HealthPAC Formulary - By Class

HealthPAC Formulary 

Current as of December 2012 

Class I Class II Generic Name Brand Name Strength 

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 NSAID Diclofenac Voltaren 50 mg 

Analgesic NSAID Diclofenac Voltaren 75 mg 

Analgesic NSAID Ibuprofen Motrin 400 mg 



Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 1 of 25




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 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 Fluconazole Diflucan 100 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% 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 

Antimicrobials Antitubercular Rifampin Rifadin 300 mg 

Antimicrobials Antiviral Acyclovir Zovirax 200 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 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) 

Antimicrobials Penicillins Penicillin VK Veetids 250 mg 



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 

Cardiovascular ACE Inhibitor Captopril Capoten 100 mg 

Cardiovascular ACE Inhibitor Captopril Capoten 12.5 mg 



Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 10 mg 

Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 2.5 mg 



Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 10 mg 

Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 2.5 mg 









Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 1 mg 




Cardiovascular 

Angiotensin II 

Blocker 

Losartan Cozaar 100 mg 



Blocker 

Losartan Cozaar 25 mg 



Blocker 

Losartan Cozaar 50mg 

Cardiovascular Antiarrythmic Amiodarone Cordarone 200 mg 

Cardiovascular Antiarrythmic Amiodarone Cordarone 400 mg 

Cardiovascular Anticoagulants Dipyridamole Persantine 25 mg 



Cardiovascular Anticoagulants Warfarin sodium Coumadin 1 mg 



Cardiovascular Anticoagulants Warfarin sodium Coumadin 2.5 mg 





Cardiovascular Anticoagulants Warfarin sodium Coumadin 7.5 mg 

Cardiovascular Beta Blockers Atenolol Tenormin 100 mg 



Cardiovascular Beta Blockers Carvedilol Coreg 12.5 mg 

Cardiovascular Beta Blockers Carvedilol Coreg 25 mg 







Cardiovascular Beta Blockers Labetalol HCL Trandate 100 mg 



Cardiovascular Beta Blockers Metoprolol succinate Toprol XL 100 mg 



Cardiovascular Beta Blockers Metoprolol tartrate Lopressor 100 mg 



Cardiovascular Beta Blockers Propranolol HCL Inderal 10 mg 











Calcium Channel 

Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 

Amlodipine Norvasc 10 mg 

Amlodipine Norvasc 2.5 mg 

Amlodipine Norvasc 5 mg 

Dilitiazem HCI Cardizem LA 180 mg 

Diltiazem Cardizem 120 mg 

Diltiazem 

Cardizem CD, 

Dilacor Xr, Cartia 

XL, Dilt-CD 

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 6 of 25 

60 mg















Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 

Diltiazem 

Cardizem CD, 

Dilacor Xr, Cartia 

XL, Dilt-CD 

90 mg 

Diltiazem SR Cardizem SR 120 mg 




Diltiazem CD Cardizem CD 120 mg 




















Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 


Blockers 

Diltiazem CD Cardizem CD 360mg 



Nifedipine SR 

Nifedipine SR 

Nifedipine SR 

Procardia, Adalat 

CC, Nifediac 


CC, Nifediac 


CC, Nifediac 

30 mg 

60 mg 

90 mg 

Verapamil Isoptin 120 mg 

Verapamil LA Isoptin 180 mg 

Verapamil SR Calan SR 120 mg 



















Blockers 

Central Alpha 

Agonist 

Central Alpha 

Agonist 

Central Alpha 

Agonist 

Central Alpha 

Agonist 

Central Alpha 

Agonist 

Cholesterol 

Lowering Agents 

Cholesterol 


Cholesterol 


Cholesterol 


Cholesterol 


Cholesterol 



Clonidine HCI tabs Catapres 0.1 mg 



Methyldopa Aldomet 250 mg 

Methyldopa Aldomet 500 mg 

Gemfibrozil Lopid 600 mg 

Lovastatin Mevacor 10, 20, 40 mg 

Pravastatin Pravachol 20, 40, 80 mg tabs 

Simvastatin Zocor 10 mg 



Cardiovascular Diurectics Metolazone Zaroxolyn 10 mg 

Cardiovascular Diurectics Metolazone Zaroxolyn 2.5 mg 





Cardiovascular Diurectics Metolazone Zaroxolyn 5 mg 

Cardiovascular Diuretics Chlorthalidone Thalitone 25mg 

Cardiovascular Diuretics Chlorthalidone Thalitone 50 mg 

Cardiovascular Diuretics Furosemide Lasix 20 mg 



Cardiovascular Diuretics Hydrochlorothiazide Microzide 12.5 mg cap 

Cardiovascular Diuretics Hydrochlorothiazide Esidrix 25 mg 

Cardiovascular Diuretics Hydrochlorothiazide Esidrix 50 mg 

Cardiovascular Diuretics Spironolactone Aldactone 25 mg 

Cardiovascular Diuretics Spironolactone Aldactone 50 mg 

Cardiovascular Diuretics Spironolatone Aldactone 100 mg 

Cardiovascular Diuretics Triamterene hctz Maxzide 37.5/25 mg 

Cardiovascular Diuretics Triamterene hctz Maxzide 75 / 50 mg 

Cardiovascular Glycosides Digoxin Lanoxin 0.125 mg 

Cardiovascular Glycosides Digoxin Lanoxin 0.25 mg 


Nitrate 

Vasodilators 

Isosorbide dinitrate Isordil 10 mg 


Nitrate 

Vasodilators 



Nitrate 

Vasodilators 



Nitrate 

Vasodilators 



Nitrate 

Vasodilators 

Isosorbide mononitrate IR, SR Imdur 10 mg 


Nitrate 

Vasodilators 



Nitrate 

Vasodilators 



Nitrate 

Vasodilators 







Nitrate 

Vasodilators 



Nitrate 

Vasodilators 

Nitroglycerine SL Nitrostat 0.4 mg 


Other 

Vasodilators 

Hydralazine Apresoline 10 mg 


Other 

Vasodilators 



Other 

Vasodilators 



Other 

Vasodilators 



Potassium 

Supplement 

Potassium chloride 10% (480 cc) 


Potassium 

Supplement 

Potassium chloride tabs 

K-Tab, K-Dur, 

Slow-K, Klor-con 

10 mEq 


Potassium 

Supplement 


K-Tab, K-Dur, 


20 mEq 


Potassium 

Supplement 


K-Tab, K-Dur, 


8 mEq 

Cardiovascular Niacin IR & ER tabs only 100 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 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% 

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 Hydrocortisone HC 10mg 

Derm Antiinflammatory Hydrocortisone HC 2.5% lotion 


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 


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% 


Diabetes Biquanides Metformin Glucophage 1000 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 


es 


Diabetes 


es 


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 2.5 mg 




Endocrine Thyroid Levothyroxine Levoxyl 0.025 mg 
















Endocrine Thyroid Methimazole Tapazole 10 mg 

Endocrine Thyroid Methimazole Tapazole 5 mg 

Endocrine Thyroid Propylthiouracil PTU 50 mg 

Endocrine 

5-alpha 

Fludrocortisone Florinef 0.1 mg 

Genitourinary 

reductase 

inhibitor 

Finasteride Proscar 5mg 

Genitourinary Oxybutynin Ditropan 5 mg 

Genitourinary Phenazopyridine HCL Pyridium 100 mg 

Genitourinary Phenazopyridine HCL Pyridium 200 mg 

Genitourinary Alpha-blocker Tamsulosin Flomax 0.4mg 

Genitourinary Terazosin HCL Hytrin 1 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 

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 Cortizone 25mg 

GI 

GI 


bowel 


bowel 

Mesalamine Asacol 400 mg 

Sulfasalazine Azulfidine 500 mg 

GI 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 

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 0.625 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 Lamotrigine Lamictal 100 mg tab 








Neurologic Anticonvulsant Phenobarbital (SCH IV) 100 mg 




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 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 10 - 100 mg 



Neurologic Parkinson Carbidopa - levodopa LA Sinemet CR 25 - 100 mg 

Neurologic Parkinson Carbidopa - levodopa LA Sinemet CR 50 - 200 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 



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% 

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 Bupropion XL Wellbutrin XL 150 mg, 300 mg 

Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 100 mg 





Psychiatric Antidepressant Citalopram Hydrobromide Celexa 10 mg 

Psychiatric Antidepressant Citalopram Hydrobromide Celexa 10 mg / 5 cc 



Psychiatric Antidepressant Clomipramine Anafranil 25 mg 



Psychiatric Antidepressant Doxepin HCL Sinequan 10 mg 






Psychiatric Antidepressant Fluoxetine Prozac 10 mg 


Psychiatric Antidepressant Fluoxetine Prozac 20 mg / 5 ml 


Psychiatric Antidepressant Imipramine Tofranil 10 mg 



Psychiatric Antidepressant Mirtazapine Remeron 15 mg 



Psychiatric Antidepressant Nortriptyline Pamelor 10 mg 








Psychiatric Antidepressant Paroxetine Paxil 10 mg 

Psychiatric Antidepressant Paroxetine Paxil 10 mg / 5 ml 




Psychiatric Antidepressant Sertraline Zoloft 100 mg 

Psychiatric Antidepressant Sertraline Zoloft 20 mg/ml 



Psychiatric Antidepressant Trazodone Desyrel 100 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/ml 



Psychiatric Antipsychotic Chlorpromazine Thorazine 30 mg/ml 


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 2 mg / cc (120 cc) 

Psychiatric Antipsychotic Haloperidol Haldol 2 mg / cc (15 cc) 



Psychiatric Antipsychotic Haloperidol decanoate Haldol 100 mg/cc (inj) 

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 Risperidone Risperdal 0.5 mg 

Psychiatric Antipsychotic Risperidone Risperdal 1 mg 

Psychiatric Antipsychotic Risperidone Risperdal 1 mg/ml solution 




Psychiatric Antipsychotic Thiothixene Navane 1 mg 





Psychiatric Antipsychotic Thiothixene Navane 5 mg/ml 

Psychiatric Antipsychotic Trifluoperazine Stelazine 10 mg 







Psychiatric Benzos Clonazepam (SCH IV) Klonopin 0.5 mg 

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 Lorazepam (SCH IV) Ativan 0.5 mg 



Psychiatric Hypnotic Temazepam (SCH IV) Restoril 15 mg 

Psychiatric Hypnotic Temazepam (SCH IV) Restoril 30 mg 

Psychiatric Hypnotic Zolpidem Ambien 5, 10 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 ER 250 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 Stimulant Dextroamphetamine/amphetamine Adderall XR 10mg 








Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 10mg 




Psychiatric Stimulant Methylphenidate short acting Ritalin 10mg 



Respiratory Asthma Ipratropium MDI Atrovent 18mcg/dose MDI (14gm) 

Respiratory Asthma Salmeterol xinafoate Serevent Diskus 50 mcg 

Respiratory Inhaler 

Albuterol HFA (IDP) tablet, MDI, 

solution, UD 

Proventil HFA 

(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 



Vitamin Calcitriol Rocaltrol 0.25 mcg 

Vitamin Calcitriol Rocaltrol 0.5mcg 

Vitamin Folic Acid 800 MicorGrams 

Vitamin Pyridoxine Vitamin B6 100mg 

Vitamin Pyridoxine Vitamin B5 25mg 





Vitamin Vitamin B6 50 mg 

Vitamin Vitamin D Calciferol 50,000 units 

Vitamin Vitamin K Phytonadione 5mg tab

HealthPAC Formulary - By Class

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