32 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
FORMULARY: THERAPEUTIC CATEGORY LISTING* *Most current Formulary List of Drugs can be found:
1. DUH intranet [click on DRH (Duke Regional Hospital), Departments and Services, Pharmacy, then Lincoln Community Health Center Formulary] (https://lincolnchc.org/?page_id=6808)
2. LCHC website (https://lincolnchc.org/?page_id=6808) 3. PADC website (http://www.projectaccessdurham.org/), then click on the Lincoln Pharmacy formulary. 4. LCHC Intranet/ Pharmacy Department/ Formulary of Drugs
Use Ctrl-F to quickly search the listing for a specific item.
Pfizer Institutional Patient Assistance Program Pfizer drugs are available to uninsured patients who are at or below 400% of the
federal poverty level. Only a dispensing fee is charged. NOTE: These medications are labeled as “IPAP”.
Patient Assistance Program Patients who meet specific eligibility requirements may receive formulary medications through manufacturer-sponsored patient assistance programs (PAPs). Medications labeled as “PAP” are available to eligible patients through manufacturer-sponsored PAPs. These medications may not be readily available and may require up to an 8-week processing period.
HIV Patient Assistance Program EI Clinic may access medications through ADAP for qualified patients. For patients that do not qualify for ADAP, HIV medications may be obtained from manufacturer programs. http://epi.publichealth.nc.gov/cd/hiv/docs/ADAPProgrammanual.pdf
Project Access Durham County Project Access Durham County (PADC) serves eligible low-income, uninsured Durham residents who have specialty medical care needs. PADC enrolls members based on referrals from a primary care provider at Lincoln Community Health Center (LCHC). PADC patients are eligible for LCHC formulary medications.
Safety in Lactation Lactation safety data from American Academy of Pediatrics (www.aap.org) Medicaid Preferred Drug List http://www.ncdhhs.gov/dma/pharmacy/PDL.pdf
Medicaid Prior Authorizations https://www.nctracks.nc.gov/content/public/providers.html Hazardous Drugs Drugs identified by National Institute of Occupational Safety and Health as
hazardous are labeled as “HD”. Use caution when handling. (https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf?id=10.26616/NIOSHPUB2016161)
Beers List 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Jan 29. doi: 10.1111/jgs.15767.
33 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
ALZHEIMER DISEASE
Acetylcholinesterase Inhibitor (Central)
Donepezil Tablet 10mg Aricept
C ? +
N-Methyl-D-Aspartate
Receptor Antagonist
Memantine extended
release tablet 7mg, 14mg, 21mg, 28mg Patient Assistance Program
Namenda XR 90 day
supply PAP
B ? - K
ANALGESIC AND ANTIPYRETICS
Anticonvulsant, Analgesic Pregabalin Capsule 75mg, 150mg IPAP
Lyrica
C ? - K
Anticonvulsant,
Neuropathic pain (unlabeled)
Gabapentin Capsule
100mg, 300mg
Neurontin C ? - K
Miscellaneous Acetaminophen Suspension 160mg/5mL
Tylenol Susp 120 mL B +
L
Acetaminophen Tablet 325mg
Tylenol #100 tabs B + + L
Miscellaneous, Topical Capsaicin 0.025% Cream Capzasin 60 gm B +
NSAID Ibuprofen Suspension 100mg/5mL
Motrin
B (D in 3rd trimester)
+
+ See page
69
K
Ibuprofen Tablet 400mg Motrin
B (D in 3rd trimester)
+ + (taste may be unaccept
able)
+ See page
69
K
Indomethacin Capsule 25mg, 50mg
Indocin
B (D in 3rd trimester)
+ - + See page
69
K
Naproxen Sodium Tablet 500mg
Naprosyn
B (D in 3rd trimester)
+ + + See page
69
K
NSAID, COX-2 Inhibitor Celecoxib Capsule 200mg IPAP
Celebrex
C (D in 3rd trimester)
? - K/L
Opioid Acetaminophen/Codeine Tab 300mg/30mg
Tylenol With Codeine #3
C ? + L
Buprenorphine/Naloxone SL Tab 2mg/0.5mg, 8mg/ 2mg
Zubsolv C ? + K/L
Hydrocodone/
Acetaminophen Tab 5mg/325mg
Norco
C ? + +
See page 69
L
Tramadol Tablet 50mg Ultram C - + K/L
ANTIANEMIA AGENTS
Iron Preparations Ferrous Sulfate Drops 75mg/mL (15mg/mL
elemental)
50mL + +
34 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
ANTIANEMIA AGENTS
Iron Preparations Ferrous Sulfate Elixer 220mg/5mL (44mg/5mL elemental)
480mL + +
Ferrous Sulfate Tablet 325mg (65mg
elemental)
#100 tabs + + +
ANTICONVULSANT AGENTS
Anticonvulsant, Analgesic Pregabalin Capsule 150mg IPAP
Lyrica
C ? - K
Pregabalin Capsule 75mg IPAP
Lyrica
C ? - K
Anticonvulsant, Neuropathic pain
(unlabeled)
Gabapentin Capsule 100mg, 300mg
Neurontin C ? - K
Barbiturate Phenobarbital Tablet 30mg
D - + +
See page 68
K/L
Hydantoin Phenytoin Sodium Capsule 100mgHD
Dilantin
D + - L
Phenytoin Sodium Chewable tablet 50gHD
Dilantin Infatabs
D + + L
Miscellaneous Carbamazepine Tablet 200mgHD
Tegretol
D + + K/L
Divalproex Sodium Tablet 250mg HD
Depakote
X ? - L
Lamotrigine Tablet 25mg, 100mg
Lamictal C - + L
Levetiracetam Tablet 250 mg, 500 mg, 750
mg
Keppra C - + K
Topiramate Tablet 25mg, 200mgHD
Topamax
D ? - (taste may be unaccept
able)
K/L
ANTIDEPRESSANT AGENTS
Alpha2 Antagonist Mirtazapine Tablet 30mg Remeron
C ? + K/L
Dopamine Reuptake Inhibitor
Bupropion ER Tablet 150mg, 300mg
Wellbutrin XL
C - + K/L
Selective Serotonin Reuptake Inhibitor
Fluoxetine Capsule 20mg Prozac
C (- in 3rd trimester)
- - L
Sertraline Tablet 50mg, 100mg
Zoloft
C (- in 3rd trimester)
+ + L
Serotonin Reuptake Inhibitor/Antagonist
Trazodone Tablet 50mg Desyrel
C - + K/L
35 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
ANTIDEPRESSANT AGENTS
Serotonin/Norepinephrine Reuptake Inhibitor
Duloxetine Capsule 20mg, 30mg, 60mg
Cymbalta
C ? - (may open & mix w/
applesauce, NOT
chocolate)
K/L
Tricyclic Amitriptyline Tablet 25mg, 50mg
Elavil
D - + + See page
67
Doxepin Capsule 25mg,
50mg
Sinequan
C - - +
See page 67
Imipramine Tablet 10mg, 25mg
Tofranil
D - + + See page
67
Nortriptyline Tablet 25mg
Pamelor
D + + + See page
67
K/L
ANTIDOTE Aldehyde Dehydrogenase Inhibitor
Disulfiram Tablet 250mg Antabuse C ? +
Alpha/Beta Adrenergic Agonist
Epinephrine IM Injection 0.15mg/0.15mL, 0.3mg/0.3mL
EpiPen 2 Auto-Injectors
C -
Antihistamine Diphenhydramine
Capsule 25mg, 50mg
Benadryl
B - - +
See page 66
Diphenhydramine Elixer 12.5ml/5mL
Benadryl
B -
+ See page
66
Opioid Antagonist Naloxone Nasal Spray
4 mg/0.1mL
Narcan 2 devices C ?
Naltrexone Tablet 50mg Revia C ? +
Naltrexone IM Injection 380 mg
Vivitrol C ?
ANTIEMETIC/ANTI-VERTIGO AGENTS
5-HT3 Receptor Antagonist
Ondansetron Disintegrating Tablet 4mg
Zofran ODT
B ? + L
Anticholinergic, Antihistamine
Meclizine Tablet 12.5mg Antivert
B ? + + See page
66
Antidopaminergic, Phenothiazine
Promethazine Suppository 25mg
Phenergan
C -
+ See page
66
L
Promethazine Tablet 25mg
Phenergan
C -
+ See page
66
L
36 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
ANTI-INFECTIVES Antifungal Nystatin Cream 100,000 units/gm
Mycostatin 15 gm C ?
Nystatin Suspension 100,000 units/mL
Nilstat 60 mL bottle C ?
Fluconazole Tablet 150mg HD
Diflucan
C (single dose vag
candida), D all other
indications
+ + K
Griseofulvin Susp 125mg/5mL
Grifulvin
C ?
Terbinafine Cream 1% Lamisil AT 15 gm B ?
Terbinafine Tablet 250mg
Lamisil
B - + K/L
Antihelmintic Albendazole Tablet 200mg
Albenza C ? + K
Ivermectin Tablet 3 mg Stromectol C ? +
Praziquantel Tablet 600 mg
Biltricide B - + L
Antimalarial Hydroxychloroquine Tablet 200mg
Plaquenil C + + K/L
Antiviral Acyclovir Suspension
200mg/5mL
Zovirax B + K/L
Oseltamivir Capsule 75mg
Tamiflu B + + K
Oseltamivir Suspension 6mg/ mL
Tamiflu B + + K
Valacyclovir Tablet 1 gm Valtrex B + + K
Antiviral (Antihepaciviral) Glecaprevir-pibrentasvir
Tablet 100-40mg Patient Assistance Program
Mavyret C ? -/+ L
Ledaspasvir/sofosbuvir Tablet 90 mg/ 400mg Patient Assistance Program
Harvoni 28 day supply PAP
B ? - (taste)
L
Sofosbuvir/ velpatasvir Tablet 400 mg/ 100 mg Patient Assistance Program
Epclusa 28 day supply PAP
B ? - (taste)
Antiviral (PrEP) Tenofovir disoproxil/ emtricitabine Tablet 200
mg/ 300 mg Patient Assistance Program
Truvada 90 day supply PAP
B + + K
37 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
ANTI-INFECTIVES Cephalosporin, 1st gen Cephalexin Capsule 250mg
Keflex B ? - K
Cephalexin Suspension 250mg/5ml
Keflex B ? K
Cephalosporin, 2nd gen Cefuroxime Tablets
250mg
Ceftin B ? -
(taste)
Cephalosporin, 3rd gen Cefdinir Suspension 250mg/5mL
Omnicef B ? K
Macrolide Azithromycin Suspension 200mg/5mL
Zithromax
B ?
K/L
Azithromycin Tablet 250mg
Zithromax
B ? + K/L
Clarithromycin Tablet
500mg
Biaxin
C ? + K
Miscellaneous Bismuth/Metronidazole/ Tetracycline Capsule 140mg/125mg/125mg
Pylera #120 D ? - K/L
Clindamycin Capsule 150mg
Cleocin
B ? + K
Clindamycin Oral Solution 75mg/5mL
Cleocin 100 mL B ? K
Clindamycin Topical Solution 1%
Cleocin-T 60 mL B ?
Metronidazole Tablet 500mg
Flagyl
B ? + K/L
Penicillin Amoxicillin Capsule 250mg
Amoxil
B + - K
Amoxicillin Suspension 400mg/5mL
Amoxil B + K
Amoxicillin/Clavulanic Acid Suspension 600mg/42.9mg
Augmentin ES B ? + K/L
Amoxicillin/Clavulanic Acid Tablet
875mg/125mg
Augmentin XR
B ? + K/L
Penicillin VK Suspension 250mg/5mL
Pen-Vee K
B ?
K
Penicillin VK Tablet 500mg
Veetids
B ? + K
Quinolone Ciprofloxacin Ophth Soln 0.3%
Cipro 5 mL bottle C (but teratogenici
ty unlikely)
?
Ciprofloxacin Tablets 500mg
Cipro C (but teratogenicity unlikely)
? + K/L
38 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
ANTI-INFECTIVES Levofloxacin Tablet 500mg
Levaquin C ? + K
Sulfonamide Sulfamethoxazole/ Trimethoprim
Suspension 200mg-40mg/5mL
Septra Suspension
C +
+
See page
69
K/L
Sulfonamide Sulfamethoxazole/ Trimethoprim Tablet 800mg/160mg
Septra DS
C +
+ See page
69
K/L
Sulfasalazine Tablet 500mg
Sulfazine, Azulfadine
D - + K/L
Tetracycline Doxycycline Tablet
100mg
Vibramycin
D ? +
Urinary Nitrofurantoin Capsule 100mg
Macrobid
B +? - + See page
66
K/L
ANTINEOPLASTIC AGENTS
Anti-estrogen Tamoxifen Tablet 10mg HD
Nolvadex
D - -
ANTIPARKINSON AGENTS
Anticholinergic Trihexphenidyl Tablet 2mg
Artane
C - + + See page
66
K/L
Dopamine Agonist Carbidopa/Levodopa Tablet 25mg/100mg
Sinemet
C - + K/L
ANTIPSYCHOTIC AGENTS
Atypical, mixed serotonin-dopamine
antagonist
Aripiprazole Tablet 5mg, 15mg
Abilify C ? +
Lurasidone Tablet 20mg, 40mg, 60mg, 80mg, 120mg Patient Assistance Program
Latuda 90 day supply PAP
B ? + K/L
Quetiapine tablet 25mg, 50mg, 100mg, 200mg,
300mg
Seroquel C - + K
Atypical, serotonin-dopamine antagonist
Risperidone 0.5mg, 1mg, 2mg HD
Risperdal C - + K/L
Bipolar Disorder Lithium Carbonate Capsule 300mg
Eskalith
D - - + See page
69
K
Typical, D2 Antagonist Haloperidol Tablet 1mg, 2mg
Haldol
C - +
ANXIOLYTICS, SEDATIVES, HYPNOTICS
Antianxiety Agent Buspirone Tablet 15mg Buspar
B - + K/L
39 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
ANXIOLYTICS, SEDATIVES, HYPNOTICS
Antihistamine Diphenhydramine Capsule 25mg, 50mg
Benadryl
B - - + See page
66
Antihistamine Diphenhydramine Elixer 12.5ml/5mL
Benadryl
B -
+ See page
66
Hydroxyzine HCL Syrup 10mg/5mL
Atarax
C -
+ See page
66
K/L
Hydroxyzine HCL Tablet 25mg, 50mg
Atarax
C - + + See page
66
K/L
Benzodiazepine Diazepam Tablets 5mg Valium
D - + +
See page 68
L
Oxazepam Capsule 15mg
Serax
D - - + See page
68
Neurohormone, indole Melatonin Tablet 3mg
#120 - -
CARDIOVASCULAR DRUGS
Antihypertensive: ACE-Inhibitor
Lisinopril Tablet 5mg, 10mg, 20mg, 40mg
Zestril D ? + K
Antihypertensive: ACE-Inhibitor/ Diuretic,
Thiazide
Lisinopril/HCTZ Tablet 20/12.5mg, 20/25mg
Zestoretic D ? + K
Antihypertensive: Alpha1 Blocker
Doxazosin Tablet 2mg, 8mg
Cardura
C ? + + See page
66
L
Antihypertensive: Alpha2 Adrenergic Agonist
Clonidine Tablet 0.1mg, 0.2mg, 0.3mg
Catapres
C ? + + See page
66
K
Antihypertensive:
Angiotensin Receptor Blocker
Losartan Tablet 25mg,
50mg, 100mg
Cozaar
D ? +
L
Antihypertensive: Beta Blocker w/ alpha blocking ability
Carvedilol Tablet 3.125mg, 12.5mg, 25mg
Coreg
C ? +
L
Antihypertensive: Beta
Blocker, cardioselective
Atenolol Tablet 50mg,
100mg
Tenormin
D - -
K
Antihypertensive: Beta Blocker, cardioselective
Metoprolol succinate Tablet 25mg, 50mg, 100mg, 200mg XL
Toprol XL
C ? +
L
Antihypertensive: Calcium Channel Blocker
Amlodipine Tablets 5mg, 10mg
Norvasc
C ? +
L
Antihypertensive: Calcium Channel Blocker
Diltiazem HCl XR 180mg, 240mg Capsule
Cardizem CD
C + - +
40 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
CARDIOVASCULAR DRUGS
Antihypertensive: Calcium Channel Blocker
Nifedipine XL Tablet 30mg, 60mg, 90mg
Procardia XL
C - -
L
Antihypertensive: Calcium Channel Blocker
Verapamil SR Tablet 180mg, 240mg
Calan SR
C - + split/- crush
+ K/L
Antihypertensive: Calcium Channel Blocker- ACE-Inhibitor
Amlodipine-benazepril Capsule 2.5-10mg, 5-20mg, 10-40mg
Lotrel
D ? -
L,K
Antihypertensive: Diuretic, Loop
Furosemide Tablet 40mg Lasix
C ? +
K/L
Antihypertensive: Diuretic, Potassium
Sparing
Spironolactone/HCTZ Tablet 25mg/25mg HD
Aldactazide
D + +
K
Antihypertensive: Diuretic, Potassium Sparing
Spironolactone Tablet 25mg HD
Aldactone
D + +
K
Antihypertensive: Diuretic, Thiazide
Chlorthalidone Tablet 25mg
Thalitone
B ? +
K
Antihypertensive:
Diuretic, Thiazide
Hydrochlorothiazide
Tablet 25mg, 50mg
Hydrodiuril
B (D is used
in pregnancy-
induced HTN)
+ +
K
Antihypertensive: Vasodilator
Hydralazine Tablet 25mg, 50mg
Apresoline
C + +
K
Alpha1 Blocker Prazosin Capsule 1mg,
2mg, 5mg Minipress
C ? -
L
Antiarrhythmic Amiodarone Tablet
200mg Cordarone
D - + +
See page 67
L
Antiarrhythmic Digoxin Tablets
0.125mg, 0.25mg Lanoxin
C + + +
See page 67
K
Anticoagulant Enoxaparin SQ Injection
30mg, 40mg, 60mg, 80mg, 100mg, 120mg,
150mg Patient Assistance Program
Lovenox
B +
K
41 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
CARDIOVASCULAR DRUGS
Anticoagulant Warfarin Tablet 5mg Coumadin
- (1st trimester),
C
Use caution
+ + See page
69
K/L
Anticoagulant (Direct Oral Anticoagulant)
Apixaban Tablets2.5 mg, 5mg, 10mg Patient Assistance Program
Anticoagulant (Direct Oral Anticoagulant)
Rivaroxaban Tablet 15mg, 20mg
Xarelto
C - + + See page
67
K/L
Antihyperlipidemic, 2-Azetidinone
Ezetimibe tablet 10mg Zetia
C ? +
L
Antihyperlipidemic, Fibric Acid
Gemfibrozil Tablet 600mg
Lopid
C ? +
K
Antihyperlipidemic, HMG-CoA Reductase Inhibitor
Atorvastatin Tablet 10mg, 20mg, 40mg, 80mg
Lipitor
X - +
L
Antihyperlipidemic, HMG-CoA Reductase Inhibitor
Pravastatin Tablet 40mg Pravachol
X - +
K/L
Antiplatelet Aspirin Tablet 81mg,
325mg (enteric coated) Ecotrin
D ? -
K/L
Antiplatelet Clopidogrel Tablet 75mg Plavix
B ? +
L
Beta Blocker, non-selective
Propranolol Tablet 10mg, 40mg
Inderal
C + +
K/L
Carbonic Anhydrase Inhibitor
Acetazolamide Tablet 500mg ER 12 hr
Diamox Sequels
C - +
K/L
Vasodilator Isosorbide Dinitrate
Tablet 10mg, 20mg, 40mg
Isordil
C ? +
Vasodilator Nitroglycerin SL Tablet
0.4mg
Nitrostat #100 tabs C ?
Vasodilator Nitroglycerin
Transdermal Patch 0.2mg/hr, 0.4mg/hr, 0.6mg/hr
Transderm Nitro #30 patches C ? -
DEVICE Nasal Aspirator + +
Nasal Irrigation Kit Neti Pot
+ +
Peak Flow Meter
+ +
42 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
DEVICE Pill Box
+ +
Spacer Aerochamber
+ +
Spacer, with mask Aerochamber
+ +
Syringes 31G 5/16" 0.5mL, 1mL
Monoject
+ +
Tablet Cutter
+ +
ELECTROLYTE
SUPPLEMENT
Treatment of Dehydration Electrolyte Solution Pedialyte/
Infalyte
1,000 mL ? ?
ELECTROLYTE SUPPLEMENT
Treatment of Hypokalemia
Potassium Chloride Tablet 8mEq
Klor-Con
C ? - K
Androgen Hormone Inhibitor, 5 Alpha-Reductase Inhibitor
Finasteride Tablet 5mg HD Proscar
X - - HD
L
ENDOCRINE AND METABOLIC AGENTS
Antidiabetic, Biguanide Metformin Tablet 1000mg
Glucophage
B ? + K/L
Antidiabetic, Dipeptidyl Peptidase IV (DPP-IV) Inhib
Sitagliptin Tablet 25mg, 50mg, 100mg
Januvia
B ? - K/L
Antidiabetic, GLP-1 Agonist
Liraglutide 18mg/3mL Pen Injector Patient
Assistance Program
Victoza 120 day supply PAP
C -
Antidiabetic, GLP-1 Agonist and Insulin Long-Acting Combination
Insulin glargine and lixisenatide 100units-33mcg/mL Patient Assistance Program
Soliqua 90 day supply PAP, 3 mL pen
B/C -
Antidiabetic, Insulin Rapid-Acting
Insulin Aspart 100units/mL
Novolog, Novolog FlexPen
10 mL vial, 3 mL pen
B/C + -
Antidiabetic, Insulin Rapid-Acting
Insulin Lispro 100units/mL
Humalog, Humalog KwikPen
Insured only, 10 mL vial, 3 mL pen
B/C +
Insulin Glulisine 100units/mL Patient Assistance Program
Apidra, Apidra Solostar
90 day supply PAP, 10 mL vial, 3 mL pen
B/C +
Antidiabetic, Insulin Short-Acting
Insulin Regular 100units/mL
Novolin R 10 mL vial B/C +
Antidiabetic, Insulin
Combination
Insulin Aspart Protamine
and Insulin Aspart 100units/mL
NovoLog Mix
70/30, NovoLog Mix 70/30 FlexPen
10 mL vial,
3 mL pen
B/C +
Insulin Lispro Protamine and Insulin Lispro 100units/mL
Humalog Mix 75/25
10 mL vial B/C +
43 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
ENDOCRINE AND METABOLIC AGENTS
Insulin NPH and Insulin Regular 100units/mL
Novolin 70/30, Humulin 70/30, Humulin 70/30 KwikPen
Humulin insured only, 10 mL vial, 3 mL pen
B/C +
Antidiabetic, Insulin Intermediate-Acting
Insulin NPH 100units/mL Novolin NPH 10 mL vial B/C +
Antidiabetic, Insulin Long-Acting
Insulin Detemir 100units/mL
Levemir, Levemir FlexTouch
10 mL vial, 3 mL pen
B/C +
Antidiabetic, Insulin
Long-Acting
Insulin Glargine
100units/mL
Lantus, Lantus
SoloStar
90 day
supply PAP or insured only, 10 mL vial, 3 mL pen
B/C +
Antidiabetic, SGLT-2 Inhibitor
Empagliflozin Tablet 10mg, 25mg
Jardiance C - + K
Antidiabetic, Sulfonylurea Glipizide ER Tablet 5mg, 10mg
Glucotrol XL C ? - L
Antidiabetic, Thiazolidinedione
Pioglitazone Tablet 15mg, 30mg
Actos
C ? + L
Biphosphonates, Osteoporosis
Alendronate Tablet 4mg Fosamax #4 tabs C - + K
Contraceptive Hormone, Combination
Norethindrone/ E. Estradiol (triphasic)
Tablet 0.5-0.75-1mg/0.035mg HD
Ortho-Novum 7/7/7
#28 tabs X/D - + + See page
68
L
Norgestrel/ E. Estradiol Tablet 0.3mg/0.03mg HD
Lo-Ovral #28 tabs X - + + See page
68
L
Contraceptive Hormone, Progestin
Medroxyprogesterone Acetate Tablet 10mg HD
Provera
X + + L
Norethindrone Tablet 0.35mg HD
Nor-Q-D #28 tabs X - (may start 6
wks after preg)
+ L
Contraceptive, Postcoital Levonorgestrel Plan B One-Step #1 X - + L
Estrogen Estradiol Tablet 2mg HD Estrace
X - + + See page
68
L
Estrogen Estrogens, conjugated
Tablet 0.625mg HD
Premarin X - + +
See page 68
L
Glucocorticoids Methylprednisolone Tablet 4mg Dose Pack
Medrol 21 tablets C ? + K/L
44 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
ENDOCRINE AND METABOLIC AGENTS
Prednisolone Syrup 15mg/mL
Prelone C + K/L
Prednisone Tablet 5mg, 20mg
Deltasone
C + + K/L
Gonadotropin Releasing
Hormone Agonist
Leuprolide IM Injection
11.25mg, 22mg, 30mg Patient Assistance ProgramHD
Lupron 90 day
supply PAP
X -
Gout Colchicine Tablet 0.6mg
HD Colcrys
C ? + K/L
Gout, Xanthine Oxidase Inhibitors
Allopurinol Tablet 100mg, 300mg
Zyloprim
C + + K
Thyroid Levothyroxine 0.025mg,
0.1mg, 0.112mg, 0.125mg, 0.15mg, 0.175mg, 0.2mg Tablet
Levoxyl
A + +
Methimazole Tablet 10mg HD
Tapazole D + +
EYE, EAR, NOSE,
AND THROAT
Analgesic Lidocaine (Viscous) Oral
Solution 2%
Xylocaine 100 mL B +
Antiglaucoma, Alpha2 Agonist
Brimonidine Tartrate Ophthalmic 0.2%
Alphagan 5 mL B ?
Antiglaucoma, Beta-Adrenergic Blocker
Timolol Maleate Ophth Soln 0.5%
Timoptic 5 mL C +
Antiglaucoma, Carbonic Anhydrase Inhibitor
Dorzolamide 2% Trusopt 10 mL C -
Antiglaucoma,
Cholinergic Agent
Pilocarpine Ophth Soln
4%
Pilocar 15 mL C ?
Antiglaucoma, Prostaglandin Inhibitor
Latanoprost Ophth Sol 0.005%
Xalatan 2.5 mL C ?
Anti-infective Chlorhexidine Oral Rinse 0.12%
Peridex 480 mL B ?
EYE, EAR, NOSE, AND THROAT
Erythromycin 5mg/gm Ilotycin 3.5 gm B +
Polymyxin/Trimethoprim
Ophth Soln 10,000 units-1mg/mL
Polytrim 10 mL C ?
Anti-infective, Corticosteroid
Neomycin/Polymyxin B/Hydrocortisone Otic Susp
Cortisporin Otic Otic 10mL ? ?
Cerumenolytic Carbamide Peroxide Otic Drops 6.5%
Debrox 15 mL ? ?
Corticosteroid Fluticasone Propionate
Nasal Spray 50mcg/spray
Flonase 16 gm C ?
Ketorolac 0.5% Ophth Soln
Acular 5 mL C ?
45 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
EYE, EAR, NOSE, AND THROAT
Prednisolone Acetate Ophth Soln 1%
Pred Forte 15 mL C ?
Corticosteroid, Antifungal, Antihistamine
Hydrocortisone, Nystatin, Diphenhydramine Susp
Duke's Mouthwash
120 mL per bottle
? -
Irrigation Saline Nose Spray Saline Spray 45 mL + +
Lubricant Artificial Tear Drops Artificial Tears 15 Ml + +
Artificial Tear Ointment Duratears 3.5 gm + +
Mydriatic Atropine Ophth Soln 1% Atropine 15 mL C +
Antihistamine, Mast Cell Stabilizer
Ketotifen Ophth Soln 0.025%
Zaditor
5 mL C ?
Vasoconstrictor/ Antihistamine
Naphazoline/Pheniramine Ophth Soln 0.025%/0.3%
Vasocon-A 15 mL C ?
Antacid Magnesium/Aluminum/ Simethicone Suspension
Maalox Max Strength
480 mL C ?
K
GASTROINTESTINAL DRUGS
Anticholinergic Dicyclomine Capsules 10mg
Bentyl
B - - + See page
66
Antidiarrheal Diphenoxylate/Atropine Sulf Tablets 2.5/0.025mg
Lomotil; Lonox
C - - K/L
Bismuth Subsalicylate
Tablet 262mg
Pepto-Bismol #30 tabs D ? +
Loperamide Tablet 2mg Imodium #12 tabs C + +
Antiflatulent Simethicone Drops 40mg/0.6mL
Mylicon 30 mL C but + ?
Constipation, Chronic Lactulose Syrup 10gm/15mL
Duphalac Syrup
B ?
Constipation, IBS Lubiprostone Capsule
24mcg Patient Assistance Program
Amitiza 90 day
supply PAP
C ? -
Laxative, Diphenylmethane
Bisacodyl Tablet 5mg Dulcolax
C ? -
Laxative, Osmotic Glycerin 1 gm suppository
Pedia-Lax Rectal A + +
Glycerin 2 gm suppository
Sani-Supp Adult Rectal
A + +
Polyethylene Glycol MiraLax 255 gm C ?
Laxative, Osmotic (for Bowel Prep)
Polyethylene Glycol with Electrolytes
GoLytely 4,000 mL C ?
46 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
GASTROINTESTINAL DRUGS
Laxative, Bulk Psyllium Hydrophilic Powder
Metamucil 284 gm + ?
Pancreatic Enzymes Pancreatic Enzymes Capsule Lipase/Protease/Amylase
6k/19k/30k, 12k/38k/60k, 24k/76k/120k Patient Assistance Program
Creon 90 day supply PAP
C ? - (OK to open
and give
with apple-
sauce or pudding)
K
Prokinetic Metoclopramide Tablet 10mg
Reglan
B ? + K
Proton Pump Inhibitor Omeprazole Capsule 20mg
Prilosec
C ? - L
Stool Softener Docusate Sodium Capsule 100mg
Colace #100 caps C ? - (taste may be unaccept
able)
Alpha1 Blocker Tamsulosin 0.4mg Capsule
Flomax
B + -
GENITOURINARY AGENTS
Analgesic, Urinary Phenazopyridine Tablet 100mg, 97.5mg or 95mg
Pyridium
B ? + K
Anticholinergic, Urinary Tolterodine Tartrate extended release tablet
4mg IPAP
Detrol LA
C - - K/L
Antispasmodic, Urinary Oxybutynin Chloride Tablet 5mg
Ditropan
B ? + K/L
GENITOURINARY AGENTS
Migraine Combinations Butalbital, Acetaminophen and Caffeine Tablet
50mg/325mg/40mg
Note: Fioricet changed strength April
2014 and no longer has a generic
C - + +
See page 68
K/L
MIGRAINE AGENTS Serotonin 5-HT1 Receptor Agonist
Eletriptan Tablet 40mg Relpax 6 tabs per box
C ? + L
Calcium, Phosphate Binder
Calcium Acetate Capsule 667mg
PhosLo
C ? -
NEPHROLOGY Treatment of Hyperkalemia
Sodium Polystyrene Sulfonate Susp 15gm/60mL
Kayexalate 60 mL per bottle
C ?
47 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
NUTRIENTS AND NUTRITIONAL AGENTS
Vitamin D Analog Calcitriol Capsule 0.5mcg Rocaltrol
C ? -
Calcium Supplement Calcium (elemental) Tablet 500mg
Calcium #60 tabs per bottle
+ (? 1st trimester)
? + K
Hypomagnesemia Magnesium Oxide Tablet 400mg (240mg elemental)
MagOx #120 A + + L
Nutritional Supplement Thiamine Tablet 100mg Various #100 tabs A + +
Vitamin Cyanocobalamin Tablets
500mcg
Vitamin B12 #130 tabs C + +
Folic Acid Tablet 1mg
A + +
Multivitamin Drops with Iron
Poly-vi-sol 50 mL + +
Multivitamin Tablet, Adult
Centrum #100 tabs + + +
Multivitamin tablet, Children
Flintstones #100 tabs + + +
Omega-3 Fatty Acids (180 EPA / 120 DHA)
Fish Oil #100 caps C ? - L
Prenatal Vitamins Natalins RX #100 tablets + + +
Vitamin Vitamin D3 Tablet 400 IU, 1000 IU
#100 tabs C Avoid high
doses
Vitamin D3 Capsule
50000 IU
C Avoid high
doses
Vitamin D3 Liquid 400 IU/mL
D-Vi-Sol 50 mL
Antihistamine Cetirizine Solution 1mg/mL
Zyrtec 120 mL B - K
RESPIRATORY AGENTS
Cetirizine Tablet 10mg Zyrtec #30 tablets B - + K
Antihistamine Loratadine Tablet 10mg Claritin #30 tabs B + + K
48 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
RESPIRATORY AGENTS
Antihistamine and Decongestant (Alpha/Beta Adrenergic Agonist)
Triprolidine/ Pseudoephedrine Tablet 2.5mg/60mg
Actifed #24 tabs - (1st trimester),
C
? + + See page
66
Antitussive Benzonatate Capsule
100mg
Tessalon Perles #20 caps C ? -
Beta2 Adrenergic Agonist/ Corticosteroid, Inhalant
Fluticasone Propionate/Salmeterol Diskus 100/50mcg, 250/50mcg, 500/50mcg
Advair Diskus
C ?
Bronchodilator,
Anticholinergic
Ipratropium Bromide
Nebulizer Soln 0.02%
Atrovent 25 vials per
box
B ?
Tiotropium Bromide Cap for inhalation 18mcg
Spiriva
C - -
Bronchodilator, Beta2-Adrenergic Agonist
Albuterol MDI Proventil, Ventolin, ProAir
C ?
Albuterol Nebulizer
Solution 0.083%
Proventil,
Ventolin
#25 C ?
Corticosteroids, Inhalant Fluticasone Propionate MDI 44mcg/puff, 110mcg/puff, 220mcg/puff
Flovent
C ?
Decongestant (Alpha/Beta Adrenergic
Agonist)
Pseudoephedrine Tablet 30mg, 60mg
Sudafed #24 tabs C + + K
Decongestant (topical) Oxymetazoline Nasal Spray 0.05%
Afrin 15 mL C ?
Expectorant Guaifenesin Tablet 200mg
Humibid #100 tabs C + +
Leukotriene Inhibitor Montelukast Chewable Tablet 4mg, 5mg
Singulair
B ? + L
Montelukast Tablet 10mg Singulair B ? + L
Disease Modifying Antirheumatic Drug (DMARD)
Methotrexate Tablet 2.5mgHD
Rheumatrex
X - + K/L
RHEUMATOLOGY Tumor Necrosis Factor Blocking Agent
Adalimumab Injection 40mg Patient Assistance
Program
Humira 90 day supply PAP
B - - ?
Centrally Acting Cyclobenzaprine Tablets 5mg
Flexeril
B ? + + See page
69
L
SKELETAL MUSCLE RELAXANT
Methocarbamol Tablet 500mg
Robaxin
C ? + + See page
69
L
49 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
SKELETAL MUSCLE RELAXANT
Centrally Acting Baclofen Tablet 10mg Lioresal
C + + K
Acne Benzoyl Peroxide Gel 5% Panoxyl 42.5 gm C ?
SKIN AND MUCOUS
MEMBRANE AGENTS
Tretinoin Cream 0.05%
HD
Retin-A 45 gm D -
Antibiotic, Topical Bacitracin Ointment 500 units/gm
15 gm B ?
Mupirocin 2% Ointment Bactroban 22 gm B ?
Antifungal Ketoconazole 2% Shampoo
Nizoral 120 mL C ?
Miconazole Cream 2% Micatin 30 gm + ?
Nystatin Cream 100,000 units/gm
Mycostatin 15 gm C ?
Terconazole Vaginal Cream 0.8%
Terazol-3 20 gm C -
Anti-infective Silver Sulfadiazine Silvadene 20 gm B -
Antiparasitic Agent,
Pediculocide
Piperonyl Butoxide and
Pyrethrum Extract Kit
Rid Shampoo 120 mL C ?
Permethrin Cream 5% Elimite 60 gm B ?
Anti-viral, topical immunomodulator
Imiquimod Cream 5% Aldara #12 single-use packets
C ?
Corticosteroid Clobetasol Ointment 0.05%
Temovate 15 gm C ?
Clobetasol Solution
0.05%
Temovate 50 mL C ?
Fluocinonide Cream 0.05%
Lidex 30 gm C -
Hydrocortisone Cream 1%, 2.5%
30gm (1%) 20gm(2.5%)
C ?
Corticosteroid Hydrocortisone Ointment 1%
30 gm
SKIN AND MUCOUS
MEMBRANE AGENTS
Hydrocortisone
Suppository 25mg
Anusol-HC #12 per box C ?
Triamcinolone Acetonide Cream 0.1%
Aristocort; Kenalog
15 gm, 80 gm
C ?
Triamcinolone Acetonide Dental Paste 0.1%
Oralone 5 gm C ?
Dandruff Sulfur/Salicylic Acid Shampoo 2%/2%
Sebulex 120 mL C -
Estrogen Estrogens, conjugated
Cream 0.625mg/gm HD
Premarin 30 gm X -
50 n:\lchc_pharm\formulary management\formulary of drugs book\2020\lean formulary book\8. formulary of drugs (therapeutic) pp32,49.docx
Therapeutic
Category
Pharmacologic
Category
Medication Brand Name Package
Size (if applicable)
Preg Cat Safety in
Lactation
Crush/
Split
Beers
List
Dose
Adjust K=Kidney L=Liver
SKIN AND MUCOUS MEMBRANE AGENTS
Miscellaneous Metronidazole Gel 0.75% (Topical)
Metrogel 45 gm B ?
Moisturizing Moisturizing Cream Eucerin 120 gm + +
Protectant Zinc Oxide Ointment
20%
Desitin 30 gm + +
Tinea Versicolor; Dandruff; Seborrheic Dermatitis
Selenium Sulfide Lotion 2.5%
Selsun 120 mL C ?
Dopamine Reuptake Inhibitor
Bupropion Tablet 100mg Wellbutrin
C - + K/L
SMOKING
CESSATION
Nicotine Product Nicotine Gum 2mg, 4mg Nicorette Gum 110 pieces C -
K/L
Nicotine Transdermal Patch 7mg/hr, 14mg/hr, 21mg/hr1
Nicoderm CQ #14 patches D -
K/L
Partial Nicotine Agonist Varenicline Tablet Starter Pack IPAP
Chantix
C - + K
VareniclineTablet
Continuing Pack IPAP
Chantix
C - + K
ADHD, Narcolepsy Dextroamphetamine /Amphetamine Tabs 10mg
Adderall C - + K
STIMULANT Methylphenidate HCl Tablet 5mg
Ritalin C ? +
Updated: April 24, 2020
1 up to 42 mg/day of nicotine via patch may be appropriate and is thought to be safe for those with high nicotine consumption