HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Acetaminophen Tylenol 325 mg Analgesic Acetaminophen Acetaminophen Tylenol 500 mg Analgesic Acetaminophen Acetaminophen Tylenol 650 mg Analgesic Acetaminophen Acetaminophen/Oxycodone Percocet 325 mg-10 mg Analgesic Narcotic Acetaminophen/Oxycodone Percocet 325 mg-5 mg Analgesic Narcotic Acetaminophen/Codeine #3 Tylenol #3 300 mg-30 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325 mg-5 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325 mg-7.5 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325 mg-10 mg Analgesic Narcotic Acetaminophen/Hydrocodone Vicodin 500 mg-5 mg Analgesic Narcotic bitartrate Acetic acid Vosol 15 ml drops Otic Acetic acid/Hydrocortisone Vosol HC 2%-1% Otic Acyclovir Zovirax 200 mg Antimicrobials Antiviral Acyclovir Zovirax 400 mg Antimicrobials Antiviral Acyclovir Zovirax 800 mg Antimicrobials Antiviral Albuterol HFA (IDP) tablet, MDI, Proventil HFA (IDP) 90 mcg Respiratory Inhaler solution, UD Albuterol liquid Ventolin 2 mg/5 ml (120 cc) Respiratory Albuterol solution neb Proventil 5 mg/ml (20 cc bottle) Respiratory Nebulizer soln Albuterol Unit Dose Proventil 0.83 mg/ml Respiratory Albuterol-ipratropium Inhaler Combivent MDI Respiratory Alclometasone Cream Aclovate 45 gm Anti-inflammatory Agents Alclometasone Ointment Aclovate 45 gm Anti-inflammatory Agents Alendronate Fosamax 70 mg Osteoporosis Alendronate Fosamax 35 mg Osteoporosis Allopurinol Zyloprim 300 mg Gout Allopurinol Zyloprim 100 mg Gout Amantadine Symmetrel 50 mg/5 ml (120 cc) Neurologic Parkinson Amantadine Symmetrel 100 mg Neurologic Parkinson Amikacin Amikin 1000 mg/4 ml (4 cc) Antimicrobials Aminoglycoside Amikacin Amikin 500 mg/2 ml (2 cc) Antimicrobials Aminoglycoside Aminosalicylic acid Paser 4 g Antimicrobials Antitubercular

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 1 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Amiodarone Cordarone 400 mg Cardiovascular Antiarrythmic Amiodarone Cordarone 200 mg Cardiovascular Antiarrythmic Amitriptyline Elavil 50 mg Psychiatric Antidepressant Amitriptyline Elavil 25 mg Psychiatric Antidepressant Amitriptyline Elavil 10 mg Psychiatric Antidepressant Amitriptyline Elavil 75 mg Psychiatric Antidepressant Amitriptyline Elavil 100 mg Psychiatric Antidepressant Amlodipine Norvasc 5 mg Cardiovascular Calcium Channel Blockers Amlodipine Norvasc 2.5 mg Cardiovascular Calcium Channel Blockers Amlodipine Norvasc 10 mg Cardiovascular Calcium Channel Blockers Amoxicillin Amoxil 500 mg Antimicrobials Penicillins Amoxicillin Amoxil 250 mg/5 ml (150 cc) Antimicrobials Penicillins Amoxicillin Amoxil 250 mg Antimicrobials Penicillins Amoxicillin Amoxil 125 mg/5 ml (80 cc) Antimicrobials Penicillins Amoxicillin Amoxil 400 mg/5 ml Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 500 mg-125 mg Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 875 mg-125 mg Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 200 mg/5 ml (100 cc) Antimicrobials Penicillins Antipyrene, Benzocaine, Glycerine Auralgan 10 ml drops Otic dehyd Aspirin (acetylsalicylic acid, ASA) 325 mg Analgesic Salicylates Aspirin (acetylsalicylic acid, ASA) 81 mg Analgesic Salicylates Atenolol Tenormin 50 mg Cardiovascular Beta Blockers Atenolol Tenormin 25 mg Cardiovascular Beta Blockers Atenolol Tenormin 100 mg Cardiovascular Beta Blockers Cholesterol Lowering Atorvastatin Lipitor 10 mg Cardiovascular Agents Cholesterol Lowering Atorvastatin Lipitor 20 mg Cardiovascular Agents Cholesterol Lowering Atorvastatin Lipitor 40 mg Cardiovascular Agents Cholesterol Lowering Atorvastatin Lipitor 80 mg Cardiovascular Agents

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 2 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Azathioprine Imuran 50 mg Immunosupressive Azithromycin Zithromax 250 mg Antimicrobials Macrolides Baclofen Lioresal 10 mg Analgesic Muscle Relaxant Baclofen Lioresal 20 mg Analgesic Muscle Relaxant Beclomethasone dipropionate Qvar 80 mcg Respiratory Steroid inhaler Beclomethasone dipropionate Qvar 40 mcg Respiratory Steroid inhaler Belladonna alkaloids, phenobarbital Donnatal 16.2 mg GI Antispasmodics Benztropine mesylate Cogentin 2 mg Neurologic Parkinson Benztropine mesylate Cogentin 1 mg Neurologic Parkinson Benztropine mesylate Cogentin 0.5 mg Neurologic Parkinson Benztropine mesylate Cogentin 1 mg/ml (inj) Neurologic Parkinson Bismuth subsalicylate-metronidazole- Helidac Helicobacter pylori agent tetracycline Brimonidine tartrate solution Alphagan 0.2% Ophthalmic Glaucoma Brinzolamide Azopt 1% suspension Ophthalmic Glaucoma Bromocriptine Parlodel 2.5 mg Hypoprolactinemic Buprenorphine Butrans 10 mcg/hr Analgesic Opiate Agonist Buprenorphine Butrans 15 mcg/hr Analgesic Opiate Agonist Buprenorphine Butrans 5 mcg/hr Analgesic Opiate Agonist Buprenorphine Butrans 7.5 mcg/hr Analgesic Opiate Agonist Buprenorphine Subutex 2 mg Analgesic Opiate Agonist Mixed Opiate Buprenorphine/naloxone Suboxone 2 mg-0.5 mg Analgesic Agonist/Antagonist Mixed Opiate Buprenorphine/naloxone Suboxone 8 mg-2 mg Analgesic Agonist/Antagonist Bupropion XL Wellbutrin XL 150 mg Psychiatric Antidepressant Bupropion XL Wellbutrin XL 300 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 150 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 75 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 100 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 200 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 300 mg Psychiatric Antidepressant Buspirone HCI BuSpar 5 mg Psychiatric Other

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 3 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Buspirone HCI BuSpar 10 mg Psychiatric Other Buspirone HCI BuSpar 15 mg Psychiatric Other Buspirone HCI BuSpar 30 mg Psychiatric Other Butalbital/APAP/Caffeine Fioricet 50 mg-325 mg-40 mg Analgesic Misc Calcitriol Rocaltrol 0.25 mcg Vitamin Calcitriol Rocaltrol 0.5 mcg Vitamin Calcium acetate Phoslo 667 mg Phosphate binder Capsaicin 0.025% cream Derm Analgesic Capsaicin 0.075% cream Derm Analgesic Capsaicin 0.1% cream Derm Analgesic Captopril Capoten 50 mg Cardiovascular ACE Inhibitor Captopril Capoten 25 mg Cardiovascular ACE Inhibitor Captopril Capoten 12.5 mg Cardiovascular ACE Inhibitor Captopril Capoten 100 mg Cardiovascular ACE Inhibitor Carbamazepine Tegretol 200 mg Psychiatric Mood Stabilizer Carbamazepine Tegretol 100 mg Psychiatric Mood Stabilizer Carbamazepine Tegretol 100 mg/5 ml Psychiatric Mood Stabilizer Carbidopa/levodopa Sinemet 25 mg-250 mg Neurologic Parkinson Carbidopa/levodopa Sinemet 25 mg-100 mg Neurologic Parkinson Carbidopa/levodopa Sinemet 10 mg-100 mg Neurologic Parkinson Carbidopa/levodopa LA Sinemet CR 50-200 mg Neurologic Parkinson Carbidopa/levodopa LA Sinemet CR 25-100 mg Neurologic Parkinson Carisoprodol Soma 250 mg Muscle Relaxant Carvedilol Coreg 6.25 mg Cardiovascular Beta Blockers Carvedilol Coreg 3.125 mg Cardiovascular Beta Blockers Carvedilol Coreg 12.5 mg Cardiovascular Beta Blockers Carvedilol Coreg 25 mg Cardiovascular Beta Blockers Celecoxib Celebrex 100 mg Analgesic NSAID Celecoxib Celebrex 200 mg Analgesic NSAID Celecoxib Celebrex 400 mg Analgesic NSAID Celecoxib Celebrex 50 mg Analgesic NSAID Cephalexin Keflex 250 mg/5 ml (100 cc) Antimicrobials Cephalosporins Cephalexin Keflex 250 mg Antimicrobials Cephalosporins

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 4 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Cephalexin Keflex 125 mg/5 ml (200 cc) Antimicrobials Cephalosporins Cephalexin Keflex 500 mg Antimicrobials Cephalosporins Chlorpromazine Thorazine 50 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 25 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 200 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 100 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 10 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 30 mg/ml Psychiatric Antipsychotic Chlorpromazine Thorazine 100 mg/ml Psychiatric Antipsychotic Chlorthalidone Thalitone 25 mg Cardiovascular Diuretics Chlorthalidone Thalitone 50 mg Cardiovascular Diuretics Cimetidine Tagamet 400 mg GI H2 blockers Ciprofloxacin Cipro 500 mg Antimicrobials Quinolones Ciprofloxacin Cipro 250 mg Antimicrobials Quinolones Ciprofloxacin eye drop Ciloxan 0.3% Ophthalmic Citalopram Hydrobromide Celexa 40 mg Psychiatric Antidepressant Citalopram Hydrobromide Celexa 20 mg Psychiatric Antidepressant Citalopram Hydrobromide Celexa 10 mg Psychiatric Antidepressant Citalopram Hydrobromide Celexa 10 mg/5 ml Psychiatric Antidepressant Clarithromycin Biaxin 500 mg Antimicrobials Clindamycin Cleocin 150 mg Antimicrobials Misc Clindamycin Cleocin 300 mg Antimicrobials Misc Clindamycin topical gel, lotion Cleocin 1% Derm Acne Clindamycin topical solution Cleocin-T 1% (60 cc) Derm Acne Clobetasol lotion Temovate 0.05% Derm Clobetasol propionate Temovate 0.05% crm (15 Gms) Derm Antiinflammatory Clobetasol propionate Temovate 0.05% oint (30 Gms) Derm Antiinflammatory Clobetasol propionate Temovate 0.05% oint (15 Gms) Derm Antiinflammatory Clomipramine Anafranil 75 mg Psychiatric Antidepressant Clomipramine Anafranil 50 mg Psychiatric Antidepressant Clomipramine Anafranil 25 mg Psychiatric Antidepressant Clonazepam (SCH IV) Klonopin 2 mg Psychiatric Benzos Clonazepam (SCH IV) Klonopin 1 mg Psychiatric Benzos

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 5 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Clonazepam (SCH IV) Klonopin 0.5 mg Psychiatric Benzos Clonidine HCI tabs Catapres 0.1 mg Cardiovascular Central Alpha Agonist Clonidine HCI tabs Catapres 0.2 mg Cardiovascular Central Alpha Agonist Clonidine HCI tabs Catapres 0.3 mg Cardiovascular Central Alpha Agonist Platelet aggregation Clopidogrel Plavix 75 mg inhibitor Colchicine Colcrys 0.6 mg Gout Conjugated Estrogen Cream Premarin 0.625 mg/g crm (43 Gm) Hormone Replacement Cortisporin otic soln 1%-0.35%-10000u/mL (10 ml) Otic Cortisporin otic susp drops (10 ml) Otic Cromolyn inhaler Intal 14.2 Gm Respiratory Cyclobenzaprine Flexeril 10 mg Analgesic Muscle Relaxant Cycloserine Seromycin 250 mg Antimicrobials Antitubercular Dextroamphetamine/amphetamine Adderall XR 10 mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 15 mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 20 mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 30 mg Psychiatric Stimulant Diabetes supplies - glucometer Diabetes Diabetes supplies - lancets Diabetes Diabetes supplies - syringes/needles Diabetes Diabetes supplies - test strips Diabetes Diabetes supplies - testing control Diabetes solution Diazepam (SCH IV) Valium 5 mg Psychiatric Benzos Diazepam (SCH IV) Valium 2 mg Psychiatric Benzos Diazepam (SCH IV) Valium 10 mg Psychiatric Benzos Diclofenac Pennsaid 2% sol Derm NSAID Diclofenac Voltaren 50 mg Analgesic NSAID Diclofenac Voltaren 75 mg Analgesic NSAID Dicloxacillin Dynapen 500 mg Antimicrobials Penicillins Dicloxacillin Dynapen 250 mg Antimicrobials Penicillins Dicyclomine Bentyl 20 mg GI Antispasmodics Dicyclomine Bentyl 10 mg GI Antispasmodics Digoxin Lanoxin 0.25 mg Cardiovascular Glycosides

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 6 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Digoxin Lanoxin 0.125 mg Cardiovascular Glycosides Dilitiazem HCI Cardizem LA 180 mg Cardiovascular Calcium Channel Blockers Diltiazem Cardizem 120 mg Cardiovascular Calcium Channel Blockers Cardizem CD, Diltiazem Dilacor Xr, Cartia 90 mg Cardiovascular Calcium Channel Blockers XL, Dilt-CD Cardizem CD, Diltiazem Dilacor Xr, Cartia 60 mg Cardiovascular Calcium Channel Blockers XL, Dilt-CD Diltiazem SR Cardizem SR 300 mg Cardiovascular Calcium Channel Blockers Diltiazem SR Cardizem SR 240 mg Cardiovascular Calcium Channel Blockers Diltiazem SR Cardizem SR 180 mg Cardiovascular Calcium Channel Blockers Diltiazem SR Cardizem SR 120 mg Cardiovascular Calcium Channel Blockers Diltiazem CD Cardizem CD 360 mg Cardiovascular Calcium Channel Blockers Diltiazem CD Cardizem CD 90 mg Cardiovascular Calcium Channel Blockers Diltiazem CD Cardizem CD 60 mg Cardiovascular Calcium Channel Blockers Diltiazem CD Cardizem CD 300 mg Cardiovascular Calcium Channel Blockers Diltiazem CD Cardizem CD 30 mg Cardiovascular Calcium Channel Blockers Diltiazem CD Cardizem CD 240 mg Cardiovascular Calcium Channel Blockers Diltiazem CD Cardizem CD 180 mg Cardiovascular Calcium Channel Blockers Diltiazem CD Cardizem CD 120 mg Cardiovascular Calcium Channel Blockers Diphenhydramine Benadryl 25, 50 mg capsules Cold, Cough, Allergy Antihistamine Diphenhydramine Benadryl 12.5 mg/ 5ml Cold, Cough, Allergy Antihistamine Diphenhydramine Benadryl 50 mg/ml (inj) Cold, Cough, Allergy Antihistamine Diphenoxylate-atropine Lomotil 2.5 mg-0.025 mg GI Antidiarrhea Diphenoxylate-atropine (SCH V) Lomotil 2.5 mg-0.025 mg/5 ml (60 ml) GI Antidiarrhea Dipyridamole Persantine 25 mg Cardiovascular Anticoagulants Dipyridamole Persantine 50 mg Cardiovascular Anticoagulants Dipyridamole Persantine 75 mg Cardiovascular Anticoagulants Divalproex sodium Depakote DR 125 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote DR 500 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote DR 250 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote ER 250 mg Psychiatric Mood Stabilizer

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 7 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Divalproex sodium Depakote ER 500 mg Psychiatric Mood Stabilizer Dolutegravir Tivicay 10 mg Antiretrovirals Integrase Inhibitor Dolutegravir Tivicay 25 mg Antiretrovirals Integrase Inhibitor Dolutegravir Tivicay 50 mg Antiretrovirals Integrase Inhibitor Doxazosin mesylate Cardura 8 mg Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 4 mg Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 2 mg Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 1 mg Cardiovascular Alpha-1 blocker Doxepin HCL Sinequan 50 mg Psychiatric Antidepressant Doxepin HCL Sinequan 25 mg Psychiatric Antidepressant Doxepin HCL Sinequan 10 mg Psychiatric Antidepressant Doxepin HCL Sinequan 75 mg Psychiatric Antidepressant Doxepin HCL Sinequan 100 mg Psychiatric Antidepressant Doxepin HCL Sinequan 150 mg Psychiatric Antidepressant Doxycycline Doryx Vibramycin 50 mg Antimicrobials Tetracyclines Doxycycline Doryx Vibramycin 100 mg Antimicrobials Tetracyclines Duloxetine Cymbalta 20 mg Psychiatric Antidepressant Duloxetine Cymbalta 30 mg Psychiatric Antidepressant Duloxetine Cymbalta 40 mg Psychiatric Antidepressant Duloxetine Cymbalta 60 mg Psychiatric Antidepressant Econazole Spectazole 1% crm 15 Gm (15 Gm) Antimicrobials Antifungals Econazole Spectazole 1% crm 85 Gm (85 Gm) Antimicrobials Antifungals Econazole Spectazole 1% crm 30 Gm (30 Gm) Antimicrobials Antifungals Reverse Transcriptase Emtricitabine and tenofovir disoproxil Truvada 200-300 mg Antiretrovirals Inhibitor, fumarate Nucleoside/Nucleotide Enalapril maleate Vasotec 5 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 20 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 2.5 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 10 mg Cardiovascular ACE Inhibitor Enalapril maleate/Hctz Vaseretic 10 mg-25 mg Cardiovascular Antihypertensive Enalapril maleate/Hctz Vaseretic 5 mg-12.5 mg Cardiovascular Antihypertensive Erythromycin eye ointment 5 mg / Gm (3.5 Gm) Ophthalmic

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 8 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Erythromycin gel or solution Erygel 2% Derm Acne Erythromycin stearate Ery-Tab 500 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 250 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 333 mg Antimicrobials Macrolides Escitalopram Lexapro 10 mg Psychiatric Antidepressant Escitalopram Lexapro 20 mg Psychiatric Antidepressant Escitalopram Lexapro 5 mg Psychiatric Antidepressant Estradiol Estrace 2 mg Hormone Replacement Estradiol Estrace 1 mg Hormone Replacement Estradiol Estrace 0.5 mg Hormone Replacement Ethambutol Myambutol 400 mg Antimicrobials Antitubercular Ethambutol Myambutol 100 mg Antimicrobials Antitubercular Ethionamide Trecator 250 mg Antimicrobials Antitubercular Exenatide Byetta 10 mcg/0.04 mL (2.4 mL) Diabetes GLP-1 Receptor Agonist Exenatide Byetta 5 mcg/0.02 mL (1.2 mL) Diabetes GLP-1 Receptor Agonist Famotidine Pepcid 20 mg GI H2 Antagonists Famotidine Pepcid 40 mg GI H2 Antagonists Cholesterol Lowering Fenofibrate Tricor 145 mg Cardiovascular Agents Cholesterol Lowering Fenofibrate Tricor 48 mg Cardiovascular Agents Finasteride Proscar 5 mg Genitourinary 5-alpha reductase inhibitor Fluconazole Diflucan 200 mg Antimicrobials Antifungals Fluconazole Diflucan 150 mg Antimicrobials Antifungals Fluconazole Diflucan 100 mg Antimicrobials Antifungals Fludrocortisone Florinef 0.2 mg Adrenals Fludrocortisone Florinef 0.1 mg Endocrine Flunisolide Nasarel 25 mcg/spray (0.025%) Cold, Cough, Allergy Nasal Steroids Fluocinolone acetonide Synalar 0.025% cream Derm Antiinflammatory Fluocinolone acetonide Synalar 0.01% cream Derm Antiinflammatory Fluocinolone acetonide Synalar 0.025% ointment Derm Antiinflammatory Fluocinolone acetonide Synalar 0.01% ointment Derm Antiinflammatory Fluocinolone acetonide Synalar 0.025%, 0.01% solution, 60 ml Derm Antiinflammatory

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 9 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Fluocinonide Lidex 0.05% gel (60 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% solution 60 ml Derm Antiinflammatory Fluocinonide Lidex 0.05% oint (60 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% oint (30 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% oint (15 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% cream (60 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% cream (30 gm) Derm Antiinflammatory Fluoxetine Prozac 20 mg Psychiatric Antidepressant Fluoxetine Prozac 10 mg Psychiatric Antidepressant Fluoxetine Prozac 40 mg Psychiatric Antidepressant Fluoxetine Prozac 20 mg/5 ml Psychiatric Antidepressant Fluphenazine Prolixin 5 mg/ml Psychiatric Antipsychotic Fluphenazine Prolixin 0.5 mg/ml Psychiatric Antipsychotic Fluphenazine Prolixin 2.5 mg Psychiatric Antipsychotic Fluphenazine Prolixin 10 mg Psychiatric Antipsychotic Fluphenazine Prolixin 1 mg Psychiatric Antipsychotic Fluphenazine decanoate Prolixin 25 mg/ml (inj) Psychiatric Antipsychotic Fluticasone propionate Flonase 50 mcg/spray Respiratory Nasal Inhaler Folic Acid 800 MicroGrams Vitamin Furosemide Lasix 80 mg Cardiovascular Diuretics Furosemide Lasix 40 mg Cardiovascular Diuretics Furosemide Lasix 20 mg Cardiovascular Diuretics Gabapentin Neurontin 300 mg Neurologic Anticonvulsant Gabapentin Neurontin 100 mg Neurologic Anticonvulsant Gabapentin Neurontin 400 mg Neurologic Anticonvulsant Gabapentin Neurontin 600 mg Neurologic Anticonvulsant Cholesterol Lowering Gemfibrozil Lopid 600 mg Cardiovascular Agents Gentamicin eye drops Garamycin 0.3% (5 ml) Ophthalmic Glipizide Glucotrol 5 mg Diabetes Sulfonylureas Glipizide Glucotrol 10 mg Diabetes Sulfonylureas Glyburide Micronase Diabeta 5 mg Diabetes Sulfonylureas Glyburide Micronase Diabeta 2.5 mg Diabetes Sulfonylureas

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 10 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Glyburide Micronase Diabeta 1.25 mg Diabetes Sulfonylureas Griseofulvin micro liquid Grifulvin V 125 mg/5 mL (120 ml) Antimicrobials Antifungals Griseofulvin ultramicro Grisactin Fulvicin 250 mg Antimicrobials Antifungals Griseofulvin ultramicro Grisactin Fulvicin 125 mg Antimicrobials Antifungals Guaifenesin/Codeine Robitussin AC 100 mg-10 mg/5 ml Cold, Cough, Allergy Antitussive Haloperidol Haldol 5 mg Psychiatric Antipsychotic Haloperidol Haldol 2 mg Psychiatric Antipsychotic Haloperidol Haldol 1 mg Psychiatric Antipsychotic Haloperidol Haldol 0.5 mg Psychiatric Antipsychotic Haloperidol Haldol 2 mg/ml (15 ml) Psychiatric Antipsychotic Haloperidol Haldol 2 mg/ml (120 ml) Psychiatric Antipsychotic Haloperidol Haldol 10 mg Psychiatric Antipsychotic Haloperidol Haldol 20 mg Psychiatric Antipsychotic Haloperidol decanoate Haldol 50 mg/ml (inj) Psychiatric Antipsychotic Haloperidol decanoate Haldol 100 mg/ml (inj) Psychiatric Antipsychotic Hydralazine Apresoline 50 mg Cardiovascular Other Vasodilators Hydralazine Apresoline 25 mg Cardiovascular Other Vasodilators Hydralazine Apresoline 100 mg Cardiovascular Other Vasodilators Hydralazine Apresoline 10 mg Cardiovascular Other Vasodilators Hydrochlorothiazide Esidrix 25 mg Cardiovascular Diuretics Hydrochlorothiazide Esidrix 50 mg Cardiovascular Diuretics Hydrochlorothiazide Microzide 12.5 mg cap Cardiovascular Diuretics Hydrocortisone HC 2.5% lotion Derm Antiinflammatory Hydrocortisone HC 5 mg Derm Antiinflammatory Hydrocortisone HC 10 mg Derm Antiinflammatory Hydrocortisone HC 20 mg Derm Antiinflammatory Hydrocortisone cream Cortizone 2.5% Derm Antiinflammatory Hydrocortisone ointment Cortizone 2.5% Derm Antiinflammatory Hydrocortisone Suppositories Cortizone 25 mg GI Antiinflammatory Hydroxychloroquine Plaquenil 200 mg Rheumatology Hydroxyzine HCL Atarax 25 mg Cold, Cough, Allergy Antihistamine Hydroxyzine HCL Atarax 10 mg Cold, Cough, Allergy Antihistamine Hydroxyzine HCL Atarax 10 mg/5 ml (120 ml) Cold, Cough, Allergy Antihistamine

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 11 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Hydroxyzine HCL Atarax 50 mg Cold, Cough, Allergy Antihistamine Ibuprofen Motrin 400 mg Analgesic NSAID Ibuprofen Motrin 600 mg Analgesic NSAID Ibuprofen Motrin 800 mg Analgesic NSAID Imipramine Tofranil 50 mg Psychiatric Antidepressant Imipramine Tofranil 25 mg Psychiatric Antidepressant Imipramine Tofranil 10 mg Psychiatric Antidepressant Indomethacin Indocin 50 mg Analgesic NSAID Indomethacin Indocin 25 mg Analgesic NSAID Insulin 70/30 Humulin, Novolin U100 (10 ml) Diabetes Insulin Product Insulin glargine Lantus 100 IU/mL Diabetes Insulin Product Insulin Lispro Humalog 100U/mL Diabetes Insulin Product Insulin NPH Humulin N U100 (10 ml) Diabetes Insulin Product Insulin Regular Humulin R U100 (10 ml) Diabetes Insulin Product Insulin Regular Humulin R U500 Diabetes Insulin Product Insulin Regular Humulin R Kwikpen U500 Diabetes Insulin Product Ipratropium bromide 0.02% Atrovent Inh Sol 500 mcg (3 cc/amp) Respiratory Nebulizer soln Ipratropium MDI Atrovent 18mcg/dose MDI (14gm) Respiratory Asthma Isoniazid INH 300 mg Antimicrobials Antitubercular Isoniazid INH 100 mg Antimicrobials Antitubercular Isoniazid INH 10 mg / ml Antimicrobials Antitubercular Isosorbide dinitrate Isordil 5 mg Cardiovascular Nitrate Vasodilators Isosorbide dinitrate Isordil 20 mg Cardiovascular Nitrate Vasodilators Isosorbide dinitrate Isordil 10 mg Cardiovascular Nitrate Vasodilators Isosorbide dinitrate Isordil 30 mg Cardiovascular Nitrate Vasodilators Isosorbide mononitrate IR, SR Imdur 60 mg Cardiovascular Nitrate Vasodilators Isosorbide mononitrate IR, SR Imdur 30 mg Cardiovascular Nitrate Vasodilators Isosorbide mononitrate IR, SR Imdur 10 mg Cardiovascular Nitrate Vasodilators Isosorbide mononitrate IR, SR Imdur 20 mg Cardiovascular Nitrate Vasodilators Isosorbide mononitrate IR, SR Imdur 120 mg Cardiovascular Nitrate Vasodilators Ketoconazole Nizoral 200 mg (tabs) Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (60 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (30 Gm) Antimicrobials Antifungals

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 12 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Ketoconazole Nizoral 2% crm (15 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% shampoo Antimicrobials Antifungals Ketotifen Alaway 0.025% Ophthalmic Labetalol HCL Trandate 200 mg Cardiovascular Beta Blockers Labetalol HCL Trandate 100 mg Cardiovascular Beta Blockers Labetalol HCL Trandate 300 mg Cardiovascular Beta Blockers Lactulose Duphalac 10g/15 ml syrup GI Laxatives Lamotrigine Lamictal 25 mg tab Neurologic Anticonvulsant Lamotrigine Lamictal 200 mg tab Neurologic Anticonvulsant Lamotrigine Lamictal 150 mg tab Neurologic Anticonvulsant Lamotrigine Lamictal 100 mg tab Neurologic Anticonvulsant Latanoprost Xalatan 0.005% Ophthalmic Levetiracetam Keppra 500 mg Neurologic Levetiracetam Keppra 750 mg Neurologic Levetiracetam Keppra 1000 mg Neurologic Levofloxacin Levaquin 500 mg Antimicrobials Levothyroxine Levoxyl 0.3 mg Endocrine Thyroid Levothyroxine Levoxyl 0.2 mg Endocrine Thyroid Levothyroxine Levoxyl 0.175 mg Endocrine Thyroid Levothyroxine Levoxyl 0.15 mg Endocrine Thyroid Levothyroxine Levoxyl 0.125 mg Endocrine Thyroid Levothyroxine Levoxyl 0.112 mg Endocrine Thyroid Levothyroxine Levoxyl 0.1 mg Endocrine Thyroid Levothyroxine Levoxyl 0.088 mg Endocrine Thyroid Levothyroxine Levoxyl 0.075 mg Endocrine Thyroid Levothyroxine Levoxyl 0.050 mg Endocrine Thyroid Levothyroxine Levoxyl 0.025 mg Endocrine Thyroid Levothyroxine Levoxyl 0.137 mg Endocrine Thyroid Lidocaine 4% cream Derm Anesthetic Lidocaine 4% solution Derm Anesthetic Lidocaine 5% cream Derm Anesthetic Lidocaine 5% ointment Derm Anesthetic Linezolid Zyvox 600 mg Antimicrobials Oxazolidinone

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 13 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Lisinopril Prinivil, Zestril 5 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 20 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 40 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 2.5 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 10 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 30 mg Cardiovascular ACE Inhibitor Lisinopril/Hctz Zestoretic 10 mg-12.5 mg Cardiovascular Antihypertensive Lisinopril/Hctz Zestoretic 20 mg-12.5 mg Cardiovascular Antihypertensive Lisinopril/Hctz Zestoretic 20 mg-25 mg Cardiovascular Antihypertensive Lithium carbonate Eskalith CR 300 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith CR 150 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith SR 300 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith SR 450 mg Psychiatric Mood Stabilizer Loratadine Claritin 10 mg Antihistamine Lorazepam (SCH IV) Ativan 2 mg Psychiatric Benzos Lorazepam (SCH IV) Ativan 1 mg Psychiatric Benzos Lorazepam (SCH IV) Ativan 0.5 mg Psychiatric Benzos Losartan Cozaar 25 mg Cardiovascular Angiotensin II Blocker Losartan Cozaar 50 mg Cardiovascular Angiotensin II Blocker Losartan Cozaar 100 mg Cardiovascular Angiotensin II Blocker Losartan/Hctz Hyzaar 100 mg-12.5 mg Cardiovascular Antihypertensive Losartan/Hctz Hyzaar 100 mg-25 mg Cardiovascular Antihypertensive Losartan/Hctz Hyzaar 50 mg-12.5 mg Cardiovascular Antihypertensive Cholesterol Lowering Lovastatin Mevacor 10, 20, 40 mg Cardiovascular Agents Loxapine Loxitane 5, 10, 25, 50 mg Psychiatric Antipsychotic Meclizine Antivert 25 mg tabs Neurologic Misc Medroxyprogesterone Provera 5 mg Hormone Replacement Medroxyprogesterone Provera 2.5 mg Hormone Replacement Medroxyprogesterone Provera 10 mg Hormone Replacement Mesalamine Asacol 400 mg GI Anti-inflammatory bowel Metformin Glucophage 500 mg Diabetes Biguanides Metformin Glucophage 850 mg Diabetes Biguanides

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 14 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Metformin Glucophage 1000 mg Diabetes Biguanides Metformin ER Glucophage XR 500 mg Diabetes Biguanides Metformin ER Glucophage XR 750 mg Diabetes Biguanides Metformin ER Glucophage XR 1000 mg Diabetes Biguanides Methadone 5 mg Analgesic Narcotic Methadone 10 mg Analgesic Narcotic Methimazole Tapazole 5 mg Endocrine Thyroid Methimazole Tapazole 10 mg Endocrine Thyroid Methocarbamol Robaxin 500 mg Analgesic Muscle Relaxant Methocarbamol Robaxin 750 mg Analgesic Muscle Relaxant Methotrexate Rheumatrex 2.5 mg Chemotherapy Methyldopa Aldomet 500 mg Cardiovascular Central Alpha Agonist Methyldopa Aldomet 250 mg Cardiovascular Central Alpha Agonist Methylphenidate long-acting Ritalin LA 10 mg Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 20 mg Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 30 mg Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 40 mg Psychiatric Stimulant Methylphenidate short acting Ritalin 10 mg Psychiatric Stimulant Methylphenidate short acting Ritalin 20 mg Psychiatric Stimulant Methylphenidate short acting Ritalin 30 mg Psychiatric Stimulant Metoclopramide Reglan 10 mg GI Antiemetic Metoclopramide hcl Reglan 5 mg GI Antiemetic Metolazone Zaroxolyn 5 mg Cardiovascular Diuretics Metolazone Zaroxolyn 10 mg Cardiovascular Diuretics Metolazone Zaroxolyn 2.5 mg Cardiovascular Diuretics Metoprolol succinate Toprol XL 50 mg Cardiovascular Beta Blockers Metoprolol succinate Toprol XL 25 mg Cardiovascular Beta Blockers Metoprolol succinate Toprol XL 100 mg Cardiovascular Beta Blockers Metoprolol tartrate Lopressor 50 mg Cardiovascular Beta Blockers Metoprolol tartrate Lopressor 100 mg Cardiovascular Beta Blockers Metoprolol tartrate Lopressor 25 mg Cardiovascular Beta Blockers Metronidazole Flagyl 250 mg Antimicrobials Misc Metronidazole Flagyl 500 mg Antimicrobials Misc

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 15 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Metronidazole cream Metrocream 0.075% Antimicrobials Misc Metronidazole cream Metrocream 0.75% Derm Acne Metronidazole topical gel Metrogel 0.75% Derm Acne Mirtazapine Remeron 45 mg Psychiatric Antidepressant Mirtazapine Remeron 30 mg Psychiatric Antidepressant Mirtazapine Remeron 15 mg Psychiatric Antidepressant Misoprostol Cytotec 100 mg GI Misoprostol Cytotec 200 mg GI Montelukast Singulair 5 mg chew Respiratory Montelukast Singulair 10 mg Respiratory Morphine sulfate liquid MS 20 mg/5 ml Analgesic Narcotic Morphine sulfate short acting MS 15 mg Analgesic Narcotic Morphine sulfate short acting MS 30 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 15 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 30 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 60 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 100 mg Analgesic Narcotic Moxifloxacin Avelox 400 mg Antimicrobials Quinolones Mupirocin Bactroban 2% ointment Derm Antimicrobial Nabumetone Relafen 750 mg Analgesic NSAID Naloxone Narcan 0.4 mg/ml Toxicology Agents Opiate Antagonists Naloxone Narcan 1 mg/ml Toxicology Agents Opiate Antagonists Naproxen Naprosyn 250 mg Analgesic NSAID Naproxen Naprosyn 375 mg Analgesic NSAID Naproxen Naprosyn 500 mg Analgesic NSAID Niacin IR & ER tabs only 500 mg Cardiovascular Niacin IR & ER tabs only 100 mg Cardiovascular Niacin IR & ER tabs only 250 mg Cardiovascular Nicotine Gum 2 mg Smoking deterrents Nicotine Gum 4 mg Smoking deterrents Nicotine Lozenge 2 mg Smoking deterrents Nicotine Lozenge 4 mg Smoking deterrents Nicotine Patches- 28 weeks NicoDerm 7 mg Smoking deterrents

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 16 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Nicotine Patches- 28 weeks NicoDerm 14 mg Smoking deterrents Nicotine Patches- 28 weeks NicoDerm 21 mg Smoking deterrents Procardia, Adalat Nifedipine SR 90 mg Cardiovascular Calcium Channel Blockers CC, Nifediac Procardia, Adalat Nifedipine SR 60 mg Cardiovascular Calcium Channel Blockers CC, Nifediac Procardia, Adalat Nifedipine SR 30 mg Cardiovascular Calcium Channel Blockers CC, Nifediac Nitrofurantoin macrocryst Macrodantin 50 mg Antimicrobials Misc Nitrofurantoin macrocryst Macrodantin 100 mg Antimicrobials Misc Nitrofurantoin monohydrate Macrobid 100 mg Antimicrobials Misc Nitroglycerine SL Nitrostat 0.4 mg Cardiovascular Nitrate Vasodilators Norethindrone Aygestin 5 mg Hormone Replacement Progestins Nortriptyline Pamelor 75 mg Psychiatric Antidepressant Nortriptyline Pamelor 50 mg Psychiatric Antidepressant Nortriptyline Pamelor 25 mg Psychiatric Antidepressant Nortriptyline Pamelor 10 mg Psychiatric Antidepressant Nystatin (cream or ointment) Derm Antifungals Nystatin oral suspension 100,000 units/ml Antimicrobials Antifungals Olanzapine Zyprexa 5 mg Psychiatric Antipsychotic Olanzapine Zyprexa 2.5mg Psychiatric Antipsychotic Omeprazole Prilosec 20 mg GI PPI Oseltamivir Tamiflu 75mg Antimicrobials Antiviral Oseltamivir Tamiflu 12 mg/ml Antimicrobials Antiviral Oxybutynin Ditropan 5 mg Genitourinary Paroxetine Paxil 40 mg Psychiatric Antidepressant Paroxetine Paxil 20 mg Psychiatric Antidepressant Paroxetine Paxil 30 mg Psychiatric Antidepressant Paroxetine Paxil 10 mg Psychiatric Antidepressant Paroxetine Paxil 10 mg/5 ml Psychiatric Antidepressant Penicillin VK Veetids 500 mg Antimicrobials Penicillins Penicillin VK Veetids 250 mg/5 ml (100 cc) Antimicrobials Penicillins Penicillin VK Veetids 250 mg Antimicrobials Penicillins

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 17 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Penicillin VK Veetids 125 mg/5 ml (200 cc) Antimicrobials Penicillins Penicillin VK Veetids 250 mg/5 ml (150 cc) Antimicrobials Penicillins Pentoxifylline ER Trental 400 mg Hemorrheologic Agents Permethrin cream Elimite 5% (60 Gm) Derm Scabicide and Lice Perphenazine Trilafon 8 mg Psychiatric Antipsychotic Perphenazine Trilafon 4 mg Psychiatric Antipsychotic Perphenazine Trilafon 2 mg Psychiatric Antipsychotic Perphenazine Trilafon 16 mg / 5 cc (120 ml) Psychiatric Antipsychotic Perphenazine Trilafon 16 mg Psychiatric Antipsychotic Phenazopyridine HCL Pyridium 200 mg Genitourinary Phenazopyridine HCL Pyridium 100 mg Genitourinary Phenobarbital (SCH IV) 30 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 100 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 60 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 15 mg Neurologic Anticonvulsant Phenytoin Dilantin 100 mg Neurologic Anticonvulsant Phenytoin Dilantin 50 mg Neurologic Anticonvulsant Pioglitazone hydrochloride Actos 15 mg Diabetes Thiazolidinediones Pioglitazone hydrochloride Actos 30 mg Diabetes Thiazolidinediones Pioglitazone hydrochloride Actos 45 mg Diabetes Thiazolidinediones Polyethylene glycol Miralax 238 g GI Polyethylene glycol Miralax 510 g GI Polyethylene glycol electrolyte Mix Golytely 240 g GI Prep solution Polymyxin b- trimethoprim Polytrim 10 mL drops Ophthalmic Polymyxin b- trimethoprim Polytrim 3.5 gm ointment Ophthalmic Potassium chloride 10% (480 cc) Cardiovascular Potassium Supplement K-Tab, K-Dur, Slow- Potassium chloride tabs 8 mEq Cardiovascular Potassium Supplement K, Klor-con K-Tab, K-Dur, Slow- Potassium chloride tabs 20 mEq Cardiovascular Potassium Supplement K, Klor-con K-Tab, K-Dur, Slow- Potassium chloride tabs 10 mEq Cardiovascular Potassium Supplement K, Klor-con

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 18 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Cholesterol Lowering Pravastatin Pravachol 20, 40, 80 mg tabs Cardiovascular Agents Praziquantel Biltricide 600 mg Anthelmintics Prazosin Minipress 1 mg Cardiovascular Alpha-blockers Prazosin Minipress 2 mg Cardiovascular Alpha-blockers Prazosin Minipress 5 mg Cardiovascular Alpha-blockers Prednisolone Prelone 15mg/5ml oral sol Endocrine Glucocorticoids Prednisolone ophth solu or susp 1% Ophthalmic Prednisone Deltasone 1 mg Endocrine Glucocorticoids Prednisone Deltasone 2.5 mg Endocrine Glucocorticoids Prednisone Deltasone 5 mg Endocrine Glucocorticoids Prednisone Deltasone 20 mg Endocrine Glucocorticoids Prednisone Deltasone 10 mg Endocrine Glucocorticoids Prednisone Deltasone 50 mg Endocrine Glucocorticoids Primidone Mysoline 50 mg Neurologic Anticonvulsant Primidone Mysoline 250 mg Neurologic Anticonvulsant Probenecid Benemid 500 mg Gout Prochlorperazine Compazine 25 mg supp GI Antiemetic Prochlorperazine Compazine 10 mg GI Antiemetic Prochlorperazine Compazine 5 mg GI Antiemetic Promethazine HCI Phenergan 50 mg GI Antiemetic Promethazine HCI Phenergan supp 25 mg supp GI Antiemetic Promethazine HCI Phenergan 25 mg GI Antiemetic Promethazine HCI Phenergan 12.5 mg supp GI Antiemetic Promethazine HCI Phenergan syrup 6.25 mg/5 ml (120 ml) GI Antiemetic Promethazine HCI Phenergan 12.5 mg GI Antiemetic Promethazine/VC/DM Cold, Cough, Allergy Antitussive Propranolol HCL Inderal 80 mg Cardiovascular Beta Blockers Propranolol HCL Inderal 40 mg Cardiovascular Beta Blockers Propranolol HCL Inderal 20 mg Cardiovascular Beta Blockers Propranolol HCL Inderal 10 mg Cardiovascular Beta Blockers Propranolol HCL Inderal 60 mg Cardiovascular Beta Blockers Propylthiouracil PTU 50 mg Endocrine Thyroid

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 19 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Pyrazinamide 500 mg Antimicrobials Antitubercular Pyridoxine Vitamin B5 25 mg Vitamin Pyridoxine Vitamin B6 100 mg Vitamin Quetiapine fumarate Seroquel 100 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 200 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 25 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 300 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 400 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 50 mg Psychiatric Antipsychotic Ranitidine Zantac 300 mg GI H2 blockers Ranitidine Zantac 150 mg GI H2 blockers Rifampin Rifadin 300 mg Antimicrobials Antitubercular Rifampin Rifadin 150 mg Antimicrobials Antitubercular Rifapentine Priftin 150 mg Antimicrobials Antitubercular Risperidone Risperdal 1 mg Psychiatric Antipsychotic Risperidone Risperdal 1 mg/ml solution Psychiatric Antipsychotic Risperidone Risperdal 0.5 mg Psychiatric Antipsychotic Risperidone Risperdal 2 mg Psychiatric Antipsychotic Risperidone Risperdal 3 mg Psychiatric Antipsychotic Risperidone Risperdal 4 mg Psychiatric Antipsychotic Salmeterol xinafoate Serevent Diskus 50 mcg Respiratory Asthma Salsalate 750 mg Analgesic Salicylates Salsalate 500 mg Analgesic Salicylates Selenium sulfide lotion Selsun 2.50% Derm Anti-seborrhea Sertraline Zoloft 20 mg/ml Psychiatric Antidepressant Sertraline Zoloft 25 mg Psychiatric Antidepressant Sertraline Zoloft 50 mg Psychiatric Antidepressant Sertraline Zoloft 100 mg Psychiatric Antidepressant Flint SSD, Silver sulfadiazine 1% crm Derm Other Silvadene Cholesterol Lowering Simvastatin Zocor 40 mg Cardiovascular Agents Cholesterol Lowering Simvastatin Zocor 20 mg Cardiovascular Agents Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 20 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Cholesterol Lowering Simvastatin Zocor 10 mg Cardiovascular Agents Dipeptidyl Peptidase 4 Sitagliptin Januvia 100 mg Diabetes (DPP-4) Inhibitor Dipeptidyl Peptidase 4 Sitagliptin Januvia 25 mg Diabetes (DPP-4) Inhibitor Dipeptidyl Peptidase 4 Sitagliptin Januvia 50 mg Diabetes (DPP-4) Inhibitor Spironolactone Aldactone 25 mg Cardiovascular Diuretics Spironolactone Aldactone 50 mg Cardiovascular Diuretics Spironolactone Aldactone 100 mg Cardiovascular Diuretics Sucralfate Carafate 1 Gm GI Sulfacetamide sodium eye drop sol Sulamyd 10% Ophthalmic Sulfacetamide sodium eye ointment Sulamyd 10% Ophthalmic Sulfamethxzl/Trimethoprim Septra 400 mg-80 mg Antimicrobials Sulfas Sulfamethxzl/Trimethoprim Bactrim 200 mg-40 mg/5 ml (60 ml) Antimicrobials Sulfas Sulfamethxzl/Trimethoprim DS Septra 800 mg-160 mg Antimicrobials Sulfas Sulfasalazine Azulfidine 500 mg GI Anti-inflammatory bowel Sulindac Clinoril 200 mg Analgesic NSAID Sulindac Clinoril 150 mg Analgesic NSAID Sumatriptan Imitrex 50 mg Neurologic Migraine Sumatriptan Imitrex 25 mg Neurologic Migraine Sumatriptan Imitrex 100 mg Neurologic Migraine Tamoxifen Soltamox 10 mg Hormone Replacement Tamsulosin Flomax 0.4 mg Genitourinary Alpha-blockers Temazepam (SCH IV) Restoril 30 mg Psychiatric Hypnotic Temazepam (SCH IV) Restoril 15 mg Psychiatric Hypnotic Terazosin HCL Hytrin 5 mg Genitourinary Terazosin HCL Hytrin 2 mg Genitourinary Terazosin HCL Hytrin 1 mg Genitourinary Terazosin HCL Hytrin 10 mg Genitourinary Testosterone Inj Depo Testosterone 100 mg/ml Hormone Replacement Testosterone Inj Depo Testosterone 200 mg/ml Hormone Replacement

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 21 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Tetracycline Sumycin 500 mg Antimicrobials Tetracyclines Tetracycline Sumycin 250 mg Antimicrobials Tetracyclines Theophylline Theo-Dur 300 mg Respiratory Theophylline Theo-Dur 200 mg Respiratory Thiothixene Navane 5 mg Psychiatric Antipsychotic Thiothixene Navane 20 mg Psychiatric Antipsychotic Thiothixene Navane 2 mg Psychiatric Antipsychotic Thiothixene Navane 10 mg Psychiatric Antipsychotic Thiothixene Navane 1 mg Psychiatric Antipsychotic Thiothixene Navane 5 mg/ml Psychiatric Antipsychotic Platelet aggregation Ticlopidine Ticlid 250mg inhibitor Timolol Maleate eye drops 0.5% Ophthalmic Glaucoma Timolol Maleate eye drops 0.25% Ophthalmic Glaucoma Tobramycin ophthal soln. 0.3% Ophthalmic Tramadol Ultram, Rybix 50 mg Analgesic Misc Trazodone Desyrel 50 mg Psychiatric Antidepressant Trazodone Desyrel 150 mg Psychiatric Antidepressant Trazodone Desyrel 100 mg Psychiatric Antidepressant 0.01%, 0.025%, 0.05%, 0.1% Tretinoin Retin-A Derm Acne cream, gel Triamcinolone cream, ointment, or Kenalog, Aristocort 0.10% Derm Antiinflammatory lotion Triamcinolone cream, ointment, or Kenalog, Aristocort 0.025% Derm Antiinflammatory lotion Triamterene/Hctz Maxzide 37.5 mg-25 mg Cardiovascular Diuretics Triamterene/Hctz Maxzide 75 mg-50 mg Cardiovascular Diuretics Trifluoperazine Stelazine 5 mg Psychiatric Antipsychotic Trifluoperazine Stelazine 2 mg Psychiatric Antipsychotic Trifluoperazine Stelazine 10 mg Psychiatric Antipsychotic Trihexyphenidyl Artane 5 mg Neurologic Parkinson Trihexyphenidyl Artane 2 mg/5 ml Neurologic Parkinson Trihexyphenidyl Artane 2 mg Neurologic Parkinson

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 22 of 23 HealthPAC Formulary Current as of January 2018

Generic Name Brand Name Strength Class I Class II Ursodiol Actigall 300 mg GI Venlafaxine Effexor IR 25 mg Psychiatric Antidepressant Venlafaxine XR Effexor XR 75 mg Psychiatric Antidepressant Venlafaxine XR Effexor XR 37.5 mg Psychiatric Antidepressant Venlafaxine XR Effexor XR 100 mg Psychiatric Antidepressant Verapamil Isoptin 120 mg Cardiovascular Calcium Channel Blockers Verapamil LA Isoptin 180 mg Cardiovascular Calcium Channel Blockers Verapamil SR Calan SR 240 mg Cardiovascular Calcium Channel Blockers Verapamil SR Calan SR 180 mg Cardiovascular Calcium Channel Blockers Verapamil SR Calan SR 120 mg Cardiovascular Calcium Channel Blockers Vitamin B6 50 mg Vitamin Vitamin D Calciferol 50,000 units Vitamin Vitamin K Phytonadione 5 mg tab Vitamin Warfarin sodium Coumadin 1 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 10 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 2 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 2.5 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 3 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 4 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 5 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 6 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 7.5 mg Cardiovascular Anticoagulants Zolpidem Ambien 10 mg Psychiatric Hypnotic Zolpidem Ambien 5 mg Psychiatric Hypnotic

Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 23 of 23