HealthPAC Formulary - By Brand Name
HealthPAC Formulary - By Brand Name
HealthPAC Formulary - By Brand Name
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<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Aclovate Alclometasone Cream 45gm Anti-inflammatory Agents<br />
Aclovate Alclometasone Ointment 45gm Anti-inflammatory Agents<br />
Actigall Ursodiol 300mg GI<br />
Actos Pioglitazone hydrochloride 15 mg Diabetes<br />
Thiazolidinedion<br />
es<br />
Actos Pioglitazone hydrochloride 30 mg Diabetes<br />
Thiazolidinedion<br />
es<br />
Actos Pioglitazone hydrochloride 45 mg Diabetes<br />
Thiazolidinedion<br />
es<br />
Adderall XR Dextroamphetamine/amphetamine 10mg Psychiatric Stimulant<br />
Adderall XR Dextroamphetamine/amphetamine 15mg Psychiatric Stimulant<br />
Adderall XR Dextroamphetamine/amphetamine 20mg Psychiatric Stimulant<br />
Adderall XR Dextroamphetamine/amphetamine 30mg Psychiatric Stimulant<br />
Alaway Ketotifen 0.025% Ophthalmic<br />
Aldactone Spironolactone 25 mg Cardiovascular Diuretics<br />
Aldactone Spironolactone 50 mg Cardiovascular Diuretics<br />
Aldactone Spironolatone 100 mg Cardiovascular Diuretics<br />
Aldomet Methyldopa 250 mg Cardiovascular<br />
Central Alpha<br />
Agonist<br />
Aldomet Methyldopa 500 mg Cardiovascular<br />
Central Alpha<br />
Agonist<br />
Alphagan Brimonidine tartrate solution 0.2% Ophthalmic Glaucoma<br />
Alphagan Brimonidine tartrate solution 0.2% Ophthalmic Glaucoma<br />
Ambien Zolpidem 5, 10 mg tabs Psychiatric Hypnotic<br />
Amoxil Amoxicillin 125 mg / 5 cc (80 cc) Antimicrobials Penicillins<br />
Amoxil Amoxicillin 250 mg Antimicrobials Penicillins<br />
Amoxil Amoxicillin 250 mg / 5 cc (150 cc) Antimicrobials Penicillins<br />
Amoxil Amoxicillin 400 mg/ 5 cc Antimicrobials Penicillins<br />
Amoxil Amoxicillin 500 mg Antimicrobials Penicillins<br />
Anafranil Clomipramine 25 mg Psychiatric Antidepressant<br />
Anafranil Clomipramine 50 mg Psychiatric Antidepressant<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 1 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Anafranil Clomipramine 75 mg Psychiatric Antidepressant<br />
Antivert Meclizine 25mg tabs Neurologic Misc<br />
Apresoline Hydralazine 10 mg Cardiovascular<br />
Other<br />
Vasodilators<br />
Apresoline Hydralazine 100 mg Cardiovascular<br />
Other<br />
Vasodilators<br />
Apresoline Hydralazine 25 mg Cardiovascular<br />
Other<br />
Vasodilators<br />
Apresoline Hydralazine 50 mg Cardiovascular<br />
Other<br />
Vasodilators<br />
Artane Trihexyphenidyl 2 mg Neurologic Parkinson<br />
Artane Trihexyphenidyl 2 mg / 5 cc Neurologic Parkinson<br />
Artane Trihexyphenidyl 5 mg Neurologic Parkinson<br />
Anti-<br />
Asacol Mesalamine 400 mg GI<br />
inflammatory<br />
bowel<br />
Atarax Hydroxyzine HCL 10 mg Cold, Cough, Allergy Antihistamine<br />
Atarax Hydroxyzine HCL 10 mg / 5 cc (120 ml) Cold, Cough, Allergy Antihistamine<br />
Atarax Hydroxyzine HCL 25 mg Cold, Cough, Allergy Antihistamine<br />
Atarax Hydroxyzine HCL 50 mg Cold, Cough, Allergy Antihistamine<br />
Ativan Lorazepam (SCH IV) 0.5 mg Psychiatric Benzos<br />
Ativan Lorazepam (SCH IV) 1.0 mg Psychiatric Benzos<br />
Ativan Lorazepam (SCH IV) 2.0 mg Psychiatric Benzos<br />
Atrovent Ipratropium MDI 18mcg/dose MDI (14gm) Respiratory Asthma<br />
Atrovent Inh Sol Ipratropium bromide 0.02% 500 mcg (3 cc/amp) Respiratory Nebulizer soln<br />
Augmentin Amoxicillin-clavulanate 200 mg / 5 cc (100 ml) Antimicrobials Penicillins<br />
Augmentin Amoxicillin-clavulanate 500 mg-125 mg Antimicrobials Penicillins<br />
Augmentin Amoxicillin-clavulanate 875 mg Antimicrobials Penicillins<br />
Auralgan<br />
Antipyrene, Benzodine, Glycerine<br />
dehyd<br />
10 ml drops Otic<br />
Azopt Brinzolamide 1% solution Ophthalmic Glaucoma<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 2 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Azulfidine Sulfasalazine 500 mg GI<br />
Bactrim Sulfamethxzl Trimethoprim 40mg / 5ml - 200mg / 5-ml (60 ml) Antimicrobials Sulfas<br />
Antiinflammatory<br />
bowel<br />
Bactroban Mupirocin 2%ointment Antibiotic<br />
Benadryl Diphenhydramine 12.5 mg/ 5ml Cold, Cough, Allergy Antihistamine<br />
Benadryl Diphenhydramine 25, 50 mg capsules Cold, Cough, Allergy Antihistamine<br />
Benadryl Diphenhydramine 50 mg/cc (inj) Cold, Cough, Allergy Antihistamine<br />
Benemid Probenecid 500 mg Gout<br />
Bentyl Dicyclomine 10 mg GI Antispasmodics<br />
Bentyl Dicyclomine 20 mg GI Antispasmodics<br />
Biaxin Clarithromycin 500 mg Antimicrobials<br />
Biltricide Praziquantel 600mg Anthelmintics<br />
BuSpar Buspirone HCI 10 mg Psychiatric Other<br />
BuSpar Buspirone HCI 15 mg Psychiatric Other<br />
BuSpar Buspirone HCI 30 mg Psychiatric Other<br />
BuSpar Buspirone HCI 5 mg Psychiatric Other<br />
Calan SR Verapamil SR 120 mg Cardiovascular<br />
Calan SR Verapamil SR 180 mg Cardiovascular<br />
Calan SR Verapamil SR 240 mg Cardiovascular<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calciferol Vitamin D 50,000 units Vitamin<br />
Capoten Captopril 100 mg Cardiovascular ACE Inhibitor<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 3 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Capoten Captopril 12.5 mg Cardiovascular ACE Inhibitor<br />
Capoten Captopril 25 mg Cardiovascular ACE Inhibitor<br />
Capoten Captopril 50 mg Cardiovascular ACE Inhibitor<br />
Carafate Sucralfate 1 Gm GI<br />
Cardizem Diltiazem 120 mg Cardiovascular<br />
Cardizem CD Diltiazem CD 120 mg Cardiovascular<br />
Cardizem CD Diltiazem CD 180 mg Cardiovascular<br />
Cardizem CD Diltiazem CD 240 mg Cardiovascular<br />
Cardizem CD Diltiazem CD 30 mg Cardiovascular<br />
Cardizem CD Diltiazem CD 300 mg Cardiovascular<br />
Cardizem CD Diltiazem CD 360mg Cardiovascular<br />
Cardizem CD Diltiazem CD 60 mg Cardiovascular<br />
Cardizem CD Diltiazem CD 90 mg Cardiovascular<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 4 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Cardizem CD,<br />
Dilacor Xr, Cartia<br />
XL, Dilt-CD<br />
Cardizem CD,<br />
Dilacor Xr, Cartia<br />
XL, Dilt-CD<br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Diltiazem 60 mg Cardiovascular<br />
Diltiazem 90 mg Cardiovascular<br />
Cardizem LA Dilitiazem HCI 180 mg Cardiovascular<br />
Cardizem SR Diltiazem SR 120 mg Cardiovascular<br />
Cardizem SR Diltiazem SR 180 mg Cardiovascular<br />
Cardizem SR Diltiazem SR 240 mg Cardiovascular<br />
Cardizem SR Diltiazem SR 300 mg Cardiovascular<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Cardura Doxazosin mesylate 1 mg Cardiovascular Alpha-1 blocker<br />
Cardura Doxazosin mesylate 2 mg Cardiovascular Alpha-1 blocker<br />
Cardura Doxazosin mesylate 4 mg Cardiovascular Alpha-1 blocker<br />
Cardura Doxazosin mesylate 8 mg Cardiovascular Alpha-1 blocker<br />
Catapres Clonidine HCI tabs 0.1 mg Cardiovascular<br />
Central Alpha<br />
Agonist<br />
Catapres Clonidine HCI tabs 0.2 mg Cardiovascular<br />
Central Alpha<br />
Agonist<br />
Catapres Clonidine HCI tabs 0.3 mg Cardiovascular<br />
Central Alpha<br />
Agonist<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 5 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Celexa Citalopram Hydrobromide 10 mg Psychiatric Antidepressant<br />
Celexa Citalopram Hydrobromide 10 mg / 5 cc Psychiatric Antidepressant<br />
Celexa Citalopram Hydrobromide 20 mg Psychiatric Antidepressant<br />
Celexa Citalopram Hydrobromide 40 mg Psychiatric Antidepressant<br />
Ciloxan Ciprofloxacin eye drop 0.3% Ophthalmic<br />
Cipro Ciprofloxacin 250 mg Antimicrobials Quinolones<br />
Cipro Ciprofloxacin 500 mg Antimicrobials Quinolones<br />
Claritin Loratidine 10mg Antihistamine<br />
Cleocin Clindamycin 150 mg Antimicrobials Misc<br />
Cleocin Clindamycin 300 mg Antimicrobials Misc<br />
Cleocin Clindamycin topical gel, lotion 1% Derm Acne<br />
Cleocin-T Clindamycin topical solution 1% (60 ml) Derm Acne<br />
Clinoril Sulindac 150 mg Analgesic NSAID<br />
Clinoril Sulindac 200 mg Analgesic NSAID<br />
Cogentin Benztropine mesylate 0.5 mg Neurologic Parkinson<br />
Cogentin Benztropine mesylate 1 mg Neurologic Parkinson<br />
Cogentin Benztropine mesylate 1 mg/cc (inj) Neurologic Parkinson<br />
Cogentin Benztropine mesylate 2 mg Neurologic Parkinson<br />
Colcrys Colchicine 0.6 mg Gout<br />
Combivent MDI Albuterol-ipratropium Inhaler Respiratory<br />
Compazine Prochlorperazine 10 mg GI Antiemetic<br />
Compazine Prochlorperazine 25 mg supp GI Antiemetic<br />
Compazine Prochlorperazine 5 mg GI Antiemetic<br />
Cordarone Amiodarone 200 mg Cardiovascular Antiarrythmic<br />
Cordarone Amiodarone 400 mg Cardiovascular Antiarrythmic<br />
Coreg Carvedilol 12.5 mg Cardiovascular Beta Blockers<br />
Coreg Carvedilol 25 mg Cardiovascular Beta Blockers<br />
Coreg Carvedilol 3.125 mg Cardiovascular Beta Blockers<br />
Coreg Carvedilol 6.25 mg Cardiovascular Beta Blockers<br />
Cortizone Hydrocortisone cream 2.5% Derm Antiinflammatory<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 6 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Cortizone Hydrocortisone ointment 2.50% Derm Antiinflammatory<br />
Cortizone Hydrocortisone Suppositories 25mg GI Antiinflammatory<br />
Coumadin Warfarin sodium 1 mg Cardiovascular Anticoagulants<br />
Coumadin Warfarin sodium 10 mg Cardiovascular Anticoagulants<br />
Coumadin Warfarin sodium 2 mg Cardiovascular Anticoagulants<br />
Coumadin Warfarin sodium 2.5 mg Cardiovascular Anticoagulants<br />
Coumadin Warfarin sodium 3 mg Cardiovascular Anticoagulants<br />
Coumadin Warfarin sodium 4 mg Cardiovascular Anticoagulants<br />
Coumadin Warfarin sodium 5 mg Cardiovascular Anticoagulants<br />
Coumadin Warfarin sodium 6 mg Cardiovascular Anticoagulants<br />
Coumadin Warfarin sodium 7.5 mg Cardiovascular Anticoagulants<br />
Cozaar Losartan 100 mg Cardiovascular<br />
Angiotensin II<br />
Blocker<br />
Cozaar Losartan 25 mg Cardiovascular<br />
Angiotensin II<br />
Blocker<br />
Cozaar Losartan 50mg Cardiovascular<br />
Angiotensin II<br />
Blocker<br />
Cytotec Misoprostol 100mg GI<br />
Cytotec Misoprostol 200mg GI<br />
Deltasone Prednisone 1 mg Endocrine Glucocorticoids<br />
Deltasone Prednisone 10 mg Endocrine Glucocorticoids<br />
Deltasone Prednisone 2.5 mg Endocrine Glucocorticoids<br />
Deltasone Prednisone 20 mg Endocrine Glucocorticoids<br />
Deltasone Prednisone 5 mg Endocrine Glucocorticoids<br />
Deltasone Prednisone 50 mg Endocrine Glucocorticoids<br />
Depakote DR Divalproex sodium 125 mg Psychiatric Mood Stabilizer<br />
Depakote DR Divalproex sodium 250 mg Psychiatric Mood Stabilizer<br />
Depakote DR Divalproex sodium 500 mg Psychiatric Mood Stabilizer<br />
Depakote ER Divalproex sodium 250 mg Psychiatric Mood Stabilizer<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 7 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Depakote ER Divalproex sodium 500 mg Psychiatric Mood Stabilizer<br />
Depo Testosterone Testosterone Inj 100 mg/ml Hormone Replacement<br />
Depo Testosterone Testosterone Inj 200mg/ml Hormone Replacement<br />
Desyrel Trazodone 100 mg Psychiatric Antidepressant<br />
Desyrel Trazodone 150 mg Psychiatric Antidepressant<br />
Desyrel Trazodone 50 mg Psychiatric Antidepressant<br />
Diflucan Fluconazole 100 mg Antimicrobials Antifungals<br />
Diflucan Fluconazole 150 mg Antimicrobials Antifungals<br />
Diflucan Fluconazole 200 mg Antimicrobials Antifungals<br />
Dilantin Phenytoin 100 mg Neurologic Anticonvulsant<br />
Dilantin Phenytoin 50 mg Neurologic Anticonvulsant<br />
Ditropan Oxybutynin 5 mg Genitourinary<br />
Donnatal Belladona alkaloids, phenobarbital 16.2 mg GI Antispasmodics<br />
Doryx Vibramycin Doxycycline 100 mg Antimicrobials Tetracyclines<br />
Doryx Vibramycin Doxycycline 50 mg Antimicrobials Tetracyclines<br />
Duphalac Lactulose 10g/15 ml syrup GI Laxatives<br />
Dynapen Dicloxacillin 250 mg Antimicrobials Penicillins<br />
Dynapen Dicloxacillin 500 mg Antimicrobials Penicillins<br />
Effexor IR Venlafaxine 25 mg Psychiatric Antidepressant<br />
Effexor XR Venlafaxine XR 100 mg Psychiatric Antidepressant<br />
Effexor XR Venlafaxine XR 37.5 mg Psychiatric Antidepressant<br />
Effexor XR Venlafaxine XR 75 mg Psychiatric Antidepressant<br />
Elavil Amitriptyline 10 mg Psychiatric Antidepressant<br />
Elavil Amitriptyline 100 mg Psychiatric Antidepressant<br />
Elavil Amitriptyline 25 mg Psychiatric Antidepressant<br />
Elavil Amitriptyline 50 mg Psychiatric Antidepressant<br />
Elavil Amitriptyline 75 mg Psychiatric Antidepressant<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 8 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Elimite Permethrin cream 5% (60 Gm) Derm<br />
Scabicide and<br />
Lice<br />
Erygel Erythromycin gel or solution 2% Derm Acne<br />
Ery-Tab Erythromycin stearate 250 mg Antimicrobials Macrolides<br />
Ery-Tab Erythromycin stearate 333 mg Antimicrobials Macrolides<br />
Ery-Tab Erythromycin stearate 500 mg Antimicrobials Macrolides<br />
Esidrix Hydrochlorothiazide 25 mg Cardiovascular Diuretics<br />
Esidrix Hydrochlorothiazide 50 mg Cardiovascular Diuretics<br />
Eskalith CR Lithium carbonate 150 mg Psychiatric Mood Stabilizer<br />
Eskalith CR Lithium carbonate 300 mg Psychiatric Mood Stabilizer<br />
Eskalith SR Lithium carbonate 300 mg Psychiatric Mood Stabilizer<br />
Eskalith SR Lithium carbonate 450 mg Psychiatric Mood Stabilizer<br />
Estrace Estradiol 0.5 mg Hormone Replacement<br />
Estrace Estradiol 1 mg Hormone Replacement<br />
Estrace Estradiol 2 mg Hormone Replacement<br />
Fioricet Butalbital-APAP-Caffeine 50/325/40 Analgesic Misc<br />
Flagyl Metronidazole 250 mg Antimicrobials Misc<br />
Flagyl Metronidazole 500 mg Antimicrobials Misc<br />
Flexeril Cyclobenzaprine 10 mg Analgesic Muscle Relaxant<br />
Flint SSD,<br />
Silvadene<br />
Silver sulfadiazine 1% crm Derm Other<br />
Flomax Tamsulosin 0.4mg Genitourinary Alpha-blocker<br />
Flonase Fluticasone propionate 50 mcg/spray Respiratory Nasal Inhaler<br />
Florinef Fludrocortisone 0.1 mg Endocrine<br />
Florinef Fludrocortisone 0.2 mg Adrenals<br />
Fosamax Alendronate 35 mg Osteoporosis<br />
Fosamax Alendronate 70 mg Osteoporosis<br />
Garamycin Gentamicin eye drops 0.3% (5 ml) Ophthalmic<br />
Glucophage Metformin 1000 mg Diabetes Biquanides<br />
Glucophage Metformin 500 mg Diabetes Biquanides<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 9 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Glucophage Metformin 850 mg Diabetes Biquanides<br />
Glucotrol Glipizide 10 mg Diabetes Sulfonylureas<br />
Glucotrol Glipizide 5 mg Diabetes Sulfonylureas<br />
Grifulvin V Griseofulvin micro liquid 125 mg / 5 mL (120 ml) Antimicrobials Antifungals<br />
Grisactin Fulvicin Griseofulvin ultramicro 125 mg Antimicrobials Antifungals<br />
Grisactin Fulvicin Griseofulvin ultramicro 250 mg Antimicrobials Antifungals<br />
Haldol Haloperidol 0.5 mg Psychiatric Antipsychotic<br />
Haldol Haloperidol 1 mg Psychiatric Antipsychotic<br />
Haldol Haloperidol 10 mg Psychiatric Antipsychotic<br />
Haldol Haloperidol 2 mg Psychiatric Antipsychotic<br />
Haldol Haloperidol 2 mg / cc (120 cc) Psychiatric Antipsychotic<br />
Haldol Haloperidol 2 mg / cc (15 cc) Psychiatric Antipsychotic<br />
Haldol Haloperidol 20 mg Psychiatric Antipsychotic<br />
Haldol Haloperidol 5 mg Psychiatric Antipsychotic<br />
Haldol Haloperidol decanoate 100 mg/cc (inj) Psychiatric Antipsychotic<br />
Haldol Haloperidol decanoate 50 mg/cc (inj) Psychiatric Antipsychotic<br />
HC Hydrocortisone 10mg Derm Antiinflammatory<br />
HC Hydrocortisone 2.5% lotion Derm Antiinflammatory<br />
HC Hydrocortisone 20mg Derm Antiinflammatory<br />
HC Hydrocortisone 5mg Derm Antiinflammatory<br />
Helidac<br />
bismuth subsalicylate-metronidazoletetracycline<br />
Helicobacter pylori agent<br />
Humalog Insulin Lispro 100U/mL Diabetes Insulin Product<br />
Humulin N Insulin NPH U100 (10 ml) Diabetes Insulin Product<br />
Humulin R Insulin Regular U100 (10 ml) Diabetes Insulin Product<br />
Humulin, Novolin Insulin 70/30 U100 (10 ml) Diabetes Insulin Product<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 10 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Hytrin Terazosin HCL 1 mg Genitourinary<br />
Hytrin Terazosin HCL 10 mg Genitourinary<br />
Hytrin Terazosin HCL 2 mg Genitourinary<br />
Hytrin Terazosin HCL 5 mg Genitourinary<br />
Imdur Isosorbide mononitrate IR, SR 10 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Imdur Isosorbide mononitrate IR, SR 120 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Imdur Isosorbide mononitrate IR, SR 20 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Imdur Isosorbide mononitrate IR, SR 30 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Imdur Isosorbide mononitrate IR, SR 60 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Imitrex Sumatriptan 100 mg Neurologic Migraine<br />
Imitrex Sumatriptan 25 mg Neurologic Migraine<br />
Imitrex Sumatriptan 50 mg Neurologic Migraine<br />
Imuran Azathioprine 50mg Immunosupressive<br />
Inderal Propranolol HCL 10 mg Cardiovascular Beta Blockers<br />
Inderal Propranolol HCL 20 mg Cardiovascular Beta Blockers<br />
Inderal Propranolol HCL 40 mg Cardiovascular Beta Blockers<br />
Inderal Propranolol HCL 60 mg Cardiovascular Beta Blockers<br />
Inderal Propranolol HCL 80 mg Cardiovascular Beta Blockers<br />
Indocin Indomethacin 25 mg Analgesic NSAID<br />
Indocin Indomethacin 50 mg Analgesic NSAID<br />
INH Isoniazid 10 mg / ml Antimicrobials Antitubercular<br />
INH Isoniazid 100 mg Antimicrobials Antitubercular<br />
INH Isoniazid 300 mg Antimicrobials Antitubercular<br />
Intal Cromolyn inhaler 14.2 Gm Respiratory<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 11 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Isoptin Verapamil 120 mg Cardiovascular<br />
Isoptin Verapamil LA 180 mg Cardiovascular<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Isordil Isosorbide dinitrate 10 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Isordil Isosorbide dinitrate 20 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Isordil Isosorbide dinitrate 30 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Isordil Isosorbide dinitrate 5 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Keflex Cephalexin 125 mg / 5 ml (200 ml) Antimicrobials Cephalosporins<br />
Keflex Cephalexin 250 mg Antimicrobials Cephalosporins<br />
Keflex Cephalexin 250 mg / 5 ml (100 ml) Antimicrobials Cephalosporins<br />
Keflex Cephalexin 500 mg Antimicrobials Cephalosporins<br />
Triamcinolone cream, ointment, or<br />
Kenalog, Aristocort<br />
lotion<br />
0.025% Derm Antiinflammatory<br />
Triamcinolone cream, ointment, or<br />
Kenalog, Aristocort<br />
lotion<br />
0.10% Derm Antiinflammatory<br />
Keppra Levetiracetam 1000 mg Neurologic<br />
Keppra Levetiracetam 500 mg Neurologic<br />
Keppra Levetiracetam 750 mg Neurologic<br />
Klonopin Clonazepam (SCH IV) 0.5 mg Psychiatric Benzos<br />
Klonopin Clonazepam (SCH IV) 1 mg Psychiatric Benzos<br />
Klonopin Clonazepam (SCH IV) 2 mg Psychiatric Benzos<br />
K-Tab, K-Dur,<br />
Slow-K, Klor-con<br />
Potassium chloride tabs 10 mEq Cardiovascular<br />
Potassium<br />
Supplement<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 12 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
K-Tab, K-Dur,<br />
Slow-K, Klor-con<br />
Potassium chloride tabs 20 mEq Cardiovascular<br />
Potassium<br />
Supplement<br />
K-Tab, K-Dur,<br />
Slow-K, Klor-con<br />
Potassium chloride tabs 8 mEq Cardiovascular<br />
Potassium<br />
Supplement<br />
Lamictal Lamotrigine 100 mg tab Neurologic Anticonvulsant<br />
Lamictal Lamotrigine 150 mg tab Neurologic Anticonvulsant<br />
Lamictal Lamotrigine 200 mg tab Neurologic Anticonvulsant<br />
Lamictal Lamotrigine 25 mg tab Neurologic Anticonvulsant<br />
Lanoxin Digoxin 0.125 mg Cardiovascular Glycosides<br />
Lanoxin Digoxin 0.25 mg Cardiovascular Glycosides<br />
Lantus Insulin glargine 100 IU/mL Diabetes Insulin Product<br />
Lasix Furosemide 20 mg Cardiovascular Diuretics<br />
Lasix Furosemide 40 mg Cardiovascular Diuretics<br />
Lasix Furosemide 80 mg Cardiovascular Diuretics<br />
Levaquin Levofloxacin 500 mg Antimicrobials<br />
Levoxyl Levothyroxine 0.025 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.050 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.075 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.088 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.1 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.112 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.125 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.137 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.15 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.175 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.2 mg Endocrine Thyroid<br />
Levoxyl Levothyroxine 0.3 mg Endocrine Thyroid<br />
Lidex Fluocinonide 0.05% solution 60ml Derm Antiinflammatory<br />
Lidex Fluocinonide 0.05% gel (60gm) Derm Antiinflammatory<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 13 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Lidex Fluocinonide 0.05% cream (30 gm) Derm Antiinflammatory<br />
Lidex Fluocinonide 0.05% cream (60 gm) Derm Antiinflammatory<br />
Lidex Fluocinonide 0.05% oint (15 gm) Derm Antiinflammatory<br />
Lidex Fluocinonide 0.05% oint (30 gm) Derm Antiinflammatory<br />
Lidex Fluocinonide 0.05% oint (60 gm) Derm Antiinflammatory<br />
Lioresal Baclofen 10 mg Analgesic Muscle Relaxant<br />
Lioresal Baclofen 20 mg Analgesic Muscle Relaxant<br />
Lomotil Diphenoxylate-atropine 2.5 mg GI Antidiarrhea<br />
Lomotil Diphenoxylate-atropine (SCH V) 2.5 / .025 / 5 (60 ml) GI Antidiarrhea<br />
Lopid Gemfibrozil 600 mg Cardiovascular<br />
Cholesterol<br />
Lowering Agents<br />
Lopressor Metoprolol tartrate 100 mg Cardiovascular Beta Blockers<br />
Lopressor Metoprolol tartrate 25 mg Cardiovascular Beta Blockers<br />
Lopressor Metoprolol tartrate 50 mg Cardiovascular Beta Blockers<br />
Loxitane Loxapin 5, 10, 25, 50 mg Psychiatric Antipsychotic<br />
Macrobid Nitrofurantoin monohydrate 100 mg Antimicrobials Misc<br />
Macrodantin Nitrofurantoin macrocryst 100 mg Antimicrobials Misc<br />
Macrodantin Nitrofurantoin macrocryst 50 mg Antimicrobials Misc<br />
Maxzide Triamterene hctz 37.5/25 mg Cardiovascular Diuretics<br />
Maxzide Triamterene hctz 75 / 50 mg Cardiovascular Diuretics<br />
Metrocream Metronidazole cream 0.075% Antimicrobials Misc<br />
Metrocream Metronidazole cream 0.75% Derm Acne<br />
Metrogel Metronidazole topical gel 0.75% Derm Acne<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 14 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Mevacor Lovastatin 10, 20, 40 mg Cardiovascular<br />
Cholesterol<br />
Lowering Agents<br />
Micronase Diabeta Glyburide 1.25 mg Diabetes Sulfonylureas<br />
Micronase Diabeta Glyburide 2.5 mg Diabetes Sulfonylureas<br />
Micronase Diabeta Glyburide 5 mg Diabetes Sulfonylureas<br />
Microzide Hydrochlorothiazide 12.5 mg cap Cardiovascular Diuretics<br />
Mix Golytely<br />
Polyethylene glycol electrolyte<br />
solution<br />
240g GI Prep<br />
Motrin Ibuprofen 400 mg Analgesic NSAID<br />
Motrin Ibuprofen 600 mg Analgesic NSAID<br />
Motrin Ibuprofen 800 mg Analgesic NSAID<br />
MS Morphine sulfate Liquid 20mg/ 5 ml Analgesic Narcotic<br />
MS Morphine sulfate short acting 15,30mg Analgesic Narcotic<br />
Myambutol Ethambutol 100 mg Antimicrobials Antitubercular<br />
Myambutol Ethambutol 400 mg Antimicrobials Antitubercular<br />
Mysoline Primidone 250 mg Neurologic Anticonvulsant<br />
Mysoline Primidone 50 mg Neurologic Anticonvulsant<br />
Naprosyn Naproxen 250 mg Analgesic NSAID<br />
Naprosyn Naproxen 375 mg Analgesic NSAID<br />
Naprosyn Naproxen 500 mg Analgesic NSAID<br />
Nasarel Flunisolide 25 mcg/spray (0.025%) Cold, Cough, Allergy Nasal Steroids<br />
Navane Thiothixene 1 mg Psychiatric Antipsychotic<br />
Navane Thiothixene 10 mg Psychiatric Antipsychotic<br />
Navane Thiothixene 2 mg Psychiatric Antipsychotic<br />
Navane Thiothixene 20 mg Psychiatric Antipsychotic<br />
Navane Thiothixene 5 mg Psychiatric Antipsychotic<br />
Navane Thiothixene 5 mg/ml Psychiatric Antipsychotic<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 15 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Neurontin Gabapentin 100 mg Neurologic Anticonvulsant<br />
Neurontin Gabapentin 300 mg Neurologic Anticonvulsant<br />
Neurontin Gabapentin 400 mg Neurologic Anticonvulsant<br />
Neurontin Gabapentin 600 mg Neurologic Anticonvulsant<br />
NicoDerm Nicotine Patches- 28 weeks 14mg Smoking deterrents<br />
NicoDerm Nicotine Patches- 28 weeks 21mg Smoking deterrents<br />
NicoDerm Nicotine Patches- 28 weeks 7mg Smoking deterrents<br />
Nitrostat Nitroglycerine SL 0.4 mg Cardiovascular<br />
Nitrate<br />
Vasodilators<br />
Nizoral Ketoconazole 2% crm (15 Gm) Antimicrobials Antifungals<br />
Nizoral Ketoconazole 2% crm (30 Gm) Antimicrobials Antifungals<br />
Nizoral Ketoconazole 2% crm (60 Gm) Antimicrobials Antifungals<br />
Nizoral Ketoconazole 2% shampoo Antimicrobials Antifungals<br />
Nizoral Ketoconazole 200 mg (tabs) Antimicrobials Antifungals<br />
Norco Acetaminophen/Hydrocodone 325/10 mg Analgesic Narcotic<br />
Norco Acetaminophen/Hydrocodone 325/5 mg Analgesic Narcotic<br />
Norco Acetaminophen/Hydrocodone 325/7.5 mg Analgesic Narcotic<br />
Norvasc Amlodipine 10 mg Cardiovascular<br />
Norvasc Amlodipine 2.5 mg Cardiovascular<br />
Norvasc Amlodipine 5 mg Cardiovascular<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Oramorph SR Morphine sulfate SR 100 mg Analgesic Narcotic<br />
Oramorph SR Morphine sulfate SR 15 mg Analgesic Narcotic<br />
Oramorph SR Morphine sulfate SR 30 mg Analgesic Narcotic<br />
Oramorph SR Morphine sulfate SR 60 mg Analgesic Narcotic<br />
Pamelor Nortriptyline 10 mg Psychiatric Antidepressant<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 16 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Pamelor Nortriptyline 25 mg Psychiatric Antidepressant<br />
Pamelor Nortriptyline 50 mg Psychiatric Antidepressant<br />
Pamelor Nortriptyline 75 mg Psychiatric Antidepressant<br />
Parlodel Bromocriptine 2.5mg Hypoprolactinemic<br />
Paxil Paroxetine 10 mg Psychiatric Antidepressant<br />
Paxil Paroxetine 10 mg / 5 ml Psychiatric Antidepressant<br />
Paxil Paroxetine 20 mg Psychiatric Antidepressant<br />
Paxil Paroxetine 30 mg Psychiatric Antidepressant<br />
Paxil Paroxetine 40 mg Psychiatric Antidepressant<br />
Pepcid Famotidine 20 mg GI H2 Antagonists<br />
Pepcid Famotidine 40 mg GI H2 Antagonists<br />
Percocet Acetaminophen / Oxycodone 325/5 and 325/10 Analgesic Narcotic<br />
Persantine Dipyridamole 25 mg Cardiovascular Anticoagulants<br />
Persantine Dipyridamole 50 mg Cardiovascular Anticoagulants<br />
Persantine Dipyridamole 75 mg Cardiovascular Anticoagulants<br />
Phenergan Promethazine HCI 12.5 mg GI Antiemetic<br />
Phenergan Promethazine HCI 12.5 mg supp GI Antiemetic<br />
Phenergan Promethazine HCI 25 mg GI Antiemetic<br />
Phenergan Promethazine HCI 50 mg GI Antiemetic<br />
Phenergan<br />
suppositor<br />
Promethazine HCI 25 mg supp GI Antiemetic<br />
Phenergan syrup Promethazine HCI 6.25 / 5 ml (120 ml) GI Antiemetic<br />
Phoslo Calcium acetate 667mg phosphate binder<br />
Phytonadione Vitamin K 5mg tab Vitamin<br />
Plaquenil Hydroxychloroquine 200 mg Rheumatology<br />
Plavix Clopidogrel 75 mg<br />
platelet aggregation<br />
inhibitor<br />
polyethylene glycol Miralax 238g GI<br />
polyethylene glycol Miralax 510g GI<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 17 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Polytrim Polymyxin b- trimethoprim 10 mL drops Ophthalmic<br />
Polytrim Polymyxin b- trimethoprim 3.5 gm ointment Ophthalmic<br />
Pravachol Pravastatin 20, 40, 80 mg tabs Cardiovascular<br />
Cholesterol<br />
Lowering Agents<br />
Prelone Prednisolone 15mg/5ml oral sol Endocrine Glucocorticoids<br />
Premarin Conjugated Estrogen Cream 0.625 mg/g crm (43 Gm) Hormone Replacement<br />
Prilosec Omeprazole 20 mg GI PPI<br />
Prinivil, Zestril Lisinopril 10 mg Cardiovascular ACE Inhibitor<br />
Prinivil, Zestril Lisinopril 2.5 mg Cardiovascular ACE Inhibitor<br />
Prinivil, Zestril Lisinopril 20 mg Cardiovascular ACE Inhibitor<br />
Prinivil, Zestril Lisinopril 30 mg Cardiovascular ACE Inhibitor<br />
Prinivil, Zestril Lisinopril 40 mg Cardiovascular ACE Inhibitor<br />
Prinivil, Zestril Lisinopril 5 mg Cardiovascular ACE Inhibitor<br />
Procardia, Adalat<br />
CC, Nifediac<br />
Procardia, Adalat<br />
CC, Nifediac<br />
Procardia, Adalat<br />
CC, Nifediac<br />
Nifedipine SR 30 mg Cardiovascular<br />
Nifedipine SR 60 mg Cardiovascular<br />
Nifedipine SR 90 mg Cardiovascular<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Calcium Channel<br />
Blockers<br />
Prolixin Fluphenazine 0.5 mg/ml Psychiatric Antipsychotic<br />
Prolixin Fluphenazine 1 mg Psychiatric Antipsychotic<br />
Prolixin Fluphenazine 10 mg Psychiatric Antipsychotic<br />
Prolixin Fluphenazine 2.5 mg Psychiatric Antipsychotic<br />
Prolixin Fluphenazine 5 mg / cc Psychiatric Antipsychotic<br />
Prolixin Fluphenazine decanoate 25 mg/cc (inj) Psychiatric Antipsychotic<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 18 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Proscar Finasteride 5mg Genitourinary<br />
5-alpha<br />
reductase<br />
inhibitor<br />
Proventil Albuterol solution neb 5 mg/ml (20 ml bottle) Respiratory Nebulizer soln<br />
Proventil Albuterol Unit Dose 0.83 mg/ml Respiratory<br />
Proventil HFA<br />
(IDP)<br />
Albuterol HFA (IDP) tablet, MDI,<br />
solution, UD<br />
90 mcg Respiratory Inhaler<br />
Provera Medroxyprogesterone 10 mg Hormone Replacement<br />
Provera Medroxyprogesterone 2.5 mg Hormone Replacement<br />
Provera Medroxyprogesterone 5 mg Hormone Replacement<br />
Prozac Fluoxetine 10 mg Psychiatric Antidepressant<br />
Prozac Fluoxetine 20 mg Psychiatric Antidepressant<br />
Prozac Fluoxetine 20 mg / 5 ml Psychiatric Antidepressant<br />
Prozac Fluoxetine 40 mg Psychiatric Antidepressant<br />
PTU Propylthiouracil 50 mg Endocrine Thyroid<br />
Pyridium Phenazopyridine HCL 100 mg Genitourinary<br />
Pyridium Phenazopyridine HCL 200 mg Genitourinary<br />
Qvar Beclomethasone dipropinate 40 mcg Respiratory Steroid inhaler<br />
Qvar Beclomethasone dipropinate 80 mcg Respiratory Steroid inhaler<br />
Reglan Metoclopramide 10 mg GI Antiemetic<br />
Reglan Metoclopramide hcl 5 mg GI Antiemetic<br />
Relafen Nabumetone 750 mg Analgesic NSAID<br />
Remeron Mirtazapine 15 mg Psychiatric Antidepressant<br />
Remeron Mirtazapine 30 mg Psychiatric Antidepressant<br />
Remeron Mirtazapine 45 mg Psychiatric Antidepressant<br />
Restoril Temazepam (SCH IV) 15 mg Psychiatric Hypnotic<br />
Restoril Temazepam (SCH IV) 30 mg Psychiatric Hypnotic<br />
Retin-A Tretinoin<br />
0.01%, 0.025%, 0.05%, 0.1%<br />
cream, gel<br />
Derm Acne<br />
Rheumatrex Methotrexate 2.5 mg Chemotherapy<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 19 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Rifadin Rifampin 150 mg Antimicrobials Antitubercular<br />
Rifadin Rifampin 300 mg Antimicrobials Antitubercular<br />
Risperdal Risperidone 0.5 mg Psychiatric Antipsychotic<br />
Risperdal Risperidone 1 mg Psychiatric Antipsychotic<br />
Risperdal Risperidone 1 mg/ml solution Psychiatric Antipsychotic<br />
Risperdal Risperidone 2 mg Psychiatric Antipsychotic<br />
Risperdal Risperidone 3 mg Psychiatric Antipsychotic<br />
Risperdal Risperidone 4 mg Psychiatric Antipsychotic<br />
Ritalin Methylphenidate short acting 10mg Psychiatric Stimulant<br />
Ritalin Methylphenidate short acting 20mg Psychiatric Stimulant<br />
Ritalin Methylphenidate short acting 30mg Psychiatric Stimulant<br />
Ritalin LA Methylphenidate long-acting 10mg Psychiatric Stimulant<br />
Ritalin LA Methylphenidate long-acting 20mg Psychiatric Stimulant<br />
Ritalin LA Methylphenidate long-acting 30mg Psychiatric Stimulant<br />
Ritalin LA Methylphenidate long-acting 40mg Psychiatric Stimulant<br />
Robaxin Methocarbamol 500 mg Analgesic Muscle Relaxant<br />
Robaxin Methocarbamol 750 mg Analgesic Muscle Relaxant<br />
Robitussin AC Guaifenesin + Codeine 100 mg - 10mg / 5 ml Cold, Cough, Allergy Antitussive<br />
Rocaltrol Calcitriol 0.25 mcg Vitamin<br />
Rocaltrol Calcitriol 0.5mcg Vitamin<br />
Selsun Selenium sulfide lotion 2.50% Derm Anti-seborrhea<br />
Septra Sulfamethxzl Trimethoprim 80 / 400 mg Antimicrobials Sulfas<br />
Septra Sulfamethxzl Trimethoprim DS 160 / 800 mg Antimicrobials Sulfas<br />
Serevent Diskus Salmeterol xinafoate 50 mcg Respiratory Asthma<br />
Sinemet Carbidopa - levodopa 10 - 100 mg Neurologic Parkinson<br />
Sinemet Carbidopa - levodopa 25 - 100 mg Neurologic Parkinson<br />
Sinemet Carbidopa - levodopa 25 - 250 mg Neurologic Parkinson<br />
Sinemet CR Carbidopa - levodopa LA 25 - 100 mg Neurologic Parkinson<br />
Sinemet CR Carbidopa - levodopa LA 50 - 200 mg Neurologic Parkinson<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 20 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Sinequan Doxepin HCL 10 mg Psychiatric Antidepressant<br />
Sinequan Doxepin HCL 100 mg Psychiatric Antidepressant<br />
Sinequan Doxepin HCL 150 mg Psychiatric Antidepressant<br />
Sinequan Doxepin HCL 25 mg Psychiatric Antidepressant<br />
Sinequan Doxepin HCL 50 mg Psychiatric Antidepressant<br />
Sinequan Doxepin HCL 75 mg Psychiatric Antidepressant<br />
Singulair Montelukast 10 mg Respiratory<br />
Singulair Montelukast 5 mg chew Respiratory<br />
Soltamox Tamoxifen 10mg Hormone Replacement<br />
Soma Carisoprodol 250mg muscle relaxant<br />
Spectazole Econazole 1% crm 30 Gm (30 Gm) Antimicrobials Antifungals<br />
Spectazole Econazole 1% crm 85 Gm (85 Gm) Antimicrobials Antifungals<br />
Spectazole Econazole 1% crm 15 Gm (15 Gm) Antimicrobials Antifungals<br />
Stelazine Trifluoperazine 10 mg Psychiatric Antipsychotic<br />
Stelazine Trifluoperazine 2 mg Psychiatric Antipsychotic<br />
Stelazine Trifluoperazine 5 mg Psychiatric Antipsychotic<br />
Sulamyd Sulfacetamide sodium eye drop sol 10% Ophthalmic<br />
Sulamyd Sulfacetamide sodium eye ointment 10% Ophthalmic<br />
Sumycin Tetracycline 250 mg Antimicrobials Tetracyclines<br />
Sumycin Tetracycline 500 mg Antimicrobials Tetracyclines<br />
Symmetrel Amantadine 100 mg Neurologic Parkinson<br />
Symmetrel Amantadine 50 mg / 5 ml (120 ml) Neurologic Parkinson<br />
Synalar Fluocinolone acetonide 0.01% cream Derm Antiinflammatory<br />
Synalar Fluocinolone acetonide 0.01% ointment Derm Antiinflammatory<br />
Synalar Fluocinolone acetonide 0.025% cream Derm Antiinflammatory<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 21 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Synalar Fluocinolone acetonide 0.025% ointment Derm Antiinflammatory<br />
Synalar Fluocinolone acetonide 0.025%, 0.01% solution, 60 ml Derm Antiinflammatory<br />
Tagamet Cimetidine 400 mg GI H2 blockers<br />
Tamiflu Oseltamivir 12mg/ml Antimicrobials Antiviral<br />
Tamiflu Oseltamivir 75mg Antimicrobials Antiviral<br />
Tapazole Methimazole 10 mg Endocrine Thyroid<br />
Tapazole Methimazole 5 mg Endocrine Thyroid<br />
Tegretol Carbamazepine 100 mg Psychiatric Mood Stabilizer<br />
Tegretol Carbamazepine 100 mg / 5 cc Psychiatric Mood Stabilizer<br />
Tegretol Carbamazepine 200 mg Psychiatric Mood Stabilizer<br />
Temovate Clobetasol lotion 0.05% Derm<br />
Temovate Clobetasol propionate 0.05% crm (15 Gms) Derm Antiinflammatory<br />
Temovate Clobetasol propionate 0.05% oint (15 Gms) Derm Antiinflammatory<br />
Temovate Clobetasol propionate 0.05% oint (30 Gms) Derm Antiinflammatory<br />
Tenormin Atenolol 100 mg Cardiovascular Beta Blockers<br />
Tenormin Atenolol 25 mg Cardiovascular Beta Blockers<br />
Tenormin Atenolol 50 mg Cardiovascular Beta Blockers<br />
Thalitone Chlorthalidone 25mg Cardiovascular Diuretics<br />
Thalitone Chlorthalidone 50 mg Cardiovascular Diuretics<br />
Theo-Dur Theophylline 200 mg Respiratory<br />
Theo-Dur Theophylline 300 mg Respiratory<br />
Thorazine Chlorpromazine 10 mg Psychiatric Antipsychotic<br />
Thorazine Chlorpromazine 100 mg Psychiatric Antipsychotic<br />
Thorazine Chlorpromazine 100 mg/ml Psychiatric Antipsychotic<br />
Thorazine Chlorpromazine 200 mg Psychiatric Antipsychotic<br />
Thorazine Chlorpromazine 25 mg Psychiatric Antipsychotic<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 22 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Thorazine Chlorpromazine 30 mg/ml Psychiatric Antipsychotic<br />
Thorazine Chlorpromazine 50 mg Psychiatric Antipsychotic<br />
Ticlid Ticlopidine 250mg<br />
platelet aggregation<br />
inhibitor<br />
Tofranil Imipramine 10 mg Psychiatric Antidepressant<br />
Tofranil Imipramine 25 mg Psychiatric Antidepressant<br />
Tofranil Imipramine 50 mg Psychiatric Antidepressant<br />
Toprol XL Metoprolol succinate 100 mg Cardiovascular Beta Blockers<br />
Toprol XL Metoprolol succinate 25 mg Cardiovascular Beta Blockers<br />
Toprol XL Metoprolol succinate 50 mg Cardiovascular Beta Blockers<br />
Trandate Labetalol HCL 100 mg Cardiovascular Beta Blockers<br />
Trandate Labetalol HCL 200 mg Cardiovascular Beta Blockers<br />
Trandate Labetalol HCL 300 mg Cardiovascular Beta Blockers<br />
Trental Pentoxifylline ER 400 mg Hemorrheologic Agents<br />
Trilafon Perphenazine 16 mg Psychiatric Antipsychotic<br />
Trilafon Perphenazine 16 mg / 5 cc (120 ml) Psychiatric Antipsychotic<br />
Trilafon Perphenazine 2 mg Psychiatric Antipsychotic<br />
Trilafon Perphenazine 4 mg Psychiatric Antipsychotic<br />
Trilafon Perphenazine 8 mg Psychiatric Antipsychotic<br />
Tylenol #3 Acetaminophen/Codeine #3 300 / 30 mg Analgesic Narcotic<br />
Ultram, Rybix Tramadol 50 mg Analgesic Misc<br />
Valium Diazepam (SCH IV) 10 mg Psychiatric Benzos<br />
Valium Diazepam (SCH IV) 2 mg Psychiatric Benzos<br />
Valium Diazepam (SCH IV) 5 mg Psychiatric Benzos<br />
Vasotec Enalapril maleate 10 mg Cardiovascular ACE Inhibitor<br />
Vasotec Enalapril maleate 2.5 mg Cardiovascular ACE Inhibitor<br />
Vasotec Enalapril maleate 20 mg Cardiovascular ACE Inhibitor<br />
Vasotec Enalapril maleate 5 mg Cardiovascular ACE Inhibitor<br />
Veetids Penicillin VK 250 mg Antimicrobials Penicillins<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 23 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Ventolin, Proventil Albuterol liquid 2 mg / 5 cc (120 ml) Respiratory<br />
Vicodin<br />
Acetaminophen/Hydrocodone<br />
bitartrate<br />
500 mg - 5 mg Analgesic Narcotic<br />
Vitamin B5 Pyridoxine 25mg Vitamin<br />
Vitamin B6 Pyridoxine 100mg Vitamin<br />
Voltaren Diclofenac 50 mg Analgesic NSAID<br />
Voltaren Diclofenac 75 mg Analgesic NSAID<br />
Vosol Acetic acid 15 ml drops Otic<br />
Vosol HC Acetic acid/Hydrocortisone 2%-1% Otic<br />
Wellbutrin SR Buproprion IR, SR 100 mg Psychiatric Antidepressant<br />
Wellbutrin SR Buproprion IR, SR 150 mg Psychiatric Antidepressant<br />
Wellbutrin SR Buproprion IR, SR 200 mg Psychiatric Antidepressant<br />
Wellbutrin SR Buproprion IR, SR 300 mg Psychiatric Antidepressant<br />
Wellbutrin SR Buproprion IR, SR 75 mg Psychiatric Antidepressant<br />
Wellbutrin XL Bupropion XL 150 mg, 300 mg Psychiatric Antidepressant<br />
Xalatan Latanoprost 0.005% Ophthalmic<br />
Zantac Ranitidine 150 mg GI H2 blockers<br />
Zantac Ranitidine 300 mg GI H2 blockers<br />
Zaroxolyn Metolazone 10 mg Cardiovascular Diurectics<br />
Zaroxolyn Metolazone 2.5 mg Cardiovascular Diurectics<br />
Zaroxolyn Metolazone 5 mg Cardiovascular Diurectics<br />
Zithromax Azithromycin 250 mg Antimicrobials Macrolides<br />
Zocor Simvastatin 10 mg Cardiovascular<br />
Zocor Simvastatin 20 mg Cardiovascular<br />
Zocor Simvastatin 40 mg Cardiovascular<br />
Cholesterol<br />
Lowering Agents<br />
Cholesterol<br />
Lowering Agents<br />
Cholesterol<br />
Lowering Agents<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 24 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Zoloft Sertraline 100 mg Psychiatric Antidepressant<br />
Zoloft Sertraline 20 mg/ml Psychiatric Antidepressant<br />
Zoloft Sertraline 25 mg Psychiatric Antidepressant<br />
Zoloft Sertraline 50 mg Psychiatric Antidepressant<br />
Zovirax Acyclovir 200 mg Antimicrobials Antiviral<br />
Zovirax Acyclovir 400 mg Antimicrobials Antiviral<br />
Zovirax Acyclovir 800 mg Antimicrobials Antiviral<br />
Zyloprim Allopurinol 100 mg Gout<br />
Zyloprim Allopurinol 300 mg Gout<br />
Zyprexa Olanzapine 2.5mg Psychiatric Antipsychotic<br />
Zyprexa Olanzapine 5 mg Psychiatric Antipsychotic<br />
Acetylsalicylic acid (ASA) 81, 325 mg Analgesic Salicylates<br />
Cortisporin otic soln 1%-0.35%-10000u/mL (10 ml) Otic<br />
Cortisporin otic susp drops (10 ml) Otic<br />
Diabetes supplies - glucometer Diabetes<br />
Diabetes supplies - lancets Diabetes<br />
Diabetes supplies - syringes/needles Diabetes<br />
Diabetes supplies - test strips Diabetes<br />
Diabetes supplies - testing control<br />
solution<br />
Diabetes<br />
Erythromycin eye ointment 5 mg / Gm (3.5 Gm) Ophthalmic<br />
Folic Acid 800 MicorGrams Vitamin<br />
Methadone 10 mg Analgesic Narcotic<br />
Methadone 5 mg Analgesic Narcotic<br />
Niacin IR & ER tabs only 100 mg Cardiovascular<br />
Niacin IR & ER tabs only 250 mg Cardiovascular<br />
Niacin IR & ER tabs only 500 mg Cardiovascular<br />
Nystatin (cream or ointment) Derm Antifungals<br />
Nystatin oral suspension 100,000 units/ml Antimicrobials Antifungals<br />
Penicillin VK 125 mg / 5 cc (200 cc) Antimicrobials Penicillins<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 25 of 26
<strong>HealthPAC</strong> <strong>Formulary</strong><br />
Current as of December 2012<br />
<strong>Brand</strong><br />
<strong>Name</strong><br />
Generic <strong>Name</strong> Strength Class I Class II<br />
Penicillin VK 250 mg / 5 cc (100 cc) Antimicrobials Penicillins<br />
Penicillin VK 250 mg / 5 cc (150 cc) Antimicrobials Penicillins<br />
Penicillin VK 500 mg Antimicrobials Penicillins<br />
Phenobarbital (SCH IV) 100 mg Neurologic Anticonvulsant<br />
Phenobarbital (SCH IV) 15 mg Neurologic Anticonvulsant<br />
Phenobarbital (SCH IV) 30 mg Neurologic Anticonvulsant<br />
Phenobarbital (SCH IV) 60 mg Neurologic Anticonvulsant<br />
Potassium chloride 10% (480 cc) Cardiovascular<br />
Potassium<br />
Supplement<br />
Prednisolone ophth solu or susp 1% Ophthalmic<br />
Promethazine/VC/DM Cold, Cough, Allergy Antitussive<br />
Pyrazinamide 500 mg Antimicrobials Antitubercular<br />
Salsalate 500 mg Analgesic Salicyclates<br />
Salsalate 750 mg Analgesic Salicyclates<br />
Timolol Maleate eye drops 0.25% Ophthalmic Glaucoma<br />
Timolol Maleate eye drops 0.5% Ophthalmic Glaucoma<br />
Tobramycin ophthal soln. 0.30% Ophthalmic<br />
Vitamin B6 50 mg Vitamin<br />
Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 26 of 26
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