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OVH Pharmacy Medication Formulary

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OVH Pharmacy Medication Formulary Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes AMIKACIN 500 MG/2 ML 500 MG/2ML AA‐AMINOGLYCOSIDES 703903203 TEVA PARENTERAL IJ 2 GENTAMICIN 40 MG/ML VIAL 40 MG/M AA‐AMINOGLYCOSIDES 63323001002 APP PHARMACEUTI IJ 2 TOBRAMYCIN 40 MG/ML VIAL 40 MG/M AA‐AMINOGLYCOSIDES 63323030602 APP PHARMACEUTI IJ 2 GENTAMICIN 100MG IVPB 100MG AA‐AMINOGLYCOSIDES 338050548 BAXTER HEALTHCA IV 100 GENTAMICIN 120MG IVPB 120MG AA‐AMINOGLYCOSIDES 338050748 BAXTER HEALTHCA IV 100 GENTAMICIN 60 MG/NS 50 ML P 60 MG/5 AA‐AMINOGLYCOSIDES 409787913 HOSPIRA IV 50 GENTAMICIN 80MG IVPB 80MG AA‐AMINOGLYCOSIDES 338050348 BAXTER HEALTHCA IV 100 VANCOMYCIN 500 MG VIAL 500 MG AA‐AMINOGLYCOSIDES 67457033950 MYLAN INSTITUTI IV 1 VANCOMYCIN 500MG IVPB 500MG/0 AA‐AMINOGLYCOSIDES 338355148 BAXTER HEALTHCA IV 100 VANCOMYCIN 750MG IVPB 750MG AA‐AMINOGLYCOSIDES 338358048 BAXTER HEALTHCA IV 150 NEOMYCIN 500 MG TABLET 500 MG AA‐AMINOGLYCOSIDES 51991073801 BRECKENRIDGE PO 100 PLEASE USE OTHER OPTIONS FIRST VANCOCIN HCL 250 MG PULVULE 250 MG AA‐AMINOGLYCOSIDES 66593312602 VIROPHARMA INCO PO 20 USED ONLY WITH PRIOR APPROVAL VANCOMYCIN HCL 125 MG CAPSU 125 MG AA‐AMINOGLYCOSIDES 66993021019 PRASCO LABS PO 20 USED ONLY WITH PRIOR APPROVAL FLUCONAZOLE 100 MG TABLET 100 MG AA‐ANTIFUNGALS 16714069102 NORTHSTAR RX LL PO 100 FLUCONAZOLE 150 MG TABLET 150 MG AA‐ANTIFUNGALS 55111014512 DR.REDDY'S LAB PO 12 NYSTATIN 100000U/ML SUSP 100K U/ AA‐ANTIFUNGALS 60432053716 MORTON GROVE PH PO 473 TERBINAFINE HCL 250MG TABLE 250MG AA‐ANTIFUNGALS 60429022230 GSMS PO 30 METRONIDAZOLE 500 MG IV SOL 500MG AA‐ANTIMICROBIAL 338105548 BAXTER HEALTHCA IV 100 METRONIDAZOLE 500 MG/100 ML 500MG/0 AA‐ANTIMICROBIAL 409781124 HOSPIRA IV 100 METRONIDAZOLE 250 MG TABLET 250 MG AA‐ANTIMICROBIAL 50111033301 PLIVA, INC PO 100 METRONIDAZOLE 500 MG TABLET 500 MG AA‐ANTIMICROBIAL 50111033402 PLIVA, INC PO 500 NITROFURANTOIN MCR 50 MG CA 50MG AA‐ANTIMICROBIAL 378165001 MYLAN PO 100 NITROFURANTOIN‐MACRO 100 MG 100MG AA‐ANTIMICROBIAL 185012201 EON LABS PO 100 ZYVOX 600MG IVPB 600MG AA‐ANTIMICROBIAL/MAO INHIBITOR 9514001 PHARMACIA/UPJHN IV 300 USED ONLY IN EXTREME EMERGENCY WITH PRIOR APPROVAL RIFAMPIN 150MG CAP 150MG AA‐ANTIMICROBIAL/TB 61748001530 VERSA PHARMACEU PO 30 RIFAMPIN 300 MG CAPSULE 300 MG AA‐ANTIMICROBIAL/TB 61748001801 VERSA PHARMACEU PO 100 XIFAXAN 550 MG TABLET 550 MG AA‐ANTIMICROBIALS/DIARRHEA 65649030302 SALIX PHARMACEU PO 60 USED ONLY IN EXTREME EMERGENCY WITH PRIOR APPROVAL DAPSONE 100 MG TABLET 100 MG AA‐ANTIPARASITIC 49938010130 JACOBUS PHARM. PO 30 DAPSONE 25 MG TABLET 25 MG AA‐ANTIPARASITIC 49938010230 JACOBUS PHARM. PO 30 STROMECTOL 3MG 3MG AA‐ANTIPARASITIC 6003220 MERCK SHARP & DPO 20 ACYCLOVIR 200 MG CAPSULE 200 MG AA‐ANTIVIRAL 60429001201 GSMS, INC. PO 100 ACYCLOVIR 400 MG TABLET 400 MG AA‐ANTIVIRAL 60429030901 APOTEX PO 100 ACYCLOVIR 800 MG TABLET 800 MG AA‐ANTIVIRAL 60429031001 GSMS INC PO 100 FAMCICLOVIR 250 MG TABLET 250 MG AA‐ANTIVIRAL 60505324603 APOTEX CORP PO 30 FAMCICLOVIR 500 MG TABLET 500 MG AA‐ANTIVIRAL 60505324703 APOTEX CORP PO 30 TAMIFLU 75 MG GELCAP 75MG AA‐ANTIVIRAL 4080085 ROCHE LABS. PO 10 USED ONLY WITH PRIOR APPROVAL IF NEEDED FOR LARGE QUANTITIES ACETIC ACID 0.25% IRRIG SOL 0.25% AA‐BACTERICIDAL/FUNGICIDAL 409614309 HOSPIRA IR 1,000.00 INVANZ INJECTION 1 GM AA‐CARBAPENEMS 6384371 MERCK SHARP & D IM 1 USED ONLY WITH PRIOR APPROVAL CEFADROXIL 500 MG CAPSULE 500 MG AA‐CEPHALOSPORINS1 143994701 WEST‐WARD,INC. PO 100 CEPHALEXIN 250 MG CAPSULE 250 MG AA‐CEPHALOSPORINS1 65862001801 AUROBINDO PHARM PO 100 CEPHALEXIN 500 MG CAPSULE 500 MG AA‐CEPHALOSPORINS1 42291020950 AVKARE PO 500 Page 1 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes CEFACLOR 250 MG CAPSULE 250 MG AA‐CEPHALOSPORINS2 61442017130 CARLSBAD TECH PO 30 CEFACLOR 500 MG CAPSULE 500 MG AA‐CEPHALOSPORINS2 47781026703 ALVOGEN INC PO 30 CEFUROXIME AXETIL 250 MG TA 250 MG AA‐CEPHALOSPORINS2 16714040001 NORTHSTAR RX LL PO 20 CEFTRIAXONE 1 GM VIAL 1 GAA‐CEPHALOSPORINS3 25021010610 SAGENT PHARMACE IJ 1 CEFTRIAXONE 1GM IVPB 1G AA‐CEPHALOSPORINS3 338500241 BAXTER HEALTHCA IV 50 CEFEPIME HCL 1 GM VIAL 1G AA‐CEPHALOSPORINS4 32502112120 SAGENT PHARMACE IJ 1 CEFEPIME 1 GM IVPG 1 G/50 ML AA‐CEPHALOSPORINS4 338130141 BAXTER HEALTHCA IV 50 AVELOX 400MG IVPB 400MG AA‐FLUOROQUINOLONES 85173701 SCHERING CORP. IV 250 CIPROFLOXACN‐D5W 200 MG/100 200MG/0 AA‐FLUOROQUINOLONES 25021011482 SAGENT PHARMACE IV 100 CIPROFLOXACN‐D5W 400 MG/200 400MG/0.2L AA‐FLUOROQUINOLONES 409477702 HOSPIRA IV 200 LEVOFLOXACIN‐D5W 500 MG/100 500MG/0.1L AA‐FLUOROQUINOLONES 25021013282 SAGENT PHARMACE IV 100 LEVOFLOXACIN‐D5W 750 MG/150 750MG/.15L AA‐FLUOROQUINOLONES 63323035560 APP PHARMACEUTI IV 150 CIPROFLOXACIN HCL 250 MG TA 250 MG AA‐FLUOROQUINOLONES 42291021901 AVKARE PO 100 CIPROFLOXACIN HCL 500 MG TA 500 MG AA‐FLUOROQUINOLONES 24658025005 BLU PHARMACEUTI PO 500 LEVOFLOXACIN 250 MG TABLET 250 MG AA‐FLUOROQUINOLONES 904635161 MAJOR PHARMACEU PO 100 LEVOFLOXACIN 500 MG TABLET 500 MG AA‐FLUOROQUINOLONES 904635261 MAJOR PHARMACEU PO 100 LEVOFLOXACIN 750 MG TABLET 750 MG AA‐FLUOROQUINOLONES 904635361 MAJOR PHARMACEU PO 100 MOXIFLOXACIN HCL 400 MG TAB 400 MG AA‐FLUOROQUINOLONES 47781026830 ALVOGEN INC PO 30 EPIVIR HBV 100 MG TABLET 100MG AA‐HIV PROTEASE INH 173066200 GLAXOSMITHKLINE PO 60 USED ONLY WITH PRIOR APPROVAL ISENTRESS 400 MG TABLET 400 MG AA‐HIV PROTEASE INH 6022761 MERCK SHARP & D PO 60 USED ONLY WITH PRIOR APPROVAL NORVIR 100 MG TABLET 100 MG AA‐HIV PROTEASE INH 74333330 ABBVIE US LLC PO 30 USED ONLY WITH PRIOR APPROVAL TRUVADA TABLET 200‐300 AA‐HIV PROTEASE INH 61958070101 GILEAD SCIENCES PO 30 USED ONLY WITH PRIOR APPROVAL TACROLIMUS 1 MG CAPSULE N/F 1 MG AA‐IMMUNOSUPPRESSANT 378204601 MYLAN PO 100 USED ONLY WITH PRIOR APPROVAL CLINDAMYCIN‐D5W 600 MG/50 M 600MG/50ML AA‐LINCOSAMIDES 17478012150 AKORN INC. IV 50 CLINDAMYCIN HCL 150 MG CAPS 150 MG AA‐LINCOSAMIDES 63304069205 RANBAXY PHARMAC PO 500 CLINDAMYCIN HCL 300 MG CAPS 300 MG AA‐LINCOSAMIDES 63304069301 RANBAXY PHARMAC PO 100 AZITHROMYCIN 250 MG TABLET 250MG AA‐MACROLIDES 781149631 SANDOZ PO 30 AZITHROMYCIN 250MGTABLET 250MG AA‐MACROLIDES 781149668 SANDOZ PO 6 CLARITHROMYCIN 250 MG TABLE 250 MG AA‐MACROLIDES 68382076114 ZYDUS PHARMACEU PO 60 CLARITHROMYCIN 500 MG TABLE 500 MG AA‐MACROLIDES 68382076214 ZYDUS PHARMACEU PO 60 ERY‐TAB 250 MG TABLET EC 250MG AA‐MACROLIDES 32433812213 ARBOR PHARMACEU PO 100 PENICILLIN G 1 MILL UNIT 1 MILL AA‐PENICILLIN 338102141 BAXTER HEALTHCA IV 50 AMOX TR‐K CLV 400‐57/5 SUSP 400‐57M AA‐PENICILLIN 66685101202 SANDOZ PO 100 AMOX TR‐K CLV 500‐125 MG TA 500‐125 MG AA‐PENICILLIN 16714029601 NORTHSTAR RX LL PO 20 AMOX TR‐K CLV 875‐125 MG TA 875‐125 MG AA‐PENICILLIN 65862050320 AUROBINDO PHARM PO 20 AMOXICILLIN 250 MG CAPSULE 250 MG AA‐PENICILLIN 781202001 SANDOZ PO 100 AMOXICILLIN 250 MG/5 ML SUS 250 MG/5ML AA‐PENICILLIN 781604158 SANDOZ PO 80 AMOXICILLIN 500 MG CAPSULE 500MG AA‐PENICILLIN 781261305 SANDOZ PO 500 AMPICILLIN 250 MG CAPSULE 250 MG AA‐PENICILLIN 67253018010 QUALITEST PO 100 AMPICILLIN TR 500 MG CAPSUL 500 MG AA‐PENICILLIN 67253018110 DAVA PHARMACEUT PO 100 DICLOXACILLIN 250MG CAPSULE 250MG AA‐PENICILLIN 93312301 TEVA USA PO 100 Page 2 of 23 Ohio Department of Veteran Services Formulary List of Drugs REV. 12.16.2016 Georgetown Home Drug Name Drug Strength Specfic Ther Cls NDC Nbr Manufacturer RTE‐Drug Record Package Size Notes PENICILLIN VK 250 MG TABLET 250 MG AA‐PENICILLIN 60429014701 GSMS, INC. PO 100 PENICILLIN VK 500 MG TABLET 500 MG AA‐PENICILLIN 16714023501 NORTHSTAR RX LL PO 100 ZOSYN 2.25 GM PRE MIX‐BAG 2.25 GM AA‐PENICILLIN/BROAD‐SPECTRUM 206886001 WYETH PHARM IV 50 ZOSYN 3.375 GM PRE MIX‐BAG 3.375G/ AA‐PENICILLIN/BROAD‐SPECTRUM 206886101 WYETH PHARM IV 50 ZOSYN 4.5 GM PRE‐MIX BAG 4.5G/10 AA‐PENICILLIN/BROAD‐SPECTRUM 206886202 WYETH PHARM IV 100 SULFAMIDE 10% EYE DROPS 10% AA‐SULFONAMIDES 904272835 MAJOR PHARMACEU OP 15 SULFAMETHOXAZOLE‐TMP DS TAB 800‐160 MG AA‐SULFONAMIDES 53489014605 MUTUAL PHARM CO PO 500 SULFAMETHOXAZOLE‐TMP SUSP 200‐40M AA‐SULFONAMIDES 50383082316 HI‐TECH PHARMAC PO 473 ISONIAZID 300MG TABLET 300MG AA‐TB 555007102 BARR PO 100 MYAMBUTOL 400 MG TABLET 400 MG AA‐TB 68850001202 X‐GEN PHARMACEU PO 100 DOXYCYCLINE MONO 100 MG CAP 100 MG AA‐TETRACYCLINES 591041150 WATSON LABS PO 50 DOXYCYCLINE MONO 50 MG CAP 50 MG AA‐TETRACYCLINES 591041001 ACTAVIS PHARMA, PO 100 MINOCYCLINE 100 MG CAPSULE 100 MG AA‐TETRACYCLINES 93316753 TEVA USA PO 50 MINOCYCLINE 50MG CAPSULE 50MG AA‐TETRACYCLINES 93316501 TEVA USA PO 100 DONEPEZIL HCL 10 MG TABLET 10 MG ALZHEIMERS/DEMENTIA 33342002815 MACLEODS PHARMA PO 500 DONEPEZIL HCL 5 MG TABLET 5 MG ALZHEIMERS/DEMENTIA 33342002715 MACLEODS PHARMA PO 500 GALANTAMINE ER 16 MG CAPSUL 16 MG ALZHEIMERS/DEMENTIA 10147089203 PATRIOT PHARMAC PO 30 GALANTAMINE ER 24 MG CAPSUL 24 MG ALZHEIMERS/DEMENTIA 10147089303 PATRIOT PHARMAC PO 30 GALANTAMINE ER 8 MG CAPSULE 8 MG ALZHEIMERS/DEMENTIA 591349630 ACTAVIS PHARMA, PO 30 GALANTAMINE HBR 12 MG TABLE 12 MG ALZHEIMERS/DEMENTIA 10147088306 PATRIOT PHARMAC PO 60 GALANTAMINE HBR 4 MG TABLET 4 MG ALZHEIMERS/DEMENTIA 10147088106 PATRIOT PHARMAC PO 60 GALANTAMINE HBR 8 MG TABLET 8 MG ALZHEIMERS/DEMENTIA 10147088206 PATRIOT PHARMAC PO 60 MEMANTINE HCL 10 MG TABLET 10 MG ALZHEIMERS/DEMENTIA 47335032286 SUN PHARMACEUTI PO 60 MEMANTINE HCL 5 MG TABLET 5 MG ALZHEIMERS/DEMENTIA 53746017360 AMNEAL PHARMACE PO 60 PYRIDOSTIGMINE BR 60 MG TAB 60 MG ALZHEIMERS/DEMENTIA 68682030210 OCEANSIDE PHARM PO 100 EPIPEN 0.3 MG AUTO‐INJECTOR 0.3MG/0 ANAPHYLAXIS 49502050002 DEY LABS.
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