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Formulary for LeChee (PDF)

 

  Legend
  Alerts, Recalls, & Shortages
  Look Alike Sound Alike Drugs
  Drug Substitution
  Notes/Comments
 {P} Preferred
 {R} Restricted
 {S} Status Pending
 {TI} Therapeutic Interchange

 

 

 

 

  

 

  acetaminophen 

 

 

   oral, liquid

80 mg/0.8 mL, 160 mg/5 mL

   oral, tablet

325 mg {R: see note}

   oral, tablet, chewable

80 mg

 

 

     

Feverall (acetaminophen)

ASHP has recently posted a shortage pertaining to this drug. Please view the link for further details to see if this applies to your facility

http://www.ashp.org/Import/PRACTICEANDPOLICY/PracticeResourceCenters/DrugShortages/GettingStarted/CurrentShortages/Bulletin.aspx?id=660

     {R}- Restriction: APAP 325mg tablets for children less than 16 years of age,

  acetaminophen-codeine

   oral, liquid

120 mg-12 mg/5 mL

   oral, tablet

300 mg-30 mg

      acetaminophen-hydrocodone,  acetaminophen-oxycodone

  acetaminophen-HYDROcodone

   oral, elixir

500 mg-7.5 mg/15 mL {R: See Note}

   oral, tablet

500 mg-7.5 mg

      acetaminophen-codeine

     Lortab Elixir Resticted to ENT Providers after pediatric postop tonsillectomies.

  acetaminophen-oxyCODONE

   oral, tablet

325 mg-5 mg

      acetaminophen-codeine

  acetaZOLAMIDE 

   injectable, powder for injection

500 mg

   oral, capsule, extended release

500 mg

   oral, tablet

250 mg

 

 

 

  acetic acid-aluminum acetate otic

   otic, solution

2%-0.79%

  acetylcysteine 

   inhalation, solution

20%

 

 

  acyclovir 

 

 

   oral, suspension

200 mg/5 mL

   oral, capsule

200 mg

   oral, tablet

800 mg

  adalimumab

   subcutaneous, kit

40 mg/0.8 mL {R: See Note}

     New start requires Rheumatology consultation. Primary care providers are permitted to write for refills, but new start prescriptions require rheumatologic consultation (phone consults are accepted).  As a reminder, our Adult Rheumatology Clinic is now fully operational.

 

  albuterol 

   inhalation, solution

5 mg/mL, 1.25 mg/3 mL (0.042%) {R: Inpt Use Only}, 2.5 mg/3 mL (0.083%)

   inhalation, aerosol

90 mcg/inh

     

 (Albuterol )

ASHP has recently posted a shortage pertaining to this drug.  Please view the link for further details to see if this applies to your facility.

http://www.ashp.org/s_ashp/bulletin.asp?id=112&CID=1500&DID=1544&sort=2

      acebutolol

  albuterol-ipratropium

   inhalation, solution

2.5 mg-0.5 mg/3 mL

  alendronate

   oral, tablet

10 mg, 70 mg

  alendronate-cholecalciferol

   oral, tablet

70 mg-5600 intl units

  allantoin/camphor/phenol topical

   topical, ointment

1%-0.5%-0.5% {R: Inpatient Use Only}

  allopurinol 

   oral, tablet

100 mg, 300 mg

  ALPRAZolam

   oral, tablet

0.25 mg, 0.5 mg

      clonazepam,  diazepam,  lorazepam

  aluminum hydroxide

   oral, suspension

600 mg/5 mL

     Inpatient and Dinnebito Clinic use only

  aluminum sulfate-calcium acetate topical

   topical, powder for reconstitution

- {R: Inpt, Grp.Home, Dinnebito}

  amantadine

   oral, syrup

50 mg/5 mL

   oral, capsule

100 mg

      amiodarone,  ranitidine,  rimantadine

  amcinonide topical

   topical, ointment

0.1% {TI: See Note}

     1)For Dr. DeCapite's patients- either triamcinolone 0.5% ointment or fluocinonide 0.05% cream, depending on the patient's preference for a cream vs. ointment. If the patient has no preference or you cannot contact him/her, please use triamcinolone 0.5% ointment.

2)For anyone else's patients- switch to triamcinolone 0.5% ointment

Use "per P&T decision" as the reason for discontinuing amcinonide. We will do this until further notice.

  amiodarone 

 

 

   oral, tablet

200 mg

 

  amitriptyline

   oral, tablet

10 mg, 25 mg, 50 mg

      aminophylline,  imipramine,  nortriptyline

 

   amLODIPine

   oral, tablet

5 mg, 10 mg

      amiloride,  amiodarone,  felodipine

  amoxicillin

   oral, capsule

250 mg, 500 mg

   oral, powder for reconstitution

250 mg/5 mL

      Amoxil,  ampicillin,  Atarax,  Augmentin

 

amoxicillin-clavulanate

   oral, powder for reconstitution

600 mg-42.9 mg/5 mL

   oral, tablet

250 mg-125 mg, 500 mg-125 mg, 875 mg-125 mg

  amphetamine-dextroamphetamine 

   oral, capsule, extended release

10 mg, 15 mg

   oral, tablet

5 mg

     

Dextroamphetamine Tablets (dextroamphetamine)

ASHP has recently posted a shortage pertaining to this drug. Please view the link for further details to see if this applies to your facility.

http://www.ashp.org/DrugShortages/Current/Bulletin.aspx?id=853

 

 

  antipyrine-benzocaine otic

   otic, solution

54 mg-14 mg/mL

  APAP/butalbital/caffeine

   oral, tablet

325 mg-50 mg-40 mg

  apraclonidine ophthalmic

   ophthalmic, solution

1%

  ARIPiprazole

   oral, tablet

2 mg {R: Mental Hlth. Dept. only}, 5 mg {R: Mental Hlth. Dept. only}, 20 mg {R: Mental Hlth. Dept. only}, 30 mg {R: Mental Hlth. Dept. only}

  ascorbic acid 

   oral, tablet

500 mg {R: Inpt, Grp.Home, Dinnebito}

     

Ascorbic Acid Injection (ascorbic acid)

ASHP has recently posted a shortage pertaining to this drug. Please view the link for further details to see if this applies to your facility.

http://www.ashp.org/DrugShortages/Current/Bulletin.aspx?id=934

  aspirin

   oral, delayed release tablet

81 mg, 325 mg

   oral, tablet

325 mg

   oral, tablet, chewable

81 mg

   rectal, suppository

300 mg, 600 mg

  atenolol

   oral, tablet

25 mg, 50 mg

      metoprolol

      Akarpine

  atropine ophthalmic

   ophthalmic, solution

1%

 

 atropine-diphenoxylate

   oral, tablet

0.025 mg-2.5 mg {R: see note}

     NOT for use with simple diarrhea

  azaTHIOprine 

   oral, tablet

50 mg

     

 

  azithromycin 

 

 

   oral, powder for reconstitution

1 g {R: For Chlamydia Only}, 200 mg/5 mL

   oral, tablet

250 mg {R: See Note}

     Azithromycin remains on the formulary, however it is now restricted for use in the treatments of: Pneumonia. Bacterial Bronchitis in patients with chronic lung disease/interstitial lung disease. Infections in Immunocompromised patients. Infections in patients with endstage renal disease on dialysis.Infections that have failed other first line treatments. STDs. P&T update 05/2012: Usage approved for Empiric treatment of pertussis & prophylxis for close contacts.

 

  bacitracin-polymyxin B ophthalmic

   ophthalmic, ointment

500 units-10000 units/g

  baclofen

   oral, tablet

10 mg

  barium sulfate 

   oral, suspension

2.1% {See Note}, 40% {See Note}

     

Barium Sulfate Oral Suspension (barium sulfate)

ASHP has recently posted a shortage pertaining to this drug. Please view the link for further details to see if this applies to your facility.

http://www.ashp.org/DrugShortages/Current/Bulletin.aspx?id=963

     BASIC ORAL CONTRAST GUIDELINES

CT Abdomen (Outpatient Prescriptions): 1 bottle of Readi-Cat

CT Abdominal/Pelvic (Outpatient Prescriptions): 2 bottles of Readi-Cat

(All Emergency Room and Inpatient Prescriptions will receive Gastroview  1000mL or 1500mL as per previous Guidelines.)

CT Colongraphy: Tagitol V with BE Prep Kit (If Tagitol V is NOT available, may substitute 1 bottle of Readi-Cat to be divided into 3 doses: 1/3 bottle at breakfast, 1/3 bottle at Noon, and 1/3 bottle with Evening Meal the day BEFORE the scan, AND 65mL of Gastrografin to be taken with NOON meal the day BEFORE the scan.

Colonoscopy: Golytely

  becaplermin topical

   topical, gel

0.01%

  beclomethasone

   inhalation, aerosol

80 mcg/inh

  belladonna-opium

   rectal, suppository

16.2 mg-60 mg

  benzonatate

   oral, capsule

100 mg

      benazepril,  benztropine

  benzoyl peroxide-erythromycin topical

   topical, gel

5%-3%

  benztropine

   oral, tablet

2 mg

      benzonatate

  betamethasone topical

   topical, lotion

dipropionate 0.05%

  bimatoprost ophthalmic

   ophthalmic, solution

0.03% {R: For Eye Clinic Use ONLY}

  bisacodyl 

   oral, delayed release tablet

5 mg {R: see note}

   rectal, suppository

10 mg {R: See Note}

     

Fleet Bisacodyl (bisacodyl)

ASHP has recently posted a shortage pertaining to this drug. Please view the link for further details to see if this applies to your facility.

http://www.ashp.org/DrugShortages/Current/Bulletin.aspx?id=760

      bisoprolol,  Visicol

     {R}-Restricted: Bowel Preps or Spinal Patients on Bowel Program only

  bismuth subsalicylate

   oral, suspension

262 mg/15 mL {Inpatient Use Only}

   oral, tablet, chewable

262 mg {R: H. Pylori only}

  brimonidine ophthalmic

   ophthalmic, solution

0.15%, 0.2%

  brinzolamide ophthalmic

   ophthalmic, suspension

1%

  bromocriptine

   oral, tablet

2.5 mg

  budesonide

   inhalation, suspension

0.25 mg/2 mL, 0.5 mg/2 mL

 

buPROPion

   oral, tablet

75 mg

   oral, tablet, extended release

150 mg/12 hours, 150 mg/24 hours, 300 mg/24 hours

      busPIRone

     Use for Smoking Cessation will NOT be honored

  busPIRone

   oral, tablet

5 mg, 10 mg

      buPROPion

  caffeine 

   oral, liquid

citrate 20 mg/mL

     

Cafcit (caffeine citrate)

 

  calcipotriene topical

   topical, cream

0.005%

  calcitonin

   nasal, spray

200 intl units/inh

  calcitriol

   oral, capsule

0.25 mcg

   oral, liquid

1 mcg/mL

      Calciferol

  calcium acetate 

   oral, tablet

667 mg

calcium carbonate

   oral, tablet

500 mg {R: see note}

      calcium acetate,  calcium gluconate

     {R}- Restricted: Diagnosis of Osteoporosis, Osteopenia or Metabolic Disorders causing Hypocalcemia and High School Clinic Patients on Depo-Provera

  carBAMazepine

   oral, suspension

100 mg/5 mL

   oral, tablet

200 mg

   oral, tablet, chewable

100 mg

  carbidopa-levodopa

   oral, tablet

10 mg-100 mg, 25 mg-100 mg, 25 mg-250 mg

   oral, tablet, extended release

50 mg-200 mg

  carteolol ophthalmic

   ophthalmic, solution

1%

 

carvedilol

   oral, tablet

3.125 mg {R: see note}, 6.25 mg {R: see note}, 12.5 mg {R: see note}, 25 mg {R: see note}

      captopril,  carteolol

     Restricted to patients w/ Refractory CHF with EF of 30-35% or less.

 

  cefdinir

   oral, powder for reconstitution

250 mg/5 mL {R: See Note}

     Suspension: Available for use in pediatric pneumonia or resistant otitis media

  cefixime

   oral, tablet

400 mg {R: For Documented Gonorrhea}

  cefpodoxime 

   oral, powder for reconstitution

50 mg/5 mL {R: see note}

   oral, tablet

200 mg {R: see note}

     

Cefpodoxime (cefpodoxime)

ASHP has recently posted a shortage pertaining to this drug. Please view the link for further details to see if this applies to your facility.

http://www.ashp.org/DrugShortages/Current/Bulletin.aspx?id=793

      cefixime

     Tablet: Restricted to use only for IV to PO step down therapy in pneumonia
Suspension: Available for use in pediatric pneumonia or resistant otitis media

  cephalexin

   oral, capsule

250 mg, 500 mg

   oral, powder for reconstitution

250 mg/5 mL

      cefaclor,  cefazolin,  cefuroxime,  ciprofloxacin

  charcoal

   oral, suspension

25 g

  charcoal-sorbitol

   oral, suspension

25 g

  chlordiazePOXIDE

   oral, capsule

25 mg

      chlorproMAZINE

  chlorhexidine topical

   mucous membrane, liquid

0.12%

   topical, soap

4% {R: Inpatient Use Only}

      chlorproMAZINE

  chlorothiazide

   oral, suspension

250 mg/5 mL

  chlorproMAZINE

 

 

   oral, tablet

25 mg, 50 mg

      chlordiazepoxide,  chlorhexidine topical,  chlorproPAMIDE,  chlorthalidone,  prochlorperazine,  thioridazine

  chlorthalidone

   oral, tablet

25 mg

      chlorproMAZINE

  cholecalciferol

   oral, tablet

400 intl units {R}

     NON-FORMULARY: Vitamin D 400 units

 RESTRICTED: Vitamin D 800 units (400 units x 2) for osteoporosis, osteopenia, Vitamin D defieciency maintenance therapy

  ciprofloxacin 

 

 

   oral, tablet

250 mg {limited supply. On B/O}, 500 mg {limited supply. On B/O}

  ciprofloxacin ophthalmic

   ophthalmic, solution

0.3%

  ciprofloxacin-dexamethasone otic

   otic, suspension

0.3%-0.1% {R: TO: ENT Only}

  citalopram

   oral, tablet

20 mg, 40 mg

      escitalopram

  clarithromycin 

   oral, powder for reconstitution

250 mg/5 mL

   oral, tablet

250 mg {R: see note}, 500 mg {R: see note}

  clindamycin

 

 

   oral, capsule

150 mg

   oral, powder for reconstitution

75 mg/5 mL

  clindamycin topical

   topical, gel

1%

  clobetasol topical

   topical, ointment

0.05%

  clomiPHENE

   oral, tablet

50 mg

      clomiPRAMINE

 

  clomiPRAMINE

   oral, capsule

25 mg, 50 mg

      clomiPHENE,  desipramine

  clonazePAM

   oral, tablet

0.5 mg, 1 mg

      alprazolam,  clonidine,  clorazepate,  diazepam,  Klonopin,  lorazepam

  cloNIDine

   oral, tablet

0.1 mg, 0.2 mg

   transdermal, film, extended release

0.1 mg/24 hr, 0.2 mg/24 hr

      Cardizem,  clonazepam,  colchicine,  Klonopin

  clopidogrel

   oral, tablet

75 mg

  clorazepate

   oral, tablet

3.75 mg

      clonazepam

  clotrimazole topical

   topical, cream

1% {R: see note}

   topical, solution

1%

 

 

 

  cloZAPine

   oral, tablet

25 mg, 100 mg

  cocaine topical

   topical, solution

4%

  codeine

   oral, tablet

sulfate 30 mg

      Cardene,  iodine topical,  Lodine

  colchicine

   oral, tablet

0.6 mg

      clonidine

  colestipol

   oral, granule for reconstitution

5 g

  collagenase topical

   topical, ointment

250 units/g

  conjugated estrogens

 

 

   oral, tablet

0.3 mg, 0.625 mg, 1.25 mg

  conjugated estrogens topical

   vaginal, cream with applicator

0.625 mg/g

  conjugated estrogens-medroxyPROGESTERone

   oral, tablet

0.625 mg-2.5 mg

  cyanocobalamin 

 

 

   oral, tablet

1000 mcg

 

  cyclobenzaprine

   oral, tablet

10 mg

      cetirizine,  cyproheptadine

  cyclopentolate ophthalmic

   ophthalmic, solution

1%

  cycloSPORINE 

   oral, solution

100 mg/mL

   oral, capsule

modified 25 mg, modified 100 mg

  cycloSPORINE ophthalmic

   ophthalmic, emulsion

0.05% {R: Eye Clinic use only}

  cyproheptadine

   oral, syrup

2 mg/5 mL

   oral, tablet

4 mg

      cyclobenzaprine

  danazol

   oral, capsule

100 mg, 200 mg

      Dantrium

  dantrolene

 

 

   oral, capsule

25 mg

  dapsone

   oral, tablet

100 mg

 

  desflurane

   inhalation, liquid

100%

  desipramine

   oral, tablet

25 mg, 50 mg

      clomiPRAMINE,  imipramine,  nortriptyline

  desogestrel-ethinyl estradiol

   oral, tablet

0.15 mg-0.03 mg {Reclipsen}

  dexamethasone/neomycin/polymyxin B ophthalmic

   ophthalmic, suspension

1 mg-3.5 mg-10000 units/mL {R: Eye Clinic Use Only}

   ophthalmic, ointment

1 mg-3.5 mg-10000 units/g {R: Eye Clinic Use Only}

  dexamethasone-tobramycin ophthalmic

   ophthalmic, suspension

0.1%-0.3% {R: Eye Clinic Use Only}

 

  dextroamphetamine

   oral, capsule, extended release

15 mg

   oral, tablet

5 mg

      dextroamphetamine-amphetamine

  dextromethorphan-guaiFENesin

   oral, liquid

10 mg-100 mg/5 mL {R: Inpt, Grp.Home, Dinnebito}

  diazepam 

 

 

   oral, tablet

5 mg

  dibucaine topical

   topical, ointment

1%

  diclofenac

   oral, delayed release tablet

sodium 50 mg, sodium 75 mg

  diclofenac topical

   topical, gel

1%

  dicloxacillin

   oral, capsule

250 mg

      doxycycline

  dicyclomine

   oral, capsule

10 mg

      demeclocycline,  diphenhydrAMINE

  digoxin

 

 

   oral, elixir

50 mcg/mL (0.05 mg/mL)

   oral, tablet

125 mcg (0.125 mg), 250 mcg (0.25 mg)

      doxepin

  diltiazem 

 

 

   oral, capsule, extended release

120 mg/24 hours, 180 mg/24 hours, 240 mg/24 hours

   oral, tablet

30 mg

 

  diphenhydrAMINE

 

 

   oral, capsule

25 mg {R: Inpt, Grp.Home, Dinnebito}

   oral, liquid

12.5 mg/5 mL {R: Inpt, Grp.Home, Dinnebito}

      dicyclomine,  dipyridamole

  dipyridamole 

 

 

   oral, tablet

25 mg

  disulfiram

   oral, tablet

250 mg

  divalproex sodium

   oral, delayed release capsule

125 mg

   oral, delayed release tablet

250 mg, 500 mg

  docusate

   oral, capsule

sodium 100 mg {R: see note}

   oral, liquid

10 mg/mL {R: see note}

     {R}-Restricted: For use in post-operative patients or active bleeding hemorrhoids, or spinal patients on bowel program

  doxepin

   oral, capsule

10 mg, 25 mg, 50 mg

      digoxin,  doxycycline

  doxycycline 

 

 

   oral, capsule

hyclate 100 mg

   oral, tablet

hyclate 100 mg

     

Doxycycline Capsules and Tablets (doxycycline)

ASHP has recently posted a shortage pertaining to this drug. Please view the link for further details to see if this applies to your facility.

http://www.ashp.org/DrugShortages/Current/Bulletin.aspx?id=977

  drospirenone-ethinyl estradiol

   oral, tablet

3 mg-0.02 mg {R: Patients w/ PCOS & PMDD}

  DULoxetine

   oral, delayed release capsule

20 mg, 30 mg

  econazole topical

   topical, cream

1%

  efavirenz

   oral, capsule

200 mg

  efavirenz/emtricitabine/tenofovir

   oral, tablet

600 mg-200 mg-300 mg

  emollients, topical 

   topical, cream

- {R: age < 18 yrs.}

   topical, gel

- {R}

     

Surgilube (emolients, topical)

ASHP has recently posted a shortage pertaining to this drug. Please view the link for further details to see if this applies to your facility.

http://www.ashp.org/DrugShortages/Current/Bulletin.aspx?id=822

     {R}-Hydrocerin is restricted Pediatric patients with eczema.{R}- Surgilube restricted to OR.

  emtricitabine-tenofovir

   oral, tablet

200 mg-300 mg

      epinephrine

  EPINEPHrine 

 

 

 

 

   injectable, kit

0.15 mg, 0.3 mg

 

  epoetin alfa

   injectable, solution

10000 units/mL, 20000 units/mL

  ergocalciferol

   oral, capsule

50,000 intl units {For Vitamin D Deficiency}

  erythromycin 

 

 

   oral, granule for reconstitution

ethylsuccinate 200 mg/5 mL

   oral, tablet

stearate 250 mg

  erythromycin ophthalmic

   ophthalmic, ointment

0.5%

  erythromycin-sulfiSOXAZOLE

   oral, granule for reconstitution

200 mg-600 mg/5 mL

  estradiol 

   oral, tablet

1 mg

  etanercept

   subcutaneous, solution

25 mg/0.5 mL {R: See Note}, 50 mg/mL {R: See Note}

     New start requires Rheumatology consultation. Primary care providers are permitted to write for refills, but new start prescriptions require rheumatologic consultation (phone consults are accepted).  As a reminder, our Adult Rheumatology Clinic is now fully operational.

  ethacrynic acid

   oral, tablet

25 mg

  ethambutol 

   oral, tablet

400 mg

 

  ethinyl estradiol-etonogestrel

   vaginal, ring

0.015 mg-0.120 mg

  ethinyl estradiol-levonorgestrel

   oral, tablet

triphasic {Enpresse}, 20 mcg-100 mcg {Sronyx}, 30 mcg-0.15 mg {Nordette}

  ethinyl estradiol-norelgestromin

   transdermal, film, extended release

20 mcg-150 mcg/24 hr

  ethinyl estradiol-norethindrone 

   oral, tablet

20 mcg-1 mg {Loestrin Fe 1/20}, 35 mcg-1 mg {Norinyl 1/35}

 

  ethosuximide

   oral, syrup

250 mg/5 mL

  ethyl chloride topical

   topical, spray

100%

 

Eye Wash

   ophthalmic, solution

neutral {R: In-hospital use only}

  ezetimibe

   oral, tablet

10 mg

 

 

 

  fenofibrate

   oral, tablet

50 mg, 160 mg

     Tricor has been removed from the formulary effective October 1st. All prescriptions for Tricor 48 mg ($0.71/per pill) will automatically be switched to Triglide 50 mg ($0.39/per pill). All prescriptions for Tricor 145 mg ($2.10/per pill) will be switched to Triglide 160 mg ($0.46/per pill). Triglide is a different brand of generic Fenofibrate that is significantly cheaper with similar effectiveness.  Pharmacy will not be calling providers for permission to make this switch; it will be automatic.  Pharmacists will also have permission to document this change on the Chronic Medication List.

  fentaNYL 

 

 

   transdermal, film, extended release

25 mcg/hr, 50 mcg/hr, 100 mcg/hr

  ferrous gluconate

   oral, tablet

324 mg {R: Inpt, Grp.Home, Dinnebito}

  ferrous sulfate

   oral, liquid

75 mg/0.6 mL {SEE NOTE}

   oral, tablet

325 mg {SEE NOTE}

     ***Ferrous Sulfate Liquid 75mg/0.6ml = 15mg/0.6ml Elemental Iron

***Ferrous Sulfate Tablets 325mg/tablet = 65mg/tablet Elemental Iron

  filgrastim

   injectable, solution

300 mcg/mL

  finasteride

   oral, tablet

5 mg

  fluconazole 

 

 

   oral, powder for reconstitution

10 mg/mL

   oral, tablet

200 mg

 

 

fludrocortisone

   oral, tablet

0.1 mg

 

  flunisolide nasal

   nasal, spray

25 mcg/inh

 

  fluocinonide topical

   topical, cream

0.05%

   topical, solution

0.05% {R: For Dermatology Use Only}

      fluocinolone topical,  fluorouracil

  fluorescein ophthalmic

   ophthalmic, test

1 mg

  fluoride 

   oral, liquid

0.25 mg/drop

   oral, tablet, chewable

0.5 mg

  FLUoxetine

   oral, capsule

10 mg, 20 mg

   oral, delayed release capsule

90 mg

      famotidine,  fluphenazine,  fluvastatin,  fluvoxamine,  furosemide,  paroxetine

  fluPHENAZine

 

 

   oral, tablet

2.5 mg, 5 mg, 10 mg

      fluoxetine,  perphenazine,  trifluoperazine

  flurandrenolide topical

   topical, lotion

0.05%

  fluticasone 

   inhalation, aerosol

CFC free 110 mcg/inh, CFC free 220 mcg/inh

 

  fluticasone nasal

   nasal, spray

50 mcg/inh

  fluticasone-salmeterol

   inhalation, powder

100 mcg-50 mcg {R}, 250 mcg-50 mcg {R}, 500 mcg-50 mcg {R}

     For patients already on Flovent and Serevent since it is cheaper than the cost of the two inhalers separately.   The Committee emphasized that not all patients need an inhaled corticosteroid of the potency of Flovent.  Patients who are controlled on lower potency inhaled steroids should not be switched to Advair.   Providers must write for the change in inhaler if it is desired.  Close monitoring of use will be done.

  folic acid 

 

 

   oral, tablet

1 mg

 

  formoterol-mometasone

   inhalation, aerosol

5 mcg-100 mcg/inh {See Note}, 5 mcg-200 mcg/inh {See Note}

 

  furosemide 

 

 

   oral, solution

40 mg/5 mL

   oral, tablet

20 mg, 40 mg

  gabapentin

   oral, capsule

100 mg, 300 mg

   oral, tablet

300 mg, 600 mg

  ganciclovir ophthalmic

   ophthalmic, gel

Restricted to Eye Providers Only.

0.15%

  gastrografin

   compounding, solution

37%

  gemfibrozil 

   oral, tablet

600 mg {TI: see note}

  glipiZIDE

   oral, tablet

5 mg, 10 mg

      glyBURIDE

  glyBURIDE

   oral, tablet

5 mg

      glipiZIDE,  Glucotrol

  glycopyrrolate 

 

 

   oral, tablet

1 mg

 

  gramicidin/neomycin/polymyxin B ophthalmic

   ophthalmic, solution

0.025 mg-1.75 mg-10000 units/mL

  griseofulvin

   oral, suspension

microcrystalline 125 mg/5 mL

   oral, tablet

ultramicrocrystalline 250 mg

  guanFACINE

   oral, tablet

1 mg {R: See Note}

      guaifenesin

     Restricted to Mental Health

  H. Pylori (Clarithromycin/Amoxicillin/Omeprazole)

   oral, combination

500mg/1000mg/20mg

     
First Line H. Pylori Regimen for Adults:
Clarithromycin 500mg PO BID for 14 days
Amoxicillin 500mg x 2 (1000mg) PO BID for 14 days
Omeprazole 20mg PO BID for 14 days


For allergies to Penicillins:
Clarithromycin 500mg PO BID for 14 days
Metronidazole 250mg x 2 (500mg) PO BID for 14 days
Omeprazole 20mg PO BID for 14 days

H. Pylori Regimen for Dialysis Patients
Half the Dose of Clarithromycin (250mg)

H. Pylori Regimen for Pediatric Patients
Amoxicillin 250mg PO TID for 14 days
Clarithromycin 500mg x 1/2 tablet (250mg) PO BID for 14 days
Omeprazole 20mg PO QDAY for 14 days

  haemophilus b conjugate (PRP-OMP) vaccine

   intramuscular, suspension

7.5 mcg-125 mcg/0.5 mL

haloperidol

 

   oral, tablet

1 mg, 2 mg, 5 mg, 10 mg

  hepatitis A adult vaccine 

   intramuscular, suspension

1440 units/mL

 

  hepatitis A pediatric vaccine

   intramuscular, suspension

720 units/0.5 mL

  hepatitis B immune globulin

   intramuscular, solution

-

  hepatitis B vaccine (obsolete) 

   intramuscular, suspension

adult 20 mcg/mL

 

 

 

 (not on formulary. Manufactured D/C

  human papillomavirus vaccine

   intramuscular, suspension

type 6,11,16,18 {R: See Note}

     Restricted to Vaccine Clinic

 

  hydrALAZINE

 

   oral, tablet

25 mg

      hydrochlorothiazide,  hydrocortisone,  hydrOXYzine

  hydrochlorothiazide

   oral, tablet

25 mg, 50 mg

      hydrALAZINE,  hydroxychloroquine

  hydrochlorothiazide-triamterene

   oral, tablet

25 mg-37.5 mg, 50 mg-75 mg

 

 

 hydrocortisone 

 

 

   oral, tablet

5 mg, 10 mg, 20 mg

  hydrocortisone topical

   rectal, suppository

25 mg

   topical, ointment

1% {R: see note}, 2.5%

   topical, cream

1% {R: see note}, 2.5%

     {R} - Restricted for Peds Eczema/Atopic Dermatitis

  hydrocortisone/neomycin/polymyxin B otic

   otic, suspension

1%-0.35%-10000 units/mL

  hydrogen peroxide topical

   topical, solution

3% {R: Inpatient Use Only}

 

HYDROmorphone 

 

   oral, tablet

2 mg, 4 mg

   rectal, suppository

3 mg

  hydroquinone topical

   topical, cream

4%

  hydroxychloroquine

   oral, tablet

200 mg

      hydrochlorothiazide

  hydrOXYzine 

   oral, syrup

hydrochloride 10 mg/5 mL

   oral, tablet

hydrochloride 10 mg, hydrochloride 25 mg

  hyoscyamine

   oral, tablet

0.125 mg

  ibuprofen 

   oral, suspension

100 mg/5 mL

   oral, tablet

200 mg {R: age < 16 yrs.}, 400 mg, 800 mg

 

  imipramine

   oral, tablet

10 mg, 25 mg

      amitriptyline,  desipramine

  imiquimod topical

   topical, cream

5% {R: see note!!}

     Use for Genital Warts that are small or that have not responded to other treatments, Basal Cell Carcinoma, and Dermatology Use

  indomethacin 

   oral, capsule

25 mg

   

 

  insulin aspart

   subcutaneous, solution

100 units/mL

  insulin detemir

   subcutaneous, solution

100 units/mL

     Insulin Detemir will be substituted automatically for all current prescriptions for Lantus/insulin Glargine.   All previously approved nonformulary requests for Lantus will be void after October 1st.  All patients with such Lantus prescriptions will instead be given insulin detemir, which will be dosed the same as Lantus (eg, Lantus 20 units qhs would be detemir 20 units qhs).  Any provider who feels that this switch is not appropriate will need to fill out a new nonformulary drug request.  This change applies to inpatient and outpatient Lantus prescribing.

  insulin isophane

   subcutaneous, suspension

human recombinant 100 units/mL

  insulin isophane-insulin regular

   subcutaneous, suspension

human recombinant 70 units-30 units/mL

  insulin regular

   injectable, solution

human recombinant 100 units/mL

  insulin syringe

   other, syringe

1 mL

     1mL Syringe w/ Needle, 31GX5/16&quot;

  iodine-potassium iodide

   oral and topical, solution

5%-10%

  ipratropium

   inhalation, solution

500 mcg/2.5 mL

   inhalation, aerosol

CFC free 17 mcg/inh, 18 mcg/inh

  isoflurane

   inhalation, liquid

100%

  isoniazid 

   oral, tablet

100 mg, 300 mg

 

  isosorbide dinitrate 

   oral, tablet

10 mg, 20 mg

  ISOtretinoin

   oral, capsule

10 mg {R: Dermatologist Use Only}, 20 mg {R: Dermatologist Use Only}, 40 mg {R: Dermatologist Use Only}

  ketorolac 

 

 

   oral, tablet

10 mg {R: see note}

 

 ketorolac ophthalmic

   ophthalmic, solution

0.5%

  labetalol 

 

 

   oral, tablet

200 mg

  lactulose

   oral, syrup

10 g/15 mL

  lamiVUDine

   oral, tablet

150 mg

      lamotrigine,  zidovudine

  lamiVUDine-zidovudine

   oral, tablet

150 mg-300 mg {See Note}

     For use as BASIC REGIMEN for HIV Post Exposure Prophylaxis

  lamoTRIgine

   oral, tablet

25 mg {R: See Note}, 100 mg {R: See Note}, 200 mg {R: See Note}

      lamivudine

     Restricted to Mental Health Only

  LANCETS

   other, test

-

  lanolin topical

   topical, ointment

- {R: see note}

     {R}-Restricted: Discharged breast-feeding mothers

  lanolin-mineral oil topical

   topical, oil

- {Dinnebito clinic use only}

  latanoprost ophthalmic

   ophthalmic, solution

0.005% {R: See Note}

     Latanoprost is now generic and less expensive than Travaprost ($1.62 vs $9.00) but requires refrigeration. Pharmacy would like for patients that are not mail order to be changed to Latanoprost. Ophthalmology will try to switch patients and put new patients who aren't mail order on Latanoprost. Pharmacy can call eye clinic for a verbel order to switch patients if needed. Pharmacy will not automatically switch patients.

  leflunomide

   oral, tablet

10 mg

  leucovorin 

   oral, tablet

5 mg

  levETIRAcetam 

   oral, solution

100 mg/mL {R: Neurology Consult/SZ D/O}

   oral, tablet

500 mg {R: Neurology Consult/SZ D/O}

  levofloxacin

 

 

   oral, tablet

250 mg {See Note}, 500 mg {See Note}, 750 mg {See Note}

      ciprofloxacin

     Restricted to Pneumonia/Sepsis

  levonorgestrel

 

 

   oral, tablet

1.5 mg

 

levothyroxine 

 

   oral, tablet

25 mcg (0.025 mg), 50 mcg (0.05 mg), 88 mcg (0.088 mg), 100 mcg (0.1 mg), 125 mcg (0.125 mg), 150 mcg (0.15 mg), 200 mcg (0.2 mg)

  lidocaine topical

   mucous membrane, solution

2%

   topical, ointment

5%

   topical, solution

4%

   topical, gel with applicator

2%

  lisinopril

   oral, tablet

2.5 mg {TI: Use 1/2 of 5mg tablet}, 5 mg, 10 mg, 20 mg, 40 mg

      benazepril,  enalapril,  fosinopril,  quinapril,  Risperdal

  lithium

   oral, capsule

300 mg

  lopinavir-ritonavir

   oral, tablet

200 mg-50 mg

  loratadine

   oral, syrup

5 mg/5 mL

   oral, tablet

10 mg

      losartan

  LORazepam 

 

 

   oral, tablet

1 mg

  losartan

   oral, tablet

25 mg, 50 mg, 100 mg

      loratadine,  valsartan

  lovastatin

   oral, tablet

20 mg, 40 mg

      Lotensin

  magnesium citrate

   oral, liquid

1.745 g/30 mL {R: see note}

      magnesium sulfate

     (1) For use in Bowel Preps or for spinal patients on bowel program
(2) Outpatient pediatrics with documented Obstipation/Encopretic

  magnesium hydroxide

 

 

  magnesium oxide

   oral, tablet

400 mg, 420 mg

  measles/mumps/rubella virus vaccine

   subcutaneous, powder for injection

-

  mebendazole

   oral, tablet, chewable

100 mg

  meclizine

   oral, tablet

25 mg

  medroxyPROGESTERone

   intramuscular, suspension

150 mg/mL

   oral, tablet

2.5 mg, 10 mg

      methylPREDNISolone,  metolazone

  megestrol

   oral, suspension

40 mg/mL

   oral, tablet

40 mg

  meningococcal polysaccharide vaccine

   subcutaneous, powder for injection

single dose

  meperidine 

 

 

   oral, tablet

50 mg

 

mercaptopurine 

   oral, tablet

50 mg

 

  metFORMIN

   oral, tablet

500 mg, 850 mg, 1000 mg

   oral, tablet, extended release

500 mg

      metronidazole

  methadone

   oral, tablet

5 mg

      meperidine,  methylphenidate

  methimazole

   oral, tablet

10 mg

      methazolamide,  metolazone

 

methotrexate 

 

   oral, tablet

2.5 mg

     MUST HAVE CBC WITHIN 3 MONTHS OF MEDICATION FILL.PROVIDER MUST BE CONTACTED IF NO LABS AVAILABLE.

  methyl salicylate topical

   topical, ointment

- {R: Inpatient Use Only}

  methyldopa 

   oral, tablet

250 mg, 500 mg

 

  methylergonovine

 

   oral, tablet

0.2 mg

  methylphenidate 

   oral, tablet

5 mg, 10 mg

   oral, tablet, extended release

18 mg/24 hr, 20 mg/8 hr, 36 mg/24 hr

methylPREDNISolone 

 

   oral, tablet

4 mg

 

  metoclopramide 

 

   oral, syrup

5 mg/5 mL

   oral, tablet

10 mg

  metolazone

   oral, tablet

2.5 mg

 

 

metoprolol 

 

   oral, tablet

50 mg

   oral, tablet, extended release

25 mg, 50 mg, 100 mg

 

metroNIDAZOLE 

 

   oral, tablet

250 mg

  metroNIDAZOLE topical

   topical, gel

1% {R}

   vaginal, gel with applicator

0.75%

     For patients with Rosacea

 

  minocycline

 

   oral, capsule

50 mg {R: For Dermatology Only}

  mirtazapine

   oral, tablet

15 mg, 30 mg

  misoprostol

   oral, tablet

200 mcg

      metoprolol,  mifepristone

  mometasone

   inhalation, aerosol powder

110 mcg/inh, 220 mcg/inh

  montelukast

   oral, tablet, chewable

4 mg, 5 mg, 10mg

morphine 

 

   oral, solution

10 mg/5 mL

   oral, tablet

10 mg, 30 mg

   oral, tablet, extended release

15 mg/12 hr, 30 mg/12 hr

multivitamin

 

   oral, tablet

Multiple Vitamins {R}

  

  multivitamin with fluoride

   oral, tablet, chewable

Multiple Vitamins with Fluoride 0.25 mg {R}

     Restricted to kids 2 years and older ONLY with doucmented Microctosis. This agent will only be dispensed for a 30 day supply with refills available

  multivitamin with iron

   oral, tablet, chewable

Multiple Vitamins with Iron {R: See Note...}

     Restricted to kids 2 years and older ONLY with doucmented Microctosis. This agent will only be dispensed for a 30 day supply with refills available

  multivitamin with iron and fluoride

   oral, liquid

Multiple Vitamins with Iron and Fluoride 0.25 mg/mL

     

Chewable MultiVitamins w/ Fluoride and Iron has been removed from the Formulary because they are no longer being made.

  multivitamin, prenatal

   oral, tablet

Prenatal Multivitamins with Folic Acid 1 mg

  mupirocin topical

   topical, ointment

2%

  mycophenolate mofetil

   oral, capsule

250 mg

   oral, tablet

500 mg

      meclofenamate

  nabumetone

   oral, tablet

500 mg

  naphazoline-pheniramine ophthalmic

   ophthalmic, solution

Restricted to Eye Providers, Group Home use, High School Clinic use and Dinnebito Clinic use only

0.027%-0.315% {R}

  naproxen

   oral, suspension

125 mg/5 mL

   oral, tablet

250 mg

  nelfinavir

   oral, tablet

250 mg

      nefazodone,  nevirapine

  neomycin 

   oral, tablet

500 mg

 

  neomycin-polymyxin B sulfate topical

   irrigation, solution

40 mg-200000 units/mL

  niacin

   oral, tablet, extended release

500 mg, 1000 mg

      Niaspan ER,  Niaspan ER Starter Pack

 

 

 

  NIFEdipine

   oral, capsule

10 mg

   oral, tablet, extended release

30 mg

      felodipine,  niCARdipine,  nimodipine

 

 

 

  nitrofurantoin

   oral, suspension

25 mg/5 mL

   oral, capsule

macrocrystals 50 mg, macrocrystals-monohydrate 100 mg

 

  nitroglycerin 

 

   sublingual, tablet

0.4 mg

   transdermal, ointment

2%

  norethindrone

   oral, tablet

0.35 mg {Nor-QD}

  nortriptyline

   oral, capsule

10 mg, 25 mg

      amitriptyline,  desipramine,  Norpramin

  nystatin 

   oral, suspension

100000 units/mL

  ocular lubricant 

   ophthalmic, ointment

- {R: see note}

   ophthalmic, solution

- {R: see note}, preserved {R: see note}

 

 

Artificial Tears, Tears Renewed, AKWA Tears, Tears Again (ocular lubricant)

ASHP has recently posted a shortage pertaining to this drug. Please view the link for further details to see if this applies to your facility.

http://www.ashp.org/Import/PRACTICEANDPOLICY/PracticeResourceCenters/DrugShortages/GettingStarted/CurrentShortages/Bulletin.aspx?id=626

     Eye Clinic, Bells Palsy (any CN VII palsy,paralysis,paresis) w/ Eye Clinic Referral, Group Home and Dinnebito Clinic use only

  OLANZapine

   oral, tablet

5 mg, 10 mg

      oxcarbazepine

 

olopatadine ophthalmic

   ophthalmic, solution

0.1% {R: See Comments}

     Patanol is restricted to the Eye and Pediatric Clinics. Pediatric providers may only prescribe for patients age 3-16 yo.

  omeprazole

   oral, delayed release capsule

20 mg {R: see note}

      esomeprazole