologic Parkinson Benztropine mesylate Cogentin 0.5 mg Neurologic Parkinson Benztropine mesylate Cogentin 1 mg Neurologic Parkinson Benztropine mesylate Cogentin 1 mg/cc (inj) Neurologic Parkinson Benztropine mesylate Cogentin 2 mg Neurologic Parkinson Carbidopa - levodopa Sinemet mg Neurologic Parkinson Carbidopa - levodopa Sinemet mg Neurologic Parkinson Carbidopa - levodopa Sinemet mg Neurologic Parkinson Carbidopa - levodopa LA Sinemet CR mg Neurologic Parkinson Carbidopa - levodopa LA Sinemet CR mg Neurologic Parkinson Trihexyphenidyl Artane 2 mg Neurologic Parkinson Trihexyphenidyl Artane 2 mg / 5 cc Neurologic Parkinson Trihexyphenidyl Artane 5 mg Neurologic Levetiracetam Keppra 1000 mg Neurologic Levetiracetam Keppra 500 mg Neurologic Levetiracetam Keppra 750 mg Ophthalmic Glaucoma Brimonidine tartrate solution Alphagan 0.2% Ophthalmic Glaucoma Brimonidine tartrate solution Alphagan 0.2% Ophthalmic Glaucoma Brinzolamide Azopt 1% solution Ophthalmic Glaucoma Timolol Maleate eye drops 0.25% Ophthalmic Glaucoma Timolol Maleate eye drops 0.5% Ophthalmic Ciprofloxacin eye drop Ciloxan 0.3% Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 16 of 23

17 Ophthalmic Erythromycin eye ointment 5 mg / Gm (3.5 Gm) Ophthalmic Gentamicin eye drops Garamycin 0.3% (5 ml) Ophthalmic Ketotifen Alaway 0.025% Ophthalmic Latanoprost Xalatan 0.005% Ophthalmic Polymyxin b- trimethoprim Polytrim 10 ml drops Ophthalmic Polymyxin b- trimethoprim Polytrim 3.5 gm ointment Ophthalmic Prednisolone ophth solu or susp 1% Ophthalmic Sulfacetamide sodium eye drop sol Sulamyd 10% Ophthalmic Sulfacetamide sodium eye ointment Sulamyd 10% Ophthalmic Tobramycin ophthal soln. 0.30% Osteoporosis Alendronate Fosamax 35 mg Osteoporosis Alendronate Fosamax 70 mg Otic Acetic acid Vosol 15 ml drops Otic Acetic acid/hydrocortisone Vosol HC 2%-1% Otic Antipyrene, Benzodine, Glycerine dehyd Auralgan 10 ml drops Otic Cortisporin otic soln 1%-0.35%-10000u/mL (10 ml) Otic Cortisporin otic susp drops (10 ml) Phosphate binder Calcium acetate Phoslo 667mg Platelet aggregation inhibitor Clopidogrel Plavix 75 mg Platelet aggregation inhibitor Ticlopidine Ticlid 250mg Psychiatric Antidepressant Amitriptyline Elavil 10 mg Psychiatric Antidepressant Amitriptyline Elavil 100 mg Psychiatric Antidepressant Amitriptyline Elavil 25 mg Psychiatric Antidepressant Amitriptyline Elavil 50 mg Psychiatric Antidepressant Amitriptyline Elavil 75 mg Psychiatric Antidepressant Bupropion XL Wellbutrin XL 150 mg, 300 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 100 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 150 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 200 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 300 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 17 of 23

18 Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 75 mg Psychiatric Antidepressant Citalopram Hydrobromide Celexa 10 mg Psychiatric Antidepressant Citalopram Hydrobromide Celexa 10 mg / 5 cc Psychiatric Antidepressant Citalopram Hydrobromide Celexa 20 mg Psychiatric Antidepressant Citalopram Hydrobromide Celexa 40 mg Psychiatric Antidepressant Clomipramine Anafranil 25 mg Psychiatric Antidepressant Clomipramine Anafranil 50 mg Psychiatric Antidepressant Clomipramine Anafranil 75 mg Psychiatric Antidepressant Doxepin HCL Sinequan 10 mg Psychiatric Antidepressant Doxepin HCL Sinequan 100 mg Psychiatric Antidepressant Doxepin HCL Sinequan 150 mg Psychiatric Antidepressant Doxepin HCL Sinequan 25 mg Psychiatric Antidepressant Doxepin HCL Sinequan 50 mg Psychiatric Antidepressant Doxepin HCL Sinequan 75 mg Psychiatric Antidepressant Fluoxetine Prozac 10 mg Psychiatric Antidepressant Fluoxetine Prozac 20 mg Psychiatric Antidepressant Fluoxetine Prozac 20 mg / 5 ml Psychiatric Antidepressant Fluoxetine Prozac 40 mg Psychiatric Antidepressant Imipramine Tofranil 10 mg Psychiatric Antidepressant Imipramine Tofranil 25 mg Psychiatric Antidepressant Imipramine Tofranil 50 mg Psychiatric Antidepressant Mirtazapine Remeron 15 mg Psychiatric Antidepressant Mirtazapine Remeron 30 mg Psychiatric Antidepressant Mirtazapine Remeron 45 mg Psychiatric Antidepressant Nortriptyline Pamelor 10 mg Psychiatric Antidepressant Nortriptyline Pamelor 25 mg Psychiatric Antidepressant Nortriptyline Pamelor 50 mg Psychiatric Antidepressant Nortriptyline Pamelor 75 mg Psychiatric Antidepressant Paroxetine Paxil 10 mg Psychiatric Antidepressant Paroxetine Paxil 10 mg / 5 ml Psychiatric Antidepressant Paroxetine Paxil 20 mg Psychiatric Antidepressant Paroxetine Paxil 30 mg Psychiatric Antidepressant Paroxetine Paxil 40 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 18 of 23

19 Psychiatric Antidepressant Sertraline Zoloft 100 mg Psychiatric Antidepressant Sertraline Zoloft 20 mg/ml Psychiatric Antidepressant Sertraline Zoloft 25 mg Psychiatric Antidepressant Sertraline Zoloft 50 mg Psychiatric Antidepressant Trazodone Desyrel 100 mg Psychiatric Antidepressant Trazodone Desyrel 150 mg Psychiatric Antidepressant Trazodone Desyrel 50 mg Psychiatric Antidepressant Venlafaxine Effexor IR 25 mg Psychiatric Antidepressant Venlafaxine XR Effexor XR 100 mg Psychiatric Antidepressant Venlafaxine XR Effexor XR 37.5 mg Psychiatric Antidepressant Venlafaxine XR Effexor XR 75 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 10 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 100 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 100 mg/ml Psychiatric Antipsychotic Chlorpromazine Thorazine 200 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 25 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 30 mg/ml Psychiatric Antipsychotic Chlorpromazine Thorazine 50 mg Psychiatric Antipsychotic Fluphenazine Prolixin 0.5 mg/ml Psychiatric Antipsychotic Fluphenazine Prolixin 1 mg Psychiatric Antipsychotic Fluphenazine Prolixin 10 mg Psychiatric Antipsychotic Fluphenazine Prolixin 2.5 mg Psychiatric Antipsychotic Fluphenazine Prolixin 5 mg / cc Psychiatric Antipsychotic Fluphenazine decanoate Prolixin 25 mg/cc (inj) Psychiatric Antipsychotic Haloperidol Haldol 0.5 mg Psychiatric Antipsychotic Haloperidol Haldol 1 mg Psychiatric Antipsychotic Haloperidol Haldol 10 mg Psychiatric Antipsychotic Haloperidol Haldol 2 mg Psychiatric Antipsychotic Haloperidol Haldol 2 mg / cc (120 cc) Psychiatric Antipsychotic Haloperidol Haldol 2 mg / cc (15 cc) Psychiatric Antipsychotic Haloperidol Haldol 20 mg Psychiatric Antipsychotic Haloperidol Haldol 5 mg Psychiatric Antipsychotic Haloperidol decanoate Haldol 100 mg/cc (inj) Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 19 of 23

20 Psychiatric Antipsychotic Haloperidol decanoate Haldol 50 mg/cc (inj) Psychiatric Antipsychotic Loxapin Loxitane 5, 10, 25, 50 mg Psychiatric Antipsychotic Olanzapine Zyprexa 2.5mg Psychiatric Antipsychotic Olanzapine Zyprexa 5 mg Psychiatric Antipsychotic Perphenazine Trilafon 16 mg Psychiatric Antipsychotic Perphenazine Trilafon 16 mg / 5 cc (120 ml) Psychiatric Antipsychotic Perphenazine Trilafon 2 mg Psychiatric Antipsychotic Perphenazine Trilafon 4 mg Psychiatric Antipsychotic Perphenazine Trilafon 8 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 100 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 200 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 25 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 300 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 400 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 50 mg Psychiatric Antipsychotic Risperidone Risperdal 0.5 mg Psychiatric Antipsychotic Risperidone Risperdal 1 mg Psychiatric Antipsychotic Risperidone Risperdal 1 mg/ml solution Psychiatric Antipsychotic Risperidone Risperdal 2 mg Psychiatric Antipsychotic Risperidone Risperdal 3 mg Psychiatric Antipsychotic Risperidone Risperdal 4 mg Psychiatric Antipsychotic Thiothixene Navane 1 mg Psychiatric Antipsychotic Thiothixene Navane 10 mg Psychiatric Antipsychotic Thiothixene Navane 2 mg Psychiatric Antipsychotic Thiothixene Navane 20 mg Psychiatric Antipsychotic Thiothixene Navane 5 mg Psychiatric Antipsychotic Thiothixene Navane 5 mg/ml Psychiatric Antipsychotic Trifluoperazine Stelazine 10 mg Psychiatric Antipsychotic Trifluoperazine Stelazine 2 mg Psychiatric Antipsychotic Trifluoperazine Stelazine 5 mg Psychiatric Benzos Clonazepam (SCH IV) Klonopin 0.5 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 20 of 23

21 Psychiatric Benzos Clonazepam (SCH IV) Klonopin 1 mg Psychiatric Benzos Clonazepam (SCH IV) Klonopin 2 mg Psychiatric Benzos Diazepam (SCH IV) Valium 10 mg Psychiatric Benzos Diazepam (SCH IV) Valium 2 mg Psychiatric Benzos Diazepam (SCH IV) Valium 5 mg Psychiatric Benzos Lorazepam (SCH IV) Ativan 0.5 mg Psychiatric Benzos Lorazepam (SCH IV) Ativan 1.0 mg Psychiatric Benzos Lorazepam (SCH IV) Ativan 2.0 mg Psychiatric Hypnotic Temazepam (SCH IV) Restoril 15 mg Psychiatric Hypnotic Temazepam (SCH IV) Restoril 30 mg Psychiatric Hypnotic Zolpidem Ambien 10 mg tabs Psychiatric Hypnotic Zolpidem Ambien 5 mg tabs Psychiatric Mood Stabilizer Carbamazepine Tegretol 100 mg Psychiatric Mood Stabilizer Carbamazepine Tegretol 100 mg / 5 cc Psychiatric Mood Stabilizer Carbamazepine Tegretol 200 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote DR 125 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote DR 250 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote ER 250 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote DR 500 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote ER 500 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith CR 150 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith CR 300 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith SR 300 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith SR 450 mg Psychiatric Other Buspirone HCI BuSpar 10 mg Psychiatric Other Buspirone HCI BuSpar 15 mg Psychiatric Other Buspirone HCI BuSpar 30 mg Psychiatric Other Buspirone HCI BuSpar 5 mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 10 mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 15mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 20 mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 30 mg Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 10 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 21 of 23

22 Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 20 mg Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 30 mg Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 40 mg Psychiatric Stimulant Methylphenidate short acting Ritalin 10 mg Psychiatric Stimulant Methylphenidate short acting Ritalin 20 mg Psychiatric Stimulant Methylphenidate short acting Ritalin 30 mg Respiratory Asthma Ipratropium MDI Atrovent 18mcg/dose MDI (14gm) Respiratory Asthma Salmeterol xinafoate Serevent Diskus 50 mcg Respiratory Inhaler Albuterol HFA (IDP) tablet, MDI, Proventil HFA solution, UD (IDP) 90 mcg Respiratory Nasal Inhaler Fluticasone propionate Flonase 50 mcg/spray Respiratory Nebulizer soln Albuterol solution neb Proventil 5 mg/ml (20 ml bottle) Respiratory Nebulizer soln Ipratropium bromide 0.02% Atrovent Inh Sol 500 mcg (3 cc/amp) Respiratory Steroid inhaler Beclomethasone dipropinate Qvar 40 mcg Respiratory Steroid inhaler Beclomethasone dipropinate Qvar 80 mcg Respiratory Albuterol liquid Ventolin, Proventil 2 mg / 5 cc (120 ml) Respiratory Albuterol Unit Dose Proventil 0.83 mg/ml Respiratory Albuterol-ipratropium Inhaler Combivent MDI Respiratory Cromolyn inhaler Intal 14.2 Gm Respiratory Montelukast Singulair 10 mg Respiratory Montelukast Singulair 5 mg chew Respiratory Theophylline Theo-Dur 200 mg Respiratory Theophylline Theo-Dur 300 mg Rheumatology Hydroxychloroquine Plaquenil 200 mg Smoking deterrents Nicotine Patches- 28 weeks NicoDerm 14mg Smoking deterrents Nicotine Patches- 28 weeks NicoDerm 21mg Smoking deterrents Nicotine Patches- 28 weeks NicoDerm 7 mg Toxicology Agents Opiate Antagonists Naloxone Narcan 0.4 mg/ ml Toxicology Agents Opiate Antagonists Naloxone Narcan 1 mg/ ml Vitamin Calcitriol Rocaltrol 0.25 mcg Vitamin Calcitriol Rocaltrol 0.5 mcg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 22 of 23

23 Vitamin Folic Acid 800 MicroGrams Vitamin Pyridoxine Vitamin B6 100 mg Vitamin Pyridoxine Vitamin B5 25 mg Vitamin Vitamin B6 50 mg Vitamin Vitamin D Calciferol 50,000 units Vitamin Vitamin K Phytonadione 5 mg tab Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 23 of 23