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Healthpac Formulary Current As of July 2015 HealthPAC Formulary Current as of July 2015 Class I Class II Generic Name Brand Name Strength Adrenals Fludrocortisone Florinef 0.2 mg Analgesic Acetaminophen Acetaminophen Tylenol 325 mg Analgesic Acetaminophen Acetaminophen Tylenol 500 mg Analgesic Acetaminophen Acetaminophen Tylenol 650 mg Analgesic Misc Butalbital-APAP-Caffeine Fioricet 50/325/40 Analgesic Misc Tramadol Ultram, Rybix 50 mg Analgesic Muscle Relaxant Baclofen Lioresal 10 mg Analgesic Muscle Relaxant Baclofen Lioresal 20 mg Analgesic Muscle Relaxant Cyclobenzaprine Flexeril 10 mg Analgesic Muscle Relaxant Methocarbamol Robaxin 500 mg Analgesic Muscle Relaxant Methocarbamol Robaxin 750 mg Analgesic Narcotic Acetaminophen/Oxycodone Percocet 325/5 and 325/10 Analgesic Narcotic Acetaminophen/Codeine #3 Tylenol #3 300 / 30 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325/10 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325/5 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325/7.5 mg Acetaminophen/Hydrocodone Analgesic Narcotic Vicodin 500 mg - 5 mg bitartrate Analgesic Narcotic Methadone 10 mg Analgesic Narcotic Methadone 5 mg Analgesic Narcotic Morphine sulfate Liquid MS 20mg/ 5 ml Analgesic Narcotic Morphine sulfate short acting MS 15,30mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 100 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 15 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 30 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 60 mg Analgesic NSAID Celecoxib Celebrex 100 mg Analgesic NSAID Celecoxib Celebrex 200 mg Analgesic NSAID Celecoxib Celebrex 400 mg Analgesic NSAID Celecoxib Celebrex 50 mg Analgesic NSAID Diclofenac Voltaren 50 mg Analgesic NSAID Diclofenac Voltaren 75 mg Analgesic NSAID Ibuprofen Motrin 400 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 1 of 23 HealthPAC Formulary Current as of July 2015 Class I Class II Generic Name Brand Name Strength Analgesic NSAID Ibuprofen Motrin 600 mg Analgesic NSAID Ibuprofen Motrin 800 mg Analgesic NSAID Indomethacin Indocin 25 mg Analgesic NSAID Indomethacin Indocin 50 mg Analgesic NSAID Nabumetone Relafen 750 mg Analgesic NSAID Naproxen Naprosyn 250 mg Analgesic NSAID Naproxen Naprosyn 375 mg Analgesic NSAID Naproxen Naprosyn 500 mg Analgesic NSAID Sulindac Clinoril 150 mg Analgesic NSAID Sulindac Clinoril 200 mg Analgesic Opiate Agonist Buprenorphine Butrans 10 mcg/hr Analgesic Opiate Agonist Buprenorphine Butrans 15 mcg/hr Analgesic Opiate Agonist Buprenorphine Butrans 5 mcg/hr Analgesic Opiate Agonist Buprenorphine Butrans 7.5 mcg/hr Analgesic Opiate Agonist Buprenorphine Subutex 2 mg Mixed Opiate Analgesic Buprenorphine/naloxone Suboxone 2-0.5 mg Agonist/Antagonist Mixed Opiate Analgesic Buprenorphine/naloxone Suboxone 8-2 mg Agonist/Antagonist Analgesic Salicylates Salsalate 500 mg Analgesic Salicylates Salsalate 750 mg Analgesic Salicylates Asprin (acetylsalicylic acid, ASA) 325 mg Analgesic Salicylates Asprin (acetylsalicylic acid, ASA) 81 mg Anthelmintics Praziquantel Biltricide 600mg Antibiotic Mupirocin Bactroban 2%ointment Antihistamine Loratadine Claritin 10mg Anti-inflammatory Agents Alclometasone Cream Aclovate 45gm Anti-inflammatory Agents Alclometasone Ointment Aclovate 45gm Antimicrobials Antifungals Econazole Spectazole 1% crm 30 Gm (30 Gm) Antimicrobials Antifungals Econazole Spectazole 1% crm 85 Gm (85 Gm) Antimicrobials Antifungals Econazole Spectazole 1% crm 15 Gm (15 Gm) Antimicrobials Antifungals Fluconazole Diflucan 100 mg Antimicrobials Antifungals Fluconazole Diflucan 150 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 2 of 23 HealthPAC Formulary Current as of July 2015 Class I Class II Generic Name Brand Name Strength Antimicrobials Antifungals Fluconazole Diflucan 200 mg Antimicrobials Antifungals Griseofulvin micro liquid Grifulvin V 125 mg / 5 mL (120 ml) Antimicrobials Antifungals Griseofulvin ultramicro Grisactin Fulvicin 125 mg Antimicrobials Antifungals Griseofulvin ultramicro Grisactin Fulvicin 250 mg Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (15 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (30 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (60 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% shampoo Antimicrobials Antifungals Ketoconazole Nizoral 200 mg (tabs) Antimicrobials Antifungals Nystatin oral suspension 100,000 units/ml Antimicrobials Antitubercular Ethambutol Myambutol 100 mg Antimicrobials Antitubercular Ethambutol Myambutol 400 mg Antimicrobials Antitubercular Isoniazid INH 10 mg / ml Antimicrobials Antitubercular Isoniazid INH 100 mg Antimicrobials Antitubercular Isoniazid INH 300 mg Antimicrobials Antitubercular Pyrazinamide 500 mg Antimicrobials Antitubercular Rifampin Rifadin 150 mg Antimicrobials Antitubercular Rifampin Rifadin 300 mg Antimicrobials Antiviral Acyclovir Zovirax 200 mg Antimicrobials Antiviral Acyclovir Zovirax 400 mg Antimicrobials Antiviral Acyclovir Zovirax 800 mg Antimicrobials Antiviral Oseltamivir Tamiflu 12mg/ml Antimicrobials Antiviral Oseltamivir Tamiflu 75mg Antimicrobials Cephalosporins Cephalexin Keflex 125 mg / 5 ml (200 ml) Antimicrobials Cephalosporins Cephalexin Keflex 250 mg Antimicrobials Cephalosporins Cephalexin Keflex 250 mg / 5 ml (100 ml) Antimicrobials Cephalosporins Cephalexin Keflex 500 mg Antimicrobials Macrolides Azithromycin Zithromax 250 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 250 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 333 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 500 mg Antimicrobials Misc Clindamycin Cleocin 150 mg Antimicrobials Misc Clindamycin Cleocin 300 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 3 of 23 HealthPAC Formulary Current as of July 2015 Class I Class II Generic Name Brand Name Strength Antimicrobials Misc Metronidazole Flagyl 250 mg Antimicrobials Misc Metronidazole Flagyl 500 mg Antimicrobials Misc Metronidazole cream Metrocream 0.075% Antimicrobials Misc Nitrofurantoin macrocryst Macrodantin 100 mg Antimicrobials Misc Nitrofurantoin macrocryst Macrodantin 50 mg Antimicrobials Misc Nitrofurantoin monohydrate Macrobid 100 mg Antimicrobials Penicillins Amoxicillin Amoxil 125 mg / 5 cc (80 cc) Antimicrobials Penicillins Amoxicillin Amoxil 250 mg Antimicrobials Penicillins Amoxicillin Amoxil 250 mg / 5 cc (150 cc) Antimicrobials Penicillins Amoxicillin Amoxil 400 mg/ 5 cc Antimicrobials Penicillins Amoxicillin Amoxil 500 mg Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 200 mg / 5 cc (100 ml) Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 500 mg-125 mg Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 875 mg Antimicrobials Penicillins Dicloxacillin Dynapen 250 mg Antimicrobials Penicillins Dicloxacillin Dynapen 500 mg Antimicrobials Penicillins Penicillin VK 125 mg / 5 cc (200 cc) Antimicrobials Penicillins Penicillin VK Veetids 250 mg Antimicrobials Penicillins Penicillin VK 250 mg / 5 cc (100 cc) Antimicrobials Penicillins Penicillin VK 250 mg / 5 cc (150 cc) Antimicrobials Penicillins Penicillin VK 500 mg Antimicrobials Quinolones Ciprofloxacin Cipro 250 mg Antimicrobials Quinolones Ciprofloxacin Cipro 500 mg Antimicrobials Sulfas Sulfamethxzl Trimethoprim Bactrim 40mg / 5ml - 200mg / 5-ml (60 ml) Antimicrobials Sulfas Sulfamethxzl Trimethoprim Septra 80 / 400 mg Antimicrobials Sulfas Sulfamethxzl Trimethoprim DS Septra 160 / 800 mg Antimicrobials Tetracyclines Doxycycline Doryx Vibramycin 100 mg Antimicrobials Tetracyclines Doxycycline Doryx Vibramycin 50 mg Antimicrobials Tetracyclines Tetracycline Sumycin 250 mg Antimicrobials Tetracyclines Tetracycline Sumycin 500 mg Antimicrobials Clarithromycin Biaxin 500 mg Antimicrobials Levofloxacin Levaquin 500 mg Cardiovascular ACE Inhibitor Captopril Capoten 100 mg Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 4 of 23 HealthPAC Formulary Current as of July 2015 Class I Class II Generic Name Brand Name Strength Cardiovascular ACE Inhibitor Captopril Capoten 12.5 mg Cardiovascular ACE Inhibitor Captopril Capoten 25 mg Cardiovascular ACE Inhibitor Captopril Capoten 50 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 10 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 2.5 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 20 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 5 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 10 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 2.5 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 20 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 30 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 40 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 5 mg Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 1 mg Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 2 mg Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 4 mg Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 8 mg Cardiovascular Alpha-blockers Prazosin Minipress 1 mg Cardiovascular Alpha-blockers Prazosin Minipress 2 mg Cardiovascular Alpha-blockers Prazosin Minipress 5 mg Angiotensin II Cardiovascular Losartan Cozaar
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