JOINT REGIONAL FORMULARY for EVANS ARMY COMMUNITY HOSPITAL, PETERSON AFB, and USAFA Alphabetical Listing by Name

JOINT REGIONAL FORMULARY for EVANS ARMY COMMUNITY HOSPITAL, PETERSON AFB, AND USAFA Alphabetical Listing by Name

This document is curr ent as of December 17, 2020. The availability of formulary items is subject to change.

1 Joint Regional Oupatient Formulary

Alphabetical Drug Listing Available Dosage Forms Acamprosate Tablet Delayed Release, Oral, as calcium: Generic: 333 mg Acetaminophen Suppository, Rectal: Generic: 120 mg (12s) Suspension, Oral: Tylenol Childrens: 160 mg/5 mL (100 mL) [alcohol free, aspirin free, ibuprofen free; contains brilliant blue fcf (fd&c blue #1), butylparaben, propylene glycol, sodium benzoate; grape flavor] Generic: 160 mg/5 mL (5 mL) Tablet, Oral: Generic: 325 mg Tablet Chewable, Oral: Pain & Fever Childrens: 80 mg [scored; aspirin free; contains aspartame, fd&c yellow #6 (sunset yellow); fruit flavor]

Acetaminophen and Codeine Solution, Oral: Generic: Acetaminophen 120 mg and codeine phosphate 12 mg per 5 mL (5 mL, 118 mL) [BCF] Tablet, Oral: Generic: Acetaminophen 300 mg and codeine phosphate 30 mg [BCF] AcetaZOLAMIDE Capsule Extended Release 12 Hour, Oral: Generic: 500 mg Tablet, Oral: Generic: 250 mg Acetic Acid (Otic) Solution, Otic: Generic: 2% (15 mL, 60 mL) Acetic Acid, Propylene Glycol Solution, Otic: Diacetate, and Hydrocortisone Generic: Acetic acid 2%, propylene glycol diacetate 3%, and hydrocortisone 1% (10 mL) Acetylcysteine Solution, Inhalation: Generic: 10% (10 mL); 20% (30 mL) Aclidinium Aerosol Powder Breath Activated, Inhalation, as bromide: Tudorza Pressair: 400 mcg/actuation (1 ea) [contains lactose monohydrate] Acyclovir (Systemic) Capsule, Oral: Generic: 200 mg [BCF] Suspension, Oral: Generic: 200 mg/5 mL (473 mL) [BCF] Tablet, Oral: Generic: 400 mg [BCF], 800 mg [BCF] Acyclovir (Topical) Cream, External: Generic: 5% (5 g) Adalimumab Kit, Subcutaneous [preservative free]: Humira Pen: 40 mg/0.8 mL [contains polysorbate 80] [BCF] Prefilled Syringe Kit, Subcutaneous [preservative free]: Humira Pediatric Crohns Start: 40 mg/0.8 mL (1 ea) [contains polysorbate 80] [BCF] Adapalene Cream, External: Generic: 0.1% (45 g) Gel, External: Generic: 0.3% (45 g) Albendazole Tablet, Oral: Albenza: 200 mg [contains saccharin sodium] Albiglutide Pen-injector, Subcutaneous [preservative free]: Tanzeum: 30 mg (1 ea); 50 mg (1 ea) [contains polysorbate 80]

1 Joint Regional Oupatient Formulary

Albuterol Aerosol Powder Breath Activated, Inhalation: ProAir RespiClick: 90 mcg/actuation (1 ea) [contains milk protein] Aerosol Solution, Inhalation: ProAir HFA: 108 (90 Base) mcg/actuation (8.5 g) [BCF] Nebulization Solution, Inhalation: Generic: 0.083% [2.5 mg/3 mL] (25s, 30s, 60s) [BCF]; 0.5% [5 mg/mL] (20 mL) Nebulization Solution, Inhalation [preservative free]: Generic: 1.25 mg/3 mL (3 mL) Syrup, Oral: Generic: 2 mg/5 mL (473 mL) Alcohol (Isopropyl) Pad, External: Easy Touch Alcohol Prep Pad [medium]: 70% (200 ea) Alendronate Tablet, Oral: Generic: 5 mg [BCF], 10 mg [BCF], 35 mg [BCF], 70 mg [BCF] Alfuzosin Tablet Extended Release 24 Hour, Oral, as hydrochloride: Generic: 10 mg [BCF] Aliskiren Tablet, Oral: Tekturna: 150 mg, 300 mg Aliskiren and Tablet, Oral: Hydrochlorothiazide Tekturna HCT: 150/12.5: Aliskiren 150 mg and hydrochlorothiazide 12.5 mg 150/25: Aliskiren 150 mg and hydrochlorothiazide 25 mg 300/25: Aliskiren 300 mg and hydrochlorothiazide 25 mg Allopurinol Tablet, Oral: Generic: 100 mg [BCF], 300 mg [BCF] ALPRAZolam Tablet, Oral: Generic: 0.25 mg, 0.5 mg, 1 mg, 2 mg Alprostadil Kit, Intracavernosal: Edex: 10 mcg, 20 mcg Pellet, Urethral: Muse: 125 mcg (6 ea); 250 mcg (6 ea); 500 mcg (6 ea); 1000 mcg (6 ea) Aluminum Acetate and Acetic Solution, Otic: Acid Generic: Aluminum acetate 10% and acetic acid 2% (60 mL) Aluminum Chloride Hexahydrate Solution, External: Hypercare: 20% (35 mL) Aluminum Hydroxide, Liquid, Oral: Magnesium Hydroxide, and Mag-Al Plus XS: 400-400-40 MG/5ML (30 mL) [sugar free; contains butylparaben, propylene Simethicone glycol, propylparaben, saccharin sodium; cherry flavor] Suspension, Oral: Geri-Lanta: 200-200-20 MG/5ML (355 mL) [contains benzyl alcohol, butylparaben, propylparaben, saccharin sodium] Mi-Acid Maximum Strength: 400-400-40 MG/5ML (355 mL) [contains butylparaben, propylparaben, saccharin sodium] Amantadine Capsule, Oral, as hydrochloride: Generic: 100 mg [BCF] AMILoride Tablet, Oral, as hydrochloride: Generic: 5 mg Aminocaproic Acid Tablet, Oral: Generic: 500 mg Amiodarone Tablet, Oral, as hydrochloride: Pacerone: 200 mg [scored] [BCF] Amitriptyline Tablet, Oral, as hydrochloride: Generic: 10 mg [BCF], 25 mg [BCF], 50 mg [BCF], 75 mg [BCF] AmLODIPine Tablet, Oral: Generic: 2.5 mg [BCF], 5 mg [BCF], 10 mg [BCF]

2 Joint Regional Oupatient Formulary

Amlodipine and Benazepril Capsule, Oral: Generic: 2.5/10: Amlodipine 2.5 mg and benazepril hydrochloride 10 mg [BCF] Generic: 5/10: Amlodipine 5 mg and benazepril hydrochloride 10 mg [BCF] Generic: 5/20: Amlodipine 5 mg and benazepril hydrochloride 20 mg [BCF] Generic: 5/40: Amlodipine 5 mg and benazepril hydrochloride 40 mg [BCF] Generic: 10/20: Amlodipine 10 mg and benazepril hydrochloride 20 mg [BCF] Generic: 10/40: Amlodipine 10 mg and benazepril hydrochloride 40 mg [BCF] Amoxicillin Capsule, Oral: Generic: 250 mg [BCF], 500 mg [BCF] Suspension Reconstituted, Oral: Generic: 125 mg/5 mL (150 mL); 250 mg/5 mL (150 mL) [BCF]; 400 mg/5 mL (100 mL) [BCF] Tablet, Oral: Generic: 875 mg

Amoxicillin and Clavulanate Suspension Reconstituted, Oral: Generic: 200: Amoxicillin 200 mg and clavulanate potassium 28.5 mg per 5 mL (100 mL) [BCF] Generic: 400: Amoxicillin 400 mg and clavulanate potassium 57 mg per 5 mL (100 mL) [BCF] Generic: 600: Amoxicillin 600 mg and clavulanate potassium 42.9 mg per 5 mL (200 mL) [BCF] Tablet, Oral: Generic: Amoxicillin 500 mg and clavulanate potassium 125 mg [BCF] Generic: Amoxicillin 875 mg and clavulanate potassium 125 mg [BCF]

Amyl Nitrite Liquid, for inhalation: Generic: USP: 85% to 103% (0.3 mL) Anastrozole Tablet, Oral: Generic: 1 mg Anthralin Cream, External: Dritho-Creme HP: 1% (50 g) [contains methylparaben] Apixaban Tablet, Oral: Eliquis: 2.5 mg [BCF], 5 mg [BCF] Apraclonidine Solution, Ophthalmic: Generic: 0.5% (UD) Arformoterol Nebulization Solution, Inhalation: Brovana: 15 mcg/2 mL (2 mL) ARIPiprazole Tablet, Oral: Abilify: 2 mg [BCF], 5 mg [BCF], 10 mg [BCF], 15 mg [BCF], 20 mg [BCF], 30 mg [BCF] Artificial Tears Ointment, Ophthalmic [preservative free]: Artificial Tears: 83-15 % (3.5 g) Solution, Ophthalmic [preservative free]: Systane Preservative Free: Polyethylene glycol 400 0.4% and propylene glycol 0.3% (28 ea) [contains boric acid, calcium chloride anhydrous, hydroxylpropyl guar, magnesium chloride, potassium chloride, sodium chloride, zinc chloride] Aspirin Tablet, Oral: Generic: 325 mg Tablet Delayed Release, Oral: Generic: 81 mg, 325 mg Aspirin and Dipyridamole Capsule Extended Release 12 Hour, Oral: Aggrenox: Aspirin 25 mg [immediate release] and dipyridamole 200 mg [extended release] [contains lactose, sucrose] Atenolol Tablet, Oral: Generic: 25 mg [BCF], 50 mg [BCF], 100 mg [BCF] AtoMOXetine Capsule, Oral: Strattera: 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg

3 Joint Regional Oupatient Formulary

AtorvaSTATin Tablet, Oral: Generic: 10 mg [BCF], 20 mg [BCF], 40 mg [BCF], 80 mg [BCF] Atovaquone and Proguanil Tablet, Oral: Malarone: Atovaquone 62.5 mg and proguanil hydrochloride 25 mg Generic: Atovaquone 250 mg and proguanil hydrochloride 100 mg Atropine (Ophthalmic) Ointment, Ophthalmic, as sulfate: Generic: 1% (3.5 g) Solution, Ophthalmic, as sulfate: Atropine-Care: 1% (15 mL) [contains benzalkonium chloride, edetate disodium] Auranofin Capsule, Oral: Ridaura: 3 mg [contains benzyl alcohol] AzaTHIOprine Tablet, Oral: Generic: 50 mg Azelastine (Nasal) Solution, Nasal, as hydrochloride: Astelin: 137 mcg/spray (30 mL) [contains benzalkonium chloride, edetate disodium] Azelastine (Ophthalmic) Solution, Ophthalmic, as hydrochloride: Optivar: 0.05% (6 mL) [contains benzalkonium chloride] Azithromycin (Systemic) Packet, Oral, as dihydrate [strength expressed as base]: Zithromax: 1 g (10 ea) [cherry-banana flavor] [BCF] Solution Reconstituted, Intravenous, as dihydrate [strength expressed as base]: Zithromax: 500 mg (1 ea) Solution Reconstituted, Intravenous, as monohydrate [strength expressed as base]: Generic: 500 mg (1 ea) Suspension Reconstituted, Oral, as dihydrate [strength expressed as base]: Zithromax: 100 mg/5 mL (15 mL) [cherry-vanilla-banana flavor] [BCF] Zithromax: 200 mg/5 mL (30 mL) [cherry flavor] Tablet, Oral, as dihydrate [strength expressed as base]: Zithromax Tri-Pak: 500 mg [BCF] Tablet, Oral, as monohydrate [strength expressed as base]: Generic: 250 mg [BCF]; 500 mg [BCF] Bacitracin, Neomycin, and Ointment, Ophthalmic: Polymyxin B (Ophthalmic) Generic: Bacitracin 400 units, neomycin 3.5 mg, and polymyxin B 10,000 units per g (3.5 g) [BCF] Bacitracin, Neomycin, and Ointment, External: Polymyxin B (Topical) Generic: Bacitracin 400 units, neomycin 5 mg, and polymyxin B 5000 units per g (14 g) Bacitracin (Ophthalmic) Ointment, Ophthalmic: Generic: 500 units/g (3.5 g) Bacitracin (Topical) Ointment, External, as zinc [strength expressed as base]: Generic: 500 units/g (1 g, 28.4 g) Baclofen Tablet, Oral: Generic: 10 mg Belladonna and Opium Suppository, Rectal: Generic: Belladonna extract 16.2 mg and opium 60 mg (12 ea) Benazepril Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg, 20 mg, 40 mg Benzocaine Lozenge, Mouth/Throat: Cepacol Sore Throat: 15% (16 ea) [contains fd&c yellow #10 (quinoline yellow), fd&c yellow #6 (sunset yellow); honey-lemon flavor] Generic: 15 mg (18 ea) [contains menthol 3.6 mg] Benzonatate Capsule, Oral: Generic: 100 mg

4 Joint Regional Oupatient Formulary

Benzoyl Peroxide Gel, External: Acne Medication 5: 5% (42.5 g) [contains edetate disodium] Generic: 2.5% (60 g) Liquid, External: Benzoyl Peroxide Wash: 5% (148 g); 10% (148 g) [contains cetyl alcohol, edetate disodium, propylene glycol] Benztropine Tablet, Oral, as mesylate: Generic: 0.5 mg [BCF], 1 mg [BCF], 2 mg [BCF] Beta-Carotene Capsule, Oral: Generic: 25,000 units Betamethasone and Cream, External: Clotrimazole Generic: Betamethasone dipropionate 0.05% (base) and clotrimazole 1% (15 g) Betamethasone (Topical) Cream, External, as dipropionate augmented [strength expressed as base]: Generic: 0.05% (15 g) Cream, External, as valerate [strength expressed as base]: Generic: 0.1% (15 g) Lotion, External, as valerate [strength expressed as base]: Generic: 0.1% (60 mL) Ointment, External, as dipropionate [strength expressed as base]: Generic: 0.05% (15 g, 45 g) Ointment, External, as valerate [strength expressed as base]: Generic: 0.1% (15 g, 45 g) Betaxolol (Ophthalmic) Suspension, Ophthalmic: Betoptic-S: 0.25% (10 mL) Bicalutamide Tablet, Oral: Generic: 50 mg Bictegravir, Emtricitabine, and Tablet, Oral: Tenofovir Alafenamide Biktarvy: Bictegravir 50 mg, emtricitabine 200 mg, and tenofovir alafenamide 25 mg Bimatoprost Solution, Ophthalmic: Lumigan: 0.01% (5 mL) [contains benzalkonium chloride] Bisacodyl Tablet Delayed Release, Oral: Bisacodyl EC: 5 mg Bismuth, Metronidazole, and Capsule, Oral: Tetracycline Pylera: Bismuth subcitrate potassium 140 mg, metronidazole 125 mg, and tetracycline hydrochloride 125 mg Bismuth Subsalicylate Tablet Chewable, Oral, as subsalicylate: Pink Bismuth: 262 mg Brimonidine and Timolol Solution, Ophthalmic: Combigan: Brimonidine tartrate 0.2% and timolol 0.5% (5 mL) [contains benzalkonium chloride] Brimonidine (Ophthalmic) Solution, Ophthalmic, as tartrate: Alphagan P: 0.1% (10 mL); 0.15% (5 mL, 10 mL) [contains carboxymethylcellulose sodium] [BCF] Generic: 0.15% (5 mL, 10 mL) [BCF]; 0.2% (5 mL) [BCF] Brinzolamide and Brimonidine Suspension, Ophthalmic: Simbrinza: Brinzolamide 1% and brimonidine tartrate 0.2% (8 mL) [contains benzalkonium chloride, propylene glycol] Bromocriptine Tablet, Oral: Generic: 2.5 mg Brompheniramine and Elixir, Oral: Pseudoephedrine Q-Tapp: Brompheniramine maleate 1 mg and pseudoephedrine hydrochloride 15 mg per 5 mL (118 mL) [alcohol free; contains brilliant blue fcf (fd&c blue #1), fd&c red #40, propylene glycol, saccharin sodium, sodium benzoate; grape flavor]

5 Joint Regional Oupatient Formulary

Budesonide (Oral Inhalation) Suspension, Inhalation: Pulmicort: 0.25 mg/2 mL (2 mL); 0.5 mg/2 mL (2 mL) [contains disodium edta, polysorbate 80]

Budesonide (Systemic) Capsule Extended Release 24 Hour, Oral: Generic: 3 mg Bumetanide Tablet, Oral: Generic: 0.5 mg, 1 mg, 2 mg Buprenorphine and Naloxone Tablet, sublingual: Generic: Buprenorphine 8 mg and naloxone 2 mg BuPROPion Tablet, Oral, as hydrochloride: Generic: 75 mg [BCF], 100 mg [BCF] Tablet Extended Release 12 Hour, Oral, as hydrochloride: Generic: 100 mg [BCF], 150 mg [BCF] Tablet Extended Release 24 Hour, Oral, as hydrochloride: Generic: 150 mg [BCF], 300 mg [BCF] BusPIRone Tablet, Oral, as hydrochloride: Generic: 5 mg [BCF], 7.5 mg, 10 mg [BCF], 15 mg [BCF] Butalbital, Acetaminophen, and Tablet, Oral: Caffeine Generic: Butalbital 50 mg, acetaminophen 325 mg, and caffeine 40 mg [BCF] Butalbital, Aspirin, and Caffeine Capsule, Oral: Generic: Butalbital 50 mg, aspirin 325 mg, and caffeine 40 mg Cabergoline Tablet, Oral: Generic: 0.5 mg Calamine Lotion, External: Generic: 8% (180 mL) Calcipotriene Cream, External: Dovonex: 0.005% (60 g) [contains cetearyl alcohol, disodium edta] Solution, External: Generic: 0.005% (60 mL) Calcipotriene and Ointment, External: Betamethasone Taclonex: Calcipotriene 0.005% and betamethasone dipropionate 0.064% (60 g, 100 g) Calcitonin Solution, Nasal: Fortical: 200 units/actuation (3.7 mL) Calcitriol (Systemic) Capsule, Oral: Generic: 0.25 mcg Calcium and Vitamin D Tablet, Oral: Generic: Calcium 500 mg and vitamin D 200 units Tablet, Oral [preservative free]: Generic: Calcium 600 mg and vitamin D 400 units Candesartan Tablet, Oral, as cilexetil: Generic: 4 mg, 8 mg, 16 mg, 32 mg Capsaicin Cream, External: Zostrix HP: 0.1% (60 g) [contains benzyl alcohol] Generic: 0.025% (60 g) Captopril Tablet, Oral: Generic: 12.5 mg [BCF], 25 mg [BCF], 50 mg [BCF], 100 mg [BCF] CarBAMazepine Suspension, Oral: TEGretol: 100 mg/5 mL (450 mL) [contains propylene glycol; citrus-vanilla flavor] [BCF] Tablet, Oral: TEGretolÂ®: 200 mg [scored] [BCF] Tablet Chewable, Oral: Generic: 100 mg [BCF] Tablet Extended Release 12 Hour, Oral: TEGretol-XR: 100 mg, 200 mg, 400 mg [BCF]

6 Joint Regional Oupatient Formulary

Carbamide Peroxide Solution, Otic: Ear Drops Earwax Aid: 6.5% (15 mL) [contains propylene glycol, trolamine (triethanolamine)]

Carbidopa and Levodopa Tablet, Oral: Generic: 10/100: Carbidopa 10 mg and levodopa 100 mg [scored] [BCF] Generic: 25/100: Carbidopa 25 mg and levodopa 100 mg [scored] [BCF] Generic: 25/250: Carbidopa 25 mg and levodopa 250 mg [scored] [BCF] Tablet Extended Release, Oral: Generic: 25/100: Carbidopa 25 mg and levodopa 100 mg Generic: 50/200: Carbidopa 50 mg and levodopa 200 mg Carboxymethylcellulose Solution, Ophthalmic, as sodium [preservative free]: Refresh Celluvisc: 1% (30 ea) Refresh Plus: 0.5% (30 ea) Generic: 0.5% (30 ea) Carteolol (Ophthalmic) Solution, Ophthalmic, as hydrochloride: Generic: 1% (10 mL) Carvedilol Tablet, Oral: Generic: 3.125 mg [BCF], 6.25 mg [BCF], 12.5 mg [BCF], 25 mg [BCF] Cefadroxil Capsule, Oral: Generic: 500 mg Cefdinir Capsule, Oral: Generic: 300 mg Suspension Reconstituted, Oral: Generic: 125 mg/5 mL (60 mL); 250 mg/5 mL (60 mL) Cefpodoxime Tablet, Oral: Generic: 200 mg Cefuroxime Suspension Reconstituted, Oral, as axetil [strength expressed as base]: Ceftin: 125 mg/5 mL (100 mL); 250 mg/5 mL (100 mL) [contains aspartame; tutti-frutti flavor] Tablet, Oral, as axetil [strength expressed as base]: Generic: 250 mg, 500 mg

Celecoxib Capsule, Oral: CeleBREX: 100 mg, 200 mg Cephalexin Capsule, Oral: Generic: 250 mg [BCF], 500 mg [BCF] Suspension Reconstituted, Oral: Generic: 125 mg/5 mL (200 mL); 250 mg/5 mL (200 mL) [BCF] Cetirizine (Systemic) Syrup, Oral, as hydrochloride: Cetirizine HCl Childrens Alrgy: 1 mg/mL (118 mL) [contains methylparaben, propylene glycol, propylparaben; grape flavor] Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg Cevimeline Capsule, Oral, as hydrochloride: Generic: 30 mg Chlorambucil Tablet, Oral: Leukeran: 2 mg Chlorhexidine Gluconate (Oral) Solution, Mouth/Throat: Periogard: 0.12% (473 mL) [mint flavor] [BCF] Generic: 0.12% (473 mL) [BCF] Chloroquine Tablet, Oral, as phosphate: Generic: 500 mg [equivalent to chloroquine base 300 mg]

7 Joint Regional Oupatient Formulary

Chlorpheniramine Syrup, Oral, as maleate: Aller-Chlor: 2 mg/5 mL (118 mL) [contains alcohol, usp, fd&c yellow #6 (sunset yellow), menthol, methylparaben, propylene glycol, propylparaben; fruit flavor] Tablet, Oral, as maleate: Allergy: 4 mg [scored; contains fd&c yellow #10 aluminum lake] ChlorproMAZINE Tablet, Oral, as hydrochloride: Generic: 25 mg Chlorthalidone Tablet, Oral: Generic: 25 mg [BCF], 50 mg [BCF] Cholecalciferol Liquid, Oral: D-Vi-Sol: 400 units/mL (50 mL) [gluten free, lactose free, sugar free; contains polysorbate 80]

Cholestyramine Resin Powder, Oral: Generic: 4 g/dose (378 g) Ciclopirox Solution, External: Generic: 8% (6.6 mL) Cilostazol Tablet, Oral: Generic: 50 mg, 100 mg Cimetidine Solution, Oral, as hydrochloride [strength expressed as base]: Generic: 300 mg/5 mL (237 mL) Ciprofloxacin and Suspension, Otic: Dexamethasone Ciprodex: Ciprofloxacin 0.3% and dexamethasone 0.1% (7.5 mL) [contains benzalkonium chloride, edetate disodium, tyloxapol] Ciprofloxacin (Ophthalmic) Solution, Ophthalmic, as hydrochloride: Generic: 0.3% (5 mL) Ciprofloxacin (Systemic) Suspension Reconstituted, Oral: Cipro: 250 mg/5 mL (100 mL) [BCF]; 500 mg/5 mL (100 mL) [strawberry flavor] Tablet, Oral, as hydrochloride [strength expressed as base]: Generic: 250 mg [BCF], 500 mg [BCF], 750 mg [BCF] Citalopram Solution, Oral: Generic: 10 mg/5 mL (240 mL) [BCF] Tablet, Oral: Generic: 10 mg [BCF], 20 mg [BCF], 40 mg [BCF] Clarithromycin Tablet, Oral: Generic: 500 mg Cleansing Lotion Liquid, External: Cetaphil Gentle Skin Cleanser: 473 mL Clemastine Tablet, Oral, as fumarate: Generic: 2.68 mg Clidinium and Chlordiazepoxide Capsule, Oral: Generic: Clidinium bromide 2.5 mg and chlordiazepoxide hydrochloride 5 mg Clindamycin and Benzoyl Gel, External: Peroxide Generic: Clindamycin phosphate 1.2% and benzoyl peroxide 5% (45 g) Clindamycin and Tretinoin Gel, External: Ziana: Clindamycin phosphate 1.2% and tretinoin 0.025% (60 g) [contains methylparaben, propylparaben] Clindamycin (Systemic) Capsule, Oral, as hydrochloride [strength expressed as base]: Generic: 150 mg [BCF] Solution Reconstituted, Oral, as palmitate hydrochloride [strength expressed as base]: Cleocin: 75 mg/5 mL (100 mL) [contains ethylparaben]

8 Joint Regional Oupatient Formulary

Clindamycin (Topical) Cream, Vaginal, as phosphate [strength expressed as base]: Generic: 2% (40 g) [BCF] Gel, External, as phosphate [strength expressed as base]: Generic: 1% (30 g) Lotion, External, as phosphate [strength expressed as base]: Generic: 1% (60 mL) Solution, External, as phosphate [strength expressed as base]: Generic: 1% (60 mL) [BCF] Clobetasol Cream, External, as propionate: Generic: 0.05% (15 g, 60 g) Foam, External, as propionate: Generic: 0.05% (100 g) Ointment, External, as propionate: Generic: 0.05% (15 g, 60 g) Shampoo, External, as propionate: Generic: 0.05% (118 g) Solution, External, as propionate: Generic: 0.05% (25 mL) ClomiPHENE Tablet, Oral, as citrate: Generic: 50 mg ClonazePAM Tablet, Oral: Generic: 0.5 mg [BCF], 1 mg, 2 mg CloNIDine Patch Weekly, Transdermal: Catapres-TTS-1: 0.1 mg/24 hr (4 ea) Catapres-TTS-2: 0.2 mg/24 hr (4 ea) Catapres-TTS-3: 0.3 mg/24 hr (4 ea) Tablet, Oral, as hydrochloride: Generic: 0.1 mg [BCF], 0.2 mg [BCF], 0.3 mg [BCF] Clopidogrel Tablet, Oral: Generic: 75 mg [BCF] Clotrimazole (Oral) Troche, Mouth/Throat: Generic: 10 mg Clotrimazole (Topical) Cream, External: Clotrimazole Anti-Fungal: 1% (28.35 g) [contains benzyl alcohol] Cream, Vaginal: Generic: 1% (45 g) Solution, External: Generic: 1% (30 mL) [BCF] CloZAPine Tablet, Oral: Generic: 100 mg Colchicine Tablet, Oral: Colcrys: 0.6 mg [scored] Colestipol Granules, Oral, as hydrochloride: Colestid Flavored: 5 g (450 g) [contains aspartame; orange flavor] Tablet, Oral, as hydrochloride: Generic: 1 g Cromolyn (Nasal) Aerosol Solution, Nasal, as sodium: Generic: 5.2 mg/actuation (26 mL) Cromolyn (Ophthalmic) Solution, Ophthalmic, as sodium: Generic: 4% (10 mL) Cromolyn (Oral Inhalation) Nebulization Solution, Inhalation, as sodium: Generic: 20 mg/2 mL (2 mL) Cromolyn (Systemic) Concentrate, Oral, as sodium: Generic: 100 mg/5 mL (5 mL)

9 Joint Regional Oupatient Formulary

Crotamiton Cream, External: Eurax: 10% (60 g) Cyanocobalamin Tablet, Oral: Generic: 500 mcg Cyclobenzaprine Tablet, Oral, as hydrochloride: Generic: 10 mg [BCF] Cyclopentolate Solution, Ophthalmic, as hydrochloride: Cyclogyl: 2% (5 mL) Generic: 1% (2 mL, 15 mL); 2% (5 mL) Cyclophosphamide Tablet, Oral: Generic: 50 mg CycloSPORINE (Ophthalmic) Emulsion, Ophthalmic [preservative free]: Restasis: 0.05% (1 ea) [contains polysorbate 80] Cyproheptadine Syrup, Oral, as hydrochloride: Generic: 2 mg/5 mL (473 mL) [BCF] Tablet, Oral, as hydrochloride: Generic: 4 mg [BCF] Dabigatran Etexilate Capsule, Oral: Pradaxa: 75 mg, 150 mg Dalfampridine Tablet Extended Release 12 Hour, Oral: Generic: 10 mg Dapsone (Systemic) Tablet, Oral: Generic: 25 mg Desmopressin Solution, Nasal, as acetate: DDAVP: 0.01% (5 mL) DDAVP Rhinal Tube: 0.01% (2.5 mL) [contains chlorobutanol (chlorobutol)] Tablet, Oral, as acetate: Generic: 0.1 mg, 0.2 mg Desonide Cream, External: Generic: 0.05% (15 g, 60 g) Desoximetasone Cream, External: Generic: 0.25% (15 g, 60 g) DexAMETHasone (Systemic) Concentrate, Oral: Dexamethasone Intensol: 1 mg/mL (30 mL) [contains alcohol, usp; unflavored flavor] Elixir, Oral: Generic: 0.5 mg/5 mL (237 mL) Tablet, Oral: Generic: 0.5 mg, 0.75 mg, 4 mg Dextroamphetamine Capsule Extended Release 24 Hour, Oral, as sulfate: Dexedrine: 5 mg, 10 mg, 15 mg Tablet, Oral, as sulfate: Generic: 5 mg

10 Joint Regional Oupatient Formulary

Dextroamphetamine and Capsule Extended Release 24 Hour, Oral: Amphetamine Generic: 5 mg [dextroamphetamine sulfate 1.25 mg, dextroamphetamine saccharate 1.25 mg, amphetamine aspartate monohydrate 1.25 mg, amphetamine sulfate 1.25 mg (equivalent to amphetamine base 3.1 mg)] [BCF] Generic: 10 mg [dextroamphetamine sulfate 2.5 mg, dextroamphetamine saccharate 2.5 mg, amphetamine aspartate monohydrate 2.5 mg, amphetamine sulfate 2.5 mg (equivalent to amphetamine base 6.3 mg)] [BCF] Generic: 15 mg [dextroamphetamine sulfate 3.75 mg, dextroamphetamine saccharate 3.75 mg, amphetamine aspartate monohydrate 3.75 mg, amphetamine sulfate 3.75 mg (equivalent to amphetamine base 9.4 mg)] [BCF] Generic: 20 mg [dextroamphetamine sulfate 5 mg, dextroamphetamine saccharate 5 mg, amphetamine aspartate monohydrate 5 mg, amphetamine sulfate 5 mg (equivalent to amphetamine base 12.5 mg)] [BCF] Generic: 25 mg [dextroamphetamine sulfate 6.25 mg, dextroamphetamine saccharate 6.25 mg, amphetamine aspartate monohydrate 6.25 mg, amphetamine sulfate 6.25 mg (equivalent to amphetamine base 15.6 mg)] [BCF] Generic: 30 mg [dextroamphetamine sulfate 7.5 mg, dextroamphetamine saccharate 7.5 mg, amphetamine aspartate monohydrate 7.5 mg, amphetamine sulfate 7.5 mg (equivalent to amphetamine base 18.8 mg)] [BCF] Tablet, Oral: Generic: 5 mg, 10 mg, 20 mg Diabetic Supplies Lancet: BD Lancet Ultrafine: 33 gauge [for pediatric use] Freestyle: 100 ea Needle: BD Disp Needle: 20 gauge x 1.5" [100 ea] BD Disp Needle: 21 gauge x 1.5" [100 ea] BD Disp Needle: 22 gauge x 1" [100 ea] BD Disp Needle: 25 gauge x 5/8" [100 ea] BD Disp Needle: 27 gauge x 1/2" [100 ea] NovoFine: 30 gauge x 8 mm [100 ea] Yale Disp Needle: 22 gauge x 1" [100 ea] Test Strip: Chemstrip K In Vitro Strip: 100 ea FreeStyle Lite Test Strips: 50/box [BCF] Precision Xtra Blood Ketone: 10 ea Precision Xtra Glucose: 50 ea [BCF] DiazePAM Gel, Rectal: Diastat AcuDial: 10 mg (1 ea) [contains alcohol, usp, benzoic acid, sodium benzoate] Generic: 2.5 mg (1 ea); 20 mg (1 ea) Tablet, Oral: Generic: 2 mg, 5 mg [BCF] Diclofenac (Systemic) Tablet Delayed Release, Oral, as sodium: Generic: 50 mg, 75 mg Diclofenac (Topical) Gel, Transdermal, as sodium: Voltaren: 1% (100 g) [contains isopropyl alcohol, propylene glycol] Dicloxacillin Capsule, Oral: Generic: 250 mg [BCF] Dicyclomine Capsule, Oral, as hydrochloride: Generic: 10 mg [BCF] Solution, Oral, as hydrochloride: Generic: 10 mg/5 mL (473 mL) [BCF] Tablet, Oral, as hydrochloride: Generic: 20 mg [BCF]

11 Joint Regional Oupatient Formulary

Difluprednate Emulsion, Ophthalmic: Durezol: 0.05% (5 mL) [contains edetate sodium (tetrasodium), polysorbate 80] Digoxin Solution, Oral: Generic: 0.05 mg/mL (60 mL) Tablet, Oral: Lanoxin: 0.125 mg [BCF], 0.25 mg [BCF] [scored] DilTIAZem Capsule Extended Release 24 Hour, Oral, as hydrochloride: Generic: 120 mg [BCF], 180 mg [BCF], 240 mg [BCF], 300 mg [BCF], 360 mg [BCF] Tablet, Oral, as hydrochloride: Generic: 30 mg, 90 mg, 120 mg DiphenhydrAMINE (Systemic) Capsule, Oral, as hydrochloride: Banophen: 25 mg [contains brilliant blue fcf (fd&c blue #1), fd&c red #40, fd&c yellow #6 (sunset yellow), methylparaben, propylparaben] Banophen: 50 mg [contains brilliant blue fcf (fd&c blue #1), fd&c red #40] Generic: 25 mg Elixir, Oral, as hydrochloride: Generic: 12.5 mg/5 mL (5 mL) Liquid, Oral, as hydrochloride: Q-Dryl: 12.5 mg/5 mL (118 mL) [alcohol free; contains fd&c red #40, saccharin sodium, sodium benzoate; cherry flavor] Tablet, Oral, as hydrochloride: Banophen: 25 mg Diphenoxylate and Atropine Tablet, Oral: Generic: Diphenoxylate hydrochloride 2.5 mg and atropine sulfate 0.025 mg Dipyridamole Tablet, Oral: Persantine: 75 mg [contains fd&c yellow #10 aluminum lake, methylparaben, propylparaben, sodium benzoate] Generic: 25 mg, 75 mg Disopyramide Capsule, Oral: Generic: 100 mg, 150 mg Capsule Extended Release 12 Hour, Oral: Norpace CR: 100 mg, 150 mg Disulfiram Tablet, Oral: Antabuse: 250 mg Docusate Capsule, Oral, as sodium: DOK: 100 mg Syrup, Oral, as sodium: Generic: 20 mg/5 mL Donepezil Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg Dornase Alfa Solution, Inhalation: Pulmozyme: 1 mg/mL (2.5 mL) Dorzolamide Solution, Ophthalmic: Trusopt: 2% (10 mL) Dorzolamide and Timolol Solution, Ophthalmic: Generic: Dorzolamide 2% and timolol 0.5% (10 mL) Doxazosin Tablet, Oral: Generic: 1 mg, 2 mg, 4 mg, 8 mg Doxepin (Systemic) Capsule, Oral: Generic: 10 mg [BCF], 25 mg [BCF], 50 mg [BCF] Concentrate, Oral: Generic: 10 mg/mL (120 mL) [BCF] Tablet, Oral: Silenor: 3 mg, 6 mg

12 Joint Regional Oupatient Formulary

Doxycycline Capsule, Oral, as hyclate [strength expressed as base]: Generic: 50 mg, 100 mg [BCF] Solution Reconstituted, Intravenous, as hyclate [strength expressed as base]: Generic: 100 mg (1 ea) Tablet, Oral, as hyclate [strength expressed as base]: Generic: 20 mg Doxylamine Tablet, Oral, as succinate: Unisom: 25 mg Efavirenz, Emtricitabine, and Tablet, Oral: Tenofovir Atripla: Efavirenz 600 mg, emtricitabine 200 mg, and tenofovir disoproxil fumarate 300 mg Eletriptan Tablet, Oral: Relpax: 20 mg, 40 mg Emollients Cream, External: Cetaphil Moisturizing: (453 g) [contains benzyl alcohol, cetyl alcohol, disodium edta, peg-30 glyceryl stearate] Promiseb: (30 g) [animal products free, milk free, wheat free; contains disodium edta] Vanicream: (453 g) Cream, External [preservative free]: PruMyx: (140 g) [fragrance free] Ointment, External: Hydrophor: (454 g) Empagliflozin Tablet, Oral: Jardiance: 10 mg, 25 mg Emtricitabine and Tenofovir Tablet, Oral: Truvada: Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg Enalapril Tablet, Oral, as maleate: Generic: 2.5 mg, 5 mg, 10 mg, 20 mg Enoxaparin Solution, Injection, as sodium: Lovenox: 300 mg/3 mL (3 mL) [contains benzyl alcohol] [BCF] Solution, Subcutaneous, as sodium [preservative free]: Generic: 30 mg/0.3 mL (0.3 mL) [BCF]; 40 mg/0.4 mL (0.4 mL) [BCF]; 60 mg/0.6 mL (0.6 mL) [BCF]; 80 mg/0.8 mL (0.8 mL) [BCF]; 100 mg/mL (1 mL) [BCF]; 120 mg/0.8 mL (0.8 mL) [BCF]; 150 mg/mL (1 mL) [BCF] Entecavir Tablet, Oral: Generic: 0.5 mg EPINEPHrine (Oral Inhalation) Nebulization Solution, Inhalation [preservative free]: S2: 2.25% (1 ea) [sulfite free; contains edetate disodium] EPINEPHrine (Systemic) Device, Injection: EpiPen 2-Pak: 0.3 mg/0.3 mL (2 ea) [latex free; contains sodium metabisulfite] EpiPen Jr 2-Pak: 0.15 mg/0.3 mL (2 ea) [contains sodium metabisulfite] Eplerenone Tablet, Oral: Generic: 25 mg, 50 mg Ergocalciferol Capsule, Oral: Generic: 50,000 units Ergotamine and Caffeine Suppository, Rectal: Migergot: Ergotamine tartrate 2 mg and caffeine 100 mg (12 ea) Tablet, Oral: Generic: Ergotamine tartrate 1 mg and caffeine 100 mg Erythromycin (Ophthalmic) Ointment, Ophthalmic: Generic: 5 mg/g (3.5 g) [BCF]

13 Joint Regional Oupatient Formulary

Erythromycin (Systemic) Suspension Reconstituted, Oral, as ethylsuccinate: E.E.S. Granules: 200 mg/5 mL (100 mL, 200 mL) [cherry flavor] [BCF] Tablet, Oral, as ethylsuccinate: E.E.S. 400: 400 mg [contains fd&c red #40, fd&c yellow #10 (quinoline yellow)] Tablet Delayed Release, Oral, as base: Ery-Tab: 250 mg [BCF], 333 mg Erythromycin (Topical) Gel, External: Generic: 2% (30 g) [BCF] Solution, External: Generic: 2% (60 mL) [BCF] Escitalopram Tablet, Oral: Generic: 5 mg, 10 mg, 20 mg Estradiol and Levonorgestrel Patch Weekly, Transdermal: Climara Pro: estradiol 0.045 mg and levonorgestrel 0.015 mg per 24 hours (4 ea) Estradiol and Norethindrone Patch Biweekly, Transdermal: CombiPatch: 0.05/0.14: Estradiol 0.05 mg and norethindrone acetate 0.14 mg per day (8s) [9 sq cm] CombiPatch: 0.05/0.25: Estradiol 0.05 mg and norethindrone acetate 0.25 mg per day (8s) [16 sq cm] Estradiol (Systemic) Patch Weekly, Transdermal: Generic: 0.025 mg/24 hours (4s) [BCF]; 0.0375 mg/24 hours (4s) [BCF]; 0.05 mg/24 hours (4s) [BCF]; 0.075 mg/24 hours (4s) [BCF]; 0.1 mg/24 hours (4s) [BCF] Ring, Vaginal, as acetate: Femring: 0.05 mg/24 hr (1 ea); 0.1 mg/24 hr (1 ea) Tablet, Oral: Generic: 1 mg, 2 mg Estradiol (Topical) Cream, Vaginal: Estrace: 0.1 mg/g (42.5 g) Ring, Vaginal, as base: Estring: 2 mg (1 ea) Tablet, Vaginal, as base: Vagifem: 10 mcg Estrogens (Conjugated/Equine) Tablet, Oral: and Medroxyprogesterone Prempro: 0.3/1.5: Conjugated estrogens 0.3 mg and medroxyprogesterone acetate 1.5 mg [BCF] Prempro: 0.45/1.5: Conjugated estrogens 0.45 mg and medroxyprogesterone acetate 1.5 mg [BCF] Prempro: 0.625/2.5: Conjugated estrogens 0.625 mg and medroxyprogesterone acetate 2.5 mg [BCF] Prempro: 0.625/5: Conjugated estrogens 0.625 mg and medroxyprogesterone acetate 5 mg [BCF] Estrogens (Conjugated/Equine, Tablet, Oral: Systemic) Premarin: 0.3 mg [BCF], 0.45 mg [BCF], 0.625 mg [BCF], 0.9 mg, 1.25 mg [BCF] Estrogens (Conjugated/Equine, Cream, Vaginal: Topical) Premarin: 0.625 mg/g (30 g) [contains benzyl alcohol, cetyl alcohol, propylene glycol monostearate] [BCF] Estrogens (Esterified) and Tablet, Oral: Methyltestosterone Covaryx: Esterified estrogen 1.25 mg and methyltestosterone 2.5 mg Covaryx HS: Esterified estrogen 0.625 mg and methyltestosterone 1.25 mg Eszopiclone Tablet, Oral: Lunesta: 1 mg, 2 mg, 3 mg Ethambutol Tablet, Oral, as hydrochloride: MyambutolÂ®: 100 mg [BCF] MyambutolÂ®: 400 mg [scored] [BCF]

14 Joint Regional Oupatient Formulary

Ethinyl Estradiol and Tablet, Oral [low dose formulation]: Desogestrel Azurette: Day 1-21: Ethinyl estradiol 0.02 mg and desogestrel 0.15 mg [21 white tablets] Day 22-23: 2 inactive green tablets Day 24-28: Ethinyl estradiol 0.01 mg [5 blue tablets] (28s) Tablet, Oral [monophasic formulation]: Ortho-Cept 28: Ethinyl estradiol 0.03 mg and desogestrel 0.15 mg [21 light orange tablets and 7 green inactive tablets] (28s) Ethinyl Estradiol and Tablet, Oral: Drospirenone Gianvi: Ethinyl estradiol 0.02 mg and drospirenone 3 mg [24 light pink active tablets and 4 white inactive tablets] (28s) [BCF] Yasmin: Ethinyl estradiol 0.03 mg and drospirenone 3 mg [21 yellow active tablets and 7 white inactive tablets] (28s) [BCF] Ethinyl Estradiol and Ethynodiol Tablet, Oral: Diacetate Zovia 1/35-28: Ethinyl estradiol 0.035 mg and ethynodiol diacetate 1 mg [21 light pink tablets and 7 white inactive tablets] (28s) Ethinyl Estradiol and Ring, Vaginal: Etonogestrel NuvaRing: Ethinyl estradiol 0.015 mg/day and etonogestrel 0.12 mg/day (1 ea) Ethinyl Estradiol and Tablet, Oral [extended cycle regimen]: Levonorgestrel Jolessa: Ethinyl estradiol 0.03 mg and levonorgestrel 0.15 mg (91s) [84 pink tablets and 7 white inactive tablets] [BCF] Tablet, Oral [low dose formulation]: Sronyx: Ethinyl estradiol 0.02 mg and levonorgestrel 0.1 mg (28s) [21 white tablets and 7 peach inactive tablets] [BCF] Tablet, Oral [monophasic formulation]: Levora: Ethinyl estradiol 0.03 mg and levonorgestrel 0.15 mg (28s) [21 white tablets and 7 peach inactive tablets] [BCF] Tablet, Oral [triphasic formulation]: Trivora: Day 1-6: Ethinyl estradiol 0.03 mg and levonorgestrel 0.05 mg [6 blue tablets] Day 7-11: Ethinyl estradiol 0.04 mg and levonorgestrel 0.075 mg [5 white tablets] Day 12-21: Ethinyl estradiol 0.03 mg and levonorgestrel 0.125 mg [10 pink tablets] Day 22-28: 7 peach inactive tablets (28s) Ethinyl Estradiol and Patch Weekly, Transdermal: Norelgestromin Ortho Evra: Ethinyl estradiol 0.75 mg and norelgestromin 6 mg [releases ethinyl estradiol 20 mcg and norelgestromin 150 mcg per day] (3 ea)

15 Joint Regional Oupatient Formulary

Ethinyl Estradiol and Tablet, Oral: Norethindrone Femhrt Low Dose: Ethinyl estradiol 0.0025 mg and norethindrone acetate 0.5 mg [white tablets] Jinteli: Ethinyl estradiol 0.005 mg and norethindrone acetate 1 mg [white tablets] Tablet, Oral [monophasic formulation]: Gildess 1/20: Ethinyl estradiol 0.02 mg and norethindrone acetate 1 mg [white tablets] (21 ea) Microgestin 1/20: Ethinyl estradiol 0.02 mg and norethindrone acetate 1 mg [white tablets] (21 ea) Microgestin Fe 1/20: Ethinyl estradiol 0.02 mg and norethindrone acetate 1 mg [21 white tablets] and ferrous fumarate 75 mg [7 brown tablets] (28 ea) Microgestin Fe 1.5/30: Ethinyl estradiol 0.03 mg and norethindrone acetate 1.5 mg [21 green tablets] and ferrous fumarate 75 mg [7 brown tablets] (28 ea) Norinyl 1+35: Ethinyl estradiol 0.035 mg and norethindrone 1 mg (28 ea) [21 yellow-green tablets and 7 orange inactive tablets] [BCF] Tablet, oral [triphasic formulation]: Necon 7/7/7: Day 1-7: Ethinyl estradiol 0.035 mg and norethindrone 0.5 mg [7 white tablets] Day 8-14: Ethinyl estradiol 0.035 mg and norethindrone 0.75 mg [7 light peach tablets] Day 15-21: Ethinyl estradiol 0.035 mg and norethindrone 1 mg [7 peach tablets] Day 22-28: 7 green inactive tablets (28 ea)

Ethinyl Estradiol and Tablet, Oral [monophasic formulation]: Norgestimate MonoNessa: Ethinyl estradiol 0.035 mg and norgestimate 0.25 mg [21 blue tablets and 7 green inactive tablets] [BCF] Tablet, Oral [triphasic formulation]: Ortho Tri-Cyclen Lo [BCF]: Day 1-7: Ethinyl estradiol 0.025 mg and norgestimate 0.18 mg [7 white tablets] Day 8-14: Ethinyl estradiol 0.025 mg and norgestimate 0.215 mg [7 light blue tablets] Day 15-21: Ethinyl estradiol 0.025 mg and norgestimate 0.25 mg [7 dark blue tablets] Day 22-28: 7 dark green inactive tablets TriNessa [BCF]: Day 1-7: Ethinyl estradiol 0.035 mg and norgestimate 0.18 mg [7 white tablets] Day 8-14: Ethinyl estradiol 0.035 mg and norgestimate 0.215 mg [7 light blue tablets] Day 15-21: Ethinyl estradiol 0.035 mg and norgestimate 0.25 mg [7 blue tablets] Day 22-28: 7 green inactive tablets Ethinyl Estradiol and Norgestrel Tablet, Oral: Low-Ogestrel: Ethinyl estradiol 0.03 mg and norgestrel 0.3 mg [21 white tablets and 7 peach inactive tablets] (28s) Etodolac Tablet, Oral: Generic: 400 mg Exemestane Tablet, Oral: Aromasin: 25 mg Exenatide Pen-injector, Subcutaneous: Bydureon: 2 mg Ezetimibe Tablet, Oral: Zetia: 10 mg Famotidine Suspension Reconstituted, Oral: Generic: 40 mg/5 mL (50 mL) Tablet, Oral: Generic: 20 mg, 40 mg Felodipine Tablet Extended Release 24 Hour, Oral: Generic: 2.5 mg, 5 mg, 10 mg Fenofibrate and Derivatives Tablet, Oral, as fenofibrate: Tricor: 48 mg [BCF], 145 mg [BCF] [contains soybean lecithin] Triglide: 160 mg

16 Joint Regional Oupatient Formulary

FentaNYL Patch 72 Hour, Transdermal, as base: Generic: 12 mcg/hr (5 ea); 25 mcg/hr (5 ea); 50 mcg/hr (5 ea); 75 mcg/hr (5 ea); 100 mcg/hr (5 ea) Ferrous Sulfate Elixir, Oral: Generic: 220 (44 Fe) mg/5 mL (473 mL) Solution, Oral: Fer-Iron: 75 mg/mL (15 Fe) (50 mL) [contains sodium metabisulfite; lemon flavor] Tablet, Oral: Generic: 325 mg (65 Fe) Fexofenadine Tablet, Oral, as hydrochloride: Generic: 60 mg, 180 mg Finasteride Tablet, Oral: Generic: 5 mg [BCF] FlavoxATE Tablet, Oral, as hydrochloride: Generic: 100 mg Flecainide Tablet, Oral, as acetate: Generic: 50 mg, 100 mg, 150 mg Fluconazole Solution, Intravenous: Generic: 200 mg (100 mL) Suspension Reconstituted, Oral: Generic: 10 mg/mL (35 mL) Tablet, Oral: Generic: 100 mg, 150 mg [BCF] Fludrocortisone Tablet, Oral, as acetate: Generic: 0.1 mg Fluocinolone, Hydroquinone, Cream, External: and Tretinoin Tri-Luma: Fluocinolone acetonide 0.01%, hydroquinone 4%, and tretinoin 0.05% (30 g) [contains cetyl alcohol, methylparaben, propylparaben, sodium metabisulfite] Fluocinolone (Otic) Oil, Otic, as acetonide: Generic: 0.01% (20 mL) Fluocinolone (Topical) Oil, External, as acetonide: Derma-Smoothe/FS Scalp: 0.01% (118.28 mL) [contains isopropyl alcohol, peanut oil] Solution, External, as acetonide: Generic: 0.01% (60 mL) Fluocinonide Cream, External: Generic: 0.05% (15 g, 60 g) [BCF] Gel, External: Generic: 0.05% (30 g) Ointment, External: Generic: 0.05% (15 g, 30 g) Solution, External: Generic: 0.05% (60 mL) Fluorescein and Benoxinate Solution, Ophthalmic: Fluress: Fluorescein sodium 0.25% and benoxinate hydrochloride 0.4% (5 mL) Fluoride Cream, Dental, as sodium: PreviDent 5000 Plus: 1.1% (51 g) [spearmint flavor] Gel, Oral, as sodium [toothpaste]: PreviDent 5000 Booster Plus: 1.1% (100 mL) [contains sodium benzoate; fruitastic flavor; equivalent to fluoride 2.5 mg/dose] Solution, Oral, as sodium: Generic: 1.1 mg/mL (50 mL) [equivalent to fluoride 0.5 mg/mL] Tablet, Chewable, Oral, as sodium: Generic: 1.1 mg [equivalent to fluoride 0.5 mg] Generic: 2.2 mg [equivalent to fluoride 1 mg]

17 Joint Regional Oupatient Formulary

Fluorometholone Suspension, Ophthalmic, as acetate: Flarex: 0.1% (5 mL) Suspension, Ophthalmic, as base: Generic: 0.1% (5 mL) Fluorouracil (Topical) Cream, External: Generic: 5% (40 g) FLUoxetine Capsule, Oral: Generic: 10 mg [BCF], 20 mg [BCF], 40 mg [BCF] Solution, Oral: Generic: 20 mg/5 mL (120 mL) [BCF] Flurbiprofen (Ophthalmic) Solution, Ophthalmic, as sodium: Generic: 0.03% (2.5 mL) Fluticasone and Salmeterol Aerosol, Inhalation: Advair HFA: 45/21: Fluticasone propionate 45 mcg and salmeterol 21 mcg per inhalation (12 g) [chlorofluorocarbon free; 120 metered actuations] [BCF] Advair HFA: 115/21: Fluticasone propionate 115 mcg and salmeterol 21 mcg per inhalation (12 g) [chlorofluorocarbon free; 120 metered actuations] [BCF] Advair HFA: 230/21: Fluticasone propionate 230 mcg and salmeterol 21 mcg per inhalation (12 g) [chlorofluorocarbon free; 120 metered actuations] [BCF] Aerosol Powder Breath Activated, Inhalation: Advair Diskus: 100/50: Fluticasone propionate 100 mcg and salmeterol 50 mcg (14 ea, 60 ea) [contains milk protein] [BCF] Advair Diskus: 250/50: Fluticasone propionate 250 mcg and salmeterol 50 mcg (14 ea, 60 ea) [contains milk protein] [BCF] Advair Diskus: 500/50: Fluticasone propionate 500 mcg and salmeterol 50 mcg (14 ea, 60 ea) [contains milk protein] [BCF] Fluticasone (Nasal) Suspension, Nasal, as propionate: Generic: 50 mcg/inhalation (16 g) [BCF] Fluticasone (Oral Inhalation) Aerosol, Inhalation, as propionate: Flovent HFA: 44 mcg/inhalation (10.6 g) [chlorofluorocarbon free; 120 metered actuations] [BCF] Flovent HFA: 110 mcg/inhalation (12 g) [chlorofluorocarbon free; 120 metered actuations] [BCF] Flovent HFA: 220 mcg/inhalation (12 g) [chlorofluorocarbon free; 120 metered actuations] [BCF] Aerosol Powder Breath Activated, Inhalation, as propionate: FloventÂ® Diskus: 50 mcg/blister (60 ea) [contains lactose] [BCF] FloventÂ® Diskus: 100 mcg/blister (60 ea) [contains lactose] [BCF] FloventÂ® Diskus: 250 mcg/blister (60 ea) [contains lactose] [BCF] Fluticasone, Umeclidinium, and Aerosol Powder Breath Activated, Inhalation: Vilanterol Trelegy Ellipta: Fluticasone furoate 100 mcg, umeclidinium 62.5 mcg, and vilanterol 25 mcg (28 ea, 60 ea) [contains lactose monohydrate] FluvoxaMINE Tablet, Oral, as maleate: Generic: 25 mg, 50 mg, 100 mg Folic Acid Tablet, Oral: Generic: 1 mg [BCF] Formoterol Capsule, Inhalation, as fumarate: Foradil Aerolizer: 12 mcg [contains milk protein] Fosinopril Tablet, Oral, as sodium: Generic: 10 mg, 20 mg, 40 mg Furosemide Solution, Oral: Generic: 10 mg/mL (120 mL) [BCF] Tablet, Oral: Generic: 20 mg [BCF], 40 mg [BCF]

18 Joint Regional Oupatient Formulary

Gabapentin Capsule, Oral: Generic: 100 mg [BCF], 300 mg [BCF], 400 mg [BCF] Solution, Oral: Generic: 250 mg/5 mL (470 mL) Tablet, Oral: Generic: 600 mg [BCF], 800 mg [BCF] Ganciclovir (Ophthalmic) Gel, Ophthalmic: Zirgan: 0.15% (5 g) [contains benzalkonium chloride] Gatifloxacin Solution, Ophthalmic: Generic: 0.5% (2.5 mL) Gemfibrozil Tablet, Oral: Generic: 600 mg [BCF] Gentamicin (Ophthalmic) Ointment, Ophthalmic: Gentak: 0.3% (3.5 g) [BCF] Solution, Ophthalmic: Generic: 0.3% (5 mL) [BCF] Glimepiride Tablet, Oral: Generic: 1 mg, 2 mg, 4 mg GlipiZIDE Tablet, Oral: Generic: 5 mg [BCF], 10 mg [BCF] Tablet Extended Release 24 Hour, Oral: Generic: 2.5 mg, 5 mg, 10 mg GlyBURIDE Tablet, Oral: Generic: 1.25 mg [BCF], 1.5 mg, 2.5 mg [BCF], 3 mg, 5 mg [BCF], 6 mg Glyburide and Metformin Tablet, Oral: Generic: Glyburide 1.25 mg and metformin hydrochloride 250 mg Generic: Glyburide 2.5 mg and metformin hydrochloride 500 mg Generic: Glyburide 5 mg and metformin hydrochloride 500 mg Glycerin Suppository, Rectal: Glycerin (Adult): 2.1 g (100 ea) Sani-Supp Pediatric: 1.2 g (25 ea) Glycopyrrolate (Systemic) Tablet, Oral: Generic: 1 mg Goserelin Implant, Subcutaneous: Zoladex: 3.6 mg (1s) [1 month implant] [BCF] Zoladex: 10.8 mg (1s) [3 month implant] [BCF] Grass Pollen Allergen Extract Tablet Sublingual, Sublingual: (Timothy Grass) Grastek: 2800 bau [contains gelatin (fish)] Griseofulvin Suspension, Oral: Generic: 125 mg/5 mL (118 mL) [BCF] Tablet, Oral: Gris-PEG: 125 mg [BCF], 250 mg [BCF] [scored] GuaiFENesin Solution, Oral: Generic: 100 mg/5 mL (10 mL) Syrup, Oral: Q-Tussin: 100 mg/5 mL (118 mL) [alcohol free; contains fd&c red #40, saccharin sodium, sodium benzoate; cherry flavor] Tablet Extended Release 12 Hour, Oral: Mucinex: 600 mg [contains fd&c blue #1 aluminum lake] Guaifenesin and Codeine Solution, Oral: Generic: Guaifenesin 100 mg and codeine phosphate 10 mg per 5 mL (5 mL, 118 mL)

19 Joint Regional Oupatient Formulary

Guaifenesin and Syrup, Oral: Dextromethorphan Q-Tussin DM: Guaifenesin 100 mg and dextromethorphan hydrobromide 10 mg per 5 mL (118 mL, 237 mL) [cherry flavor] Generic: Guaifenesin 100 mg and dextromethorphan hydrobromide 10 mg per 5 mL (10 mL) Tablet Extended Release 12 Hour, Oral: Mucinex DM: Guaifenesin 600 mg and dextromethorphan hydrobromide 30 mg [contains fd&c yellow #10 aluminum lake]

Guaifenesin and Tablet, extended release, oral: Pseudoephedrine MucinexÂ® D: Guaifenesin 600 mg and pseudoephedrine hydrochloride 60 mg MucinexÂ® D Maximum Strength: Guaifenesin 1200 mg and pseudoephedrine hydrochloride 120 mg GuanFACINE Tablet, Oral: Generic: 1 mg, 2 mg Tablet Extended Release 24 Hour, Oral: Intuniv: 1 mg, 2 mg, 3 mg, 4 mg Haloperidol Concentrate, Oral, as lactate [strength expressed as base]: Generic: 2 mg/mL (120 mL) Tablet, Oral: Generic: 0.5 mg, 2 mg, 5 mg Homatropine Solution, Ophthalmic, as hydrobromide: Homatropaire: 5% (5 mL) HydrALAZINE Tablet, Oral, as hydrochloride: Generic: 10 mg [BCF], 25 mg [BCF], 50 mg [BCF], 100 mg HydroCHLOROthiazide Capsule, Oral: Generic: 12.5 mg [BCF] Tablet, Oral: Generic: 25 mg [BCF], 50 mg [BCF] Hydrochlorothiazide and Tablet, Oral: Triamterene Generic: Hydrochlorothiazide 25 mg and triamterene 37.5 mg [BCF] Generic: Hydrochlorothiazide 50 mg and triamterene 75 mg [BCF] Hydrocodone and Solution, Oral: Acetaminophen Generic: Hydrocodone bitartrate 7.5 mg and acetaminophen 325 mg per 15 mL Tablet, Oral: Generic: Hydrocodone bitartrate 5 mg and acetaminophen 325 mg Generic: Hydrocodone bitartrate 7.5 mg and acetaminophen 325 mg Generic: Hydrocodone bitartrate 10 mg and acetaminophen 325 mg Hydrocodone and Ibuprofen Tablet, Oral: Generic: Hydrocodone bitartrate 7.5 mg and ibuprofen 200 mg Hydrocortisone (Systemic) Tablet, Oral, as base: Generic: 5 mg, 20 mg

20 Joint Regional Oupatient Formulary

Hydrocortisone (Topical) Cream, External, as base: Generic: 1% (1.5 g, 28.4 g) Generic: 2.5% (30 g) [BCF] Cream, Rectal, as base: Proctozone-HC: 2.5% (30 g) Cream, External, as valerate: Generic: 0.2% (15 g, 60 g) Enema, Rectal, as base: Colocort: 100 mg/60 mL (60 mL) Ointment, External, as base: Generic: 1% (28.4 g) Ointment, External, as valerate: Generic: 0.2% (15 g, 60 g) Suppository, Rectal, as acetate: Generic: 25 mg (12s ea) [BCF] HYDROmorphone Tablet, Oral, as hydrochloride: Generic: 2 mg, 4 mg Hydroquinone Cream, External: Nuquin HP: 4% (28.4 g) [contains propylene glycol, sodium metabisulfite] Hydroxychloroquine Tablet, Oral, as sulfate: Generic: 200 mg Hydroxypropyl Cellulose Insert, Ophthalmic [preservative free]: Lacrisert: 5 mg (60 ea) Hydroxypropyl Methylcellulose Solution, Ophthalmic: Gonak: 2.5% (15 mL) Hydroxyurea Capsule, Oral: Hydrea: 500 mg HydrOXYzine Capsule, Oral, as pamoate: Generic: 25 mg, 50 mg, 100 mg Syrup, Oral, as hydrochloride: Generic: 10 mg/5 mL (473 mL) [BCF] Tablet, Oral, as hydrochloride: Generic: 10 mg [BCF], 25 mg [BCF], 50 mg [BCF] Hyoscyamine Tablet Extended Release 12 Hour, Oral, as sulfate: Symax-SR: 0.375 mg [scored] Tablet Sublingual, as sulfate: Oscimin: 0.125 mg [peppermint flavor] Hyoscyamine, Atropine, Elixir, Oral: Scopolamine, and Phenobarbital Donnatal: Hyoscyamine sulfate 0.1037 mg, atropine sulfate 0.0194 mg, scopolamine hydrobromide 0.0065 mg, and phenobarbital 16.2 mg per 5 mL (120 mL) [contains alcohol, usp, brilliant blue fcf (fd&c blue #1), saccharin sodium; grape flavor] Tablet, Oral: Donnatal: 16.2 mg Ibandronate Tablet, Oral: Generic: 150 mg Ibuprofen Suspension, Oral: Generic: 100 mg/5 mL (5 mL, 120 mL) Tablet, Oral: Generic: 200 mg, 400 mg [BCF], 600 mg [BCF], 800 mg [BCF] Imatinib Tablet, Oral: Generic: 100 mg, 400 mg Imipramine Capsule, Oral, as pamoate: Generic: 75 mg [BCF] Tablet, Oral, as hydrochloride: Generic: 10 mg [BCF], 25 mg [BCF], 50 mg [BCF]

21 Joint Regional Oupatient Formulary

Imiquimod Cream, External: Generic: 5% (24 ea) Indapamide Tablet, Oral: Generic: 2.5 mg Indomethacin Capsule, Oral: Generic: 25 mg [BCF], 50 mg [BCF] Suppository, Rectal: Indocin: 50 mg (30 ea) Ingenol Mebutate Gel, External: Picato: 0.015% (3 ea); 0.05% (2 ea) [contains benzyl alcohol, isopropyl alcohol] Inhalation Devices Holding chamber: AeroChamber Plus Flo-Vu Holding chamber with mask: AeroChamber Plus Flo-Vu: Small, medium Insulin Aspart Solution, Subcutaneous: NovoLOG: 100 units/mL (10 mL) [contains metacresol, phenol] [BCF] NovoLOG FlexPen: 100 units/mL (3 mL) [contains metacresol, phenol] [BCF] NovoLOG Penfill: 100 units/mL (3 mL) [contains metacresol, phenol] [BCF] Insulin Aspart Protamine and Suspension, Subcutaneous: Insulin Aspart NovoLOG Mix 70/30 FlexPen: Insulin aspart protamine suspension 70% [intermediate acting] and insulin aspart solution 30% [rapid-acting]: 100 units/mL (3 mL) [contains metacresol, phenol] [BCF] Insulin Detemir Solution, Subcutaneous: Levemir: 100 units/mL (10 mL) [contains metacresol, phenol] Insulin Glargine Solution, Subcutaneous: Lantus: 100 units/mL (10 mL) [contains metacresol] [BCF] Lantus Solostar: 100 units/mL (3 mL) [prefilled pen] [BCF] Insulin Lispro Solution, Subcutaneous: HumaLOG: 100 units/mL (3 mL, 10 mL) [contains metacresol, phenol] Solution Pen-injector, Subcutaneous: HumaLOG Junior KwikPen: 100 units/mL (3 mL) [contains metacresol, phenol] HumaLOG KwikPen: 200 units/mL (3 mL) [contains metacresol, phenol] Generic: 100 units/mL (3 mL) Insulin Lispro Protamine and Suspension, Subcutaneous: Insulin Lispro HumaLOG Mix 50/50: Insulin lispro protamine suspension 50% [intermediate acting] and insulin lispro solution 50% [rapid acting]: 100 units/mL (10 mL) HumaLOG Mix 75/25: Insulin lispro protamine suspension 75% [intermediate acting] and insulin lispro solution 25% [rapid acting]: 100 units/mL (10 mL) Suspension Pen-injector, Subcutaneous: HumaLOG Mix 50/50 KwikPen: Insulin lispro protamine suspension 50% [intermediate acting] and insulin lispro solution 50% [rapid acting]: 100 units/mL (3 mL) HumaLOG Mix 75/25 KwikPen: Insulin lispro protamine suspension 75% [intermediate acting] and insulin lispro solution 25% [rapid acting]: 100 units/mL (3 mL) This medication is nonformulary. For formulary alternatives, refer to Therapeutic Category. Insulin NPH Suspension, Subcutaneous: NovoLIN N: 100 units/mL (10 mL) [contains metacresol, phenol] [BCF] Insulin NPH and Insulin Regular Suspension, Subcutaneous: NovoLIN 70/30: Insulin NPH suspension 70% [intermediate acting] and insulin regular solution 30% [short acting]: 100 units/mL (10 mL) [contains metacresol, phenol] [BCF] Insulin Regular Solution, Injection: NovoLIN R: 100 units/mL (10 mL) [contains metacresol] [BCF]

22 Joint Regional Oupatient Formulary

Ipratropium and Albuterol Aerosol Solution, Inhalation: Combivent Respimat: Ipratropium bromide 20 mcg and albuterol (base) 100 mcg per inhalation (4 g) [contains benzalkonium chloride, edetate disodium] Solution, Inhalation: Generic: Ipratropium bromide 0.5 mg and albuterol (base) 2.5 mg per 3 mL (3 mL) [BCF] Ipratropium (Nasal) Solution, Nasal, as bromide: Generic: 0.03% (30 mL); 0.06% (15 mL) Ipratropium (Oral Inhalation) Aerosol Solution, Inhalation, as bromide: Atrovent HFA: 17 mcg/actuation (12.9 g) [contains alcohol, usp] [BCF] Solution, Inhalation, as bromide: Generic: 0.02% (2.5 mL) Irbesartan Tablet, Oral: Generic: 75 mg, 150 mg, 300 mg Irbesartan and Tablet, Oral: Hydrochlorothiazide 150/12.5: Irbesartan 150 mg and hydrochlorothiazide 12.5 mg 300/12.5: Irbesartan 300 mg and hydrochlorothiazide 12.5 mg Isoniazid Syrup, Oral: Generic: 50 mg/5 mL (473 mL) Tablet, Oral: Generic: 100 mg [BCF], 300 mg [BCF] Isosorbide Dinitrate Capsule Extended Release, Oral: Dilatrate-SR: 40 mg Tablet, Oral: Generic: 10 mg [BCF], 20 mg [BCF] Tablet Extended Release, Oral: Generic: 40 mg [BCF] Isosorbide Mononitrate Tablet Extended Release 24 Hour, Oral: Generic: 30 mg [BCF], 60 mg [BCF], 120 mg [BCF] ISOtretinoin (Systemic) Capsule, Oral: Amnesteem: 10 mg, 20 mg, 40 mg [contains soybean oil] Ivermectin (Systemic) Tablet, Oral: Stromectol: 3 mg Ketoconazole (Systemic) Tablet, Oral: Generic: 200 mg Ketoconazole (Topical) Cream, External: Generic: 2% (30 g) Shampoo, External: Generic: 2% (120 mL) Ketorolac (Ophthalmic) Solution, Ophthalmic, as tromethamine: Generic: 0.4% (5 mL); 0.5% (5 mL) Ketorolac (Systemic) Tablet, Oral, as tromethamine: Generic: 10 mg Labetalol Tablet, Oral, as hydrochloride: Generic: 100 mg, 200 mg, 300 mg Lacosamide Tablet, Oral: Vimpat: 50 mg, 100 mg, 150 mg, 200 mg Lactic Acid and Ammonium Cream, topical: Hydroxide Generic: Lactic acid 12% with ammonium hydroxide (140 g) Lotion, topical: Generic: Lactic acid 12% with ammonium hydroxide (225 g) Lactobacillus Tablet, Chewable, Oral: L. acidophilus: (100 ea) Lactulose Solution, Oral: Generic: 10 g/15 mL (473 mL) [BCF]

23 Joint Regional Oupatient Formulary

LamoTRIgine Tablet, Oral: Generic: 25 mg, 100 mg, 150 mg, 200 mg Tablet Extended Release 24 Hour, Oral: Generic: 25 mg, 50 mg, 100 mg, 200 mg, 250 mg, 300 mg Lansoprazole Suspension, Oral: First-Lansoprazole: 3 mg/mL (90 mL) Latanoprost Solution, Ophthalmic: Generic: 0.005% (2.5 mL) [BCF] Leflunomide Tablet, Oral: Arava: 20 mg Letrozole Tablet, Oral: Generic: 2.5 mg Leucovorin Calcium Tablet, Oral [strength expressed as base]: Generic: 5 mg Levalbuterol Nebulization Solution, Inhalation, as hydrochloride [strength expressed as base, preservative free]: Xopenex: 0.31 mg/3 mL (3 mL) Generic: 0.31 mg/3 mL (3 mL); 0.63 mg/3 mL (3 mL); 1.25 mg/3 mL (3 mL) LevETIRAcetam Solution, Oral: Keppra: 100 mg/mL (473 mL) [gluten free, lactose free; contains acesulfame potassium, methylparaben, propylparaben; grape flavor] Tablet, Oral: Keppra: 250 mg, 500 mg, 750 mg, 1000 mg [scored] Tablet Extended Release 24 Hour, Oral: Generic: 500 mg LevoFLOXacin (Systemic) Solution, Oral: Generic: 25 mg/mL (100 mL) [BCF] Tablet, Oral: Levaquin: 750 mg [BCF] Generic: 250 mg [BCF], 500 mg [BCF], 750 mg [BCF] Levonorgestrel (Systemic) Tablet, Oral: My Way: 1.5 mg Levothyroxine Tablet, Oral, as sodium: Synthroid: 25 mcg [BCF], 50 mcg [BCF], 75 mcg [BCF], 88 mcg [BCF], 100 mcg [BCF], 112 mcg [BCF], 125 mcg [BCF], 137 mcg [BCF], 150 mcg [BCF], 175 mcg [BCF], 200 mcg [BCF]

Lidocaine and Prilocaine Cream, External: Generic: Lidocaine 2.5% and prilocaine 2.5% (30 g) Lidocaine (Topical) Gel, External, as hydrochloride: Generic: 2% (30 mL) Ointment, External, as hydrochloride: Generic: 5% (35.44 g) Patch, External: Lidoderm: 5% (30 ea) [contains disodium edta, methylparaben, propylene glycol, propylparaben] Solution, External, as hydrochloride: Generic: 4% (50 mL) Solution, Mouth/Throat, as hydrochloride: Generic: 2% (100 mL) LinaCLOtide Capsule, Oral: Linzess: 72 mcg, 145 mcg, 290 mcg Lindane Lotion, External: Generic: 1% (60 mL) Shampoo, External: Generic: 1% (60 mL)

24 Joint Regional Oupatient Formulary

Liothyronine Tablet, Oral: Cytomel: 5 mcg Generic: 5 mcg, 25 mcg Lisinopril Tablet, Oral: Generic: 2.5 mg [BCF], 5 mg [BCF], 10 mg [BCF], 20 mg [BCF], 30 mg [BCF], 40 mg [BCF]

Lisinopril and Tablet, Oral: Hydrochlorothiazide Generic: 10/12.5: Lisinopril 10 mg and hydrochlorothiazide 12.5 mg [BCF] Generic: 20/12.5: Lisinopril 20 mg and hydrochlorothiazide 12.5 mg [BCF] Generic: 20/25: Lisinopril 20 mg and hydrochlorothiazide 25 mg [BCF] Lithium Capsule, Oral, as carbonate: Generic: 150 mg [BCF], 300 mg [BCF] Solution, Oral, as citrate: Generic: 8 mEq/5 mL (500 mL) [BCF] Tablet Extended Release, Oral, as carbonate: Generic: 300 mg, 450 mg Loperamide Capsule, Oral, as hydrochloride: Generic: 2 mg [BCF] Tablet, Oral, as hydrochloride: Anti-Diarrheal: 2 mg [scored] Loratadine Syrup, Oral: Childrens Loratadine: 5 mg/5 mL (120 mL) [fruit flavor] Tablet, Oral: Generic: 10 mg Loratadine and Tablet Extended Release 12 Hour, Oral: Pseudoephedrine Loratadine-D 12 Hour: Loratadine 5 mg and pseudoephedrine sulfate 120 mg LORazepam Tablet, Oral: Generic: 0.5 mg, 1 mg Losartan Tablet, Oral, as potassium: Generic: 25 mg [BCF], 50 mg [BCF], 100 mg [BCF] Losartan and Tablet, Oral: Hydrochlorothiazide Hyzaar 50/12.5: Losartan potassium 50 mg and hydrochlorothiazide 12.5 mg [contains potassium 4.24 mg (0.108 mEq)] [BCF] Generic: 50/12.5: Losartan potassium 50 mg and hydrochlorothiazide 12.5 mg [BCF] Generic: 100/12.5: Losartan potassium 100 mg and hydrochlorothiazide 12.5 mg [BCF] Generic: 100/25: Losartan potassium 100 mg and hydrochlorothiazide 25 mg [BCF] Loteprednol Gel, Ophthalmic, as etabonate: Lotemax: 0.5% (5 g) [contains benzalkonium chloride, edetate disodium dihydrate, propylene glycol] Suspension, Ophthalmic, as etabonate: Alrex: 0.2% (5 mL) Lotemax: 0.5% (5 mL) Lovastatin Tablet, Oral: Generic: 10 mg, 20 mg, 40 mg Lubiprostone Capsule, Oral: Amitiza: 8 mcg, 24 mcg Lurasidone Tablet, Oral, as hydrochloride: Latuda: 20 mg, 40 mg, 60 mg Latuda: 80 mg [contains fd&c blue #2 aluminum lake] Latuda: 120 mg Magnesium Citrate Solution, Oral: Generic: 1.745 g/30 mL (296 mL) Magnesium Gluconate Tablet, Oral: Generic: 500 mg

25 Joint Regional Oupatient Formulary

Magnesium Hydroxide Suspension, Oral: Milk of Magnesia: 7.75% (355 mL) [mint flavor] Malathion Lotion, External: Ovide: 0.5% (59 mL) [contains isopropyl alcohol] Meclizine Tablet, Oral, as hydrochloride: Dramamine Less Drowsy: 25 mg Generic: 25 mg Tablet Chewable, Oral, as hydrochloride: Travel Sickness: 25 mg [scored; contains aspartame, fd&c red #40 aluminum lake; raspberry flavor] MedroxyPROGESTERone Tablet, Oral, as acetate: Generic: 2.5 mg [BCF], 5 mg [BCF], 10 mg [BCF] Megestrol Tablet, Oral, as acetate: Generic: 40 mg Melatonin Tablet, Oral: Generic: 3 mg Meloxicam Tablet, Oral: Generic: 7.5 mg [BCF], 15 mg [BCF] Melphalan Tablet, Oral: Alkeran: 2 mg Memantine Tablet, Oral, as hydrochloride: Namenda: 5 mg, 10 mg Meperidine Tablet, Oral, as hydrochloride: Demerol: 50 mg [scored] Mesalamine Capsule Extended Release 24 Hour, Oral: Apriso: 0.375 g [contains aspartame] Enema, Rectal: Generic: 4 g (60 mL) Suppository, Rectal: Canasa: 1000 mg (30 ea) Tablet Delayed Release, Oral: Lialda: 1.2 g [BCF] Metaproterenol Syrup, Oral, as sulfate: Generic: 10 mg/5 mL (473 mL) Metaxalone Tablet, Oral: Skelaxin: 800 mg [scored] MetFORMIN Solution, Oral, as hydrochloride: Generic: 500 mg/5 mL (118 mL, 473 mL) Tablet, Oral, as hydrochloride: Generic: 500 mg [BCF], 850 mg [BCF], 1000 mg [BCF] Tablet Extended Release 24 Hour, Oral, as hydrochloride: Generic: 500 mg [BCF], 750 mg [BCF] Methadone Tablet, Oral, as hydrochloride: Generic: 10 mg Methenamine Tablet, Oral: Generic: 1 g MethIMAzole Tablet, Oral: Generic: 5 mg, 10 mg Methocarbamol Tablet, Oral: Generic: 500 mg [BCF], 750 mg Methotrexate Tablet, Oral: Generic: 2.5 mg [BCF] Methoxsalen (Systemic) Capsule, Oral: Oxsoralen Ultra: 10 mg

26 Joint Regional Oupatient Formulary

Methyldopa Tablet, Oral: Generic: 250 mg Methylergonovine Tablet, Oral, as maleate: Generic: 0.2 mg Methylphenidate Capsule Extended Release 24 Hour, Oral, as hydrochloride: Ritalin LA: 10 mg [5 mg immediate release, 5 mg extended release] [BCF] Ritalin LA: 20 mg [10 mg immediate release, 10 mg extended release] [BCF] Ritalin LA: 30 mg [15 mg immediate release, 15 mg extended release] [BCF] Ritalin LA: 40 mg [20 mg immediate release, 20 mg extended release] [BCF] Suspension Reconstituted, Oral, as hydrochloride: Quillivant XR: 25 mg/5 mL (180 mL) [contains sodium benzoate; banana flavor] Tablet, Oral, as hydrochloride: Generic: 5 mg [BCF], 10 mg [BCF] Tablet Extended Release, Oral, as hydrochloride: Generic: 18 mg [BCF], 20 mg, 27 mg [BCF], 36 mg [BCF], 54 mg [BCF] MethylPREDNISolone Tablet, Oral: Generic: 4 mg MethylTESTOSTERone Capsule, Oral: Testred: 10 mg Metoclopramide Solution, Oral: Generic: 5 mg/5 mL (473 mL) [BCF] Tablet, Oral: Generic: 10 mg [BCF] MetOLazone Tablet, Oral: Generic: 2.5 mg, 5 mg, 10 mg Metoprolol Tablet, Oral, as tartrate: Generic: 25 mg [BCF], 50 mg [BCF], 100 mg [BCF] Tablet Extended Release 24 Hour, Oral, as succinate: Generic: 25 mg [BCF], 50 mg [BCF], 100 mg [BCF] MetroNIDAZOLE (Systemic) Tablet, Oral: Generic: 250 mg [BCF], 500 mg [BCF] MetroNIDAZOLE (Topical) Cream, External: Generic: 0.75% (45 g) Gel, External: Metrogel: 1% (60 g) [contains methylparaben, propylparaben] Generic: 0.75% (45 g) Gel, Vaginal: Vandazole: 0.75% (70 g) [BCF] Miconazole (Topical) Suppository, Vaginal, as nitrate: Miconazole 3: 200 mg (3 ea) Midazolam Solution, Nasal: Nayzilam: 5 mg/0.1 mL (2 ea) [contains propylene glycol] Syrup, Oral: Generic: 2 mg/mL (5 mL, 118 mL) Midodrine Tablet, Oral, as hydrochloride: Generic: 2.5 mg, 5 mg, 10 mg Minocycline (Systemic) Capsule, Oral: Generic: 50 mg, 100 mg Minoxidil (Systemic) Tablet, Oral: Generic: 2.5 mg, 10 mg Mirtazapine Tablet, Oral: Generic: 15 mg, 30 mg, 45 mg MiSOPROStol Tablet, Oral: Cytotec: 100 mcg Generic: 100 mcg, 200 mcg

27 Joint Regional Oupatient Formulary

Modafinil Tablet, Oral: Provigil: 100 mg Generic: 100 mg, 200 mg Mometasone (Topical) Ointment, External, as furoate: Generic: 0.1% (15 g, 45 g) Montelukast Packet, Oral: Generic: 4 mg/packet (30 ea) [BCF] Tablet, Oral: Generic: 10 mg [BCF] Tablet Chewable, Oral: Generic: 4 mg [BCF], 5 mg [BCF] Morphine (Systemic) Solution, Oral, as sulfate: Generic: 20 mg/5 mL (500 mL) Tablet, Oral, as sulfate: Generic: 15 mg, 30 mg Tablet Extended Release, Oral, as sulfate: Generic: 15 mg [BCF], 30 mg [BCF], 60 mg [BCF] Mouthwash, Magic Extemporaneously prepared by Pharmacy Moxifloxacin (Ophthalmic) Solution, Ophthalmic: Vigamox: 0.5% (3 mL) Mupirocin Ointment, External: Generic: 2% (22 g) [BCF] Mycophenolate Tablet, Oral, as mofetil: Generic: 500 mg Nadolol Tablet, Oral: Generic: 40 mg Naloxone Liquid, Nasal: Narcan: 4 mg/0.1 mL (1 ea) [contains benzalkonium chloride, edetate disodium] [BCF] Naltrexone Tablet, Oral, as hydrochloride: Generic: 50 mg Naproxen Suspension, Oral: Naprosyn: 125 mg/5 mL (480 mL) [BCF] Tablet, Oral: Generic: 250 mg [BCF], 375 mg, 500 mg [BCF] Tablet, Oral, as sodium: Generic: 275 mg, 550 mg Neomycin Tablet, Oral, as sulfate: Generic: 500 mg Neomycin, Polymyxin B, and Ointment, Ophthalmic: Dexamethasone Generic: Neomycin 3.5 mg, polymyxin B sulfate 10,000 units, and dexamethasone 0.1% per g (3.5 g) Suspension, Ophthalmic: Generic: Neomycin 3.5 mg, polymyxin B sulfate 10,000 units, and dexamethasone 0.1% per 1 mL (5 mL) Neomycin, Polymyxin B, and Solution, Ophthalmic: Gramicidin Generic: Neomycin 1.75 mg, polymyxin B 10,000 units, and gramicidin 0.025 mg per 1 mL (10 mL) [BCF] Neomycin, Polymyxin B, and Suspension, Otic: Hydrocortisone (Otic) Generic: Neomycin 3.5 mg, polymyxin B 10,000 units, and hydrocortisone 10 mg per 1 mL (10 mL) [BCF] Nepafenac Suspension, Ophthalmic: Nevanac: 0.1% (3 mL) [contains edentate disodium benzalkonium chloride]

28 Joint Regional Oupatient Formulary

Niacin Tablet, Oral [preservative free]: Generic: 500 mg Tablet Extended Release, Oral: Niaspan: 500 mg [BCF], 750 mg [BCF], 1000 mg [BCF] Nicotine Gum, Mouth/Throat, as polacrilex: Nicorelief: 2 mg (110 ea) [mint flavor] [BCF] Patch 24 Hour, Transdermal: Nicoderm CQ: 7 mg/24 hr (14 ea); 14 mg/24 hr (14 ea); 21 mg/24 hr (7 ea) [BCF] Generic: 7 mg/24 hr (14 ea); 14 mg/24 hr (14 ea); 21 mg/24 hr (7 ea) [BCF] NIFEdipine Capsule, Oral: Procardia: 10 mg Tablet Extended Release 24 Hour, Oral: Adalat CC: 90 mg [BCF] Afeditab CR: 60 mg [BCF] Generic: 30 mg [BCF], 60 mg [BCF], 90 mg [BCF] Nilutamide Tablet, Oral: Nilandron: 150 mg Nitrofurantoin Capsule, Oral: Generic: 50 mg [BCF], 100 mg [BCF] Suspension, Oral: Furadantin: 25 mg/5 mL (230 mL) Nitroglycerin Capsule Extended Release, Oral: Generic: 6.5 mg Ointment, Rectal: Rectiv: 0.4% (30 g) [contains propylene glycol] Ointment, Transdermal: Nitro-Bid: 2% (1 g, 60 g) Patch 24 Hour, Transdermal: Nitro-Dur: 0.1 mg/hour (30s) [BCF]; 0.2 mg/hour (30s) [BCF]; 0.3 mg/hour (30s) [BCF]; 0.4 mg/hour (30s) [BCF]; 0.6 mg/hour (30s) [BCF]; 0.8 mg/hour (30s) [BCF] Generic: 0.1 mg/hour (30s) [BCF]; 0.2 mg/hour (30s) [BCF]; 0.4 mg/hour (30s) [BCF]; 0.6 mg/hour (30s) [BCF] Solution, Translingual: Generic: 0.4 mg/spray (12 g) [BCF] Tablet Sublingual: Nitrostat: 0.3 mg, 0.4 mg [BCF] Nonoxynol 9 Gel, Vaginal: Options Gynol II: 3% (81 g) Norethindrone Tablet, Oral: Nora-BE: 0.35 mg [BCF] Tablet, Oral, as acetate: Generic: 5 mg Norethindrone and Mestranol Tablet, Oral: Norinyl 1+50 (28): Norethindrone 1 mg and mestranol 0.05 mg [21 white tablets and 7 orange inactive tablets] Nortriptyline Capsule, Oral: Generic: 10 mg [BCF], 25 mg [BCF], 50 mg [BCF] Solution, Oral: Generic: 10 mg/5 mL (473 mL) [BCF] Nystatin and Triamcinolone Cream, External: Generic: Nystatin 100,000 units and triamcinolone acetonide 0.1% (60 g) Nystatin (Oral) Suspension, Mouth/Throat: Generic: 100,000 units/mL (60 mL) [BCF]

29 Joint Regional Oupatient Formulary

Nystatin (Topical) Cream, External: Generic: 100,000 units/g (15 g) [BCF] Ointment, External: Generic: 100,000 units/g (30 g) [BCF] Powder, External: Nystop: 100,000 units/g (15 g) Ofloxacin (Ophthalmic) Solution, Ophthalmic: Generic: 0.3% (5 mL) Ofloxacin (Otic) Solution, Otic: Generic: 0.3% (5 mL) OLANZapine Tablet, Oral: Generic: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg Tablet Dispersible, Oral: Generic: 5 mg, 10 mg Olopatadine (Ophthalmic) Solution, Ophthalmic: Patanol: 0.1% (5 mL) [contains benzalkonium chloride] [BCF] Pazeo: 0.7% (2.5 mL) [contains benzalkonium chloride] Olsalazine Capsule, Oral, as sodium: Dipentum: 250 mg Omeprazole Capsule Delayed Release, Oral: PriLOSEC: 10 mg [BCF], 20 mg [BCF] Generic: 10 mg [BCF], 20 mg [BCF] Suspension, Oral: First-Omeprazole: 2 mg/mL (90 mL, 150 mL, 300 mL) [contains benzyl alcohol, fd&c red #40, saccharin sodium; strawberry flavor] Ondansetron Solution, Oral: Zofran: 4 mg/5 mL (50 mL) [strawberry flavor] Tablet, Oral: Generic: 4 mg, 8 mg Tablet Dispersible, Oral: Generic: 4 mg, 8 mg Ophthalmic Irrigant Mixture Solution, Ophthalmic: Eye Wash: 118 mL Orphenadrine Tablet Extended Release 12 Hour, Oral, as citrate: Generic: 100 mg Oseltamivir Capsule, Oral, as phosphate: Tamiflu: 30 mg, 45 mg, 75 mg Suspension Reconstituted, Oral, as base: Tamiflu: 6 mg/mL (60 mL) [contains saccharin sodium, sodium benzoate; tutti-frutti flavor] Ospemifene Tablet, Oral: Osphena: 60 mg OXcarbazepine Suspension, Oral: Trileptal: 300 mg/5 mL (250 mL) [contains alcohol, usp, methyl hydroxybenzoate, propyl hydroxybenzoate, propylene glycol, saccharin sodium; lemon flavor] Tablet, Oral: Trileptal: 150 mg, 300 mg, 600 mg [scored] Oxybutynin Syrup, Oral, as chloride: Generic: 5 mg/5 mL (473 mL) Tablet, Oral, as chloride: Generic: 5 mg Tablet Extended Release 24 Hour, Oral, as chloride: Generic: 5 mg [BCF], 10 mg [BCF], 15 mg [BCF] OxyCODONE Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg

30 Joint Regional Oupatient Formulary

Oxycodone and Acetaminophen Solution, Oral: Roxicet: Oxycodone hydrochloride 5 mg and acetaminophen 325 mg per 5 mL (5 mL, 500 mL) [mint flavor] Tablet, Oral: Generic: 5/325: Oxycodone hydrochloride 5 mg and acetaminophen 325 mg [BCF] Generic: 7.5/325: Oxycodone hydrochloride 7.5 mg and acetaminophen 325 mg Generic: 10/325: Oxycodone hydrochloride 10 mg and acetaminophen 325 mg Oxymetazoline (Nasal) Solution, Nasal, as hydrochloride: Nasal Decongestant Spray: 0.05% (15 mL) [contains benzalkonium chloride] OxyMORphone Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg Paliperidone Tablet Extended Release 24 Hour, Oral: Invega: 3 mg, 6 mg Pancrelipase Capsule Delayed Release Particles, Oral: Creon: 6000 units [BCF], 12,000 units [BCF], 24,000 units[BCF] Pantoprazole Packet, Oral: Protonix: 40 mg (30 ea) [contains polysorbate 80] Tablet Delayed Release, Oral: Generic: 20 mg, 40 mg PARoxetine Tablet, Oral, as hydrochloride [strength expressed as base]: Generic: 10 mg, 20 mg, 30 mg PenicillAMINE Capsule, Oral: Cuprimine: 250 mg Penicillin V Potassium Solution Reconstituted, Oral: Generic: 250 mg/5 mL (200 mL) [BCF] Tablet, Oral: Generic: 250 mg [BCF], 500 mg [BCF] Pentosan Polysulfate Sodium Capsule, Oral: Elmiron: 100 mg Pentoxifylline Tablet Extended Release, Oral: Generic: 400 mg Permethrin Cream, External: NIx: 1% (59 mL) Generic: 5% (60 g) [BCF] Perphenazine Tablet, Oral: Generic: 2 mg Phenazopyridine Tablet, Oral, as hydrochloride: Generic: 100 mg [BCF] PHENobarbital Elixir, Oral: Generic: 20 mg/5 mL (473 mL) [BCF] Tablet, Oral: Generic: 15 mg [BCF], 16.2 mg, 32.4 mg Phenylephrine (Systemic) Solution, Oral, as hydrochloride: Sudafed PE Childrens: 2.5 mg/5 mL (118 mL) [alcohol free, sugar free; contains edetate disodium, sodium benzoate] Tablet, Oral, as hydrochloride: Sudogest PE: 10 mg Phenytoin Capsule, Oral, as sodium: Dilantin: 100 mg [BCF] Suspension, Oral: Dilantin: 125 mg/5 mL (237 mL) [orange-vanilla flavor] [BCF] Tablet Chewable, Oral: Dilantin: 50 mg [scored] [BCF] Phytonadione Tablet, Oral: Mephyton: 5 mg [scored]

31 Joint Regional Oupatient Formulary

Pilocarpine (Ophthalmic) Solution, Ophthalmic, as hydrochloride: Generic: 1% (15 mL) [BCF]; 2% (15 mL) [BCF] Pilocarpine (Systemic) Tablet, Oral, as hydrochloride: Generic: 5 mg Pimecrolimus Cream, External: ElidelÂ®: 1% (30 g, 100 g) [contains benzyl alcohol, cetyl alcohol, propylene glycol] [BCF] Pioglitazone Tablet, Oral: Generic: 15 mg, 30 mg, 45 mg Piroxicam (Systemic) Capsule, Oral: Generic: 20 mg Podofilox Gel, External: Condylox: 0.5% (3.5 g) Solution, External: Condylox: 0.5% (3.5 mL) [contains alcohol, usp] Polyethylene Glycol 3350 Powder, Oral: Generic: 238 g Polyethylene Glycol-Electrolyte Solution Reconstituted, Oral: Solution Golytely: 236 g (4000 mL) Generic: 240 g (4000 mL) Potassium Chloride Liquid, Oral: Generic: 20 mEq/15 mL (10%) (473 mL) [BCF] Tablet Extended Release, Oral: Klor-Con M10: 10 mEq [BCF] Generic: 20 mEq [BCF] Potassium Citrate Tablet Extended Release, Oral: Generic: 10 mEq (1080 mg), 5 mEq (540 mg) Potassium Iodide Solution, Oral: SSKI: 1 g/mL (30 mL) Povidone-Iodine (Topical) Solution, Vaginal: Summers Eve Disp Medicated: 0.3% (274 mL) Pramipexole Tablet, Oral, as dihydrochloride monohydrate: Generic: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1.5 mg Pramoxine and Hydrocortisone Cream, External: Generic: Pramoxine hydrochloride 1% and hydrocortisone acetate 1% (30 g) Generic: Pramoxine hydrochloride 1% and hydrocortisone acetate 2.5% (30 g) Foam, External: Epifoam: Pramoxine hydrochloride 1% and hydrocortisone acetate 1% (10 g) Foam, Rectal: Proctofoam HC: Pramoxine hydrochloride 1% and hydrocortisone acetate 1% (10 g) Prasugrel Tablet, Oral: Generic: 5 mg, 10 mg Pravastatin Tablet, Oral, as sodium: Generic: 10 mg [BCF], 20 mg [BCF], 40 mg [BCF], 80 mg [BCF] Prazosin Capsule, Oral: Generic: 1 mg, 2 mg, 5 mg PrednisoLONE (Ophthalmic) Suspension, Ophthalmic, as acetate: Pred Mild: 0.12% (5 mL) [contains benzalkonium chloride, sodium bisulfite] [BCF] Generic: 1% (5 mL) [BCF] PrednisoLONE (Systemic) Solution, Oral, as base: Generic: 15 mg/5 mL (480 mL) [BCF] PredniSONE Tablet, Oral: Generic: 1 mg [BCF], 2.5 mg, 5 mg [BCF], 10 mg [BCF], 20 mg [BCF], 50 mg

32 Joint Regional Oupatient Formulary

Pregabalin Capsule, Oral: Generic: 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg, 300 mg Solution, Oral: Generic: 20 mg/mL (473 mL) Primaquine Tablet, Oral, as phosphate: Generic: 26.3 mg Primidone Tablet, Oral: Generic: 50 mg, 250 mg Probenecid Tablet, Oral: Generic: 500 mg [BCF] Prochlorperazine Suppository, Rectal: Compro: 25 mg (12 ea) Tablet, Oral, as maleate [strength expressed as base]: Generic: 5 mg Progesterone Capsule, Oral: Generic: 100 mg, 200 mg Gel, Vaginal: Crinone: 8% (1.125 g) Insert, Vaginal: Endometrin: 100 mg (21 ea) Suppository, Vaginal: First-Progesterone VGS 50: 50 mg (30 ea) First-Progesterone VGS 200: 200 mg (30 ea) Promethazine Solution, Injection, as hydrochloride: Generic: 25 mg/mL (1 mL) Suppository, Rectal, as hydrochloride: Generic: 12.5 mg (12 ea) [BCF]; 25 mg (12 ea) [BCF] Syrup, Oral, as hydrochloride: Generic: 6.25 mg/5 mL (473 mL) [BCF] Tablet, Oral, as hydrochloride: Generic: 12.5 mg, 25 mg [BCF] Promethazine and Codeine Syrup, Oral: Generic: Promethazine hydrochloride 6.25 mg and codeine phosphate 10 mg per 5 mL (118 mL) Propafenone Capsule Extended Release 12 Hour, Oral, as hydrochloride: Generic: 225 mg Tablet, Oral, as hydrochloride: Generic: 150 mg, 225 mg, 300 mg Propantheline Tablet, Oral, as bromide: Generic: 15 mg Proparacaine Solution, Ophthalmic, as hydrochloride: Alcaine: 0.5% (15 mL) Propranolol Capsule Extended Release 24 Hour, Oral, as hydrochloride: Generic: 60 mg, 80 mg, 120 mg, 160 mg Solution, Oral, as hydrochloride: Generic: 20 mg/5 mL (500 mL) Tablet, Oral, as hydrochloride: Generic: 10 mg, 40 mg, 80 mg Propylthiouracil Tablet, Oral: Generic: 50 mg [BCF]

33 Joint Regional Oupatient Formulary

Pseudoephedrine Liquid, Oral, as hydrochloride: Childrens Silfedrine: 15 mg/5 mL (237 mL) [grape flavor] Tablet, Oral, as hydrochloride: Generic: 30 mg, 60 mg Tablet Extended Release 12 Hour, Oral, as hydrochloride: Generic: 120 mg Psyllium Powder, Oral: Konsyl: 100% (300 g) [gluten free, kosher certified, sugar free; bland flavor] Pyrantel Pamoate Suspension, Oral [strength expressed as base]: Reeses Pinworm Medicine: 144 (50 base) mg/mL (30 mL) [contains saccharin sodium, sodium benzoate] Pyrazinamide Tablet, Oral: Generic: 500 mg [BCF] Pyridostigmine Tablet, Oral, as bromide: Generic: 60 mg Tablet Extended Release, Oral, as bromide: Mestinon: 180 mg [scored] Pyridoxine Tablet, Oral, as hydrochloride [preservative free]: Generic: 50 mg QUEtiapine Tablet, Oral: Generic: 25 mg [BCF], 50 mg [BCF], 100 mg [BCF], 200 mg [BCF], 300 mg [BCF], 400 mg [BCF] Tablet Extended Release 24 Hour, Oral: SEROquel XR: 50 mg [BCF], 150 mg [BCF], 200 mg [BCF], 300 mg [BCF], 400 mg [BCF] QuiNIDine Tablet, Oral, as sulfate: Generic: 200 mg, 300 mg Tablet Extended Release, Oral, as gluconate: Generic: 324 mg Raloxifene Tablet, Oral, as hydrochloride: Evista: 60 mg [BCF] Raltegravir Tablet, Oral: Isentress: 400 mg [contains polyethylene glycol] Ramipril Capsule, Oral: Generic: 1.25 mg [BCF], 2.5 mg [BCF], 5 mg [BCF], 10 mg [BCF] RaNITIdine (Withdrawn From Syrup, Oral: US Market) Generic: Generic: 15 mg/mL (473 mL) [BCF] Tablet, oral: Zantac 75: 75 mg Generic: 150 mg [BCF] Ranolazine Tablet Extended Release 12 Hour, Oral: Generic: 500 mg Rasagiline Tablet, Oral: Generic: 0.5 mg, 1 mg Ribavirin (Systemic) Capsule, Oral: Generic: 200 mg [ECF] Riboflavin Tablet, Oral: Generic: 100 mg RifAMPin Capsule, Oral: Generic: 150 mg, 300 mg [BCF] RifAXIMin This medication is nonformulary. For formulary alternatives, refer to Therapeutic Category.

34 Joint Regional Oupatient Formulary

RisperiDONE Solution, Oral: Generic: 1 mg/mL (30 mL) [BCF] Tablet, Oral: Generic: 0.25 mg [BCF], 0.5 mg [BCF], 1 mg [BCF], 2 mg [BCF], 3 mg [BCF], 4 mg [BCF] Tablet Dispersible, Oral: RisperiDONE M-TAB: 0.5 mg, 1 mg, 2 mg, 4 mg [contains aspartame] Rivaroxaban Tablet, Oral: Xarelto: 10 mg, 15 mg, 20 mg Rivastigmine Patch 24 Hour, Transdermal: Exelon: 4.6 mg/24 hr (30 ea); 9.5 mg/24 hr (30 ea); 13.3 mg/24 hr (30 ea) Rizatriptan Tablet, Oral: Generic: 5 mg [BCF], 10 mg [BCF] Tablet Dispersible, Oral: Generic: 5 mg [BCF], 10 mg [BCF] Roflumilast Tablet, Oral: Daliresp: 250 mcg, 500 mcg [contains corn starch] ROPINIRole Tablet, Oral: Requip: 3 mg Generic: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg Rosuvastatin Tablet, Oral: Crestor: 5 mg, 10 mg, 20 mg, 40 mg Salicylic Acid Foam, External: Salvax: 6% (70 g) [contains ethylparaben, methylparaben, polysorbate 80, propylene glycol, propylparaben, trolamine (triethanolamine)] Pad, External: Mediplast: 40% (25 ea) Solution, External: Duofilm: 17% (9.8 mL) Salicylic Acid, Lactic Acid, Solution, External: Resorcinol, and Alcohol Jessners External Solution: 500 mL Salmeterol Aerosol Powder Breath Activated, Inhalation: Serevent Diskus: 50 mcg/dose (28 ea, 60 ea) [contains lactose] [BCF] Salsalate Tablet, Oral: Generic: 500 mg [BCF], 750 mg [BCF] Scopolamine (Systemic) Patch 72 Hour, Transdermal: Transderm-Scop: 1.5 mg (4 ea) Selegiline Tablet, Oral, as hydrochloride: Generic: 5 mg Selenium Sulfide Lotion, External: Generic: 2.5% (120 mL) [BCF] Senna Tablet, Oral: Senna Lax: 8.6 mg Sertraline Concentrate, Oral: Zoloft: 20 mg/mL (60 mL) [contains alcohol, usp, menthol] [BCF] Tablet, oral: Generic: 25 mg [BCF], 50 mg [BCF], 100 mg [BCF] Sildenafil Tablet, Oral: Generic: 25 mg [BCF], 50 mg [BCF], 100 mg [BCF] Silver Sulfadiazine Cream, External: Silvadene: 1% (20 g) [contains methylparaben, propylene glycol] [BCF] Thermazene: 1% (85 g) [contains methylparaben, propylene glycol] [BCF] Simethicone Suspension, Oral: Generic: 40 mg/0.6 mL (30 mL) Tablet Chewable, Oral: Mytab Gas: 80 mg [peppermint flavor]

35 Joint Regional Oupatient Formulary

Simvastatin Tablet, Oral: Generic: 5 mg [BCF], 10 mg [BCF], 20 mg [BCF], 40 mg [BCF], 80 mg Sirolimus Tablet, Oral: Generic: 0.5 mg, 1 mg, 2 mg SITagliptin Tablet, Oral: Januvia: 25 mg [BCF], 50 mg [BCF], 100 mg [BCF] Sitagliptin and Metformin Tablet, Oral: Janumet 50/500: Sitagliptin 50 mg and metformin hydrochloride 500 mg [BCF] Janumet 50/1000: Sitagliptin 50 mg and metformin hydrochloride 1000 mg [BCF] Tablet Extended Release 24 Hour, Oral: Janumet XR: 50/500: Sitagliptin 50 mg and metformin hydrochloride 500 mg [BCF] Janumet XR: 50/1000: Sitagliptin 50 mg and metformin hydrochloride 1000 mg [BCF] Janumet XR: 100/1000: Sitagliptin 100 mg and metformin hydrochloride 1000 mg [BCF] Sodium Chloride Ointment, Ophthalmic: Generic: 5% (3.5 g) Solution, Nasal: Baby Ayr Saline: 0.65% (30 mL) Sea Soft Nasal Mist: 0.65% (45 mL) Solution, Ophthalmic: Muro 128: 5% (15 mL) Generic: 5% (15 mL) Wash, Nasal [kit]: Sinus Rinse: 50 packets included Wash, Nasal [packet]: Sinus Rinse: 100 ea Sodium Citrate and Citric Acid Solution, oral: Generic: Sodium citrate 500 mg and citric acid 334 mg per 5 mL (473 mL) Sodium Hypochlorite Solution, External: Generic: 0.25% (473 mL) Sodium Phosphates Enema, Rectal: Fleet Pediatric: Monobasic sodium phosphate monohydrate 9.5 g and dibasic sodium phosphate heptahydrate 3.5 g per 59 mL delivered dose (66 mL) Generic: Monobasic sodium phosphate monohydrate 19 g and dibasic sodium phosphate heptahydrate 7 g per 118 mL delivered dose (133 mL) Tablet, Oral: OsmoPrep: Monobasic sodium phosphate monohydrate 1.102 g and dibasic sodium phosphate anhydrous 0.398 g [sodium phosphate 1.5 g per tablet; gluten free] Sodium Polystyrene Sulfonate Suspension, Oral: SPS: 15 g/60 mL (473 mL) [contains alcohol, usp, methylparaben, propylene glycol, propylparaben, saccharin sodium] Sodium Sulfate, Potassium Solution, Oral: Sulfate, and Magnesium Sulfate Suprep Bowel Prep Kit: Sodium sulfate 17.5 g, potassium sulfate 3.13 g, and magnesuim sulfate 1.6 g per 180 mL (177 mL) [contains sodium benzoate] Solifenacin Tablet, Oral, as succinate: VESIcare: 5 mg, 10 mg Sotalol Tablet, Oral, as hydrochloride: Generic: 80 mg, 120 mg, 160 mg Spironolactone Tablet, Oral: Generic: 25 mg [BCF], 50 mg, 100 mg Sucralfate Tablet, Oral: Generic: 1 g Sulfacetamide and Prednisolone Ointment, Ophthalmic: Blephamide S.O.P.: Sulfacetamide sodium 10% and prednisolone acetate 0.2% (3.5 g) Sulfacetamide (Ophthalmic) Solution, Ophthalmic, as sodium: Generic: 10% (15 mL) [BCF]

36 Joint Regional Oupatient Formulary

Sulfamethoxazole and Suspension, Oral: Trimethoprim Generic: Sulfamethoxazole 200 mg and trimethoprim 40 mg per 5 mL (473 mL) [BCF] Tablet, Oral: Generic: Sulfamethoxazole 400 mg and trimethoprim 80 mg[BCF] Generic: Sulamethoxazole 800 mg and trimethoprim 160 mg [BCF] SulfaSALAzine Tablet, Oral: Sulfazine: 500 mg [scored] [BCF] Tablet Delayed Release, Oral: Azulfidine EN-tabs: 500 mg [BCF] Sulfur and Salicylic Acid Shampoo, External: Sebex: Sulfur 2% and salicylic acid 2% (118 mL) Sulfur and Sulfacetamide Cream, External: Generic: Sulfur 5% and sulfacetamide sodium 10% (28 g) Emulsion, External: Generic: Sulfur 5% and sulfacetamide sodium 10% (170.3 g) Lotion, External: Generic: Sulfur 5% and sulfacetamide sodium 10% (30 g) Sulindac Tablet, Oral: Generic: 150 mg, 200 mg SUMAtriptan Solution, Nasal: Generic: 20 mg/actuation (1 ea) Solution, Subcutaneous, as succinate [strength expressed as base]: Imitrex: 6 mg/0.5 mL (0.5 mL) [BCF] Imitrex STATdose System: 6 mg/0.5 mL (0.5 mL) Generic: 6 mg/0.5 mL (0.5 mL) [BCF] Tablet, Oral, as succinate [strength expressed as base]: Imitrex: 25 mg [BCF] Generic: 25 mg [BCF], 50 mg [BCF], 100 mg [BCF] Syringe Syringe: 5-6 mL [1000 ea] 10-12 mL [1000 ea] 20-25 mL [500 ea] BD Insulin Syringe Ultrafine: 31 gauge x 5/16" (0.3 mL) [100 ea] BD Insulin Syringe Ultrafine II: 31 gauge x 5/16" (0.5 mL) [100 ea] BD Insulin Syringe Ultrafine II: 31 gauge x 5/16" (1 mL) [100 ea] BD Luer-Lok Syringe: 22 gauge x 1-1/2" (3 mL) [100 ea] BD Luer-Lok Syringe: 25 gauge x 1" (3 mL) [100 ea] BD Syringe Slip Tip: 1 mL (3000 ea) Tuberculin Syringe: 1 mL [100 ea] Tacrolimus (Systemic) Capsule, Oral: Generic: 1 mg Tablet Extended Release 24 Hour, Oral: Envarsus XR: 0.75 mg, 1 mg, 4 mg Tacrolimus (Topical) Ointment, External: Generic: 0.03% (30 g, 60 g); 0.1% (30 g, 60 g) Tamoxifen Tablet, Oral: Generic: 10 mg [BCF], 20 mg [BCF] Tamsulosin Capsule, Oral, as hydrochloride: Generic: 0.4 mg [BCF] Tazarotene Gel, External: Tazorac: 0.1% (30 g, 100 g) [contains benzyl alcohol] Telmisartan Tablet, Oral: Generic: 20 mg, 40 mg, 80 mg

37 Joint Regional Oupatient Formulary

Telmisartan and Tablet, Oral: Hydrochlorothiazide Micardis HCT: 40/12.5: Telmisartan 40 mg and hydrochlorothiazide 12.5 mg Micardis HCT: 80/12.5: Telmisartan 80 mg and hydrochlorothiazide 12.5 mg Micardis HCT: 80/25: Telmisartan 80 mg and hydrochlorothiazide 25 mg Temazepam Capsule, Oral: Generic: 7.5 mg, 15 mg [BCF] Tenofovir Alafenamide Tablet, Oral: Vemlidy: 25 mg Tenofovir Disoproxil Fumarate Powder, Oral, as disoproxil fumarate: Viread: 40 mg/g (60 g) Tablet, Oral, as disoproxil fumarate: Viread: 150 mg, 200 mg, 250 mg Viread: 300 mg [contains fd&c blue #2 aluminum lake] Terazosin Capsule, Oral: Generic: 1 mg [BCF], 2 mg [BCF], 5 mg [BCF], 10 mg [BCF] Terbinafine (Systemic) Tablet, Oral: Generic: 250 mg Terbinafine (Topical) Cream, External, as hydrochloride: Generic: 1% (30 g) Terbutaline Tablet, Oral, as sulfate: Generic: 5 mg Terconazole Cream, Vaginal: Generic: 0.4% (45 g) Testosterone Gel, Transdermal: Fortesta: 10 mg/actuation (60 g) [contains ethanol; 0.5 g gel/actuation; 120 metered actuations] [BCF] Testim: 50 mg/5 g (1%) (5 g) [contains alcohol, usp, propylene glycol, tromethamine] Solution, Intramuscular, as cypionate: Generic: 200 mg/mL (1 mL) Patch 24 Hour, Transdermal: Androderm: 4 mg/24 hr (30 ea) Tetracycline (Systemic) Capsule, Oral, as hydrochloride: Generic: 250 mg [BCF] Theophylline Capsule Extended Release 24 Hour, Oral: Theo-24: 100 mg, 200 mg, 300 mg [BCF], 400 mg [BCF] Elixir, Oral: Elixophyllin: 80 mg/15 mL (473 mL) [mixed fruit flavor] [BCF] Tablet Extended Release 12 Hour, Oral: Generic: 100 mg, 200 mg [BCF], 300 mg [BCF] Thiamine Tablet, Oral, as hydrochloride [preservative free]: Generic: 100 mg Thioridazine Tablet, Oral, as hydrochloride: Generic: 10 mg Thiothixene Capsule, Oral: Generic: 1 mg, 5 mg, 10 mg Thyroid, Desiccated Tablet, Oral: Armour Thyroid: 30 mg, 60 mg NP Thyroid: 15 mg, 30 mg, 60 mg, 90 mg, 120 mg Ticagrelor Tablet, Oral: Brilinta: 60 mg, 90 mg Timolol (Ophthalmic) Gel Forming Solution, Ophthalmic, as maleate [strength expressed as base]: Generic: 0.25% (5 mL) [BCF]; 0.5% (5 mL) [BCF] Solution, Ophthalmic, as maleate [strength expressed as base]: Generic: 0.25% (5 mL) [BCF]; 0.5% (5 mL) [BCF]

38 Joint Regional Oupatient Formulary

Tiotropium Aerosol Solution, Inhalation: Spiriva Respimat: 2.5 mcg/actuation (4 g) [contains benzalkonium chloride, disodium edta] [BCF] Capsule, Inhalation: Spiriva HandiHaler: 18 mcg [contains milk protein] [BCF] Tiotropium and Olodaterol Aerosol Solution, Inhalation: Stiolto Respimat: Tiotropium 2.5 mcg and olodaterol 2.5 mcg per actuation (4 g) [contains benzalkonium chloride, edetate disodium] TiZANidine Tablet, Oral: Generic: 2 mg, 4 mg Tobramycin and Ointment, Ophthalmic: Dexamethasone TobraDex: Tobramycin 0.3% and dexamethasone 0.1% (3.5 g) [contains chlorobutanol] Suspension, Ophthalmic: Generic: Tobramycin 0.3% and dexamethasone 0.1% (5 mL) Tobramycin (Ophthalmic) Solution, Ophthalmic: Generic: 0.3% (5 mL) Tolterodine Capsule Extended Release 24 Hour, Oral, as tartrate: Detrol LA: 2 mg [BCF], 4 mg [BCF] Topiramate Capsule Sprinkle, Oral: Topamax Sprinkle: 15 mg, 25 mg Tablet, Oral: Generic: 25 mg, 50 mg, 100 mg, 200 mg Torsemide Tablet, Oral: Generic: 5 mg, 10 mg, 20 mg, 100 mg TraMADol Tablet, Oral, as hydrochloride: Generic: 50 mg [BCF] TraZODone Tablet, Oral, as hydrochloride: Generic: 50 mg [BCF], 100 mg [BCF], 150 mg [BCF] Tretinoin (Topical) Cream, External: Generic: 0.025% (20 g) [BCF]; 0.05% (20 g) [BCF] Gel, External: Avita: 0.025% (45 g) Retin-A Micro: 0.04% (45 g); 0.1% (45 g) [contains benzyl alcohol, disodium edta, propylene glycol, trolamine (triethanolamine)] Kit, External: Tretin-X: 0.025%, 0.05%, 0.1% [contains benzyl alcohol, cetearyl alcohol, disodium edta, fd&c red #40, methylparaben, propylparaben, tartrazine (fd&c yellow #5), trolamine (triethanolamine)] Triamcinolone (Topical) Aerosol Solution, External, as acetonide: Kenalog: (63 g) Cream, External, as acetonide: Generic: 0.1% (15 g, 80 g, 454 g) [BCF]; 0.5% (15 g) Ointment, External, as acetonide: Generic: 0.1% (15 g, 80 g, 454 g) Paste, Mouth/Throat, as acetonide: Generic: 0.1% (5 g) Triazolam Tablet, Oral: Halcion: 0.25 mg [scored] Generic: 0.25 mg Trifluoperazine Tablet, Oral: Generic: 2 mg, 5 mg Trifluridine Solution, Ophthalmic: Generic: 1% (7.5 mL)

39 Joint Regional Oupatient Formulary

Trihexyphenidyl Elixir, Oral, as hydrochloride: Generic: 0.4 mg/mL (473 mL) [BCF] Tablet, Oral, as hydrochloride: Generic: 2 mg [BCF], 5 mg Trimethoprim Solution, Oral [strength expressed as base]: Primsol: 50 mg/5 mL (473 mL) [alcohol free, dye free] Tablet, Oral: Generic: 100 mg Trimethoprim and Polymyxin B Solution, Ophthalmic: Generic: Trimethoprim 1 mg and polymyxin B sulfate 10,000 units per 1 mL (10 mL) [BCF] Triprolidine and Tablet, Oral: Pseudoephedrine Aprodine: Triprolidine hydrochloride 2.5 mg and pseudoephedrine hydrochloride 60 mg [scored] Ulipristal Tablet, Oral, as acetate: Ella: 30 mg Umeclidinium Aerosol Powder Breath Activated, Inhalation: Incruse Ellipta: 62.5 mcg/inhalation (7 ea, 30 ea) [contains lactose monohydrate] Umeclidinium and Vilanterol Aerosol Powder Breath Activated, Inhalation: Anoro Ellipta: Umeclidinium 62.5 mcg and vilanterol 25 mcg per inhalation (7 dose, 30 dose) [contains milk protein] Urea (Topical) Cream, External: Generic: 40% (85 g) Lotion, External: Generic: 10% (240 mL); 40% (237 mL) Ursodiol Capsule, Oral: Generic: 300 mg ValACYclovir Tablet, Oral: Generic: 500 mg, 1 g ValGANciclovir Tablet, Oral: Generic: 450 mg Valproic Acid and Derivatives Capsule, Oral, as valproic acid: Generic: 250 mg Capsule Sprinkle, Oral, as divalproex sodium: Generic: 125 mg [BCF] Solution, Intravenous, as valproate sodium: Depacon: 100 mg/mL (5 mL) Tablet Delayed Release, Oral, as divalproex sodium: Generic: 125 mg [BCF], 250 mg [BCF], 500 mg [BCF] Tablet Extended Release 24 Hour, Oral, as divalproex sodium: Generic: 250 mg [BCF], 500 mg [BCF] Valsartan Tablet, Oral: Diovan: 40 mg [scored] [BCF], 80 mg [BCF], 160 mg [BCF], 320 mg [BCF] Valsartan and Tablet, Oral: Hydrochlorothiazide Diovan HCT: 80 mg/12.5 mg: Valsartan 80 mg and hydrochlorothiazide 12.5 mg [BCF] Diovan HCT: 160 mg/12.5 mg: Valsartan 160 mg and hydrochlorothiazide 12.5 mg [BCF] Diovan HCT: 160 mg/25 mg: Valsartan 160 mg and hydrochlorothiazide 25 mg [BCF] Diovan HCT: 320 mg/12.5 mg: Valsartan 320 mg and hydrochlorothiazide 12.5 mg [BCF] Diovan HCT: 320 mg/25 mg: Valsartan 320 mg and hydrochlorothiazide 25 mg [BCF] Vancomycin Capsule, Oral: Generic: 125 mg, 250 mg Varenicline Tablet, Oral: Chantix: 1 mg Chantix Continuing Month Pak: 1 mg (56 ea) Chantix Starting Month Pak: 0.5 mg (11 ea) & 1 mg (42 ea)

40 Joint Regional Oupatient Formulary

Venlafaxine Capsule Extended Release 24 Hour, Oral: Effexor XR: 37.5 mg Generic: 37.5 mg [BCF], 75 mg [BCF], 150 mg [BCF] Tablet, Oral: Generic: 25 mg [BCF], 37.5 mg [BCF], 50 mg [BCF] Tablet Extended Release 24 Hour, Oral: Generic: 225 mg [BCF] Verapamil Tablet, Oral, as hydrochloride: Generic: 80 mg, 120 mg Tablet Extended Release, Oral, as hydrochloride: Generic: 120 mg [BCF], 180 mg [BCF], 240 mg [BCF] Vitamin A and Vitamin D Ointment, External: (Topical) A+D Original: 42.5 g [in lanolin-petrolatum base] Vitamins (Multiple/Oral) Tablet, Oral: One-Daily: (1000 ea) Vitamins (Multiple/Pediatric) Solution, Oral: Poly-Vita/Iron: 10 mg/mL (50 mL) [alcohol free, sugar free; contains polysorbate 80, propylene glycol, sodium benzoate] Tri-Vitamin: 1500-400-35 (50 mL) [alcohol free, sugar free; contains polysorbate 80, propylene glycol, sodium benzoate; cherry flavor] Tablet, Oral [preservative free]: Tab-A-Vite/Beta Carotene: [gluten free, lactose free, milk free, no artificial flavor(s), sodium free, soy free, sugar free, wheat free, yeast free; contains fd&c blue #2 aluminum lake, fd&c red #40 aluminum lake, fd&c yellow #6 aluminum lake] Vitamins (Multiple/Prenatal) Tablet, Oral: Prenatal: 27-0.8 mg [milk free, no artificial flavor(s), sodium free, soy free, wheat free, yeast free; contains fd&c red #40 aluminum lake, fd&c yellow #6 aluminum lake, sodium benzoate] PreNatal Vitamins Plus: 27-1 mg [contains fd&c blue #2 aluminum lake, fd&c red #40 aluminum lake, fd&c yellow #5 aluminum lake, fd&c yellow #6 aluminum lake, soy protein]

Warfarin Tablet, Oral, as sodium: Coumadin: 1 mg [BCF], 2 mg [BCF], 2.5 mg [BCF], 5 mg [BCF] Generic: 3 mg [BCF], 4 mg [BCF], 6 mg [BCF], 10 mg [BCF] Witch Hazel Pad, External: A.E.R. Witch Hazel: 40 ea [contains benzalkonium chloride, methylparaben] ZOLMitriptan Solution, Nasal: Zomig: 5 mg (6 ea) Tablet, Oral: Generic: 2.5 mg, 5 mg Tablet Dispersible, Oral: Generic: 2.5 mg, 5 mg Zolpidem Tablet, Oral, as tartrate: Generic: 5 mg [BCF], 10 mg [BCF] Tablet Extended Release, Oral, as tartrate: Generic: 6.25 mg, 12.5 mg Zonisamide Capsule, Oral: Zonegran: 25 mg, 50 mg