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HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Aclovate Alclometasone Cream 45 gm Anti-inflammatory Agents Aclovate Alclometasone Ointment 45 gm Anti-inflammatory Agents Actigall Ursodiol 300 mg GI Actos Pioglitazone hydrochloride 15 mg Diabetes Thiazolidinediones Actos Pioglitazone hydrochloride 30 mg Diabetes Thiazolidinediones Actos Pioglitazone hydrochloride 45 mg Diabetes Thiazolidinediones Adderall XR Dextroamphetamine/amphetamine 10 mg Psychiatric Stimulant Adderall XR Dextroamphetamine/amphetamine 15 mg Psychiatric Stimulant Adderall XR Dextroamphetamine/amphetamine 20 mg Psychiatric Stimulant Adderall XR Dextroamphetamine/amphetamine 30 mg Psychiatric Stimulant Alaway 0.025% Ophthalmic Aldactone 25 mg Cardiovascular Aldactone Spironolactone 50 mg Cardiovascular Diuretics Aldactone Spironolactone 100 mg Cardiovascular Diuretics Aldomet 250 mg Cardiovascular Central Alpha Agonist Aldomet Methyldopa 500 mg Cardiovascular Central Alpha Agonist Alphagan tartrate solution 0.2% Ophthalmic Glaucoma Amikin Amikacin 1000 mg/4 ml (4 cc) Antimicrobials Aminoglycoside Amikin Amikacin 500 mg/2 ml (2 cc) Antimicrobials Aminoglycoside Ambien Zolpidem 10 mg Psychiatric Hypnotic Ambien Zolpidem 5 mg Psychiatric Hypnotic Amoxil Amoxicillin 125 mg/5 ml (80 cc) Antimicrobials Penicillins Amoxil Amoxicillin 250 mg Antimicrobials Penicillins Amoxil Amoxicillin 250 mg/5 ml (150 cc) Antimicrobials Penicillins Amoxil Amoxicillin 400 mg/5 ml Antimicrobials Penicillins Amoxil Amoxicillin 500 mg Antimicrobials Penicillins Anafranil 25 mg Psychiatric Anafranil Clomipramine 50 mg Psychiatric Antidepressant Anafranil Clomipramine 75 mg Psychiatric Antidepressant Antivert 25 mg tabs Neurologic Misc Apresoline Hydralazine 10 mg Cardiovascular Other Vasodilators Apresoline Hydralazine 100 mg Cardiovascular Other Vasodilators Apresoline Hydralazine 25 mg Cardiovascular Other Vasodilators

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 1 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Apresoline Hydralazine 50 mg Cardiovascular Other Vasodilators Artane Trihexyphenidyl 2 mg Neurologic Parkinson Artane Trihexyphenidyl 2 mg/5 ml Neurologic Parkinson Artane Trihexyphenidyl 5 mg Neurologic Parkinson Asacol Mesalamine 400 mg GI Anti-inflammatory bowel Atarax HCL 10 mg Cold, Cough, Allergy Antihistamine Atarax Hydroxyzine HCL 10 mg/5 ml (120 cc) Cold, Cough, Allergy Antihistamine Atarax Hydroxyzine HCL 25 mg Cold, Cough, Allergy Antihistamine Atarax Hydroxyzine HCL 50 mg Cold, Cough, Allergy Antihistamine Ativan Lorazepam (SCH IV) 0.5 mg Psychiatric Benzos Ativan Lorazepam (SCH IV) 1 mg Psychiatric Benzos Ativan Lorazepam (SCH IV) 2 mg Psychiatric Benzos Atrovent Ipratropium MDI 18mcg/dose MDI (14gm) Respiratory Asthma Atrovent Inh Sol Ipratropium bromide 0.02% 500 mcg (3 cc/amp) Respiratory Nebulizer soln Augmentin Amoxicillin-clavulanate 200 mg/5 ml (100 cc) Antimicrobials Penicillins Augmentin Amoxicillin-clavulanate 500 mg-125 mg Antimicrobials Penicillins Augmentin Amoxicillin-clavulanate 875 mg-125 mg Antimicrobials Penicillins Antipyrene, Benzocaine, Glycerine Auralgan 10 ml drops Otic dehyd Avelox Moxifloxacin 400 mg Antimicrobials Quinolones Aygestin Norethindrone 5 mg Hormone Replacement Progestins Azopt Brinzolamide 1% suspension Ophthalmic Glaucoma Azulfidine Sulfasalazine 500 mg GI Anti-inflammatory bowel 40mg / 5ml - 200mg / 5- Bactrim Sulfamethxzl Trimethoprim Antimicrobials Sulfas ml (60 ml) Bactroban Mupirocin 2% ointment Derm Antimicrobial Benadryl Diphenhydramine 12.5 mg/ 5ml Cold, Cough, Allergy Antihistamine Benadryl Diphenhydramine 25, 50 mg capsules Cold, Cough, Allergy Antihistamine Benadryl Diphenhydramine 50 mg/ml (inj) Cold, Cough, Allergy Antihistamine Benemid Probenecid 500 mg Gout Bentyl Dicyclomine 10 mg GI Antispasmodics Bentyl Dicyclomine 20 mg GI Antispasmodics Biaxin Clarithromycin 500 mg Antimicrobials

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 2 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Biltricide Praziquantel 600 mg Anthelmintics BuSpar HCI 10 mg Psychiatric Other BuSpar Buspirone HCI 15 mg Psychiatric Other BuSpar Buspirone HCI 30 mg Psychiatric Other BuSpar Buspirone HCI 5 mg Psychiatric Other Butrans Buprenorphine 10 mcg/hr Analgesic Opiate Agonist Butrans Buprenorphine 15 mcg/hr Analgesic Opiate Agonist Butrans Buprenorphine 5 mcg/hr Analgesic Opiate Agonist Butrans Buprenorphine 7.5 mcg/hr Analgesic Opiate Agonist Byetta Exenatide 10 mcg/0.04 mL (2.4 mL) Diabetes GLP-1 Receptor Agonist Byetta Exenatide 5 mcg/0.02 mL (1.2 mL) Diabetes GLP-1 Receptor Agonist Calcium Channel Calan SR Verapamil SR 120 mg Cardiovascular Blockers Calcium Channel Calan SR Verapamil SR 180 mg Cardiovascular Blockers Calcium Channel Calan SR Verapamil SR 240 mg Cardiovascular Blockers Calciferol Vitamin D 50,000 units Vitamin Capoten Captopril 100 mg Cardiovascular ACE Inhibitor Capoten Captopril 12.5 mg Cardiovascular ACE Inhibitor Capoten Captopril 25 mg Cardiovascular ACE Inhibitor Capoten Captopril 50 mg Cardiovascular ACE Inhibitor Carafate Sucralfate 1 Gm GI Calcium Channel Cardizem Diltiazem 120 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 120 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 180 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 240 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 30 mg Cardiovascular Blockers

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 3 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Calcium Channel Cardizem CD Diltiazem CD 300 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 360 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 60 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 90 mg Cardiovascular Blockers Cardizem CD, Calcium Channel Dilacor Xr, Cartia Diltiazem 60 mg Cardiovascular Blockers XL, Dilt-CD Cardizem CD, Calcium Channel Dilacor Xr, Cartia Diltiazem 90 mg Cardiovascular Blockers XL, Dilt-CD Calcium Channel Cardizem LA Dilitiazem HCI 180 mg Cardiovascular Blockers Calcium Channel Cardizem SR Diltiazem SR 120 mg Cardiovascular Blockers Calcium Channel Cardizem SR Diltiazem SR 180 mg Cardiovascular Blockers Calcium Channel Cardizem SR Diltiazem SR 240 mg Cardiovascular Blockers Calcium Channel Cardizem SR Diltiazem SR 300 mg Cardiovascular Blockers Cardura mesylate 1 mg Cardiovascular Alpha-1 blocker Cardura Doxazosin mesylate 2 mg Cardiovascular Alpha-1 blocker Cardura Doxazosin mesylate 4 mg Cardiovascular Alpha-1 blocker Cardura Doxazosin mesylate 8 mg Cardiovascular Alpha-1 blocker Catapres HCI tabs 0.1 mg Cardiovascular Central Alpha Agonist Catapres Clonidine HCI tabs 0.2 mg Cardiovascular Central Alpha Agonist Catapres Clonidine HCI tabs 0.3 mg Cardiovascular Central Alpha Agonist Celebrex Celecoxib 100 mg Analgesic NSAID Celebrex Celecoxib 200 mg Analgesic NSAID

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 4 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Celebrex Celecoxib 400 mg Analgesic NSAID Celebrex Celecoxib 50 mg Analgesic NSAID Celexa Citalopram Hydrobromide 10 mg Psychiatric Antidepressant Celexa Citalopram Hydrobromide 10 mg/5 ml Psychiatric Antidepressant Celexa Citalopram Hydrobromide 20 mg Psychiatric Antidepressant Celexa Citalopram Hydrobromide 40 mg Psychiatric Antidepressant Ciloxan Ciprofloxacin eye drop 0.3% Ophthalmic Cipro Ciprofloxacin 250 mg Antimicrobials Quinolones Cipro Ciprofloxacin 500 mg Antimicrobials Quinolones Claritin 10 mg Antihistamine Cleocin 150 mg Antimicrobials Misc Cleocin Clindamycin 300 mg Antimicrobials Misc Cleocin Clindamycin topical gel, lotion 1% Derm Acne Cleocin-T Clindamycin topical solution 1% (60 ml) Derm Acne Clinoril Sulindac 150 mg Analgesic NSAID Clinoril Sulindac 200 mg Analgesic NSAID Cogentin Benztropine mesylate 0.5 mg Neurologic Parkinson Cogentin Benztropine mesylate 1 mg Neurologic Parkinson Cogentin Benztropine mesylate 1 mg/ml (inj) Neurologic Parkinson Cogentin Benztropine mesylate 2 mg Neurologic Parkinson Colcrys Colchicine 0.6 mg Gout Combivent MDI Albuterol-ipratropium Inhaler Respiratory Compazine 10 mg GI Antiemetic Compazine Prochlorperazine 25 mg supp GI Antiemetic Compazine Prochlorperazine 5 mg GI Antiemetic Cordarone 200 mg Cardiovascular Antiarrythmic Cordarone Amiodarone 400 mg Cardiovascular Antiarrythmic Coreg Carvedilol 12.5 mg Cardiovascular Beta Blockers Coreg Carvedilol 25 mg Cardiovascular Beta Blockers Coreg Carvedilol 3.125 mg Cardiovascular Beta Blockers Coreg Carvedilol 6.25 mg Cardiovascular Beta Blockers Cortizone Hydrocortisone cream 2.5% Derm Antiinflammatory Cortizone Hydrocortisone ointment 2.5% Derm Antiinflammatory

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 5 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Cortizone Hydrocortisone Suppositories 25 mg GI Antiinflammatory Coumadin Warfarin sodium 1 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 10 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 2 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 2.5 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 3 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 4 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 5 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 6 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 7.5 mg Cardiovascular Anticoagulants Cozaar Losartan 100 mg Cardiovascular Angiotensin II Blocker Cozaar Losartan 25 mg Cardiovascular Angiotensin II Blocker Cozaar Losartan 50 mg Cardiovascular Angiotensin II Blocker Cymbalta Duloxetine 20 mg Psychiatric Antidepressant Cymbalta Duloxetine 30 mg Psychiatric Antidepressant Cymbalta Duloxetine 40 mg Psychiatric Antidepressant Cymbalta Duloxetine 60 mg Psychiatric Antidepressant Cytotec Misoprostol 100 mg GI Cytotec Misoprostol 200 mg GI Deltasone Prednisone 1 mg Endocrine Glucocorticoids Deltasone Prednisone 10 mg Endocrine Glucocorticoids Deltasone Prednisone 2.5 mg Endocrine Glucocorticoids Deltasone Prednisone 20 mg Endocrine Glucocorticoids Deltasone Prednisone 5 mg Endocrine Glucocorticoids Deltasone Prednisone 50 mg Endocrine Glucocorticoids Depakote DR Divalproex sodium 125 mg Psychiatric Mood Stabilizer Depakote DR Divalproex sodium 250 mg Psychiatric Mood Stabilizer Depakote DR Divalproex sodium 500 mg Psychiatric Mood Stabilizer Depakote ER Divalproex sodium 250 mg Psychiatric Mood Stabilizer Depakote ER Divalproex sodium 500 mg Psychiatric Mood Stabilizer Depo Testosterone Testosterone Inj 100 mg/ml Hormone Replacement Depo Testosterone Testosterone Inj 200 mg/ml Hormone Replacement Desyrel 100 mg Psychiatric Antidepressant

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 6 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Desyrel Trazodone 150 mg Psychiatric Antidepressant Desyrel Trazodone 50 mg Psychiatric Antidepressant Diflucan Fluconazole 100 mg Antimicrobials Diflucan Fluconazole 150 mg Antimicrobials Antifungals Diflucan Fluconazole 200 mg Antimicrobials Antifungals Dilantin 100 mg Neurologic Anticonvulsant Dilantin Phenytoin 50 mg Neurologic Anticonvulsant Ditropan Oxybutynin 5 mg Genitourinary Donnatal Belladonna alkaloids, 16.2 mg GI Antispasmodics Doryx Vibramycin Doxycycline 100 mg Antimicrobials Doryx Vibramycin Doxycycline 50 mg Antimicrobials Tetracyclines Duphalac Lactulose 10g / 15 ml syrup GI Laxatives Dynapen 250 mg Antimicrobials Penicillins Dynapen Dicloxacillin 500 mg Antimicrobials Penicillins Effexor IR Venlafaxine 25 mg Psychiatric Antidepressant Effexor XR Venlafaxine XR 100 mg Psychiatric Antidepressant Effexor XR Venlafaxine XR 37.5 mg Psychiatric Antidepressant Effexor XR Venlafaxine XR 75 mg Psychiatric Antidepressant Elavil 10 mg Psychiatric Antidepressant Elavil Amitriptyline 100 mg Psychiatric Antidepressant Elavil Amitriptyline 25 mg Psychiatric Antidepressant Elavil Amitriptyline 50 mg Psychiatric Antidepressant Elavil Amitriptyline 75 mg Psychiatric Antidepressant Elimite cream 5% (60 Gm) Derm Scabicide and Lice Erygel gel or solution 2% Derm Acne Ery-Tab Erythromycin stearate 250 mg Antimicrobials Macrolides Ery-Tab Erythromycin stearate 333 mg Antimicrobials Macrolides Ery-Tab Erythromycin stearate 500 mg Antimicrobials Macrolides Esidrix Hydrochlorothiazide 25 mg Cardiovascular Diuretics Esidrix Hydrochlorothiazide 50 mg Cardiovascular Diuretics Eskalith CR Lithium carbonate 150 mg Psychiatric Mood Stabilizer Eskalith CR Lithium carbonate 300 mg Psychiatric Mood Stabilizer Eskalith SR Lithium carbonate 300 mg Psychiatric Mood Stabilizer

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 7 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Eskalith SR Lithium carbonate 450 mg Psychiatric Mood Stabilizer Estrace Estradiol 0.5 mg Hormone Replacement Estrace Estradiol 1 mg Hormone Replacement Estrace Estradiol 2 mg Hormone Replacement Fioricet Butalbital/APAP/Caffeine 50 mg-325 mg-40 mg Analgesic Misc Flagyl Metronidazole 250 mg Antimicrobials Misc Flagyl Metronidazole 500 mg Antimicrobials Misc Flexeril 10 mg Analgesic Muscle Relaxant Flint SSD, Silver sulfadiazine 1% crm Derm Other Silvadene Flomax 0.4 mg Genitourinary Alpha-blockers Flonase 50 mcg/spray Respiratory Nasal Inhaler Florinef Fludrocortisone 0.1 mg Endocrine Florinef Fludrocortisone 0.2 mg Adrenals Fosamax Alendronate 35 mg Osteoporosis Fosamax Alendronate 70 mg Osteoporosis Garamycin Gentamicin eye drops 0.3% (5 ml) Ophthalmic Glucophage Metformin 1000 mg Diabetes Biguanides Glucophage Metformin 500 mg Diabetes Biguanides Glucophage Metformin 850 mg Diabetes Biguanides Glucophage XR Metformin ER 1000 mg Diabetes Biguanides Glucophage XR Metformin ER 500 mg Diabetes Biguanides Glucophage XR Metformin ER 750 mg Diabetes Biguanides Glucotrol Glipizide 10 mg Diabetes Sulfonylureas Glucotrol Glipizide 5 mg Diabetes Sulfonylureas Grifulvin V micro liquid 125 mg/5 mL (120 ml) Antimicrobials Antifungals Grisactin Fulvicin Griseofulvin ultramicro 125 mg Antimicrobials Antifungals Grisactin Fulvicin Griseofulvin ultramicro 250 mg Antimicrobials Antifungals Haldol 0.5 mg Psychiatric Antipsychotic Haldol Haloperidol 1 mg Psychiatric Antipsychotic Haldol Haloperidol 10 mg Psychiatric Antipsychotic Haldol Haloperidol 2 mg Psychiatric Antipsychotic Haldol Haloperidol 2 mg/ml (120 cc) Psychiatric Antipsychotic

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 8 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Haldol Haloperidol 2 mg/ml (15 cc) Psychiatric Antipsychotic Haldol Haloperidol 20 mg Psychiatric Antipsychotic Haldol Haloperidol 5 mg Psychiatric Antipsychotic Haldol 100 mg/ml (inj) Psychiatric Antipsychotic Haldol Haloperidol decanoate 50 mg/ml (inj) Psychiatric Antipsychotic HC Hydrocortisone 10 mg Derm Antiinflammatory HC Hydrocortisone 2.5% lotion Derm Antiinflammatory HC Hydrocortisone 20 mg Derm Antiinflammatory HC Hydrocortisone 5 mg Derm Antiinflammatory bismuth subsalicylate- Helidac Helicobacter pylori agent metronidazole- Humalog Insulin Lispro 100U/mL Diabetes Insulin Product Humulin N Insulin NPH U100 (10 ml) Diabetes Insulin Product Humulin R Insulin Regular U100 (10 ml) Diabetes Insulin Product Humulin R Insulin Regular U500 Diabetes Insulin Product Humulin R Kwikpen Insulin Regular U500 Diabetes Insulin Product Humulin, Novolin Insulin 70/30 U100 (10 ml) Diabetes Insulin Product Hytrin HCL 1 mg Genitourinary Hytrin Terazosin HCL 10 mg Genitourinary Hytrin Terazosin HCL 2 mg Genitourinary Hytrin Terazosin HCL 5 mg Genitourinary Hyzaar Losartan/Hctz 100 mg-12.5 mg Cardiovascular Antihypertensive Hyzaar Losartan/Hctz 100 mg-25 mg Cardiovascular Antihypertensive Hyzaar Losartan/Hctz 50 mg-12.5 mg Cardiovascular Antihypertensive Imdur Isosorbide mononitrate IR, SR 10 mg Cardiovascular Nitrate Vasodilators Imdur Isosorbide mononitrate IR, SR 120 mg Cardiovascular Nitrate Vasodilators Imdur Isosorbide mononitrate IR, SR 20 mg Cardiovascular Nitrate Vasodilators Imdur Isosorbide mononitrate IR, SR 30 mg Cardiovascular Nitrate Vasodilators Imdur Isosorbide mononitrate IR, SR 60 mg Cardiovascular Nitrate Vasodilators Imitrex Sumatriptan 100 mg Neurologic Migraine Imitrex Sumatriptan 25 mg Neurologic Migraine Imitrex Sumatriptan 50 mg Neurologic Migraine Imuran Azathioprine 50 mg Immunosupressive

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 9 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Inderal HCL 10 mg Cardiovascular Beta Blockers Inderal Propranolol HCL 20 mg Cardiovascular Beta Blockers Inderal Propranolol HCL 40 mg Cardiovascular Beta Blockers Inderal Propranolol HCL 60 mg Cardiovascular Beta Blockers Inderal Propranolol HCL 80 mg Cardiovascular Beta Blockers Indocin Indomethacin 25 mg Analgesic NSAID Indocin Indomethacin 50 mg Analgesic NSAID INH Isoniazid 10 mg / ml Antimicrobials Antitubercular INH Isoniazid 100 mg Antimicrobials Antitubercular INH Isoniazid 300 mg Antimicrobials Antitubercular Intal Cromolyn inhaler 14.2 Gm Respiratory Calcium Channel Isoptin Verapamil 120 mg Cardiovascular Blockers Calcium Channel Isoptin Verapamil LA 180 mg Cardiovascular Blockers Isordil Isosorbide dinitrate 10 mg Cardiovascular Nitrate Vasodilators Isordil Isosorbide dinitrate 20 mg Cardiovascular Nitrate Vasodilators Isordil Isosorbide dinitrate 30 mg Cardiovascular Nitrate Vasodilators Isordil Isosorbide dinitrate 5 mg Cardiovascular Nitrate Vasodilators Dipeptidyl Peptidase 4 Januvia Sitagliptin 100 mg Diabetes (DPP-4) Inhibitor Dipeptidyl Peptidase 4 Januvia Sitagliptin 25 mg Diabetes (DPP-4) Inhibitor Dipeptidyl Peptidase 4 Januvia Sitagliptin 50 mg Diabetes (DPP-4) Inhibitor Keflex Cephalexin 125 mg/5 ml (200 cc) Antimicrobials Cephalosporins Keflex Cephalexin 250 mg Antimicrobials Cephalosporins Keflex Cephalexin 250 mg/5 ml (100 cc) Antimicrobials Cephalosporins Keflex Cephalexin 500 mg Antimicrobials Cephalosporins Triamcinolone cream, ointment, or Kenalog, Aristocort 0.025% Derm Antiinflammatory lotion Triamcinolone cream, ointment, or Kenalog, Aristocort 0.10% Derm Antiinflammatory lotion

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 10 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Keppra Levetiracetam 1000 mg Neurologic Keppra Levetiracetam 500 mg Neurologic Keppra Levetiracetam 750 mg Neurologic Klonopin Clonazepam (SCH IV) 0.5 mg Psychiatric Benzos Klonopin Clonazepam (SCH IV) 1 mg Psychiatric Benzos Klonopin Clonazepam (SCH IV) 2 mg Psychiatric Benzos K-Tab, K-Dur, Slow- Potassium chloride tabs 10 mEq Cardiovascular Potassium Supplement K, Klor-con K-Tab, K-Dur, Slow- Potassium chloride tabs 20 mEq Cardiovascular Potassium Supplement K, Klor-con K-Tab, K-Dur, Slow- Potassium chloride tabs 8 mEq Cardiovascular Potassium Supplement K, Klor-con Lamictal 100 mg tab Neurologic Anticonvulsant Lamictal Lamotrigine 150 mg tab Neurologic Anticonvulsant Lamictal Lamotrigine 200 mg tab Neurologic Anticonvulsant Lamictal Lamotrigine 25 mg tab Neurologic Anticonvulsant Lanoxin Digoxin 0.125 mg Cardiovascular Glycosides Lanoxin Digoxin 0.25 mg Cardiovascular Glycosides Lantus Insulin glargine 100 IU/mL Diabetes Insulin Product Lasix Furosemide 20 mg Cardiovascular Diuretics Lasix Furosemide 40 mg Cardiovascular Diuretics Lasix Furosemide 80 mg Cardiovascular Diuretics Levaquin Levofloxacin 500 mg Antimicrobials Levoxyl 0.025 mg Endocrine Thyroid Levoxyl Levothyroxine 0.050 mg Endocrine Thyroid Levoxyl Levothyroxine 0.075 mg Endocrine Thyroid Levoxyl Levothyroxine 0.088 mg Endocrine Thyroid Levoxyl Levothyroxine 0.1 mg Endocrine Thyroid Levoxyl Levothyroxine 0.112 mg Endocrine Thyroid Levoxyl Levothyroxine 0.125 mg Endocrine Thyroid Levoxyl Levothyroxine 0.137 mg Endocrine Thyroid Levoxyl Levothyroxine 0.15 mg Endocrine Thyroid Levoxyl Levothyroxine 0.175 mg Endocrine Thyroid

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 11 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Levoxyl Levothyroxine 0.2 mg Endocrine Thyroid Levoxyl Levothyroxine 0.3 mg Endocrine Thyroid Lidex Fluocinonide 0.05% solution 60 ml Derm Antiinflammatory Lidex Fluocinonide 0.05% gel (60 gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% cream (30 gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% cream (60 gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% oint (15 gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% oint (30 gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% oint (60 gm) Derm Antiinflammatory Lioresal Baclofen 10 mg Analgesic Muscle Relaxant Lioresal Baclofen 20 mg Analgesic Muscle Relaxant Cholesterol Lowering Lipitor Atorvastatin 10 mg Cardiovascular Agents Cholesterol Lowering Lipitor Atorvastatin 20 mg Cardiovascular Agents Cholesterol Lowering Lipitor Atorvastatin 40 mg Cardiovascular Agents Cholesterol Lowering Lipitor Atorvastatin 80 mg Cardiovascular Agents Lomotil Diphenoxylate-atropine 2.5 mg-0.025 mg GI Antidiarrhea 2.5 mg-0.025 mg/5 ml Lomotil Diphenoxylate-atropine (SCH V) GI Antidiarrhea (60 ml) Cholesterol Lowering Lopid Gemfibrozil 600 mg Cardiovascular Agents Lopressor tartrate 100 mg Cardiovascular Beta Blockers Lopressor Metoprolol tartrate 25 mg Cardiovascular Beta Blockers Lopressor Metoprolol tartrate 50 mg Cardiovascular Beta Blockers Loxitane 5, 10, 25, 50 mg Psychiatric Antipsychotic Macrobid Nitrofurantoin monohydrate 100 mg Antimicrobials Misc Macrodantin Nitrofurantoin macrocryst 100 mg Antimicrobials Misc Macrodantin Nitrofurantoin macrocryst 50 mg Antimicrobials Misc Maxzide Triamterene/Hctz 37.5 mg/25 mg Cardiovascular Diuretics Maxzide Triamterene/Hctz 75 mg/50 mg Cardiovascular Diuretics

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 12 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Metrocream Metronidazole cream 0.075% Antimicrobials Misc Metrocream Metronidazole cream 0.75% Derm Acne Metrogel Metronidazole topical gel 0.75% Derm Acne Cholesterol Lowering Mevacor 10, 20, 40 mg Cardiovascular Agents Micronase Diabeta Glyburide 1.25 mg Diabetes Sulfonylureas Micronase Diabeta Glyburide 2.5 mg Diabetes Sulfonylureas Micronase Diabeta Glyburide 5 mg Diabetes Sulfonylureas Microzide Hydrochlorothiazide 12.5 mg cap Cardiovascular Diuretics Minipress 1 mg Cardiovascular Alpha-blockers Minipress Prazosin 2 mg Cardiovascular Alpha-blockers Minipress Prazosin 5 mg Cardiovascular Alpha-blockers Miralax Polyethylene glycol 238 g GI Miralax Polyethylene glycol 510 g GI Polyethylene glycol electrolyte Mix Golytely 240 g GI Prep solution Motrin Ibuprofen 400 mg Analgesic NSAID Motrin Ibuprofen 600 mg Analgesic NSAID Motrin Ibuprofen 800 mg Analgesic NSAID MS Morphine sulfate liquid 20 mg/5 ml Analgesic Narcotic MS Morphine sulfate short acting 15 mg Analgesic Narcotic MS Morphine sulfate short acting 30 mg Analgesic Narcotic Myambutol Ethambutol 100 mg Antimicrobials Antitubercular Myambutol Ethambutol 400 mg Antimicrobials Antitubercular Mysoline Primidone 250 mg Neurologic Anticonvulsant Mysoline Primidone 50 mg Neurologic Anticonvulsant Naprosyn Naproxen 250 mg Analgesic NSAID Naprosyn Naproxen 375 mg Analgesic NSAID Naprosyn Naproxen 500 mg Analgesic NSAID Narcan Naloxone 0.4 mg/ml Toxicology Agents Opiate Antagonists Narcan Naloxone 1 mg/ml Toxicology Agents Opiate Antagonists Nasarel Flunisolide 25 mcg/spray (0.025%) Cold, Cough, Allergy Nasal Steroids Navane Thiothixene 1 mg Psychiatric Antipsychotic

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 13 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Navane Thiothixene 10 mg Psychiatric Antipsychotic Navane Thiothixene 2 mg Psychiatric Antipsychotic Navane Thiothixene 20 mg Psychiatric Antipsychotic Navane Thiothixene 5 mg Psychiatric Antipsychotic Navane Thiothixene 5 mg/ ml Psychiatric Antipsychotic Neurontin Gabapentin 100 mg Neurologic Anticonvulsant Neurontin Gabapentin 300 mg Neurologic Anticonvulsant Neurontin Gabapentin 400 mg Neurologic Anticonvulsant Neurontin Gabapentin 600 mg Neurologic Anticonvulsant NicoDerm Patches- 28 weeks 14 mg Smoking deterrents NicoDerm Nicotine Patches- 28 weeks 21 mg Smoking deterrents NicoDerm Nicotine Patches- 28 weeks 7 mg Smoking deterrents Nitrostat Nitroglycerine SL 0.4 mg Cardiovascular Nitrate Vasodilators Nizoral 2% crm (15 Gm) Antimicrobials Antifungals Nizoral Ketoconazole 2% crm (30 Gm) Antimicrobials Antifungals Nizoral Ketoconazole 2% crm (60 Gm) Antimicrobials Antifungals Nizoral Ketoconazole 2% shampoo Antimicrobials Antifungals Nizoral Ketoconazole 200 mg (tabs) Antimicrobials Antifungals Norco Acetaminophen/Hydrocodone 325/10 mg Analgesic Narcotic Norco Acetaminophen/Hydrocodone 325/5 mg Analgesic Narcotic Norco Acetaminophen/Hydrocodone 325/7.5 mg Analgesic Narcotic Calcium Channel Norvasc 10 mg Cardiovascular Blockers Calcium Channel Norvasc Amlodipine 2.5 mg Cardiovascular Blockers Calcium Channel Norvasc Amlodipine 5 mg Cardiovascular Blockers Oramorph SR Morphine sulfate SR 100 mg Analgesic Narcotic Oramorph SR Morphine sulfate SR 15 mg Analgesic Narcotic Oramorph SR Morphine sulfate SR 30 mg Analgesic Narcotic Oramorph SR Morphine sulfate SR 60 mg Analgesic Narcotic Pamelor 10 mg Psychiatric Antidepressant Pamelor Nortriptyline 25 mg Psychiatric Antidepressant

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 14 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Pamelor Nortriptyline 50 mg Psychiatric Antidepressant Pamelor Nortriptyline 75 mg Psychiatric Antidepressant Parlodel 2.5mg Hypoprolactinemic Paser Aminosalicylic acid 4 g Antimicrobials Antitubercular Paxil 10 mg Psychiatric Antidepressant Paxil Paroxetine 10 mg/5 ml Psychiatric Antidepressant Paxil Paroxetine 20 mg Psychiatric Antidepressant Paxil Paroxetine 30 mg Psychiatric Antidepressant Paxil Paroxetine 40 mg Psychiatric Antidepressant Pennsaid Diclofenac 2% sol Derm NSAID Pepcid Famotidine 20 mg GI H2 Antagonists Pepcid Famotidine 40 mg GI H2 Antagonists Percocet Acetaminophen/Oxycodone 325 mg/10 mg Analgesic Narcotic Percocet Acetaminophen/Oxycodone 325 mg/5 mg Analgesic Narcotic Persantine Dipyridamole 25 mg Cardiovascular Anticoagulants Persantine Dipyridamole 50 mg Cardiovascular Anticoagulants Persantine Dipyridamole 75 mg Cardiovascular Anticoagulants Phenergan HCI 12.5 mg GI Antiemetic Phenergan Promethazine HCI 12.5 mg supp GI Antiemetic Phenergan Promethazine HCI 25 mg GI Antiemetic Phenergan Promethazine HCI 50 mg GI Antiemetic Phenergan Promethazine HCI 25 mg supp GI Antiemetic Phenergan syrup Promethazine HCI 6.25 mg/5 ml (120 ml) GI Antiemetic Phoslo Calcium acetate 667 mg Phosphate binder Phytonadione Vitamin K 5 mg tab Vitamin Plaquenil Hydroxychloroquine 200 mg Rheumatology Platelet aggregation Plavix Clopidogrel 75 mg inhibitor Polytrim Polymyxin b- trimethoprim 10 mL drops Ophthalmic Polytrim Polymyxin b- trimethoprim 3.5 gm ointment Ophthalmic Cholesterol Lowering Pravachol Pravastatin 20, 40, 80 mg tabs Cardiovascular Agents Prelone 15mg/5ml oral sol Endocrine Glucocorticoids

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 15 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Premarin Conjugated Estrogen Cream 0.625 mg/g crm (43 Gm) Hormone Replacement Priftin Rifapentine 150 mg Antimicrobials Antitubercular Prilosec 20 mg GI PPI Prinivil, Zestril Lisinopril 10 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 2.5 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 20 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 30 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 40 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 5 mg Cardiovascular ACE Inhibitor Procardia, Adalat Calcium Channel SR 30 mg Cardiovascular CC, Nifediac Blockers Procardia, Adalat Calcium Channel Nifedipine SR 60 mg Cardiovascular CC, Nifediac Blockers Procardia, Adalat Calcium Channel Nifedipine SR 90 mg Cardiovascular CC, Nifediac Blockers Prolixin 0.5 mg/ml Psychiatric Antipsychotic Prolixin Fluphenazine 1 mg Psychiatric Antipsychotic Prolixin Fluphenazine 10 mg Psychiatric Antipsychotic Prolixin Fluphenazine 2.5 mg Psychiatric Antipsychotic Prolixin Fluphenazine 5 mg / cc Psychiatric Antipsychotic Prolixin Fluphenazine decanoate 25 mg/ml (inj) Psychiatric Antipsychotic 5-alpha reductase Proscar Finasteride 5 mg Genitourinary inhibitor Proventil Albuterol solution neb 5 mg/ml (20 ml bottle) Respiratory Nebulizer soln Proventil Albuterol Unit Dose 0.83 mg/ml Respiratory Albuterol HFA (IDP) tablet, MDI, Proventil HFA (IDP) 90 mcg Respiratory Inhaler solution, UD Provera Medroxyprogesterone 10 mg Hormone Replacement Provera Medroxyprogesterone 2.5 mg Hormone Replacement Provera Medroxyprogesterone 5 mg Hormone Replacement Prozac Fluoxetine 10 mg Psychiatric Antidepressant

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 16 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Prozac Fluoxetine 20 mg Psychiatric Antidepressant Prozac Fluoxetine 20 mg / 5 ml Psychiatric Antidepressant Prozac Fluoxetine 40 mg Psychiatric Antidepressant PTU Propylthiouracil 50 mg Endocrine Thyroid Pyridium Phenazopyridine HCL 100 mg Genitourinary Pyridium Phenazopyridine HCL 200 mg Genitourinary Qvar Beclomethasone dipropionate 40 mcg Respiratory Steroid inhaler Qvar Beclomethasone dipropionate 80 mcg Respiratory Steroid inhaler Reglan Metoclopramide 10 mg GI Antiemetic Reglan Metoclopramide hcl 5 mg GI Antiemetic Relafen Nabumetone 750 mg Analgesic NSAID Remeron 15 mg Psychiatric Antidepressant Remeron Mirtazapine 30 mg Psychiatric Antidepressant Remeron Mirtazapine 45 mg Psychiatric Antidepressant Restoril Temazepam (SCH IV) 15 mg Psychiatric Hypnotic Restoril Temazepam (SCH IV) 30 mg Psychiatric Hypnotic 0.01%, 0.025%, 0.05%, Retin-A Tretinoin Derm Acne 0.1% cream, gel Rheumatrex Methotrexate 2.5 mg Chemotherapy Rifadin Rifampin 150 mg Antimicrobials Antitubercular Rifadin Rifampin 300 mg Antimicrobials Antitubercular Risperdal 0.5 mg Psychiatric Antipsychotic Risperdal Risperidone 1 mg Psychiatric Antipsychotic Risperdal Risperidone 1 mg/ml solution Psychiatric Antipsychotic Risperdal Risperidone 2 mg Psychiatric Antipsychotic Risperdal Risperidone 3 mg Psychiatric Antipsychotic Risperdal Risperidone 4 mg Psychiatric Antipsychotic Ritalin Methylphenidate short acting 10 mg Psychiatric Stimulant Ritalin Methylphenidate short acting 20 mg Psychiatric Stimulant Ritalin Methylphenidate short acting 30 mg Psychiatric Stimulant Ritalin LA Methylphenidate long-acting 10 mg Psychiatric Stimulant Ritalin LA Methylphenidate long-acting 20 mg Psychiatric Stimulant

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 17 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Ritalin LA Methylphenidate long-acting 30 mg Psychiatric Stimulant Ritalin LA Methylphenidate long-acting 40 mg Psychiatric Stimulant Robaxin Methocarbamol 500 mg Analgesic Muscle Relaxant Robaxin Methocarbamol 750 mg Analgesic Muscle Relaxant Robitussin AC Guaifenesin/Codeine 100 mg-10 mg/5 ml Cold, Cough, Allergy Antitussive Rocaltrol Calcitriol 0.25 mcg Vitamin Rocaltrol Calcitriol 0.5 mcg Vitamin Selsun Selenium sulfide lotion 2.50% Derm Anti-seborrhea Septra Sulfamethxzl Trimethoprim 80 / 400 mg Antimicrobials Sulfas Septra Sulfamethxzl Trimethoprim DS 160 / 800 mg Antimicrobials Sulfas Serevent Diskus xinafoate 50 mcg Respiratory Asthma Seromycin Cycloserine 250 mg Antimicrobials Antitubercular Seroquel fumarate 100 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 200 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 25 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 300 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 400 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 50 mg Psychiatric Antipsychotic Sinemet Carbidopa - levodopa 10 mg - 100 mg Neurologic Parkinson Sinemet Carbidopa - levodopa 25 mg - 100 mg Neurologic Parkinson Sinemet Carbidopa - levodopa 25 mg - 250 mg Neurologic Parkinson Sinemet CR Carbidopa - levodopa LA 25 mg - 100 mg Neurologic Parkinson Sinemet CR Carbidopa - levodopa LA 50 mg - 200 mg Neurologic Parkinson Sinequan HCL 10 mg Psychiatric Antidepressant Sinequan Doxepin HCL 100 mg Psychiatric Antidepressant Sinequan Doxepin HCL 150 mg Psychiatric Antidepressant Sinequan Doxepin HCL 25 mg Psychiatric Antidepressant Sinequan Doxepin HCL 50 mg Psychiatric Antidepressant Sinequan Doxepin HCL 75 mg Psychiatric Antidepressant Singulair Montelukast 10 mg Respiratory Singulair Montelukast 5 mg chew Respiratory Soltamox Tamoxifen 10 mg Hormone Replacement Soma Carisoprodol 250 mg Muscle Relaxant

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 18 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Spectazole Econazole 1% crm 30 Gm (30 Gm) Antimicrobials Antifungals Spectazole Econazole 1% crm 85 Gm (85 Gm) Antimicrobials Antifungals Spectazole Econazole 1% crm 15 Gm (15 Gm) Antimicrobials Antifungals Stelazine 10 mg Psychiatric Antipsychotic Stelazine Trifluoperazine 2 mg Psychiatric Antipsychotic Stelazine Trifluoperazine 5 mg Psychiatric Antipsychotic Mixed Opiate Suboxone Buprenorphine/naloxone 2 mg-0.5 mg Analgesic Agonist/Antagonist Mixed Opiate Suboxone Buprenorphine/naloxone 8 mg-2 mg Analgesic Agonist/Antagonist Subutex Buprenorphine 2 mg Analgesic Opiate Agonist Sulamyd Sulfacetamide sodium eye drop sol 10% Ophthalmic Sulamyd Sulfacetamide sodium eye ointment 10% Ophthalmic Sumycin Tetracycline 250 mg Antimicrobials Tetracyclines Sumycin Tetracycline 500 mg Antimicrobials Tetracyclines Symmetrel Amantadine 100 mg Neurologic Parkinson Symmetrel Amantadine 50 mg / 5 ml (120 ml) Neurologic Parkinson Synalar Fluocinolone acetonide 0.01% cream Derm Antiinflammatory Synalar Fluocinolone acetonide 0.01% ointment Derm Antiinflammatory Synalar Fluocinolone acetonide 0.025% cream Derm Antiinflammatory Synalar Fluocinolone acetonide 0.025% ointment Derm Antiinflammatory 0.025%, 0.01% solution, Synalar Fluocinolone acetonide Derm Antiinflammatory 60 ml Tagamet 400 mg GI H2 blockers Tamiflu Oseltamivir 12mg/ml Antimicrobials Antiviral Tamiflu Oseltamivir 75 mg Antimicrobials Antiviral Tapazole Methimazole 10 mg Endocrine Thyroid Tapazole Methimazole 5 mg Endocrine Thyroid Tegretol 100 mg Psychiatric Mood Stabilizer Tegretol Carbamazepine 100 mg / 5 cc Psychiatric Mood Stabilizer Tegretol Carbamazepine 200 mg Psychiatric Mood Stabilizer Temovate Clobetasol lotion 0.05% Derm Temovate Clobetasol propionate 0.05% crm (15 Gms) Derm Antiinflammatory

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 19 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Temovate Clobetasol propionate 0.05% oint (15 Gms) Derm Antiinflammatory Temovate Clobetasol propionate 0.05% oint (30 Gms) Derm Antiinflammatory Tenormin 100 mg Cardiovascular Beta Blockers Tenormin Atenolol 25 mg Cardiovascular Beta Blockers Tenormin Atenolol 50 mg Cardiovascular Beta Blockers Thalitone Chlorthalidone 25 mg Cardiovascular Diuretics Thalitone Chlorthalidone 50 mg Cardiovascular Diuretics Theo-Dur Theophylline 200 mg Respiratory Theo-Dur Theophylline 300 mg Respiratory Thorazine 10 mg Psychiatric Antipsychotic Thorazine Chlorpromazine 100 mg Psychiatric Antipsychotic Thorazine Chlorpromazine 100 mg/ml Psychiatric Antipsychotic Thorazine Chlorpromazine 200 mg Psychiatric Antipsychotic Thorazine Chlorpromazine 25 mg Psychiatric Antipsychotic Thorazine Chlorpromazine 30 mg/ml Psychiatric Antipsychotic Thorazine Chlorpromazine 50 mg Psychiatric Antipsychotic Platelet aggregation Ticlid Ticlopidine 250 mg inhibitor Tivicay Dolutegravir 10 mg Antiretrovirals Integrase Inhibitor Tivicay Dolutegravir 25 mg Antiretrovirals Integrase Inhibitor Tivicay Dolutegravir 50 mg Antiretrovirals Integrase Inhibitor Tofranil 10 mg Psychiatric Antidepressant Tofranil Imipramine 25 mg Psychiatric Antidepressant Tofranil Imipramine 50 mg Psychiatric Antidepressant Toprol XL Metoprolol succinate 100 mg Cardiovascular Beta Blockers Toprol XL Metoprolol succinate 25 mg Cardiovascular Beta Blockers Toprol XL Metoprolol succinate 50 mg Cardiovascular Beta Blockers Trandate HCL 100 mg Cardiovascular Beta Blockers Trandate Labetalol HCL 200 mg Cardiovascular Beta Blockers Trandate Labetalol HCL 300 mg Cardiovascular Beta Blockers Trecator Ethionamide 250 mg Antimicrobials Antitubercular Trental Pentoxifylline ER 400 mg Hemorrheologic Agents

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 20 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Cholesterol Lowering Tricor Fenofibrate 145 mg Cardiovascular Agents Cholesterol Lowering Tricor Fenofibrate 48 mg Cardiovascular Agents Trilafon 16 mg Psychiatric Antipsychotic Trilafon Perphenazine 16 mg / 5 cc (120 ml) Psychiatric Antipsychotic Trilafon Perphenazine 2 mg Psychiatric Antipsychotic Trilafon Perphenazine 4 mg Psychiatric Antipsychotic Trilafon Perphenazine 8 mg Psychiatric Antipsychotic Reverse Transcriptase Emtricitabine and tenofovir Truvada 200-300 mg Antiretrovirals Inhibitor, disoproxil fumarate Nucleoside/Nucleotide Tylenol Acetaminophen 325 mg Analgesic Acetaminophen Tylenol Acetaminophen 500 mg Analgesic Acetaminophen Tylenol Acetaminophen 650 mg Analgesic Acetaminophen Tylenol #3 Acetaminophen/Codeine #3 300 mg-30 mg Analgesic Narcotic Ultram, Rybix Tramadol 50 mg Analgesic Misc Valium Diazepam (SCH IV) 10 mg Psychiatric Benzos Valium Diazepam (SCH IV) 2 mg Psychiatric Benzos Valium Diazepam (SCH IV) 5 mg Psychiatric Benzos Vaseretic Enalapril maleate/Hctz 10 mg-25 mg Cardiovascular Antihypertensive Vaseretic Enalapril maleate/Hctz 5 mg-12.5 mg Cardiovascular Antihypertensive Vasotec Enalapril maleate 10 mg Cardiovascular ACE Inhibitor Vasotec Enalapril maleate 2.5 mg Cardiovascular ACE Inhibitor Vasotec Enalapril maleate 20 mg Cardiovascular ACE Inhibitor Vasotec Enalapril maleate 5 mg Cardiovascular ACE Inhibitor Veetids Penicillin VK 125 mg/5 ml (200 cc) Antimicrobials Penicillins Veetids Penicillin VK 250 mg Antimicrobials Penicillins Veetids Penicillin VK 250 mg/5 ml (100 cc) Antimicrobials Penicillins Veetids Penicillin VK 250 mg/5 ml (150 cc) Antimicrobials Penicillins Veetids Penicillin VK 500 mg Antimicrobials Penicillins Ventolin Albuterol liquid 2 mg/5 ml (120 cc) Respiratory

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 21 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Acetaminophen/Hydrocodone Vicodin 500 mg-5 mg Analgesic Narcotic bitartrate Vitamin B5 Pyridoxine 25 mg Vitamin Vitamin B6 Pyridoxine 100 mg Vitamin Voltaren Diclofenac 50 mg Analgesic NSAID Voltaren Diclofenac 75 mg Analgesic NSAID Vosol Acetic acid 15 ml drops Otic Vosol HC Acetic acid/Hydrocortisone 2%-1% Otic Wellbutrin SR Buproprion IR, SR 100 mg Psychiatric Antidepressant Wellbutrin SR Buproprion IR, SR 150 mg Psychiatric Antidepressant Wellbutrin SR Buproprion IR, SR 200 mg Psychiatric Antidepressant Wellbutrin SR Buproprion IR, SR 300 mg Psychiatric Antidepressant Wellbutrin SR Buproprion IR, SR 75 mg Psychiatric Antidepressant Wellbutrin XL XL 150 mg Psychiatric Antidepressant Wellbutrin XL Bupropion XL 300 mg Psychiatric Antidepressant Xalatan Latanoprost 0.005% Ophthalmic Zantac 150 mg GI H2 blockers Zantac Ranitidine 300 mg GI H2 blockers Zaroxolyn Metolazone 10 mg Cardiovascular Diuretics Zaroxolyn Metolazone 2.5 mg Cardiovascular Diuretics Zaroxolyn Metolazone 5 mg Cardiovascular Diuretics Zestoretic Lisinopril/Hctz 10 mg - 12.5 mg Cardiovascular Antihypertensive Zestoretic Lisinopril/Hctz 20 mg - 12.5 mg Cardiovascular Antihypertensive Zestoretic Lisinopril/Hctz 20 mg - 25 mg Cardiovascular Antihypertensive Zithromax Azithromycin 250 mg Antimicrobials Macrolides Cholesterol Lowering Zocor 10 mg Cardiovascular Agents Cholesterol Lowering Zocor Simvastatin 20 mg Cardiovascular Agents Cholesterol Lowering Zocor Simvastatin 40 mg Cardiovascular Agents Zoloft Sertraline 100 mg Psychiatric Antidepressant Zoloft Sertraline 20 mg/ml Psychiatric Antidepressant

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 22 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Zoloft Sertraline 25 mg Psychiatric Antidepressant Zoloft Sertraline 50 mg Psychiatric Antidepressant Zovirax Acyclovir 200 mg Antimicrobials Antiviral Zovirax Acyclovir 400 mg Antimicrobials Antiviral Zovirax Acyclovir 800 mg Antimicrobials Antiviral Zyloprim Allopurinol 100 mg Gout Zyloprim Allopurinol 300 mg Gout Zyprexa 2.5mg Psychiatric Antipsychotic Zyprexa Olanzapine 5 mg Psychiatric Antipsychotic Zyvox Linezolid 600 mg Antimicrobials Oxazolidinone Aspirin (acetylsalicylic acid, ASA) 325 mg Analgesic Salicylates Aspirin (acetylsalicylic acid, ASA) 81 mg Analgesic Salicylates Capsaicin 0.025% cream Derm Analgesic Capsaicin 0.075% cream Derm Analgesic Capsaicin 0.1% cream Derm Analgesic 1%-0.35%-10000u/mL Cortisporin otic soln Otic (10 ml) Cortisporin otic susp drops (10 ml) Otic Diabetes supplies - glucometer Diabetes Diabetes supplies - lancets Diabetes Diabetes supplies - syringes/ Diabetes needles Diabetes supplies - test strips Diabetes Diabetes supplies - testing control Diabetes solution Erythromycin eye ointment 5 mg / Gm (3.5 Gm) Ophthalmic Folic Acid 800 MicroGrams Vitamin Lidocaine 4% cream Derm Anesthetic Lidocaine 4% solution Derm Anesthetic Lidocaine 5% cream Derm Anesthetic Lidocaine 5% ointment Derm Anesthetic Methadone 10 mg Analgesic Narcotic Methadone 5 mg Analgesic Narcotic

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 23 of 24 HealthPAC Formulary Current as of July 2017

Brand Name Generic Name Strength Class I Class II Niacin IR & ER tabs only 100 mg Cardiovascular Niacin IR & ER tabs only 250 mg Cardiovascular Niacin IR & ER tabs only 500 mg Cardiovascular Nicotine Gum 2 mg Smoking deterrents Nicotine Gum 4 mg Smoking deterrents Nicotine Lozenge 2 mg Smoking deterrents Nicotine Lozenge 4 mg Smoking deterrents Nystatin (cream or ointment) Derm Antifungals Nystatin oral suspension 100,000 units/ml Antimicrobials Antifungals Phenobarbital (SCH IV) 100 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 15 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 30 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 60 mg Neurologic Anticonvulsant Potassium chloride 10% (480 cc) Cardiovascular Potassium Supplement Prednisolone ophth solu or susp 1% Ophthalmic Promethazine/VC/DM Cold, Cough, Allergy Antitussive Pyrazinamide 500 mg Antimicrobials Antitubercular Salsalate 500 mg Analgesic Salicylates Salsalate 750 mg Analgesic Salicylates Maleate eye drops 0.25% Ophthalmic Glaucoma Timolol Maleate eye drops 0.5% Ophthalmic Glaucoma Tobramycin ophthal soln. 0.3% Ophthalmic Vitamin B6 50 mg Vitamin

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 24 of 24