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HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY ACAMPROSATE 333MG CAMPRAL 333MG WITHDRAWAL AGENT ACETAZOLAMIDE 125MG TAB DIAMOX 125MG TAB Y CARBONIC ANHYDRASE INHIBITOR ACETAZOLAMIDE 250MG TAB DIAMOX 250MG TAB Y CARBONIC ANHYDRASE INHIBITOR ACETAZOLAMIDE ER 500MG CAP DIAMOX SEQUELS 500MG CAP Y CARBONIC ANHYDRASE INHIBITOR ACETIC ACID/ALUMINUM ACET 2% OTIC SOL ANTI-INFECTIVES, OTIC ACYCLOVIR 200MG CAP ZOVIRAX 200MG CAP Y ANTIVIRAL SYSTEMIC ACYCLOVIR 400MG TAB ZOVIRAX 400MG TAB Y ANTIVIRAL SYSTEMIC ACYCLOVIR 5% OINTMENT ZOVIRAX 5% OINT Y 12 MAX 30G/30 DAYS ANTIVIRAL, TOPICAL ACYCLOVIR 800MG TAB ZOVIRAX 800MG TAB Y ANTIVIRAL SYSTEMIC ALBENDAZOLE 200MG TAB ALBENZA 200MG TAB PCC RXS ONLY--REFERRALS REQUIRE PA ALBUTEROL 0.083% [2.5MG/3ML] SOL FOR NEB Y BETA , INHALED ALBUTEROL 0.63MG/3ML SOL FOR NEB Y BETA AGONIST, INHALED ALBUTEROL 1.25MG/3ML SOL FOR NEB Y BETA AGONIST, INHALED ALBUTEROL 2MG TAB Y BETA AGONIST ALBUTEROL 2MG/5ML ORAL SOL Y BETA AGONIST ALBUTEROL 4MG TAB BETA AGONIST ALBUTEROL HFA 90MCG/ACT INH MAX 2 INHS/30 DAYS SYMPATHOMIMETIC ALBUTEROL 2.5MG/IPRATROPIUM 0.5MG DUONEB Y BETA AGONIST, INHALED 70% ISOPROPYL PREP PADS Y DIABETIC SUPPLIES ALENDRONATE 35MG WEEKLY TAB FOSAMAX 35MG WEEKLY TAB Y MAX 4 TABS/28 DAYS MAX 12 TABS/84 DAYS ALENDRONATE 70MG WEEKLY TAB FOSAMAX 70MG WEEKLY TAB Y MAX 4 TABS/28 DAYS MAX 12 TABS/84 DAYS BISPHOSPHONATE ALLOPURINOL 100MG TAB ZYLOPRIM 100MG TAB Y XANTHINE OXIDASE INHIBITOR ALLOPURINOL 300MG TAB ZYLOPRIM 300MG TAB Y XANTHINE OXIDASE INHIBITOR ALPRAZOLAM 0.25MG TAB XANAX 0.25MG TAB Y 7 MAX 90 TABS/30 DAYS/ALL STRENGTHS SAME CLASS ALPRAZOLAM 0.5MG TAB XANAX 0.5MG TAB Y 7 MAX 90 TABS/30 DAYS/ALL STRENGTHS SAME BENZODIAZEPINE ALPRAZOLAM 1MG TAB XANAX 1MG TAB Y 7 MAX 90 TABS/30 DAYS/ALL STRENGTHS SAME DRUG CLASS BENZODIAZEPINE ALPRAZOLAM 2MG TAB XANAX 2MG TAB Y 7 MAX 90 TABS/30 DAYS/ALL STRENGTHS SAME DRUG CLASS BENZODIAZEPINE AMANTADINE 100MG CAP SYMMETREL 100MG CAP Y 1 ANTIVIRAL SYSTEMIC 200MG TAB CORDARONE 200MG TAB Y 100MG TAB ELAVIL 100MG TAB Y 12 AMITRIPTYLINE 10MG TAB ELAVIL 10MG TAB Y 12 AMITRIPTYLINE 150MG TAB ELAVIL 150MG TAB Y 12 TRICYCLIC ANTIDEPRESSANT AMITRIPTYLINE 25MG TAB ELAVIL 25MG TAB Y 12 TRICYCLIC ANTIDEPRESSANT AMITRIPTYLINE 50MG TAB ELAVIL 50MG TAB Y 12 TRICYCLIC ANTIDEPRESSANT AMITRIPTYLINE 75MG TAB ELAVIL 75 MG TAB Y 12 TRICYCLIC ANTIDEPRESSANT 10MG TAB NORVASC 10MG TAB Y CHANNEL BLOCKING AGENT AMLODIPINE 2.5MG TAB NORVASC 2.5MG TAB Y BLOCKING AGENT AMLODIPINE 5MG TAB NORVASC 5MG TAB Y CALCIUM CHANNEL BLOCKING AGENT AMLODIPINE/BENAZEPRIL 10-20MG CAP LOTREL 10-20MG CAP Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR/COMBO AMLODIPINE/BENAZEPRIL 10-40MG CAP LOTREL 10-40MG CAP Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR/COMBO AMLODIPINE/BENAZEPRIL 2.5-10MG CAP LOTREL 2.5-10MG CAP Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR/COMBO AMLODIPINE/BENAZEPRIL 5-10MG CAP LOTREL 5-10MG CAP Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR/COMBO AMLODIPINE/BENAZEPRIL 5-20MG CAP LOTREL 5-20MG CAP Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR/COMBO AMLODIPINE/BENAZEPRIL 5-40MG CAP LOTREL 5-40MG CAP Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR/COMBO AMLODIPINE/OLMESARTAN 10MG-20MG TAB AZOR 10MG-20MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO AMLODIPINE/OLMESARTAN 10MG-40MG TAB AZOR 10MG-40MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO AMLODIPINE/OLMESARTAN 5MG-20MG TAB AZOR 5MG-20MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO AMLODIPINE/OLMESARTAN 5MG-40MG TAB AZOR 5MG-40MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO AMOXICILLIN 250MG CAP AMOXIL 250MG CAP Y PENICILLIN SYSTEMIC AMOXICILLIN 250MG/5ML ORAL SUSP AMOXIL 250MG/5ML SUSP Y PENICILLIN SYSTEMIC AMOXICILLIN 400MG/5ML ORAL SUSP AMOXIL 400MG/5ML SUSP Y PENICILLIN SYSTEMIC AMOXICILLIN 500MG CAP AMOXIL 500MG CAP Y PENICILLIN SYSTEMIC AMOXICILLIN 875MG TAB AMOXIL 875MG TAB Y PENICILLIN SYSTEMIC AMOXICILLIN/CLAV 200/28.5MG/5ML ORAL SUSP AUGMENTIN 200MG SUSP Y PENICILLIN SYSTEMIC AMOXICILLIN/CLAV 400/57MG/5ML ORAL SUSP AUGMENTIN 400MG SUSP Y PENICILLIN SYSTEMIC AMOXICILLIN/CLAV 500/125MG TAB AUGMENTIN 500MG TAB Y PENICILLIN SYSTEMIC AMOXICILLIN/CLAV 600/42.9MG/5ML ORAL SUSP AUGMENTIN ES 600MG SUSP Y PENICILLIN SYSTEMIC FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 1 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY AMOXICILLIN/CLAV 875/125MG TAB AUGMENTIN 875MG TAB Y PENICILLIN SYSTEMIC AMPHETAMINE SALT COMBO 10MG TAB ADDERALL 10MG TAB 3 MAX 60MG TOTAL OF AMPHETAMINE PER DAY/ MAX 30 DAYS/RX CNS ADHD AMPHETAMINE SALT COMBO 20MG TAB ADDERALL 20MG TAB 3 MAX 60MG TOTAL OF AMPHETAMINE PER DAY/ MAX 30 DAYS/RX CNS STIMULANT ADHD AMPHETAMINE SALT COMBO 30MG TAB ADDERALL 30MG TAB 3 MAX 60MG TOTAL OF AMPHETAMINE PER DAY/ MAX 30 DAYS/RX CNS STIMULANT ADHD AMPHETAMINE SALT COMBO 5MG TAB ADDERALL 5MG TAB 3 MAX 60MG TOTAL OF AMPHETAMINE PER DAY/ MAX 30 DAYS/RX CNS STIMULANT ADHD AMPHETAMINE SALT COMBO XR 10MG CAP ADDERALL XR 10MG CAP 6 MAX 90 CAPS/ 30 DAYS/RX CNS STIMULANT ADHD AMPHETAMINE SALT COMBO XR 20MG CAP ADDERALL XR 20MG CAP 6 MAX 90 CAPS/ 30 DAYS/RX CNS STIMULANT ADHD AMPHETAMINE SALT COMBO XR 30MG CAP ADDERALL XR 30MG CAP 6 MAX 60 CAPS/ 30 DAYS/RX CNS STIMULANT ADHD AMPHETAMINE SALT COMBO XR 5MG CAP ADDERALL XR 5MG CAP 6 MAX 90 CAPS/ 30 DAYS/RX CNS STIMULANT ADHD AMPICILLIN 500MG CAP PRINCIPIEN 500MG CAP Y PENICILLIN SYSTEMIC ANASTROZOLE 1MG TAB ARIMIDEX 1MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTINEOPLASTIC/AROMATASE INHIBITOR 10MG TAB ABILIFY 10MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS , ATYPICAL ARIPIPRAZOLE 15MG TAB ABILIFY 15MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL ARIPIPRAZOLE 20MG TAB ABILIFY 20MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL ARIPIPRAZOLE 30MG TAB ABILIFY 30MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL ARIPIPRAZOLE 5MG TAB ABILIFY 5MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL ARMOUR 120MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE ARMOUR THYROID 15MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE ARMOUR THYROID 180MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE ARMOUR THYROID 240MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE ARMOUR THYROID 300MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE ARMOUR THYROID 30MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE ARMOUR THYROID 60MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE ARMOUR THYROID 90MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE ASMANEX 110MCG TWISTHALER POWD INH Y 4 MAX 1 INH/30 DAYS MAX 3 INH/90 DAYS , INHALED ASMANEX 220MCG TWISTHALER POWD INH Y 4 MAX 1 INH/30 DAYS MAX 3 INH/90 DAYS CORTICOSTEROID, INHALED 100MG TAB TENORMIN 100MG TAB Y ATENOLOL 25MG TAB TENORMIN 25MG TAB Y BETA BLOCKER ATENOLOL 50MG TAB TENORMIN 50MG TAB Y BETA BLOCKER 100MG CAP STRATTERA 100MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, ADHD SNRI ATOMOXETINE 10MG CAP STRATTERA 10MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, ADHD SNRI ATOMOXETINE 18MG CAP STRATTERA 18MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, ADHD SNRI ATOMOXETINE 25MG CAP STRATTERA 25MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, ADHD SNRI ATOMOXETINE 40MG CAP STRATTERA 40MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, ADHD SNRI ATOMOXETINE 60MG CAP STRATTERA 60MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, ADHD SNRI ATOMOXETINE 80MG CAP STRATTERA 80MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, ADHD SNRI ATORVASTATIN 10MG TAB LIPITOR 10MG TAB Y ANTILIPEMIC AGENT/ ATORVASTATIN 20MG TAB LIPITOR 20MG TAB Y ANTILIPEMIC AGENT/STATIN ATORVASTATIN 40MG TAB LIPITOR 40MG TAB Y ANTILIPEMIC AGENT/STATIN ATORVASTATIN 80MG TAB LIPITOR 80MG TAB Y ANTILIPEMIC AGENT/STATIN 1% OPH SOL ISOPTO ATROPINE 1% OPH SOL Y OPHTHALMIC, MYDRIATIC ATROVENT 17MCG/ACT HFA INH Y MAX 2 INH/40 DAYS MAX 5 INH/100 DAYS ANTICHOLINERGIC, INHALED AZATHIOPRINE 50MG TAB IMURAN 50MG TAB Y IMMUNOSUPRESSANT AZELASTINE 0.05% OPH SOL OPTIVAR 0.05% OPH SOL Y MAX 1 UNIT/30 DAYS MAX 3 UNITS/90 DAYS OPHTHALMIC AZITHROMYCIN 100MG/5ML SUSP ZITHROMAX 100MG/5ML SUSP Y MACROLIDE SYSTEMIC AZITHROMYCIN 200MG/5ML SUSP ZITHROMAX 200MG/5ML SUSP Y MACROLIDE SYSTEMIC AZITHROMYCIN 250MG TAB ZITHROMAX 250MG TAB Y MACROLIDE SYSTEMIC AZITHROMYCIN 600MG TAB ZITHROMAX 600MG TAB Y MAX 8 TABS/28 DAYS MACROLIDE SYSTEMIC BACITRACIN 500 UNITS-POLYMIX-B 10000U OPH OINT AK-POLY-BAC OPH OINT Y MAX 3.5G/DISPENSE OPHTHALMIC, 10MG TAB LIORESAL 10MG TAB Y RELAXANT BACLOFEN 20MG TAB LIORESAL 20MG TAB Y SKELETAL BENAZEPRIL 10MG TAB LOTENSIN 10MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR BENAZEPRIL 20MG TAB LOTENSIN 20MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR BENAZEPRIL 40MG TAB LOTENSIN 40MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR BENAZEPRIL 5MG TAB LOTENSIN 5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR BENAZEPRIL/HCTZ 5MG/6.25MG LOTENSIN HCT 5MG TAB - 6.25MG Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR BENAZEPRIL/HCTZ 10MG/12.5MG LOTENSIN HCT 10MG TAB - 12.5MG Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 2 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY BENAZEPRIL/HCTZ 20MG/12.5MG LOTENSIN HCT 20MG TAB - 12.5MG Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR BENAZEPRIL/HCTZ 20MG/25MG LOTENSIN HCT 20MG TAB - 25MG Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ACE INHIBITOR BENZONATATE 100MG CAP TESSALON PERLES 100MG CAP Y ANTITUSSIVE BENZONATATE 200MG CAP TESSALON PERLES 200MG CAP Y ANTITUSSIVE BENZTROPINE MESYLATE 0.5MG TAB COGENTIN 0.5MG TAB Y 3 ANTIPARKINSON AGENT BENZTROPINE MESYLATE 1MG TAB COGENTIN 1MG TAB Y 3 ANTIPARKINSON AGENT BENZTROPINE MESYLATE 2MG TAB COGENTIN 2MG TAB Y 3 ANTIPARKINSON AGENT BETAMETHASONE VALERATE 0.1% CRM VALISONE 0.1% CRM Y CORTICOSTEROID, TOPICAL BETAMETHASONE VALERATE 0.1% LOTION VALISONE 0.1% LOTION Y CORTICOSTEROID, TOPICAL BETAMETHASONE VALERATE 0.1% OINT VALISONE 0.1% OINT Y CORTICOSTEROID, TOPICAL BETAMETHASONE/CLOTRIM 0.05/1% CRM LOTRISONE 0.05/1% CRM Y CORTICOSTEROID/, TOPICAL BETHANECHOL 10MG TAB URECHOLINE 10MG TAB Y GU AGONIST BETHANECHOL 25MG TAB URECHOLINE 25MG TAB Y GU CHOLINERGIC AGONIST BETHANECHOL 50MG TAB URECHOLINE 50MG TAB Y GU CHOLINERGIC AGONIST BETHANECHOL 5MG TAB URECHOLINE 5MG TAB Y GU CHOLINERGIC AGONIST BICALUTAMIDE 50MG TAB CASODEX 50MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS PROSTATIC CARCINOMA AGENT 0.2% OPH SOL Y MAX 10ML/30 DAYS MAX 30ML/90 DAYS OPHTHALMIC, GLAUCOMA AGENT BRIMONIDINE / 0.2%-0.5% 5ML COMBIGAN 5ML Y OPHTHALMIC, GLAUCOMA AGENT BRIMONIDINE /TIMOLOL 0.2%-0.5% 10ML COMBIGAN 10ML Y OPHTHALMIC, GLAUCOMA AGENT BRIMONIDINE /TIMOLOL 0.2%-0.5% 15ML COMBIGAN 15ML Y OPHTHALMIC, GLAUCOMA AGENT BROMOCRIPTINE MESYLATE 2.5MG TAB PARLODEL 2.5MG TAB Y 11 ANTIPARKINSON AGENT BROMOCRIPTINE MESYLATE 5MG CAP PARLODEL 5MG CAP Y 11 ANTIPARKINSON AGENT 0.5MG TAB BUMEX 0.5MG TAB Y LOOP BUMETANIDE 1MG TAB BUMEX 1MG TAB Y LOOP BUMETANIDE 2MG TAB BUMEX 2MG TAB Y LOOP BUPROPION 100MG TAB WELLBUTRIN 100MG TAB Y 6 ANTIDEPRESSANT, NDRI BUPROPION 75MG TAB WELLBUTRIN 75MG TAB Y 6 ANTIDEPRESSANT, NDRI BUPROPION SR 100MG TAB WELLBUTRIN SR 10MG TAB Y 6 MAX 60 TABS/30 DAYS MAX 180 TABS/90 DAYS ANTIDEPRESSANT, NDRI BUPROPION SR 150MG TAB WELLBUTRIN SR 150MG TAB Y 6 MAX 60 TABS/30 DAYS MAX 180 TABS/90 DAYS ANTIDEPRESSANT, NDRI BUPROPION SR 200MG TAB WELLBUTRIN SR 200MG TAB Y 6 MAX 60 TABS/30 DAYS MAX 180 TABS/90 DAYS ANTIDEPRESSANT, NDRI BUPROPION XL 150MG TAB WELLBUTRIN XL 150MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIDEPRESSANT, NDRI BUPROPION XL 300MG TAB WELLBUTRIN XL 300MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIDEPRESSANT, NDRI 10MG TAB BUSPAR 10MG TAB Y ANTIANXIETY, MISCELLANEOUS BUSPIRONE 15MG TAB BUSPAR 15MG TAB Y ANTIANXIETY, MISCELLANEOUS BUSPIRONE 5MG TAB BUSPAR 5MG TAB Y ANTIANXIETY, MISCELLANEOUS BUTALBITAL/ACETAMIN/CAFF 50/325/40MG TAB FIORICET TAB Y MAX 120 TABS/365 DAYS /ANTI-MIGRANE BYETTA 250MCG/ML 2.4ML PACK INCRETIN MIMETIC, GLP-1 AGONIST CABERGOLINE 0.5MG DOSTINEX 0.5MG HORMONES AND HORMONE MODIFIERS CALCITRIOL 0.25MCG CAP ROCALTROL 0.25MCG CAP Y CALCITRIOL 0.5MCG CAP ROCALTROL 0.5MCG CAP Y VITAMIN CALCIUM ACETATE 667MG GEL CAP PHOSLO 667MG GELCAP Y PHOSPHATE BINDER CANASA 100MG SUPP 5-ASA DERIVATIVE, RECTAL 100MG CHEW TAB TEGRETOL 100MG CHEW TAB Y 6 , MISCELLANEOUS CARBAMAZEPINE 200MG TAB TEGRETOL 200MG TAB Y 6 ANTICONVULSANT, MISCELLANEOUS CARBAMAZEPINE ER 100MG TAB TEGRETOL XR 100MG TAB Y 6 ANTICONVULSANT, MISCELLANEOUS CARBAMAZEPINE ER 200MG TAB TEGRETOL XR 200MG TAB Y 6 ANTICONVULSANT, MISCELLANEOUS CARBAMAZEPINE ER 300MG TAB TEGRETOL XR 400MG TAB Y 6 ANTICONVULSANT, MISCELLANEOUS CARBAMAZEPINE ER 100MG CAP CARBATROL 100MG CAP Y 6 ANTICONVULSANT, MISCELLANEOUS CARBAMAZEPINE ER 200MG CAP CARBATROL 200MG CAP Y 6 ANTICONVULSANT, MISCELLANEOUS CARBAMAZEPINE ER 300MG CAP CARBATROL 300MG CAP Y 6 ANTICONVULSANT, MISCELLANEOUS CARBAMAZEPINE SUSP 100MG/5ML TEGRETOL SUSP 100MG/5ML ANTICONVULSANT, MISCELLANEOUS CARBIDOPA/LEVODOPA 10/100MG TAB SINEMET 10/100MG TAB Y 18 ANTIPARKINSON AGENT CARBIDOPA/LEVODOPA 25/100MG TAB SINEMET 25/100MG TAB Y 18 ANTIPARKINSON AGENT CARBIDOPA/LEVODOPA 25/250MG TAB SINEMET 25/250MG TAB Y 18 ANTIPARKINSON AGENT CARBIDOPA/LEVODOPA ER 25/100MG TAB SINEMENT CR 25/100MG TAB Y 18 ANTIPARKINSON AGENT CARBIDOPA/LEVODOPA ER 50/200MG TAB SINEMET CR 50/200MG TAB Y 18 ANTIPARKINSON AGENT 12.5MG TAB COREG 12.5MG TAB Y ALPHA/BETA BLOCKER FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 3 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY CARVEDILOL 25MG TAB COREG 25MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER CARVEDILOL 3.125MG TAB COREG 3.125MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER CARVEDILOL 6.25MG TAB COREG 6.25MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER CARVEDILOL CR 10MG TAB COREG CR 10MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER CARVEDILOL CR 20MG TAB COREG CR 20MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER CARVEDILOL CR 40MG TAB COREG CR 40MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER CARVEDILOL CR 80MG TAB COREG CR 80MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER CATAPRES-TTS 1 PATCH 0.1MG/24HR PATCH Y MAX 4 PATCHES/28 DAYS MAX 12 PATCHES/84 DAYS ALPHA CATAPRES-TTS 2 PATCH CLONIDINE 0.2MG/24HR PATCH Y MAX 4 PATCHES/28 DAYS MAX 12 PATCHES/84 DAYS ALPHA ADRENERGIC AGONIST CATAPRES-TTS 3 PATCH CLONIDINE 0.3MG/24HR PATCH Y MAX 4 PATCHES/28 DAYS MAX 12 PATCHES/84 DAYS ALPHA ADRENERGIC AGONIST CEFACLOR 250MG CAP CECLOR 250MG CAP Y CEPHALOSPORIN 2ND GENERATION CEFACLOR 250MG/5ML SUSP CECLOR 250MG/5ML SUSP Y CEPHALOSPORIN 2ND GENERATION CEFACLOR 500MG CAP CECLOR 500MG CAP Y CEPHALOSPORIN 2ND GENERATION CEFADROXIL 500MG CAP DURICEF 500MG CAP Y CEPHALOSPORIN 1ST GENERATION CEFADROXIL 500MG/5ML MONOHYDRATE ORAL SUSP DURICEF 500MG/5ML ORAL SUSP Y CEPHALOSPORIN 1ST GENERATION CEFDINIR 125MG/5ML SUSP OMNICEF 125MG/5ML Y CEPHALOSPORIN 3RD GENERATION CEFDINIR 250MG/5ML SUSP OMNICEF 250MG/5ML Y CEPHALOSPORIN 3RD GENERATION CEFDINIR 300MG CAP OMNICEF 300MG CAP Y CEPHALOSPORIN 3RD GENERATION CEFUROXIME AXETIL 250MG TAB CEFTIN 250MG TAB Y CEPHALOSPORIN 2ND GENERATION CEFUROXIME AXETIL 250MG/5ML ORAL SUSP CEFTIN 250MG/5ML ORAL SUSP Y CEPHALOSPORIN 2ND GENERATION CEFUROXIME AXETIL 500MG TAB CEFTIN 500MG TAB Y CEPHALOSPORIN 2ND GENERATION CEPHALEXIN 125MG/5ML ORAL SUSP KEFLEX SUSP 125MG/5ML Y CEPHALOSPORIN 1ST GENERATION CEPHALEXIN 250MG CAP KEFLEX 250MG CAP Y CEPHALOSPORIN 1ST GENERATION CEPHALEXIN 250MG/5ML ORAL SUSP KEFLEX SUSP 250MG/5ML Y CEPHALOSPORIN 1ST GENERATION CEPHALEXIN 500MG CAP KEFLEX 500MG CAP Y CEPHALOSPORIN 1ST GENERATION CHANTIX 0.5MG TAB 18 PCC RXS ONLY--NO REFERRALS-QTY AND REF PER PROTOCOL WITHDRAWAL AGENT CHANTIX 1MG TAB 18 PCC RXS ONLY--NO REFERRALS-QTY AND REF PER PROTOCOL WITHDRAWAL AGENT CHANTIX CONTINUATION PACK 18 PCC RXS ONLY--NO REFERRALS-QTY AND REF PER PROTOCOL WITHDRAWAL AGENT CHANTIX STARTER PACK 18 PCC RXS ONLY--NO REFERRALS-QTY AND REF PER PROTOCOL WITHDRAWAL AGENT CHLORHEXIDINE 0.12% ORAL RINSE PERIDEX 0.12% ORAL RINSE Y MAX 480ML/30 DAYS ANTIBIOTIC, ORAL RINSE 100MG TAB THORAZINE 100MG TAB Y 18 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE CHLORPROMAZINE 10MG TAB THORAZINE 10MG TAB Y 18 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE CHLORPROMAZINE 200MG TAB THORAZINE 200MG TAB Y 18 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE CHLORPROMAZINE 25MG TAB THORAZINE 25MG TAB Y 18 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE CHLORPROMAZINE 50MG TAB THORAZINE 50MG TAB Y 18 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE CHLORTHALIDONE 25MG Y CHLORTHALIDONE 50MG Y THIAZIDE DIURETIC CILOSTAZOL 50MG TAB PLETAL 50MG TAB Y ANTIPLATELET AGENT 0.3% OPH SOL CILOXAN 0.3% OPH SOL Y MAX 5ML/FILL OPHTHALMIC, ANTIBIOTIC CIPROFLOXACIN 250MG TAB CIPRO 250MG TAB Y MAX 4 TABS /DAY QUINOLONE SYSTEMIC CIPROFLOXACIN 500MG TAB CIPRO 500MG TAB Y MAX 4 TABS /DAY QUINOLONE SYSTEMIC CITALOPRAM 10MG TAB CELEXA 10MG TAB Y 6 ANTIDEPRESSANT, SSRI CITALOPRAM 20MG TAB CELEXA 20MG TAB Y 6 ANTIDEPRESSANT, SSRI CITALOPRAM 40MG TAB CELEXA 40MG TAB Y 6 ANTIDEPRESSANT, SSRI 500MG TAB BIAXIN 500MG TAB Y MACROLIDE SYSTEMIC CLINDAMYCIN 1% TOP SOL CLEOCIN-T 1% TOP SOL Y 12 MAX 60ML/30 DAYS LINCOSAMIDE, TOPICAL CLINDAMYCIN 150MG CAP CLEOCIN 150MG CAP Y LINCOSAMIDE, ANTIBIOTIC CLINDAMYCIN 2% VAGINAL CRM CLEOCIN 2% VAGINAL CREAM Y MAX 40G/FILL LINCOSAMIDE, VAGINAL CLINDAMYCIN 300MG CAP CLEOCIN 300MG CAP Y LINCOSAMIDE, ANTIBIOTIC CLOBETASOL 0.05% CRM TEMOVATE CREAM Y CORTICOSTEROID, TOPICAL CLOBETASOL 0.05% OINT TEMOVATE OINTMENT Y CORTICOSTEROID, TOPICAL CLOBETASOL 0.05% SOL TEMOVATE SOLUTION Y MAX 50ML/30 DAYS CORTICOSTEROID, TOPICAL 25MG CAP ANAFRANIL 25MG CAP Y 10 TRICYCLIC ANTIDEPRESSANT CLOMIPRAMINE 50MG CAP ANAFRANIL 50MG CAP Y 10 TRICYCLIC ANTIDEPRESSANT CLOMIPRAMINE 75MG CAP ANAFRANIL 75MG CAP Y 10 TRICYCLIC ANTIDEPRESSANT CLONIDINE 0.1MG TAB CATAPRES 0.1MG TAB Y ALPHA ADRENERGIC AGONIST CLONIDINE 0.2MG TAB CATAPRES 0.2MG TAB Y ALPHA ADRENERGIC AGONIST FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 4 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY CLONIDINE 0.3MG TAB CATAPRES 0.3MG TAB Y ALPHA ADRENERGIC AGONIST CLOPIDOGREL 75MG TAB PLAVIX 75MG TAB Y ANTIPLATELET AGENT CLOTRIMAZOLE 10MG ORAL TROCHES MYCELEX 10MG TROCHE Y MAX 70 TROCHES/FILL ANTIFUNGAL SYSTEMIC CODEINE/ACETAMINOPHEN 30/300MG TAB TYLENOL #3 TAB 12 MAX 120 TABS/365 DAYS/ALL STRENGTHS OF SAME DRUG CLASS COMBO CODEINE/ACETAMINOPHEN 60/300MG TAB TYLENOL #4 TAB 12 MAX 120 TABS/365 DAYS/ALL STRENGTHS OF SAME DRUG CLASS OPIOID ANALGESIC COMBO COLCRYS 0.6MG TAB COLCHICINE 0.6MG TAB Y 4 MAX 60 TABS/30 DAYS MAX 180 TABS/90 DAYS ANTI-GOUT AGENT COMPRESSION HOSE (VARIED SIZES) MAX 2 PAIRS/365 DAYS DME SUPPLY CONCERTA 18MG TAB MAX 30 TABS/30 DAYS CNS STIMULANT ADHD CONCERTA 27MG TAB MAX 30 TABS/30 DAYS CNS STIMULANT ADHD CONCERTA 36MG TAB MAX 30 TABS/30 DAYS CNS STIMULANT ADHD CONCERTA 54MG TAB MAX 30 TABS/30 DAYS CNS STIMULANT ADHD CYCLOBENZAPRINE 10MG TAB FLEXERIL 10MG TAB Y SKELETAL MUSCLE RELAXANT CYCLOBENZAPRINE 5MG TAB FLEXERIL 5MG TAB Y SKELETAL MUSCLE RELAXANT CYCLOPENTOLATE 1% OPH SOL CYCLOGYL 1% SOL Y MAX 15ML/FILL OPHTHALMIC, MYDRIATIC CYCLOSPORINE MOD 100MG CAP NEORAL 100MG CAP Y IMMUNOSUPRESSANT CYCLOSPORINE MOD 25MG CAP NEORAL 25MG CAP Y IMMUNOSUPRESSANT 2MG/5ML SYRUP ANTIHISTAMINE CYPROHEPTADINE 4MG TAB ANTIHISTAMINE 100MG TAB NORPRAMIN 100MG TAB Y 13 TRICYCLIC ANTIDEPRESSANT DESIPRAMINE 10MG TAB NORPRAMIN 10MG TAB Y 13 TRICYCLIC ANTIDEPRESSANT DESIPRAMINE 150MG TAB NORPRAMIN 150MG TAB Y 13 TRICYCLIC ANTIDEPRESSANT DESIPRAMINE 25MG TAB NORPRAMIN 25MG TAB Y 13 TRICYCLIC ANTIDEPRESSANT DESIPRAMINE 50MG TAB NORPRAMIN 50MG TAB Y 13 TRICYCLIC ANTIDEPRESSANT DESIPRAMINE 75MG TAB NORPRAMIN 75MG TAB Y 13 TRICYCLIC ANTIDEPRESSANT DEXAMETHASONE 0.5MG TAB DECADRON 0.5MG TAB Y CORTICOSTEROID, SYSTEMIC DEXAMETHASONE 1MG TAB DECADRON 1MG TAB Y CORTICOSTEROID, SYSTEMIC DEXAMETHASONE 4MG TAB DECADRON 4MG TAB Y CORTICOSTEROID, SYSTEMIC DIAZEPAM 10MG TAB VALIUM 10MG TAB MAX 90 TABS/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS BENZODIAZEPINE DIAZEPAM 2MG TAB VALIUM 2MG TAB MAX 90 TABS/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS BENZODIAZEPINE DIAZEPAM 5MG TAB VALIUM 5MG TAB MAX 90 TABS/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS BENZODIAZEPINE DICLOFENAC 0.1% OPH SOL VOLTAREN 0.1% OPH SOL Y MAX 5ML/FILL; MAX 1/12 DAYS OPHTHALMIC, NSAID DICLOFENAC ER 100MG TAB VOLTAREN XR 100MG Y NSAID DICLOFENAC 50MG EC TAB VOLTAREN 50MG TAB Y NSAID DICLOFENAC SODIUM 75MG EC TAB VOLTAREN 75MG TAB Y NSAID DICLOXACILLIN 500MG CAP PENICILLIN SYSTEMIC DICYCLOMINE 10MG CAP BENTYL 10MG CAP Y ANTICHOLINERGIC DICYCLOMINE 20MG TAB BENTYL 20MG TAB Y ANTICHOLINERGIC 0.125MG TAB LANOXIN 0.125MG TAB Y CARDIAC DIGOXIN 0.25MG TAB LANOXIN 0.25MG TAB Y DILANTIN 30MG CAP 30MG CAP Y ANTICONVULSANT, DILANTIN 50MG INFATAB PHENYTOIN 50MG INFATAB Y ANTICONVULSANT, HYDANTOIN 120MG TAB CARDIZEM 120MG TAB Y CALCIUM CHANNEL BLOCKING AGENT DILTIAZEM 30MG TAB CARDIZEM 30MG TAB Y CALCIUM CHANNEL BLOCKING AGENT DILTIAZEM 60MG TAB CARDIZEM 60MG TAB Y CALCIUM CHANNEL BLOCKING AGENT DILTIAZEM 90MG TAB CARDIZEM 90MG TAB Y CALCIUM CHANNEL BLOCKING AGENT DILTIAZEM CD 24 HOUR 120MG CAP CARDIZEM CD 120MG CAP Y MAX 30 CAPS/30 DAYS MAX 90 CAPS/90 DAYS CALCIUM CHANNEL BLOCKING AGENT DILTIAZEM CD 24 HOUR 180MG CAP CARDIZEM CD 180MG CAP Y MAX 30 CAPS/30 DAYS MAX 90 CAPS/90 DAYS CALCIUM CHANNEL BLOCKING AGENT DILTIAZEM CD 24 HOUR 240MG CAP CARDIZEM CD 240MG CAP Y MAX 30 CAPS/30 DAYS MAX 90 CAPS/90 DAYS CALCIUM CHANNEL BLOCKING AGENT DILTIAZEM CD 24 HOUR 300MG CAP CARDIZEM CD 300MG CAP Y MAX 30 CAPS/30 DAYS MAX 90 CAPS/90 DAYS CALCIUM CHANNEL BLOCKING AGENT DILTIAZEM CD 24 HOUR 360MG CAP CARDIZEM CD 360MG CAP Y MAX 30 CAPS/30 DAYS MAX 90 CAPS/90 DAYS CALCIUM CHANNEL BLOCKING AGENT DIPHENOXYLATE/ATROPINE 2.5/0.025MG TAB LOMOTIL TAB Y MAX 40 TABS/FILL/30 DAYS ANTIDIARRHEAL DISULFIRAM 250MG TAB ANTABUSE 250MG TAB Y ALDEHYDE DEHYDROGENASE INHIBITOR DIVALPROEX SODIUM EC 250MG TAB DEPAKOTE 250MG EC TAB Y ANTICONVULSANT, HISTONE DEACETYLASE INHIBITOR DIVALPROEX SODIUM EC 500MG TAB DEPAKOTE 500MG EC TAB Y ANTICONVULSANT, HISTONE DEACETYLASE INHIBITOR DIVALPROEX SODIUM ER 250MG TAB DEPAKOTE 250MG ER TAB Y ANTICONVULSANT, HISTONE DEACETYLASE INHIBITOR DIVALPROEX SODIUM ER 500MG TAB DEPAKOTE 500MG ER TAB Y ANTICONVULSANT, HISTONE DEACETYLASE INHIBITOR DONEPEZIL 10MG TAB ARICEPT 10MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 CAPS/90 DAYS ACETYLCHOLINESTERASE INHIBITOR FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 5 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY DONEPEZIL 5MG TAB ARICEPT 5MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 CAPS/90 DAYS ACETYLCHOLINESTERASE INHIBITOR DORZOLAMIDE 2% OPH SOL TRUSOPT 2% OPH SOL Y MAX 10ML/30 DAYS MAX 30ML/90 DAYS OPHTHALMIC, GLAUCOMA AGENT DORZOLAMIDE-TIMOLOL 2%-0.5% OPH COSOPT OPH Y MAX 10 ML/25 DAYS MAX 30ML/75 DAYS OPHTHALMIC, GLAUCOMA AGENT 1MG TAB CARDURA 1MG TAB Y ALPHA BLOCKER DOXAZOSIN 2MG TAB CARDURA 2MG TAB Y ALPHA BLOCKER DOXAZOSIN 4MG TAB CARDURA 4MG TAB Y ALPHA BLOCKER DOXAZOSIN 8MG TAB CARDURA 8MG TAB Y ALPHA BLOCKER 100MG CAP SINEQUAN 100MG CAP Y 12 TRICYCLIC ANTIDEPRESSANT DOXEPIN 10MG CAP SINEQUAN 10MG CAP Y 12 TRICYCLIC ANTIDEPRESSANT DOXEPIN 150MG CAP SINEQUAN 150MG CAP Y 12 TRICYCLIC ANTIDEPRESSANT DOXEPIN 25MG CAP SINEQUAN 25MG CAP Y 12 TRICYCLIC ANTIDEPRESSANT DOXEPIN 50MG CAP SINEQUAN 50MG CAP Y 12 TRICYCLIC ANTIDEPRESSANT DOXEPIN 75MG CAP SINEQUAN 75MG CAP Y 12 TRICYCLIC ANTIDEPRESSANT DOXYCYCLINE HYCLATE 100MG CAP VIBRAMYCIN 100MG CAP Y TETRACYCLINE SYSTEMIC DOXYCYCLINE HYCLATE 50MG CAP VIBRAMYCIN 50MG CAP Y TETRACYCLINE SYSTEMIC DOXYCYCLINE MONHYDRATE 100MG CAP TETRACYCLINE SYSTEMIC DOXYCYCLINE MONHYDRATE 50MG CAP TETRACYCLINE SYSTEMIC DUEXIS 800-26.6MG TAB Y MAX 90 TABS/30 DAYS MAX 270 TABS/90 DAYS NSAID/ COMBO DULOXETINE 20MG CAP CYMBALTA 20MG CAP Y 6 MAX 120 CAPS/30 DAYS MAX 360 CAPS/90 DAYS ANTIDEPRESSANT, SNRI DULOXETINE 30MG CAP CYMBALTA 30MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, SNRI DULOXETINE 40MG CAP CYMBALTA 40MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, SNRI DULOXETINE 60MG CAP CYMBALTA 60MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIDEPRESSANT, SNRI ECONAZOLE 1% CRM SPECTAZOLE 1% CRM Y ANTIFUNGAL, TOPICAL EFUDEX 5% CREAM PURINE ANALOG, TOPICAL ENALAPRIL 10MG TAB VASOTEC 10MG TAB Y ACE INHIBITOR ENALAPRIL 2.5MG TAB VASOTEC 2.5MG TAB Y ACE INHIBITOR ENALAPRIL 20MG TAB VASOTEC 20MG TAB Y ACE INHIBITOR ENALAPRIL 5MG TAB VASOTEC 5MG TAB Y ACE INHIBITOR ENALAPRIL/HCTZ 10MG/25MG TAB VASERETIC 10MG/25MG TAB Y ACE INHIBITOR ENALAPRIL/HCTZ 5MG/12.5MG TAB VASERETIC 5MG/12.5MG TAB Y ACE INHIBITOR ENOXAPARIN 100MG/ML SYRG LOVENOX 100MG/ML SYRG MAX 2 SY/DAY; MAX 3 MON/YR HEPARIN AGENT ENOXAPARIN 120MG/0.8ML SYRG LOVENOX 120MG/0.8ML SYRG MAX 2 SY/DAY; MAX 3 MON/YR HEPARIN AGENT ENOXAPARIN 150MG/ML SYRG LOVENOX 150MG/ML SYRG MAX 2 SY/DAY; MAX 3 MON/YR HEPARIN AGENT ENOXAPARIN 30MG/0.3ML SYRG LOVENOX 30MG/0.3ML SYRG MAX 2 SY/DAY; MAX 3 MON/YR HEPARIN AGENT ENOXAPARIN 40MG/0.4ML SYRG LOVENOX 40MG/0.4ML SYRG MAX 2 SY/DAY; MAX 3 MON/YR HEPARIN AGENT ENOXAPARIN 60MG/0.6ML SYRG LOVENOX 60MG/0.6ML SYRG MAX 2 SY/DAY; MAX 3 MON/YR HEPARIN AGENT ENOXAPARIN 80MG/0.8ML SYRG LOVENOX 80MG/0.8ML SYRG MAX 2 SY/DAY; MAX 3 MON/YR HEPARIN AGENT EPINEPHERINE 0.3MG/0.3ML INJ 2 PACK EPIPEN 0.3MG/0.3ML INJ 2 PACK MAX 2 PENS/FILL; MAX 4/30 DAYS SYMPATHOMIMETIC EPIPEN JR 0.15MG/0.15ML INJ 2 PACK MAX 2 PENS/FILL; MAX 4/30 DAYS SYMPATHOMIMETIC 0.5% OPH OINT OPHTHALMIC, ANTIBIOTIC 10MG TAB LEXAPRO 10MG TAB Y 6 ANTIDEPRESSANT, SSRI ESCITALOPRAM 20MG TAB LEXAPRO 20MG TAB Y 6 ANTIDEPRESSANT, SSRI ESCITALOPRAM 5MG TAB LEXAPRO 5MG TAB Y 6 ANTIDEPRESSANT, SSRI ESTRADIOL 0.025MG/24HR WEEKLY PATCH CLIMARA 0.025MG/24HR PATCH Y MAX 4 PATCHES/28 DAYS MAX 12 PATCHES/84 DAYS ESTROGEN DERIVATIVE ESTRADIOL 0.05MG/24HR WEEKLY PATCH CLIMARA 0.05MG/24HR PATCH Y MAX 4 PATCHES/28 DAYS MAX 12 PATCHES/84 DAYS ESTROGEN DERIVATIVE ESTRADIOL 0.1MG/24HR WEEKLY PATCH CLIMARA 0.1MG/24HR PATCH Y MAX 4 PATCHES/28 DAYS MAX 12 PATCHES/84 DAYS ESTROGEN DERIVATIVE ESTRADIOL 0.5MG TAB ESTRACE 0.5MG TAB Y ESTROGEN DERIVATIVE ESTRADIOL 1MG TAB ESTRACE 1MG TAB Y ESTROGEN DERIVATIVE ESTRADIOL 2MG TAB ESTRACE 2MG TAB Y ESTROGEN DERIVATIVE FAMOTIDINE 40MG TAB PEPCID 40MG TAB Y MAX 60 TABS/30 DAYS MAX 180 TABS/90 DAYS H-2 ANTAGONIST FENOFIBRATE 160MG TAB LOFIBRA 160MG TAB Y ANTILIPEMIC AGENT/FIBRIC ACID 5MG TAB PROSCAR 5MG TAB Y 5-ALPHA REDUCTASE INHIBITOR 100MG TAB TAMBOCOR 100MG TAB Y ANTIARRHYTHMIC AGENT FLECAINIDE 150MG TAB TAMBOCOR 150MG TAB Y ANTIARRHYTHMIC AGENT FLECAINIDE 50MG TAB TAMBOCOR 50MG TAB Y ANTIARRHYTHMIC AGENT FLOVENT HFA 110MCG/ACT INH Y MAX 1 INH/25 DAYS MAX 3 INH/75 DAYS CORTICOSTEROID, INHALED FLOVENT HFA 220MCG/ACT INH Y MAX 1 INH/25 DAYS MAX 3 INH/75 DAYS CORTICOSTEROID, INHALED FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 6 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY FLOVENT HFA 44MCG/ACT INH Y MAX 1 INH/25 DAYS MAX 3 INH/75 DAYS CORTICOSTEROID, INHALED FLUCONAZOLE 100MG TAB DIFLUCAN 100MG TAB Y ANTIFUNGAL SYSTEMIC FLUCONAZOLE 150MG TAB DIFLUCAN 150MG TAB Y MAX 3 TABS/FILL; 6 TABS/30 DAYS ANTIFUNGAL SYSTEMIC FLUCONAZOLE 200MG TAB DIFLUCAN 200MG TAB Y ANTIFUNGAL SYSTEMIC FLUDROCORTISONE ACETATE 0.1MG TAB FLORINEF 0.1MG TAB Y CORTICOSTEROID, SYSTEMIC FLUOROMETHOLONE 0.1% OPH SUSP FML 0.1% OPH SUSP Y OPHTHALMIC, CORTICOSTEROID 10MG CAP PROZAC 10MG CAP Y 6 ANTIDEPRESSANT, SSRI FLUOXETINE 20MG CAP PROZAC 20MG CAP Y 6 ANTIDEPRESSANT, SSRI FLUOXETINE 40MG CAP PROZAC 40MG CAP Y 6 ANTIDEPRESSANT, SSRI 10MG TAB PROLIXIN 10MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE FLUPHENAZINE 1MG TAB PROLIXIN 1MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE FLUPHENAZINE 2.5MG TAB PROLIXIN 2.5MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE FLUPHENAZINE 5MG TAB PROLIXIN 5MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE FLUTICASONE/ DISKUS 100/50MCG PWD DISKUS INHADVAIR DISKUS 100/50MCG PWD DISKUS INH Y 4 MAX 1 INH/30 DAYS BETA AGONIST/CORTICOSTEROID INH COMBO FLUTICASONE/SALMETEROL DISKUS 250/50MCG PWD DISKUS INHADVAIR DISKUS 250/50MCG PWD DISKUS INH Y 4 MAX 1 INH/30 DAYS BETA AGONIST/CORTICOSTEROID INH COMBO FLUTICASONE/SALMETEROL DISKUS 500/50MCG PWD DISKUS INHADVAIR DISKUS 500/50MCG PWD DISKUS INH Y 4 MAX 1 INH/30 DAYS BETA AGONIST/CORTICOSTEROID INH COMBO FLUVOXAMINE 100MG TAB LUVOX 100MG TAB Y 6 ANTIDEPRESSANT, SSRI FLUVOXAMINE 25MG TAB LUVOX 25MG TAB Y 6 ANTIDEPRESSANT, SSRI FLUVOXAMINE 50MG TAB LUVOX 50MG TAB Y 6 ANTIDEPRESSANT, SSRI FOLIC ACID 1MG TAB Y VITAMIN 20MG TAB LASIX 20MG TAB Y LOOP FUROSEMIDE 40MG TAB LASIX 40MG TAB Y LOOP FUROSEMIDE 80MG TAB LASIX 80MG TAB Y LOOP 100MG CAP NEURONTIN 100MG CAP Y MAX 3600MG/DAY MAX 3600MG/DAY ANTICONVULSANT, GABA ANALOG GABAPENTIN 300MG CAP NEURONTIN 300MG CAP Y MAX 3600MG/DAY MAX 3600MG/DAY ANTICONVULSANT, GABA ANALOG GABAPENTIN 400MG CAP NEURONTIN 400MG CAP Y MAX 3600MG/DAY MAX 3600MG/DAY ANTICONVULSANT, GABA ANALOG GABAPENTIN 600MG TAB NEURONTIN 600MG TAB Y MAX 3600MG/DAY MAX 3600MG/DAY ANTICONVULSANT, GABA ANALOG GABAPENTIN 800MG TAB NEURONTIN 800MG TAB Y MAX 3600MG/DAY MAX 3600MG/DAY ANTICONVULSANT, GABA ANALOG GEMFIBROZIL 600MG TAB LOPID 600MG TAB Y ANTILIPEMIC AGENT/FIBRIC ACID 10MG TAB GLUCOTROL 10MG TAB Y SULFONYLUREA GLIPIZIDE 5MG TAB GLUCOTROL 5MG TAB Y SULFONYLUREA GLIPIZIDE ER 10MG TAB GLUCOTROL XL 10MG TAB Y SULFONYLUREA GLIPIZIDE ER 2.5MG TAB GLUCOTROL XL 2.5MG TAB Y SULFONYLUREA GLIPIZIDE ER 5MG TAB GLUCOTROL XL 5MG TAB Y SULFONYLUREA GLIPIZIDE/METFORMIN 2.5/500MG TAB Y SULFONYLUREA/BIGUANIDE COMBO GLIPIZIDE/METFORMIN 5/500MG TAB Y SULFONYLUREA/BIGUANIDE COMBO GLUCAGON EMERGENCY KIT MAX 1 KIT/FILL DIABETIC SUPPLIES GLYBURIDE 1.25MG TAB DIABETA 1.25MG TAB Y SULFONYLUREA GLYBURIDE 2.5MG TAB DIABETA 2.5MG TAB Y SULFONYLUREA GLYBURIDE 5MG TAB DIABETA 5MG TAB Y SULFONYLUREA GOLYTELY SOL COLYTE SOL Y OSMOTIC GRISEOFULVIN 125MG TAB (GRIS-PEG) GRIS-PEG 125MG TAB Y ANTIFUNGAL, ORAL GRISEOFULVIN 250MG TAB (GRIS-PEG) GRIS-PEG 250MG TAB Y ANTIFUNGAL, ORAL GRISEOFULVIN SUSP 125MG/5ML GRIFULVIN V SUSP Y ANTIFUNGAL, ORAL 0.5MG TAB HALDOL 0.5MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL HALOPERIDOL 10MG TAB HALDOL 10MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL HALOPERIDOL 1MG TAB HALDOL 1MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL HALOPERIDOL 20MG TAB HALDOL 20MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL HALOPERIDOL 2MG TAB HALDOL 2MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL HALOPERIDOL 5MG TAB HALDOL 5MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL HCTZ 12.5MG CAP Y THIAZIDE HCTZ 12.5MG TAB Y THIAZIDE HCTZ 25MG TAB Y THIAZIDE HCTZ 50MG TAB Y THIAZIDE HEPARIN 10,000 UNITS/ML SINGLE DOSE VIAL >2 SDV/DAY REQUIRES PA HEPARIN AGENT HEPARIN 5000 UNITS/ML SINGLE DOSE VIAL >2 SDV/DAY REQUIRES PA HEPARIN AGENT HUMALOG KWIKPEN Y INSULIN AGENT FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 7 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY HUMALOG MIX 75/25 VIAL Y INSULIN AGENT HUMALOG VIAL Y INSULIN AGENT HUMIRA 40MG/0.8ML PEN Y IMMUNOSUPRESSANT HYDRALAZINE 100MG TAB APRESOLINE 100MG TAB Y VASODILATOR HYDRALAZINE 10MG TAB APRESOLINE 10MG TAB Y VASODILATOR HYDRALAZINE 25MG TAB APRESOLINE 25MG TAB Y VASODILATOR HYDRALAZINE 50MG TAB APRESOLINE 50MG TAB Y VASODILATOR HYDROCODONE/ACETAMIN 10/325MG TAB NORCO 10/325 TAB MAX 21 TABS/7 DAYS; MAX 120 TABS/365 DAYS/ALL STRENGTHS OF SAME DRUG CLASS OPIOID ANALGESIC COMBO HYDROCODONE/ACETAMIN 5/325MG TAB NORCO 5/325MG TAB MAX 42 TABS/7 DAYS; MAX 120 TABS/365 DAYS/ALL STRENGTHS OF SAME DRUG CLASS OPIOID ANALGESIC COMBO HYDROCORTISONE 10MG TAB CORTEF 10MG TAB Y CORTICOSTEROID, SYSTEMIC HYDROCORTISONE 2.5% CRM HYTONE 2.5% CRM Y CORTICOSTEROID, TOPICAL HYDROCORTISONE 2.5% OINT HYTONE 2.5% OINT Y CORTICOSTEROID, TOPICAL HYDROCORTISONE 20MG TAB CORTEF 20MG TAB Y CORTICOSTEROID, SYSTEMIC HYDROCORTISONE 25MG RECTAL SUPP ANUSOL HC SUPP Y CORTICOSTEROID, RECTAL HYDROXYCHLOROQUINE 200MG TAB PLAQUENIL 200MG TAB Y DISEASE MODIFYING ANTI-RHEUMATIC AGENT (DMARD) HYDROXYUREA 500MG CAP HYDREA 500MG CAP Y ANTINEOPLASTIC AGENT HCL 10MG TAB ATARAX 10MG TAB Y ANTIHISTAMINE//ANTIANXIETY HYDROXYZINE HCL 25MG TAB ATARAX 25MG TAB Y ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY HYDROXYZINE HCL 50MG TAB ATARAX 50MG TAB Y ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY HYDROXYZINE PAMOATE 100MG CAP VISTARIL 100MG CAP Y ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY HYDROXYZINE PAMOATE 25MG CAP VISTARIL 25MG CAP Y ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY HYDROXYZINE PAMOATE 50MG CAP VISTARIL 50MG CAP Y ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY HYOSCYAMINE SULF 0.125MG TAB LEVSIN 0.125MG TAB Y ANTICHOLINERGIC 400MG TAB MOTRIN 400MG TAB Y NSAID IBUPROFEN 600MG TAB MOTRIN 600MG TAB Y NSAID IBUPROFEN 800MG TAB MOTRIN 800MG TAB Y NSAID 10MG CAP TOFRANIL 10MG CAP Y 6 TRICYCLIC ANTIDEPRESSANT IMIPRAMINE 25MG CAP TOFRANIL 25MG CAP Y 6 TRICYCLIC ANTIDEPRESSANT IMIPRAMINE 50MG CAP TOFRANIL 50MG CAP Y 6 TRICYCLIC ANTIDEPRESSANT IMIQUIMOD 5% TOPICAL CREAM ALDARA CREAM 12 MAX 12 PACKETS PER DISPENSE IMMUNOMODULATOR, TOPICAL INDOMETHACIN 25MG CAP INDOCIN 25MG CAP Y NSAID INDOMETHACIN 50MG CAP INDOCIN 50MG CAP Y NSAID INSULIN SYRINGE 1IN 29G 1/2CC Y >120 SYRG/30 DAYS REQUIRES PA >360 SYRG/90 DAYS REQUIRES PA DIABETIC SUPPLIES INSULIN SYRINGE 1IN 29G 1CC Y >120 SYRG/30 DAYS REQUIRES PA >360 SYRG/90 DAYS REQUIRES PA DIABETIC SUPPLIES INVOKAMET 150/1000MG TAB Y BIGUANIDE/SGLT2 INHIBITORS COMBO INVOKAMET 150/500MG TAB Y BIGUANIDE/SGLT2 INHIBITORS COMBO INVOKAMET 50/1000MG TAB Y BIGUANIDE/SGLT2 INHIBITORS COMBO INVOKAMET 50/500MG TAB Y BIGUANIDE/SGLT2 INHIBITORS COMBO INVOKAMET XR 150/1000MG TAB Y BIGUANIDE/SGLT2 INHIBITORS COMBO INVOKAMET XR 150/500MG TAB Y BIGUANIDE/SGLT2 INHIBITORS COMBO INVOKAMET XR 50/1000MG TAB Y BIGUANIDE/SGLT2 INHIBITORS COMBO INVOKAMET XR 50/500MG TAB Y BIGUANIDE/SGLT2 INHIBITORS COMBO INVOKANA 100MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS SGLT2 INHIBITOR INVOKANA 300MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS SGLT2 INHIBITOR IPRATROPIUM 0.02%/2.5ML SOL FOR NEB ATROVENT 0.02%/2.5ML NEB SOL Y ANTICHOLINERGIC, INHALED ISOSORBIDE MONONITRATE ER 120MG TAB IMDUR 120MG TAB Y , VASODILATOR ISOSORBIDE MONONITRATE ER 30MG TAB IMDUR 30MG TAB Y ANTIANGINAL, VASODILATOR ISOSORBIDE MONONITRATE ER 60MG TAB IMDUR 60MG TAB Y ANTIANGINAL, VASODILATOR JANUMET 50/1000MG TAB Y BIGUANIDE/DPP-4 INHIBITORS COMBO JANUMET 50/500MG TAB Y BIGUANIDE/DPP-4 INHIBITORS COMBO JANUMET XR 100/1000MG TAB Y BIGUANIDE/DPP-4 INHIBITORS COMBO JANUVIA 100MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS DPP-4 INHIBITOR JANUVIA 25MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS DPP-4 INHIBITOR JANUVIA 50MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS DPP-4 INHIBITOR JARDIANCE 10 MG TAB Y SGLT2 INHIBITOR JARDIANCE 25 MG TAB Y SGLT2 INHIBITOR JENTADUETO 1000/2.5MG TAB Y BIGUANIDE/DPP-4 INHIBITORS COMBO FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 8 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY JENTADUETO 1000/5MG TAB Y BIGUANIDE/DPP-4 INHIBITORS COMBO JENTADUETO 500/2.5MG TAB Y BIGUANIDE/DPP-4 INHIBITORS COMBO JENTADUETO 850/2.5MG TAB Y BIGUANIDE/DPP-4 INHIBITORS COMBO JUNEL FE 1.5/30 TABS 28-PACK LOESTRIN FE 1.5/30 TAB 28-PACK Y 12 ORAL CONTRACEPTIVE JUNEL FE 1/20 TABS 28-PACK LOESTRIN FE 1/20 TAB 28-PACK Y 12 ORAL CONTRACEPTIVE 2% CREAM NIZORAL 2% CRM Y ANTIFUNGAL, TOPICAL KETOCONAZOLE 200MG TAB ANTIFUNGAL SYSTEMIC KETOROLAC 0.5% OPHTH MAX 1 BOTTLE/15 DAYS OPHTHALMIC, NSAID KETOSTIX Y MAX 50 STRIPS/30 DAYS MAX 150 STRIPS/90 DAYS DIABETIC SUPPLIES 100MG TAB TRANDATE 100MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER LABETALOL 200MG TAB TRANDATE 200MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER LABETALOL 300MG TAB TRANDATE 300MG TAB Y ALPHA/BETA ADRENERGIC BLOCKER LACTULOSE 10G/15ML SOL ENULOSE 10G/15ML SOL Y OSMOTIC LAXATIVE 100MG TAB LAMICTAL 100MG TAB Y ANTICONVULSANT, MISCELLANEOUS LAMOTRIGINE 150MG TAB LAMICTAL 150MG TAB Y ANTICONVULSANT, MISCELLANEOUS LAMOTRIGINE 200MG TAB LAMICTAL 200MG TAB Y ANTICONVULSANT, MISCELLANEOUS LAMOTRIGINE 25MG TAB LAMICTAL 25MG TAB Y ANTICONVULSANT, MISCELLANEOUS LANCETS LANCETS Y >100/25 DAYS REQUIRES PA MAX 300/75 DAYS DIABETIC SUPPLIES LANTUS MDV 100U/ML Y INSULIN AGENT LANTUS SOLOSTAR PEN 100U/ML Y INSULIN AGENT LATANOPROST 0.005% OPH SOL XALATAN 0.005% OPH SOL Y MAX 2.5ML/25 DAYS MAX 7.5ML/75 DAYS OPHTHALMIC, GLAUCOMA AGENT LETROZOLE 2.5MG TAB FEMARA 2.5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS AROMATASE INHIBITOR LEVEMIR PEN Y INSULIN AGENT LEVEMIR VIAL Y INSULIN AGENT 1000MG TAB KEPPRA 100MG TAB Y ANTICONVULSANT, MISCELLANEOUS LEVETIRACETAM 100MG/ML SOL KEPPRA 100MG/ML SOL Y ANTICONVULSANT, MISCELLANEOUS LEVETIRACETAM 500MG TAB KEPPRA 500MG TAB Y ANTICONVULSANT, MISCELLANEOUS LEVETIRACETAM 750MG TAB KEPPRA 750MG TAB Y ANTICONVULSANT, MISCELLANEOUS LEVOFLOXACIN 250MG TAB LEVAQUIN 250MG TAB Y QUINOLONE SYSTEMIC LEVOFLOXACIN 500MG TAB LEVAQUIN 500MG TAB Y QUINOLONE SYSTEMIC LEVOFLOXACIN 750MG TAB LEVAQUIN 750MG TAB Y QUINOLONE SYSTEMIC SODIUM 100MCG TAB SYNTHROID 100MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 112MCG TAB SYNTHROID 112MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 125MCG TAB SYNTHROID 125MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 137MCG TAB SYNTHROID 137MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 150MCG TAB SYNTHROID 150MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 175MCG TAB SYNTHROID 175MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 200MCG TAB SYNTHROID 200MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 25MCG TAB SYNTHROID 25MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 300MCG TAB SYNTHROID 300MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 50MCG TAB SYNTHROID 50MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 75MCG TAB SYNTHROID 75MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE LEVOTHYROXINE SODIUM 88MCG TAB SYNTHROID 88MCG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THYROID HORMONE VISCOUS 2% SOLN DISP AS CLOSED UNIT(S) ONLY MOUTH RINSE LINEZOLID 600MG TAB ZYVOX 600MG TAB PCC RXS ONLY--REFERRALS REQUIRE PA OXAZOLIDINONES LINZESS 145MCG CAPS GUANYLATE CYCLASE-C AGONIST LINZESS 290MCG CAPS GUANYLATE CYCLASE-C AGONIST 25MCG TAB CYTOMEL 25 MCG TAB Y THYROID HORMONE LIOTHYRONINE 50MCG TAB CYTOMEL 50 MCG TAB Y THYROID HORMONE LIOTHYRONINE 5MCG TAB CYTOMEL 5 MCG TAB Y THYROID HORMONE LISINOPRIL 10MG TAB ZESTRIL OR PRINIVIL 10MG TAB Y ACE INHIBITOR LISINOPRIL 2.5MG TAB ZESTRIL 2.5MG TAB Y ACE INHIBITOR LISINOPRIL 20MG TAB ZESTRIL OR PRINIVIL 20MG TAB Y ACE INHIBITOR LISINOPRIL 30MG TAB ZESTRIL 30MG TAB Y ACE INHIBITOR LISINOPRIL 40MG TAB ZESTRIL 40MG TAB Y ACE INHIBITOR LISINOPRIL 5MG TAB ZESTRIL OR PRINIVIL 5MG TAB Y ACE INHIBITOR LISINOPRIL/HCTZ 10MG/12.5MG TAB ZESTORETIC OR PRINZIDE 10MG/12.5MG TAB Y ACE INHIBITOR/COMBO FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 9 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY LISINOPRIL/HCTZ 20MG/12.5MG TAB ZESTORETIC OR PRINZIDE 20MG/12.5MG TAB Y ACE INHIBITOR/COMBO LISINOPRIL/HCTZ 20MG/25MG TAB ZESTORETIC OR PRINZIDE 20MG/25MG TAB Y ACE INHIBITOR/COMBO LITHIUM CARBONATE 150MG CAP 6 ANTIPSYCHOTIC LITHIUM CARBONATE 300MG CAP 6 ANTIPSYCHOTIC MOOD STABILIZER LITHIUM CARBONATE 600MG CAP 6 ANTIPSYCHOTIC MOOD STABILIZER LITHIUM CARBONATE ER 300MG TAB LITHOBID 300MG TAB 6 ANTIPSYCHOTIC MOOD STABILIZER LITHIUM CARBONATE ER 450MG TAB 6 ANTIPSYCHOTIC MOOD STABILIZER 0.5MG TAB ATIVAN 0.5MG TAB MAX 90 TABS/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS BENZODIAZEPINE LORAZEPAM 1MG TAB ATIVAN 1MG TAB MAX 90 TABS/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS BENZODIAZEPINE LORAZEPAM 2MG TAB ATIVAN 2MG TAB MAX 90 TABS/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS BENZODIAZEPINE LOSARATN/HCTZ 50MG/12.5MG TAB HYZAAR 50MG/12.5MG TAB Y ARB INHIBITOR/COMBO LOSARTAN 100MG TAB COZAAR 100MG TAB Y ARB AGENT LOSARTAN 25MG TAB COZAAR 25MG TAB Y ARB AGENT LOSARTAN 50MG TAB COZAAR 50MG TAB Y ARB AGENT LOSARTAN/HCTZ 100MG/12.5MG TAB HYZAAR 100MG/12.5MG TAB Y ARB INHIBITOR/COMBO LOSARTAN/HCTZ 100MG/25MG TAB HYZAAR 100MG/25MG TAB Y ARB INHIBITOR/COMBO MEDROXYPROGESTERONE ACETATE 10MG TAB PROVERA 10MG TAB Y PROGESTIN MEDROXYPROGESTERONE ACETATE 150MG/ML INJ Y INJECTABLE CONTRACEPTIVE MEDROXYPROGESTERONE ACETATE 2.5MG TAB PROVERA 2.5MG TAB Y PROGESTIN MEDROXYPROGESTERONE ACETATE 5MG TAB PROVERA 5MG TAB Y PROGESTIN MEGESTROL 20MG PROGESTIN MEGESTROL 40MG PROGESTIN MEGESTROL ACETATE 625MG/5ML PROGESTIN MELOXICAM 15MG TAB MOBIC 15MG TAB Y NSAID MELOXICAM 7.5MG TAB MOBIC 7.5MG TAB Y NSAID MEMANTINE HCL 10 MG NAMENDA 10 MG Y NMDA ANTAGONIST MEMANTINE HCL 5 MG NAMENDA 5 MG Y NMDA MEPHYTON 5MG TAB RESCUE AGENT MESALAMINE 1.2G LIALDA Y 5-ASA DERIVATIVE, ORAL MESALAMINE 4G/60ML RECTAL ENEMA ROWASA 4G/60ML RECT ENEMA Y MAX 1 ENEMA/DAY 5-ASA DERIVATIVE, RECTAL METFORMIN 1000MG TAB GLUCOPHAGE 1000MG TAB Y BIGUANIDE METFORMIN 500MG TAB GLUCOPHAGE 500MG TAB Y BIGUANIDE METFORMIN 850MG TAB GLUCOPHAGE 850MG TAB Y BIGUANIDE METFORMIN ER 500MG TAB GLUCOPHAGE XR 500MG TAB Y BIGUANIDE METFORMIN ER 750MG TAB GLUCOPHAGE XR 750MG TAB Y BIGUANIDE METFORMIN/GLYBURIDE 250/1.25MG TAB GLUCOVANCE 1.25/250MG TAB Y BIGUANIDE/SULFONYLUREA COMBO METFORMIN/GLYBURIDE 500/2.5MG TAB GLUCOVANCE 2.5/500MG TAB Y BIGUANIDE/SULFONYLUREA COMBO METFORMIN/GLYBURIDE 500/5MG TAB GLUCOVANCE 5/500MG TAB Y BIGUANIDE/SULFONYLUREA COMBO METHIMAZOLE 10MG TAB TAPAZOLE 10MG TAB Y METHIMAZOLE 5MG TAB TAPAZOLE 5MG TAB Y ANTITHYROID AGENT METHOCARBAMOL 500MG TAB ROBAXIN 500MG TAB Y SKELETAL MUSCLE RELAXANT METHOCARBAMOL 750MG TAB ROBAXIN 750MG TAB Y SKELETAL MUSCLE RELAXANT METHOTREXATE 2.5MG TAB ANTINEOPLASTIC/ AGENT 250MG TAB ALDOMET 250MG TAB Y ALPHA ADRENERGIC AGONIST METHYLPHENIDATE ER 20MG TAB METADATE ER 20MG TAB 6 MAX 90 TAB/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS CNS STIMULANT ADHD METHYLPHENIDATE HCL 10MG TAB RITALIN 10MG TAB 6 MAX 90 TAB/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS CNS STIMULANT ADHD METHYLPHENIDATE HCL 20MG TAB RITALIN 20MG TAB 6 MAX 90 TAB/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS CNS STIMULANT ADHD METHYLPREDNISOLONE 4MG TAB MEDROL 4MG TAB Y CORTICOSTEROID, SYSTEMIC METHYLPREDNISOLONE 4MG TAB 6/DAY DOSE PK MEDROL 4MG DOSEPAK MAX 1 PACK/FILL CORTICOSTEROID, SYSTEMIC METOCLOPRAMIDE 10MG TAB REGLAN 10MG TAB Y GASTROINTESTINAL MOTILITY METOCLOPRAMIDE 5MG TAB REGLAN 5MG TAB Y GASTROINTESTINAL MOTILITY METOLAZONE 10MG TAB ZAROXOLYN 10MG TAB Y THIAZIDE METOLAZONE 2.5MG TAB ZAROXOLYN 2.5MG TAB Y THIAZIDE METOLAZONE 5MG TAB ZAROXOLYN 5MG TAB Y THIAZIDE SUCCINATE 100MG TAB TOPROL XL TAB Y BETA BLOCKER METOPROLOL SUCCINATE 200MG TAB TOPROL XL TAB Y BETA BLOCKER METOPROLOL SUCCINATE 25MG TAB TOPROL XL TAB Y BETA BLOCKER FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 10 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY METOPROLOL SUCCINATE 50MG TAB TOPROL XL TAB Y BETA BLOCKER METOPROLOL TARTRATE 100MG TAB LOPRESSOR 100MG TAB Y BETA BLOCKER METOPROLOL TARTRATE 25MG TAB LOPRESSOR 25MG TAB Y BETA BLOCKER METOPROLOL TARTRATE 50MG TAB LOPRESSOR 50MG TAB Y BETA BLOCKER METRONIDAZOLE 0.75% TOP GEL METROGEL TOPICAL Y MAX 45G/30 DAYS , TOPICAL METRONIDAZOLE 0.75% VAGINAL GEL METROGEL VAGINAL Y MAX 70G/FILL ANTIPROTOZOAL, VAGINAL METRONIDAZOLE 250MG TAB FLAGYL 250MG TAB Y ANTIPROTOZOAL, SYSTEMIC METRONIDAZOLE 500MG TAB FLAGYL 500MG TAB Y ANTIPROTOZOAL, SYSTEMIC MICRONOR 28-PACK Y 12 ORAL CONTRACEPTIVE 10MG TAB Y ALPHA AGONIST MIDODRINE 5MG TAB Y ALPHA AGONIST 10MG TAB Y VASODILATOR MINOXIDIL 2.5MG TAB VASODILATOR MIRENA I.U.D. VAGINAL CONTRACEPTIVE 15MG TAB REMERON 15MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIDEPRESSANT, ALPHA-2 RECEPTOR ANTAGONIST MIRTAZAPINE 30MG TAB REMERON 30MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIDEPRESSANT, ALPHA-2 RECEPTOR ANTAGONIST MIRTAZAPINE 45MG TAB REMERON 45MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIDEPRESSANT, ALPHA-2 RECEPTOR ANTAGONIST MISOPROSTOL 100MCG TAB CYTOTEC 100MCG TAB ANTI-ULCER MISOPROSTOL 200MCG TAB CYTOTEC 200MCG TAB ANTI-ULCER MOMETASONE 0.1% CRM ELOCON 0.1% CRM Y CORTICOSTEROID, TOPICAL MOMETASONE 0.1% OINT ELOCON 0.1% OINT Y CORTICOSTEROID, TOPICAL MONTELUKAST 10MG TAB SINGULAIR 10MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS LEUKOTRIENE RECEPTOR ANTAGONIST MONTELUKAST 4MG CHEW TAB SINGULAIR 4MG CHEW TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS LEUKOTRIENE RECEPTOR ANTAGONIST MONTELUKAST 5MG CHEW TAB SINGULAIR 5MG CHEW TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS LEUKOTRIENE RECEPTOR ANTAGONIST MOVIPREP OSMOTIC LAXATIVE MULTIVITAMIN WITH FLUORIDE DROPS 0.25MG 12 DISP AS CLOSED UNIT(S) ONLY VITAMIN/FLUORIDE SUPPLEMENT MULTIVITAMIN WITH FLUORIDE DROPS 0.5MG 12 DISP AS CLOSED UNIT(S) ONLY VITAMIN/FLUORIDE SUPPLEMENT MULTIVITAMIN WITH IRON FLUORIDE DROPS 0.25MG 12 DISP AS CLOSED UNIT(S) ONLY VITAMIN/FLUORIDE SUPPLEMENT MUPIROCIN 2% OINT BACTROBAN 2% OINT Y MAX 44G/30 DAYS ANTIBIOTIC, TOPICAL MYCOPHENOLATE 250MG CAP CELLCEPT 250MG CAP IMMUNOSUPRESSANT MYCOPHENOLATE 500MG TAB CELLCEPT 500MG TAB IMMUNOSUPRESSANT 20MG TAB CORGARD 20MG TAB Y BETA BLOCKER NADOLOL 40MG TAB CORGARD 40MG TAB Y BETA BLOCKER NADOLOL 80MG TAB CORGARD 80MG TAB Y BETA BLOCKER NALTREXONE 50MG TAB DEPADE 50MG TAB Y OPIATE RECEPTOR ANTAGONIST NAPROXEN 500MG TAB NAPROSYN 500MG TAB Y NSAID NEO/POLY/DEX 3.5MG/10000U/0.1%/ML OPH OINT MAXITROL OPH OINTMENT Y MAX 1 TUBE PER DISPENSE ANTI-INFECTIVES/STEROID COMBO, OPH NEO/POLY/DEX 3.5MG/10000U/0.1%/ML OPH SUSP MAXITROL OPH SUSP Y OPHTHALMIC, ANTIBIOTIC/STEROID COMBO NEO/POLY/GR 1.75MG/10000U/0.025MG/ML OPH SOL NEOSPORIN OPH SOL Y OPHTHALMIC, ANTIBIOTIC NEO/POLY/HC 3.5MG/10000U/10MG/ML OPH SUSP CORTISPORIN OPH SUSP Y OPHTHALMIC, ANTIBIOTIC/STEROID COMBO NEO/POLY/HC 3.5MG/10000U/10MG/ML OTIC SOL CORTISPORIN OTIC SOL Y ANTI-INFECTIVES/STEROID COMBO, OTIC NEO/POLY/HC 3.5MG/10000U/10MG/ML OTIC SUSP CORTISPORIN OTIC SUSP Y ANTI-INFECTIVES/STEROID COMBO, OTIC NIASPAN 500MG TAB Y MAX 120 TABS/30 DAYS MAX 360 TABS/90 DAYS ANTILIPEMIC AGENT/MISC NIASPAN 750MG TAB Y MAX 60 TABS/30 DAYS MAX 180 TABS/90 DAYS ANTILIPEMIC AGENT/MISC CHEWING GUM 2MG 18 PCC RXS ONLY--NO REFERRALS-QTY AND REF PER PROTOCOL WITHDRAWAL AGENT NICOTINE CHEWING GUM 4MG 18 PCC RXS ONLY--NO REFERRALS-QTY AND REF PER PROTOCOL WITHDRAWAL AGENT NICOTINE PATCH 14MG/24HRS 18 PCC RXS ONLY--NO REFERRALS-QTY AND REF PER PROTOCOL WITHDRAWAL AGENT NICOTINE PATCH 21MG/24HRS 18 PCC RXS ONLY--NO REFERRALS-QTY AND REF PER PROTOCOL WITHDRAWAL AGENT NICOTINE PATCH 7MG/24HRS 18 PCC RXS ONLY--NO REFERRALS-QTY AND REF PER PROTOCOL WITHDRAWAL AGENT NIFEDICAL XL 30MG TAB PROCARDIA XL 30MG TAB Y CALCIUM CHANNEL BLOCKING AGENT ER 60MG TAB PROCARDIA XL 60MG TAB Y CALCIUM CHANNEL BLOCKING AGENT NIFEDIPINE ER 90MG TAB PROCARDIA XL 90MG TAB Y CALCIUM CHANNEL BLOCKING AGENT NITROFURANTOIN MONOHY MACRO 100MG CAP MACROBID 100MG CAP Y ANTIBIOTIC MISCELLANEOUS SYSTEMIC NITROGLYCERIN 0.2MG/HR TOP PATCH NITRODUR/MINITRAN 0.2MG/HR PATCH Y MAX 30 PATCHES/30 DAYS MAX 90 PATCHES/90 DAYS ANTIANGINAL, VASODILATOR NITROGLYCERIN 0.4MG/HR TOP PATCH NITRODUR/MINITRAN 0.4MG/HR PATCH Y MAX 30 PATCHES/30 DAYS MAX 90 PATCHES/90 DAYS ANTIANGINAL, VASODILATOR NITROSTAT 0.4MG SL TAB Y ANTIANGINAL, VASODILATOR 10MG CAP PAMELOR 10MG CAP Y 13 TRICYCLIC ANTIDEPRESSANT FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 11 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY NORTRIPTYLINE 25MG CAP PAMELOR 25MG CAP Y 13 TRICYCLIC ANTIDEPRESSANT NORTRIPTYLINE 50MG CAP PAMELOR 50MG CAP Y 13 TRICYCLIC ANTIDEPRESSANT NORTRIPTYLINE 75MG CAP PAMELOR 75MG CAP Y 13 TRICYCLIC ANTIDEPRESSANT NOVOLIN 70/30 VIAL Y INSULIN AGENT NOVOLIN N VIAL Y INSULIN AGENT NOVOLIN R VIAL Y INSULIN AGENT NOVOLOG FLEXPEN Y INSULIN AGENT NOVOLOG MIX 70/30 FLEXPEN Y INSULIN AGENT NOVOLOG MIX 70/30 VIAL Y INSULIN AGENT NOVOLOG VIAL Y INSULIN AGENT NUVARING Y VAGINAL CONTRACEPTIVE NYSTATIN 100,000 UNITS/GM CRM MYCOSTATIN 100,000 UNITS/GM CRM Y AVAILABLE SIZE: 30 GRAM ANTIFUNGAL, TOPICAL NYSTATIN 100,000 UNITS/GM OINT MYCOSTATIN 100,000 UNITS/GM OINT Y AVAILABLE SIZE: 30 GRAM ANTIFUNGAL, TOPICAL NYSTATIN 100,000 UNITS/ML ORAL SUSP MYCOSTATIN 100,000 UNITS/ML SUSP Y ANTIFUNGAL SYSTEMIC NYSTATIN 500,000 UNIT TAB MYCOSTATIN 500,000 UNIT TAB Y ANTIFUNGAL SYSTEMIC NYSTATIN POWDER 100,000 UNITS/GM NYSTOP POWDER 100,000 UNITS/GM Y MAX 30G/FILL ANTIFUNGAL, TOPICAL NYSTATIN/TRIAMCIN 100,000U/G/0.1% CRM MYCOLOG 100,00U/G/0.1% CRM Y CORTICOSTEROID/ANTIFUNGAL, TOPICAL NYSTATIN/TRIAMCIN 100,000U/G/0.1% OINT MYCOLOG 100,00U/G/0.1% OINT Y CORTICOSTEROID/ANTIFUNGAL, TOPICAL OFLOXACIN OPHTH SOL OCUFLOX OPHTH SOL Y MAX 5ML PER FILL OPHTHALMIC, ANTIBIOTIC OFLOXACIN OTIC SOL FLOXIN OTIC SOL Y MAX 5ML PER FILL OTIC, ANTIBIOTIC 10MG TAB ZYPREXA 10MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL OLANZAPINE 15MG TAB ZYPREXA 15MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL OLANZAPINE 2.5MG TAB ZYPREXA 2.5MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL OLANZAPINE 20MG TAB ZYPREXA 20MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL OLANZAPINE 5MG TAB ZYPREXA 5MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL OLANZAPINE 7.5MG TAB ZYPREXA 7.5MG TAB Y 6 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTIPSYCHOTIC, ATYPICAL OLMESARTAN 20MG TAB BENICAR 20MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT OLMESARTAN 40MG TAB BENICAR 40MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT OLMESARTAN 5MG TAB BENICAR 5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT OLMESARTAN/HCTZ 20MG-12.5MG TAB BENICAR HCT 20MG-12.5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO OLMESARTAN/HCTZ 40MG-12.5MG TAB BENICAR HCT 40MG-12.5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO OLMESARTAN/HCTZ 40MG-25MG TAB BENICAR HCT 40MG-25MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO OMEPRAZOLE 40MG DR CAP PRILOSEC 40MG CAP Y 1 MAX 30 CAPS/30 DAYS MAX 90 CAPS/90 DAYS PROTON PUMP INHIBITOR ONDANSETRON 4MG ODT TAB ZOFRAN ODT 4MG TAB Y ANTIEMETIC ONDANSETRON 8MG ODT TAB ZOFRAN ODT 8MG TAB Y ANTIEMETIC ONDANSETRON 4MG/5ML SOL ZOFRAN SOL ANTIEMETIC ORTHO TRI CYCLEN 28-PACK Y 12 ORAL CONTRACEPTIVE ORTHO TRI CYCLEN LO 28-PACK Y 12 ORAL CONTRACEPTIVE OSELTAMIVIR 30MG CAP TAMIFLU 30MG CAP Y MAX 5 DAY SUPPLY/DISPENSE ANTIVIRAL SYSTEMIC, ANTI INFLUENZA OSELTAMIVIR 45MG CAP TAMIFLU 45MG CAP Y MAX 5 DAY SUPPLY/DISPENSE ANTIVIRAL SYSTEMIC, ANTI INFLUENZA OSELTAMIVIR 6MG/ML SUSP TAMIFLU 6MG/ML SUSP Y MAX 5 DAY SUPPLY/DISPENSE ANTIVIRAL SYSTEMIC, ANTI INFLUENZA OSELTAMIVIR 75MG CAP TAMIFLU 75MG CAP Y MAX 5 DAY SUPPLY/DISPENSE ANTIVIRAL SYSTEMIC, ANTI INFLUENZA 150MG TAB TRILEPTAL 150MG TAB Y ANTICONVULSANT, MISCELLANEOUS OXCARBAZEPINE 300MG TAB TRILEPTAL 300MG TAB Y ANTICONVULSANT, MISCELLANEOUS OXCARBAZEPINE 600MG TAB TRILEPTAL 600MG TAB Y ANTICONVULSANT, MISCELLANEOUS OXCARBAZEPINE 300MG/5ML SUSP TRILEPTAL 300MG/5ML ANTICONVULSANT, MISCELLANEOUS OXYBUTYNIN 5MG TAB DITROPAN 5MG TAB Y GU ANTISPASMOTIC AGENT OXYCODONE/ACETAMINOPH 5/325MG TAB PERCOCET 5/325MG TAB Y MAX 42 TABS/7 DAYS; MAX 120 TABS/365 DAYS/ALL STRENGTHS OF SAME DRUG CLASS OPIOID ANALGESIC COMBO PANTOPRAZOLE 40MG TAB PROTONIX 40MG TAB Y 5 MAX 60 CAPS/30 DAYS PROTON PUMP INHIBITOR PAROXETINE 10MG TAB PAXIL 10MG TAB Y 6 ANTIDEPRESSANT, SSRI PAROXETINE 20MG TAB PAXIL 20MG TAB Y 6 ANTIDEPRESSANT, SSRI PAROXETINE 30MG TAB PAXIL 30MG TAB Y 6 ANTIDEPRESSANT, SSRI PAROXETINE 40MG TAB PAXIL 40MG TAB Y 6 ANTIDEPRESSANT, SSRI PEN NEEDLES FOR INSULIN PEN Y DISP AS CLOSED UNIT(S) ONLY DISP AS FULL BOX(ES) ONLY DIABETIC SUPPLIES PENICILLIN V K 250MG TAB PENICILLIN SYSTEMIC PENICILLIN V K 500MG TAB PENICILLIN SYSTEMIC PENICILLIN V 250MG/5ML ORAL SOL PENICILLIN SYSTEMIC FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 12 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY PENNSAID 2% TOPICAL SOLUTION Y MAX 1 UNIT/28 DAYS MAX 3 UNITS/84 DAYS TOPICAL NSAID PENTASA 500MG CR CAP Y MAX 240 CAPS/30 DAYS MAX 720 CAPS/90 DAYS 5-ASA DERIVATIVE, ORAL PENTOSAN 100MG CAP ELMIRON 100MG CAP ANTIPLATELET AGENT PERMETHRIN 5% CREAM ELIMITE 5% CREAM Y SCABICIDE/PEDICULOSIDE, TOPICAL 16MG TAB TRILAFON 16MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE PERPHENAZINE 2MG TAB TRILAFON 2MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE PERPHENAZINE 4MG TAB TRILAFON 4MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE PERPHENAZINE 8MG TAB TRILAFON 8MG TAB Y 6 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE PHENAZOPYRIDINE 100MG TAB PYRIDIUM 100MG TAB Y GU ANALGESIC PHENAZOPYRIDINE 200MG TAB PYRIDIUM 200MG TAB Y GU ANALGESIC PHENYTOIN 125MG/5ML SUSP DILANTIN 125MG/5ML SUSP Y 12 ANTICONVULSANT, HYDANTOIN PHENYTOIN SOD EXT 100MG CAP DILANTIN 100MG CAP Y ANTICONVULSANT, HYDANTOIN PILOCARPINE 5MG TAB SALAGEN 5MG TAB Y CHOLINERGIC AGENT PILOCARPINE 7.5MG TAB SALAGEN 7.5MG TAB Y CHOLINERGIC AGENT PIOGLIAZONE 15MG TAB ACTOS 15MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THIAZOLIDINEDIONE PIOGLITAZONE 30MG TAB ACTOS 30MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THIAZOLIDINEDIONE PIOGLITAZONE 45MG TAB ACTOS 45MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS THIAZOLIDINEDIONE PIOGLITAZONE HCL/METFORMIN HCL 15/500MG TAB ACTOPLUS MET 15MG-500MG Y THIAZOLIDINEDIONE/BIGUANIDE COMBO PIOGLITAZONE HCL/METFORMIN HCL 15/850MG TAB ACTOPLUS MET 15MG-850MG Y THIAZOLIDINEDIONE/BIGUANIDE COMBO PODOFILOX 0.5% TOPICAL SOLUTION CONDYLOX 0.5% TOPICAL SOLUTION Y MITOTIC, TOPICAL POTASSIUM CHL [MICRO] ER 10MEQ TAB KLOR/CON/M 10MEQ TAB Y ELECTROLYTE SUPPLEMENT POTASSIUM CHL [MICRO] ER 20MEQ TAB KLOR/CON/M 20MEQ TAB Y ELECTROLYTE SUPPLEMENT POTASSIUM CITRATE 10MEQ (1080MG) TAB UROCIT-K 10 Y URINARY ALKALINIZING AGENT POTASSIUM CITRATE 5MEQ (540MG) TAB UROCIT-K 5 Y URINARY ALKALINIZING AGENT PRAVASTATIN 10MG TAB PRAVACHOL 10MG TAB Y ANTILIPEMIC AGENT/STATIN PRAVASTATIN 20MG TAB PRAVACHOL 20MG TAB Y ANTILIPEMIC AGENT/STATIN PRAVASTATIN 40MG TAB PRAVACHOL 40MG TAB Y ANTILIPEMIC AGENT/STATIN PRAVASTATIN 80MG TAB PRAVACHOL 80MG TAB Y ANTILIPEMIC AGENT/STATIN 1MG CAP MINIPRESS 1MG CAP Y ALPHA BLOCKER PRAZOSIN 2MG CAP MINIPRESS 2MG CAP Y ALPHA BLOCKER PRAZOSIN 5MG CAP MINIPRESS 5MG CAP Y ALPHA BLOCKER PREDNISOLONE 15MG/5ML SUSPENSION PEDIAPRED SUSP Y CORTICOSTEROID, SYSTEMIC PREDNISOLONE ACETATE 1% OPH SUSP PRED FORTE 1% OPH SUSP Y MAX 10ML/FILL OPHTHALMIC, CORTICOSTEROID PREDNISONE 10MG TAB CORTICOSTEROID, SYSTEMIC PREDNISONE 2.5MG TAB CORTICOSTEROID, SYSTEMIC PREDNISONE 20MG TAB CORTICOSTEROID, SYSTEMIC PREDNISONE 5MG TAB CORTICOSTEROID, SYSTEMIC PREMARIN 0.3MG TAB Y ESTROGEN DERIVATIVE PREMARIN 0.45MG TAB Y ESTROGEN DERIVATIVE PREMARIN 0.625MG TAB Y ESTROGEN DERIVATIVE PREMARIN 0.625MG/G VAGINAL CRM Y MAX 1 TUBE/30 DAYS MAX 3 TUBES/90 DAYS ESTROGEN DERIVATIVE PREMARIN 1.25MG TAB Y ESTROGEN DERIVATIVE PREMPRO 0.3/1.5MG TAB PACK Y MAX 1 PACK/28 DAYS MAX 3 PACKS/84 DAYS ESTROGEN/PROGESTIN COMBO PREMPRO 0.45/1.5MG TAB PACK Y MAX 1 PACK/28 DAYS MAX 3 PACKS/84 DAYS ESTROGEN/PROGESTIN COMBO PREMPRO 0.625/2.5MG TAB PACK Y MAX 1 PACK/28 DAYS MAX 3 PACKS/84 DAYS ESTROGEN/PROGESTIN COMBO PREMPRO 0.625/5MG TAB PACK Y MAX 1 PACK/28 DAYS MAX 3 PACKS/84 DAYS ESTROGEN/PROGESTIN COMBO PRENAT/CA/FE FUM/FA TAB PRENATAL PLUS Y WOMEN ONLY IN CHILD BEARING YEARS PRENATAL MULTIVITAMINS WITH MINERALS 250MG TAB MYSOLINE 250MG TAB Y ANTICONVULSANT, BARBITURATE PRIMIDONE 50MG TAB MYSOLINE 50MG TAB Y ANTICONVULSANT, BARBITURATE PRISTIQ 50MG TAB 18 ANTIDEPRESSANT, SNRI 25MG RECTAL SUPP COMPRO 25MG RECTAL SUPP Y MAX 12 SUPP/FILL/6 DAYS ANTIEMETIC PROCHLORPERAZINE MALEATE 10MG TAB COMPAZINE 10MG TAB Y ANTIEMETIC PROCTOZONE 2.5% RECTAL CREAM ANUSOL HC CREAM Y CORTICOSTEROID, RECTAL 12.5MG RECTAL SUPP PROMETHEGAN 12.5 SUPP Y MAX 12 SUPP/FILL ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY PROMETHAZINE 12.5MG TAB PHENERGAN 12.5MG TAB Y MAX 30 TABS PER 30 DAYS ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY PROMETHAZINE 25MG RECTAL SUPP PROMETHEGAN 25MG SUPP Y MAX 12 SUPP/FILL ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY PROMETHAZINE 25MG TAB PHENERGAN 25MG TAB Y MAX 30 TABS PER 30 DAYS ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 13 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY PROMETHAZINE 6.25MG/5ML ORAL SYRUP PHENERGAN SYRUP Y MAX 240ML/FILL ANTIHISTAMINE/ANTIEMETIC/ANTIANXIETY 10MG TAB INDERAL 10MG TAB Y BETA BLOCKER PROPRANOLOL 120MG 24 HOUR CR CAP INDERAL LA 120MG CAP Y BETA BLOCKER PROPRANOLOL 160MG 24 HOUR CR CAP INDERAL LA 160MG CAP Y BETA BLOCKER PROPRANOLOL 20MG TAB INDERAL 20MG TAB Y BETA BLOCKER PROPRANOLOL 40MG TAB INDERAL 40MG TAB Y BETA BLOCKER PROPRANOLOL 60MG 24 HOUR CR CAP INDERAL LA 60MG CAP Y BETA BLOCKER PROPRANOLOL 60MG TAB INDERAL 60MG TAB Y BETA BLOCKER PROPRANOLOL 80MG 24 HOUR CR CAP INDERAL LA 80MG CAP Y BETA BLOCKER PROPRANOLOL 80MG TAB INDERAL 80MG TAB Y BETA BLOCKER [PTU] 50MG TAB ANTITHYROID AGENT PROTOPIC 0.01% OINT 100GM IMMUNOSUPRESSANT PROTOPIC 0.01% OINT 30GM IMMUNOSUPRESSANT PROTOPIC 0.01% OINT 60GM IMMUNOSUPRESSANT PROTOPIC 0.03% OINT 100GM IMMUNOSUPRESSANT PROTOPIC 0.03% OINT 30GM IMMUNOSUPRESSANT PROTOPIC 0.03% OINT 60GM IMMUNOSUPRESSANT PULMICORT FLEXHALER 180MCG POWD INH Y 1 MAX 1 INH/30 DAYS MAX 3 INH/90 DAYS CORTICOSTEROID, INHALED PULMICORT FLEXHALER 90MCG POWD INH Y 1 MAX 1 INH/30 DAYS MAX 3 INH/90 DAYS CORTICOSTEROID, INHALED PYLERA 125/140/125MG CAPS ANITINFECTIVE COMBO 100MG TAB SEROQUEL 100MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL QUETIAPINE 200MG TAB SEROQUEL 200MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL QUETIAPINE 25MG TAB SEROQUEL 25MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL QUETIAPINE 300MG TAB SEROQUEL 300MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL QUETIAPINE 400MG TAB SEROQUEL 400MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL QUETIAPINE 50MG TAB SEROQUEL 50MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL RALOXIFENE 60MG TAB EVISTA 60MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS SELECTIVE ESTROGEN (SERM) RANOLAZINE 500MG RANEXA 500MG Y ANTIANGINAL, PFOX INHIBITORS RENAGEL 800MG TAB BINDING RIFAMPIN 300MG CAP RIFADIN 300MG CAP Y ANTI-TUBERCULAR 0.25MG TAB RISPERDAL 0.25MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL RISPERIDONE 0.5MG TAB RISPERDAL 0.5MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL RISPERIDONE 1MG TAB RISPERDAL 1MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL RISPERIDONE 2MG TAB RISPERDAL 2MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL RISPERIDONE 3MG TAB RISPERDAL 3MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL RISPERIDONE 4MG TAB RISPERDAL 4MG TAB Y 6 ANTIPSYCHOTIC, ATYPICAL ROPINIROLE 0.25MG TAB REQUIP 0.25MG TAB Y 18 ANTIPARKINSON AGENT ROPINIROLE 0.5MG TAB REQUIP 0.5MG TAB Y 18 ANTIPARKINSON AGENT ROPINIROLE 1MG TAB REQUIP 1MG TAB Y 18 ANTIPARKINSON AGENT ROPINIROLE 2MG TAB REQUIP 2MG TAB Y 18 ANTIPARKINSON AGENT ROPINIROLE 3MG TAB REQUIP 3MG TAB Y 18 ANTIPARKINSON AGENT ROPINIROLE 4MG TAB REQUIP 4MG TAB Y 18 ANTIPARKINSON AGENT ROPINIROLE 5MG TAB REQUIP 5MG TAB Y 18 ANTIPARKINSON AGENT ROSUVASTATIN 10MG TAB CRESTOR 10MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTILIPEMIC AGENT/STATIN ROSUVASTATIN 20MG TAB CRESTOR 20MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTILIPEMIC AGENT/STATIN ROSUVASTATIN 40MG TAB CRESTOR 40MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTILIPEMIC AGENT/STATIN ROSUVASTATIN 5MG TAB CRESTOR 5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ANTILIPEMIC AGENT/STATIN SULFIDE 2.5% LOTION TOPICAL SKIN PRODUCT SEREVENT 50MCG/BLISTER PWD DISKUS INH Y 4 MAX 1 INH/30 DAYS MAX 3 INH/90 DAYS BETA AGONIST, INHALED, LONG ACTING SERTRALINE 100MG TAB ZOLOFT 100MG TAB Y 6 ANTIDEPRESSANT, SSRI SERTRALINE 25MG TAB ZOLOFT 25MG TAB Y 6 ANTIDEPRESSANT, SSRI SERTRALINE 50MG TAB ZOLOFT 50MG TAB Y 6 ANTIDEPRESSANT, SSRI SF 1.1% GEL FLUORIDE PREVIDENT 1.1% GEL Y MAX 1 UNIT/30 DAYS MAX 3 UNITS/90 DAYS FLUORIDE SUPPLEMENT SHARPS CONTAINER MAX 1/FILL/30 DAYS DIABETIC SUPPLIES SILVER SULFADINE 1% TOP CRM SILVADENE 1% CRM Y ANTIFUNGAL/ANTIBACTERIAL, TOPICAL SODIUM POLYSTYRENE SULF 15G/4TSP PWD KAYEXALATE 15G/4TSP PWD Y POTASSIUM REMOVING RESIN 120MG TAB BETAPACE 120MG TAB Y BETA BLOCKER FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 14 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY SOTALOL 160MG TAB BETAPACE 160MG TAB Y BETA BLOCKER SOTALOL 240MG TAB BETAPACE 240MG TAB Y BETA BLOCKER SOTALOL 80MG TAB BETAPACE AF 80MG TAB Y BETA BLOCKER SPACER FOR INHALER (MAX AGE IS 12 YEARS OLD) 12 MAX 1 UNIT/180 DAYS PULMONARY DEVICE SPIRIVA HANDIHALER 18MCG Y 18 MAX 1 INH/30 DAYS MAX 3 INH/90 DAYS ANTICHOLINERGIC, INHALED SPIRONOLACTONE 100MG TAB ALDACTONE 100MG TAB Y POTASSIUM SPARING SPIRONOLACTONE 25MG TAB ALDACTONE 25MG TAB Y POTASSIUM SPARING SPIRONOLACTONE 50MG TAB ALDACTONE 50MG TAB Y POTASSIUM SPARING SUCRALFATE 1G TAB CARAFATE 1G TAB Y MAX 4 TABS /DAY MAX 4 TABS/DAY ANTI-ULCER SULFACETAMIDE SODIUM 10% OPH SOL BLEPH-10 OPH SOL Y OPHTHALMIC, ANTIBIOTIC SULFAMETH/TRIMETH DS 800/160MG TAB BACTRIM DS TAB Y SULFONAMIDE ANTIBIOTIC SYSTEMIC SULFAMETHOXAZ/TRIM 200/40MG/5ML SUSP SULFATRIM SUSP Y SULFONAMIDE ANTIBIOTIC SYSTEMIC SULFASALAZINE 500MG TAB AZULFADINE 500MG TAB Y 5-ASA DERIVATIVE, ORAL SUMATRIPTAN 100MG TAB IMITREX 100MG TAB Y 18 MAX 9 TABS/30 DAYS MAX 27 TABS/90 DAYS ANTI-MIGRAINE SUMATRIPTAN 25MG TAB IMITREX 25MG TAB Y 18 MAX 9 TABS/30 DAYS MAX 27 TABS/90 DAYS ANTI-MIGRAINE SUMATRIPTAN 50MG TAB IMITREX 50MG TAB Y 18 MAX 9 TABS/30 DAYS MAX 27 TABS/90 DAYS ANTI-MIGRAINE TAMOXIFEN 10MG TAB NOLVADEX 10MG TAB Y 18 MAX 30 TABS/ 30 DAYS MAX 90 TABS/90 DAYS SELECTIVE ESTROGEN RECEPTOR MODULATOR (SERM) TAMOXIFEN 20MG TAB NOLVADEX 20MG TAB Y 18 MAX 30 TABS/ 30 DAYS MAX 90 TABS/90 DAYS SELECTIVE ESTROGEN RECEPTOR MODULATOR (SERM) 0.4MG CAP FLOMAX 0.4MG CAP Y ALPHA BLOCKER TELMISARTAN/HCTZ 40MG/12.5MG TAB MICARDIS HCT 40MG/12.5MG TAB Y 18 ARB AGENT TELMISARTAN/HCTZ 80MG/12.5MG TAB MICARDIS HCT 80MG/12.5MG TAB Y 18 ARB AGENT TELMISARTAN/HCTZ 80MG/25MG TAB MICARDIS HCT 80MG/25MG TAB Y 18 ARB AGENT TEMAZEPAM 15MG CAP RESTORIL 15MG CAP 18 MAX 30 CAPS/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS BENZODIAZEPINE TEMAZEPAM 30MG CAP RESTORIL 30MG CAP 18 MAX 30 CAPS/30 DAYS/ALL STRENGTHS OF SAME DRUG CLASS BENZODIAZEPINE TERBINAFINE 250MG TAB LAMISIL 250MG TAB Y ANTIFUNGAL SYSTEMIC TERCONAZOLE 0.4% VAGINAL CREAM TERAZOL 7 VAGINAL CREAM Y MAX 1 TUBE/ FILL/WEEK ANTIFUNGAL, VAGINAL TERCONAZOLE 0.8% VAGINAL CREAM TERAZOL 3 VAGINAL CREAM Y MAX 1 TUBE/ FILL/3 DAYS ANTIFUNGAL, VAGINAL THEOPHYLLINE 100MG ER TAB PDE INHIBITOR/XANTHINE DERIVATIVE THEOPHYLLINE 200MG ER TAB PDE INHIBITOR/XANTHINE DERIVATIVE THEOPHYLLINE 300MG ER TAB PDE INHIBITOR/XANTHINE DERIVATIVE THIAMINE 100MG FOR SUD PATIENTS ONLY VITAMIN THIOTHIXENE 10MG CAP NAVANE 10MG CAP Y 18 ANTIPSYCHOTIC, TYPICAL THIOTHIXENE 1MG CAP NAVANE 1MG CAP Y 18 ANTIPSYCHOTIC, TYPICAL THIOTHIXENE 2MG CAP NAVANE 2MG CAP Y 18 ANTIPSYCHOTIC, TYPICAL THIOTHIXENE 5MG CAP NAVANE 5MG CAP Y 18 ANTIPSYCHOTIC, TYPICAL TIMOLOL MALEATE 0.25% OPH SOL TIMOPTIC 0.25% OPH SOL Y MAX 5ML/25 DAYS MAX 15ML/75 DAYS OPHTHALMIC, GLAUCOMA AGENT TIMOLOL MALEATE 0.5% OPH SOL TIMOPTIC 0.5% OPH SOL Y MAX 5ML/25 DAYS MAX 15ML/75 DAYS OPHTHALMIC, GLAUCOMA AGENT TOBRAMYCIN 0.3% OPH SOL TOBREX OPH SOL Y OPHTHALMIC, ANTIBIOTIC TOBRAMYCIN/DEX 0.3/0.1% OPH SUSP TOBRADEX OPH SUSP Y MAX 5ML/FILL OPHTHALMIC, ANTIBIOTIC/STEROID COMBO TOBRAMYCIN/DEXAMETH OPH OINT TOBRADEX OPH OINTMENT Y MAX 1 TUBE PER DISPENSE ANTI-INFECTIVES/STEROID COMBO, OPH 100MG TAB TOPAMAX 100MG TAB Y ANTICONVULSANT, MISCELLANEOUS TOPIRAMATE 200MG TAB TOPAMAX 200MG TAB Y ANTICONVULSANT, MISCELLANEOUS TOPIRAMATE 25MG TAB TOPAMAX 25MG TAB Y ANTICONVULSANT, MISCELLANEOUS TOPIRAMATE 50MG TAB TOPAMAX 50MG TAB Y ANTICONVULSANT, MISCELLANEOUS TRADJENTA 5MG TAB Y DPP-4 INHIBITOR TRANEXAMIC ACID 650MG LYSTEDA 650MG 12 MAX 30 TABS/PER FILL HEMOSTATIC 100MG TAB DESYREL 100MG TAB Y 6 ANTIDEPRESSANT, SARI TRAZODONE 150MG TAB DESYREL 150MG TAB Y 6 ANTIDEPRESSANT, SARI TRAZODONE 50MG TAB DESYREL 50MG TAB Y 6 ANTIDEPRESSANT, SARI TRIAMCINOLONE 0.025% CRM CORTICOSTEROID, TOPICAL TRIAMCINOLONE 0.1% CRM ARISTOCORT 0.1% CRM Y CORTICOSTEROID, TOPICAL TRIAMCINOLONE 0.1% OINT ARISTOCORT 0.1% OINT Y CORTICOSTEROID, TOPICAL TRIAMCINOLONE 0.5% CRM CORTICOSTEROID, TOPICAL TRIAMCINOLONE 0.5% OINT CORTICOSTEROID, TOPICAL /HCTZ 37.5/25MG TAB MAXZIDE-25 TAB Y DIURETIC, POTASSIUM SPARING/THIAZIDE TRIAMTERENE/HCTZ 75/50MG TAB MAXZIDE TAB Y DIURETIC, POTASSIUM SPARING/THIAZIDE TRIBENZOR 20MG-5MG-12.5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 15 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY TRIBENZOR 40MG-10MG-12.5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO TRIBENZOR 40MG-10MG-25MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO TRIBENZOR 40MG-5MG-12.5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO TRIBENZOR 40MG-5MG-25MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT/COMBO 10MG TAB STELAZINE 10MG TAB Y 18 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE TRIFLUOPERAZINE 1MG TAB STELAZINE 1MG TAB Y 18 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE TRIFLUOPERAZINE 2MG TAB STELAZINE 2MG TAB Y 18 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE TRIFLUOPERAZINE 5MG TAB STELAZINE 5MG TAB Y 18 ANTIPSYCHOTIC, TYPICAL PHENOTHIAZINE TRIFLURIDINE 1% OPH SOL VIROPTIC 1% OPH SOL Y OPHTHALMIC, ANTIVIRAL TRIHEXYPHENIDYL 2MG TAB ARTANE 2MG TAB Y 18 ANTIPARKINSON AGENT TRIHEXYPHENIDYL 5MG TAB ARTANE 5MG TAB Y 18 ANTIPARKINSON AGENT TRIMETHOBENZAMIDE 300MG CAP TIGAN 300MG CAP Y 3 ANTIEMETIC TRIPHROCAPS SOFTGEL CAP NEPHROCAPS SOFTGEL Y MAX 30 CAPS/30 DAYS MAX 90 CAPS/90 DAYS GU VITAMIN TRUE METRIX CONTROL SOLUTION Y MAX 1 UNIT/30 DAYS MAX 3 UNITS/90 DAYS DIABETIC SUPPLIES TRUE METRIX GLUCOSE MONITOR Y MAX 1 MONITOR/2 YEARS DIABETIC SUPPLIES TRUE METRIX TEST STRIPS Y MAX 2 BOXES/25 DAYS MAX 6 BOXES/75 DAYS DIABETIC SUPPLIES URSODIOL 300MG CAP ACTIGALL 300MG CAPS Y BILE ACID AGENT VALACYCLOVIR 500MG VALTREX 500MG Y ANTIVIRAL SYSTEMIC VALACYCLOVIR 1000MG VALTREX 1000MG Y ANTIVIRAL SYSTEMIC VALPROIC ACID 250MG CAP DEPAKENE 250MG CAP Y ANTICONVULSANT, HISTONE DEACETYLASE INHIBITOR VALPROIC ACID SYRUP 250MG/5ML ANTICONVULSANT, HISTONE DEACETYLASE INHIBITOR VALSARTAN 160MG TAB DIOVAN 160MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT VALSARTAN 320MG TAB DIOVAN 320MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT VALSARTAN 40MG TAB DIOVAN 40MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT VALSARTAN 80MG TAB DIOVAN 80MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT VALSARTAN/HCTZ 160MG-12.5MG TAB DIOVAN HCT 160MG-12.5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT VALSARTAN/HCTZ 160MG-25MG TAB DIOVAN HCT 160MG-25MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT VALSARTAN/HCTZ 320MG-12.5MG TAB DIOVAN HCT 320MG-12.5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT VALSARTAN/HCTZ 320MG-25MG TAB DIOVAN HCT 320MG-25MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT VALSARTAN/HCTZ 80MG-12.5MG TAB DIOVAN HCT 80MG-12.5MG TAB Y MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ARB AGENT VENLAFAXINE 100MG TAB EFFEXOR 100MG TAB Y 6 ANTIDEPRESSANT, SNRI VENLAFAXINE 25MG TAB EFFEXOR 25MG TAB Y 6 ANTIDEPRESSANT, SNRI VENLAFAXINE 37.5MG TAB EFFEXOR 37.5MG TAB Y 6 ANTIDEPRESSANT, SNRI VENLAFAXINE 75MG TAB EFFEXOR 75MG TAB Y 6 ANTIDEPRESSANT, SNRI VENLAFAXINE ER 150MG CAP EFFEXOR XR 150MG CAP Y 6 ANTIDEPRESSANT, SNRI VENLAFAXINE ER 37.5MG CAP EFFEXOR XR 37.5MG CAP Y 6 ANTIDEPRESSANT, SNRI VENLAFAXINE ER 75MG CAP EFFEXOR XR 75MG CAP Y 6 ANTIDEPRESSANT, SNRI 120MG TAB CALAN 120MG TAB Y CALCIUM CHANNEL BLOCKING AGENT VERAPAMIL 40MG TAB CALAN 40MG TAB Y CALCIUM CHANNEL BLOCKING AGENT VERAPAMIL 80MG TAB CALAN 80MG TAB Y CALCIUM CHANNEL BLOCKING AGENT VERAPAMIL ER 120MG TAB ISOPTIN SR 120MG TAB Y CALCIUM CHANNEL BLOCKING AGENT VERAPAMIL ER 180MG TAB ISOPTIN SR 180MG TAB Y CALCIUM CHANNEL BLOCKING AGENT VERAPAMIL ER 240MG TAB ISOPTIN SR 240MG TAB Y CALCIUM CHANNEL BLOCKING AGENT VIMOVO 375-20MG TAB Y MAX 60 TABS/30 DAYS MAX 180 TABS/90 DAYS NSAID/PPI COMBO VIMOVO 500-20MG TAB Y MAX 60 TABS/30 DAYS MAX 180 TABS/90 DAYS NSAID/PPI COMBO VITAMIN D 50,000 UNITS CAP Y VITAMIN VIVELLE-DOT 0.05MG/24HR PATCH Y ESTROGEN DERIVATIVE VIVELLE-DOT 0.075MG/24HR PATCH Y ESTROGEN DERIVATIVE VIVELLE-DOT 0.1MG/24HR PATCH Y ESTROGEN DERIVATIVE WARFARIN 10MG TAB COUMADIN 10MG TAB Y VITAMIN K ANTAGONIST WARFARIN 1MG TAB COUMADIN 1MG TAB Y VITAMIN K ANTAGONIST WARFARIN 2.5MG TAB COUMADIN 2.5MG TAB Y VITAMIN K ANTAGONIST WARFARIN 2MG TAB COUMADIN 2MG TAB Y VITAMIN K ANTAGONIST WARFARIN 3MG TAB COUMADIN 3MG TAB Y VITAMIN K ANTAGONIST WARFARIN 4MG TAB COUMADIN 4MG TAB Y VITAMIN K ANTAGONIST WARFARIN 5MG TAB COUMADIN 5MG TAB Y VITAMIN K ANTAGONIST WARFARIN 6MG TAB COUMADIN 6MG TAB Y VITAMIN K ANTAGONIST FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 16 of 17 HEALTH CARE DISTRICT PHARMACY 340B FORMULARY UPDATED 06/01/2021 BRAND EQUIVALENT PRODUCT 90 DAY HCD MIN HCD MAX SPECIFICATIONS SPECIFICATIONS MEDICATION (FOR REFERENCE ONLY) SUPPLY AGE AGE FOR 30 DAY SUPPLY FOR 90 DAY SUPPLY PHARMACOLOGICAL CATEGORY WARFARIN 7.5MG TAB COUMADIN 7.5MG TAB Y VITAMIN K ANTAGONIST XARELTO 10MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS FACTOR XA INHIBITOR XARELTO 15MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS FACTOR XA INHIBITOR XARELTO 20MG TAB Y 18 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS FACTOR XA INHIBITOR XOPENEX 0.63MG/3ML VIAL Y MAX 2 BOXES/36 DAYS MAX 5 BOXES/90 DAYS BETA AGONIST, INHALED XOPENEX 1.25MG/3ML VIAL Y MAX 2 BOXES/36 DAYS MAX 5 BOXES/90 DAYS BETA AGONIST, INHALED YASMIN 28-PACK Y 12 ORAL CONTRACEPTIVE YAZ 28-PACK Y 12 ORAL CONTRACEPTIVE ZENPEP 10000/34000/55000 UNIT DR EC CAP 25,000 AND 40,000 STRENGTH EXCLUDED DIGESTIVE ZENPEP 15000/51000/82000 UNIT DR EC CAP 25,000 AND 40,000 STRENGTH EXCLUDED DIGESTIVE ENZYMES ZENPEP 20000/68000/109000 UNIT DR EC CAP 25,000 AND 40,000 STRENGTH EXCLUDED DIGESTIVE ENZYMES ZENPEP 5000/17000/27000 UNIT DR EC CAP 25,000 AND 40,000 STRENGTH EXCLUDED DIGESTIVE ENZYMES ZETIA 10MG TAB Y 10 MAX 30 TABS/30 DAYS MAX 90 TABS/90 DAYS ABSORPTION INHIBITOR 20MG CAP GEODON 20MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIPSYCHOTIC, ATYPICAL ZIPRASIDONE 40MG CAP GEODON 40MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIPSYCHOTIC, ATYPICAL ZIPRASIDONE 60MG CAP GEODON 60MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIPSYCHOTIC, ATYPICAL ZIPRASIDONE 80MG CAP GEODON 80MG CAP Y 6 MAX 60 CAPS/30 DAYS MAX 180 CAPS/90 DAYS ANTIPSYCHOTIC, ATYPICAL 100MG CAP ZONEGRAN 100MG CAP Y ANTICONVULSANT, MISCELLANEOUS ZONISAMIDE 25MG CAP ZONEGRAN 250MG CAP Y ANTICONVULSANT, MISCELLANEOUS ZONISAMIDE 50MG CAP ZONEGRAN 50MG CAP Y ANTICONVULSANT, MISCELLANEOUS

FORMULARY FOR PATIENTS WHO MAINTAIN THE C.L. BRUMBACK PRIMARY CARE CLINICS AS A MEDICAL HOME FORMULATIONS AND STRENGTHS ARE SUBJECT TO CHANGE 17 of 17