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Outpatient Medication Formulary Updated February 2021

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Outpatient Medication Formulary Updated February 2021 Page 1 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021 Generic Name Brand Name Limitations/Restrictions Acetaminophen 160mg/5mL oral suspension Tylenol Age Limitation Acetaminophen 120mg suppository Tylenol Usage Restriction Acetaminophen 650mg suppository Tylenol Acetaminophen 325mg tablet Tylenol Quantity Limitation Acetaminophen 120mg-Codeine 12mg/5mL elixir Tylenol with Codeine Age Limitation Acetaminophen 300mg-Codeine 30mg tablet Tylenol with Codeine Age Limitation Acetazolamide 250mg tablet Diamox Acetazolamide 500mg capsule, extended release Diamox Acetic Acid 2% otic solution VoSol Acetylcysteine 10% solution Acetadote Acetylcysteine 20% solution Mucomist Acyclovir 200mg/5mL oral suspension Zovirax Acyclovir 400mg tablet Zovirax Acyclovir 800mg tablet Zovirax Aerochamber (Adult) Aerochamber (Pediatric) Albendazole 200mg tablet Albenza Usage Restriction Albuterol 0.63mg/3mL (0.021%) inhalation solution Accuneb Albuterol 1.25mg/3mL (0.042%) inhalation solution Accuneb Albuterol 2.5mg/3mL (0.083%) inhalation solution Accuneb Albuterol 2mg/5mL syrup Proventil Albuterol 90mcg/inhalation HFA inhaler ProAir Alendronate 10mg tablet Fosamax Alendronate 70mg tablet Fosamax Allopurinol 100mg tablet Zyloprim Allopurinol 300mg tablet Zyloprim Aluminum Acetate topical powder Domeboro Aluminum Hydroxide 320mg/5mL suspension Antacid gel Usage Restriction Amantadine 100mg capsule Symmetrel Amerigel Wound Dressing gel Amerigel Usage Restriction Aminocaproic Acid 500mg tablet Amicar Amiodarone 200mg tablet Cordarone Amitriptyline 10mg tablet Elavil Amitriptyline 25mg tablet Elavil Amitriptyline 75mg tablet Elavil Amlodipine 5mg tablet Norvasc Amlodipine 10mg tablet Norvasc Amoxicillin 250mg capsule Amoxil Amoxicillin 500mg capsule Amoxil Amoxicillin 250mg/5mL oral suspension Amoxil Amoxicillin 400mg/5mL oral suspension Amoxil Amoxicillin 600mg-Clavulanate 42.9mg/5mL suspension Augmentin Usage Restriction Amoxicillin 875mg-Clavulanate 125mg tablet Augmentin Usage Restriction Anastrozole 1mg tablet Arimidex Apixaban 2.5mg tablet Eliquis Apixaban 5mg tablet Eliquis Apraclonidine 0.5% ophthalmic solution Usage Restriction Aripiprazole 2mg tablet Abilify Aripiprazole 5mg tablet Abilify Aripiprazole 10mg tablet Abilify Aripiprazole 15mg tablet Abilify Aripiprazole 20mg tablet Abilify Aripiprazole 30mg tablet Abilify Aripiprazole 300mg injection kit, extended release Abilify Aripiprazole 400mg injection kit, extended release Abilify Asenapine 5mg sublingual tablet Saphris Usage Restriction Asenapine 10mg sublingual tablet Saphris Usage Restriction Aspirin 25mg-Dipyridamole 200mg capsule Aggrenox * Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 2 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021 Generic Name Brand Name Limitations/Restrictions Aspirin 81mg chewable tablet ASA Usage Restriction Aspirin 81mg tablet, enteric coated ASA Aspirin 325mg tablet, enteric coated ASA Atenolol 25mg tablet Tenormin Atenolol 50mg tablet Tenormin Atenolol 100mg tablet Tenormin Atomoxetine 10mg capsule Strattera Atomoxetine 18mg capsule Strattera Atomoxetine 25mg capsule Strattera Atomoxetine 40mg capsule Strattera Atomoxetine 60mg capsule Strattera Atomoxetine 80mg capsule Strattera Atomoxetine 100mg capsule Strattera Atorvastatin 10mg tablet Lipitor Atorvastatin 20mg tablet Lipitor Atorvastatin 40mg tablet Lipitor Atorvastatin 80mg tablet Lipitor Atropine 1% ophthalmic ointment Atropine 1% ophthalmic solution Azathioprine 50mg tablet Imuran Azithromycin 1 gram packet Z-Max Usage Restriction Azithromycin 100mg/5mL oral suspension Zithromax Usage Restriction Azithromycin 200mg/5mL oral suspension Zithromax Usage Restriction Azithromycin 250mg tablet Zithromax, Z-Pack Azithromycin 500mg tablet Zithromax Bacitracin 500 units/g ophthalmic ointment Bacitracin topical ointment Baclofen 10mg tablet Lioresal Baloxavir 20mg tablet (40mg dose) Xofluza Usage Restriction Baloxavir 40mg tablet (80mg dose) Xofluza Usage Restriction Balsam Peru-Castor Oil-Trypsin ointment Xenaderm Bamlanivimab 700mg/20mL injection Usage Restriction Benzonatate 100mg capsule Tessalon Perles Age Limitation Benzoyl Peroxide 5% water based gel Benzamycin Benztropine 0.5mg tablet Cogentin Benztropine 1mg tablet Cogentin Betamethasone 0.1% cream Betamethasone 6mg/mL injection Celestone Soluspan Betamethasone 0.05%-Clotrimazole 1% cream Lotrisone Betaxolol 0.25% ophthalmic suspension Betoptic Bethanechol 25mg tablet Urecholine Bisacodyl 5mg tablet, enteric coated Dulcolax Bisacodyl 10mg suppository Dulcolax Bowel Cleansing Kit Evac-Q-Kwik Brimonidine 0.15% ophthalmic solution Alphagan P Brivaracetam 10mg/mL oral solution Briviact Usage Restriction Brivaracetam 10mg tablet Briviact Usage Restriction Brivaracetam 25mg tablet Briviact Usage Restriction Brivaracetam 50mg tablet Briviact Usage Restriction Brivaracetam 75mg tablet Briviact Usage Restriction Brivaracetam 100mg tablet Briviact Usage Restriction Bromocriptine 2.5mg tablet Parlodel Usage Restriction Budesonide 0.25mg/2mL inhalation solution Pulmicort Age Limitation Budesonide 0.5mg/2mL inhalation solution Pulmicrot Age Limitation Bumetanide 0.5mg tablet Bumex Usage Restriction Bumetanide 1mg tablet Bumex Usage Restriction Bumetanide 2mg tablet Bumex Usage Restriction Bupivacaine 0.5% injection Marcaine * Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 3 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021 Generic Name Brand Name Limitations/Restrictions Buprenorphine 2mg tablet, sublingual Subutex Buprenorphine 8mg tablet, sublingual Subutex Buprenorphine 100mg/0.5mL prefilled syringe Sublocade Usage Restrictions Buprenorphine 300mg/1.5mL prefilled syringe Sublocade Usage Restrictions Buprenorphine 2mg-Naloxone 0.5mg film, sublingual Suboxone Buprenorphine 4mg-Naloxone 1mg film, sublingual Suboxone Buprenorphine 8mg-Naloxone 2mg film, sublingual Suboxone Buprenorphine 12mg-Naloxone 3mg film, sublingual Suboxone Bupropion 100mg tablet Wellbutrin Bupropion 150mg tablet, sustained release Wellbutrin SR Bupropion 150mg tablet, extended release Wellbutrin XL Bupropion 300mg tablet, extended release Wellbutrin XL Buspirone 15mg tablet Buspar Calcitonin 200units/inhalation nasal spray Miacalcin Calcitriol 0.25mcg capsule Rocaltrol Usage Restriction Calcium Acetate 667mg gelcapsule PhosLo Usage Restriction Calcium Citrate 950mg tablet Caltrate Usage Restriction Canagliflozin 100mg tablet Invokana Canagliflozin 300mg tablet Invokana Canagliflozin 50mg-Metformin 500mg tablet, extended release Invokamet Canagliflozin 50mg-Metformin 1000mg tablet, extended release Invokamet Canagliflozin 150mg-Metformin 500mg tablet, extended release Invokamet Canagliflozin 150mg-Metformin 1000mg tablet, extended release Invokamet Carbachol 0.01% intraocular solution Miostat Usage Restriction Carbamazepine 100mg chewable tablet Tegretol Carbamazepine 200mg tablet Tegretol Carbidopa 10mg-Levodopa 100mg tablet Sinemet Carbidopa 25mg-Levodopa 100mg tablet Sinemet Carbidopa 25mg-Levodopa 250mg tablet Sinemet Carboxymethylcellulose 0.5% ophthalmic solution Refresh Plus Carvedilol 3.125mg tablet Coreg Carvedilol 6.25mg tablet Coreg Carvedilol 12.5mg tablet Coreg Carvedilol 25mg tablet Coreg Casirivimab 1200mg-Imdevimab 1200mg injection Usage Restriction Cefdinir 300mg capsule Omnicef Cefdinir 250mg/5mL oral suspension Omnicef Cefprozil 250mg/5mL oral suspension Cefzil Usage Restriction Ceftaroline 400mg injection Teflaro Ceftaroline 600mg injection Teflaro Cefuroxime 250mg tablet Ceftin Usage Restriction Cephalexin 250mg capsule Keflex Cephalexin 500mg capsule Keflex Cephalexin 250mg/5mL oral suspension Keflex Cetirizine 5mg/5mL oral solution Zyrtec Cetirizine 10mg tablet Zyrtec Chlorambucil 2mg tablet Leukaran Usage Restriction Chlorhexidine Gluconate 0.12% oral rinse Peridex Usage Restriction Chlorpromazine 25mg tablet Thorazine Chlorpromazine 50mg tablet Thorazine Chlorpromazine 100mg tablet Thorazine Chlorthalidone 25mg tablet Cholecalciferol 400units/mL oral liquid Vitamin D3 Choice DM Cholestyramine 4 gram powder packet Questran Ciclopirox 8% topical nail lacquer Penlac Cimetidine 300mg/5mL oral solution Tagamet Ciprofloxacin 0.3% ophthalmic solution Cipro Ciprofloxacin 500mg tablet Cipro * Medications in RED font are controlled substances * Contact a Cherokee Nation provider or pharmacist for details of medication limitations and restrictions Page 4 of 17 Cherokee Nation Outpatient Medication Formulary Updated February 2021 Generic Name Brand Name Limitations/Restrictions Ciprofloxacin 0.3%-Dexamethasone 0.1% otic suspension CiproDex Citalopram 10mg tablet Celexa Citalopram 20mg tablet Celexa Citalopram 40mg tablet Celexa Clarithromycin 500mg tablet Biaxin Usage Restriction Clindamycin 150mg capsule Cleocin Clindamycin 300mg capsule Cleocin Clindamycin 75mg/5mL oral solution Cleocin Clindamycin 1% topical pledget Cleocin T Clindamycin 2% vaginal cream Cleocin Clobazam 10mg tablet Onfi Clobazam 20mg tablet Onfi Clobetasol Propionate 0.05% cream Temovate Usage Restriction Clobetasol Propionate 0.05% topical solution Temovate Usage Restriction Clomiphene Citrate 50mg tablet Serophene Clonazepam 0.5mg tablet Klonopin Clonazepam 1mg tablet Klonopin Clonidine 0.1mg tablet Catapres Clonidine 0.2mg tablet Catapres Clopidogrel 75mg tablet Plavix Clotrimazole 1% cream Lotrimin
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