Ryan White Part A Formulary Updated ƵŐƵƐƚ 2019 Ryan White Part A Pharmacy Formulary - Updated 8/19/19 Tier 1: In order to access Tier 1, clients must qualify for the Ryan White Part A Program based on eligiblity requirements. Drug Classification Brand Name Generic Name Tier 5-Alpha-Reductase Inhibitors/BPH Avodart Dutasteride 1 Anticoagulant/Factor Xa Inhibitors Xarelto Rivaroxaban 1 Antihyperlipidemic Agents- Dietary Source Omega 3 Alpha-Linoleic Acid 1 Antiinfectives/Antifungal Lamisil Terbinafine 1 Antiinfectives/Antiinflammatory Decadron Dexamethasone 1 Antiinfectives/Antiinflammatory Deltasone Prednisone 1 Antiinfectives/Antiinflammatory Medrol dosepak Methyprednisolone 1 Antiinfectives/Antitubercular Rifamate Isoniazid/Rifampin 1 Antiinfectives/Antitubercular Seromycin Cycloserine 1 Antiinfectives/Antiviral/Antibacterial Achromycin Tetracycline 1 Antiinfectives/Antiviral/Antibacterial Amoxil Amoxicillin 1 Antiinfectives/Antiviral/Antibacterial Augmentin Amoxicillin/Clavulanate Potassium 1 Antiinfectives/Antiviral/Antibacterial Bicillin LA Penicillin Benzath 1 Antiinfectives/Antiviral/Antibacterial Ceftin Cefuroxime 1 Antiinfectives/Antiviral/Antibacterial Cipro Ciprofloxacin 1 Antiinfectives/Antiviral/Antibacterial Cleocin Clindamycin 1 Antiinfectives/Antiviral/Antibacterial Ery-tab Erythromycin base 1 Antiinfectives/Antiviral/Antibacterial Keflex Cephalexin 1 Antiinfectives/Antiviral/Antibacterial Macrodantin Nitrofurantoin 1 Antiinfectives/Antiviral/Antibacterial Omnicef Cefdinir 1 Antiinfectives/Antiviral/Antibacterial PenVK Penicililn VK 1 Antiinfectives/Antiviral/Antibacterial Proloprim Trimethoprim 1 Antiinfectives/Antiviral/Antibacterial Rocephin Ceftriaxone INJ 1 Antiinfectives/Antiviral/Antibacterial Vibramycin Doxycycline 1 Antiinfectives/Other Humatin Paromomycin 1 Antitussives Tessalon Benzonatate 1 Bronchodilator Combinations Dulera Formoterol/Mometasone 1 Cardiac & Anti-Hypertensive/Alpha Blockers Catapres Clonidine 1 Cardiac & Anti-Hypertensive/AlphaBeta Blocker Coreg Carvedilol 1 Cardiac & Anti-Hypertensive/Angiotensin Receptor Blocker (ARB) Avapro Irbesartan 1 Cardiac & Anti-Hypertensive/Antiarrythmic Cordarone Amiiodarone 1 Drug Classification Brand Name Generic Name Tier Cardiac & Anti-Hypertensive/Antiplatelet Plavix Aspirin Clopidogrel *Aspirin may only be dispensed with Clopidogrel 1 Cardiac & Anti-Hypertensive/Beta Blockers Inderal Propranolol 1 Cardiac & Anti-Hypertensive/Beta Blockers Normodyne Labetalol 1 Cardiac & Anti-Hypertensive/Diuretic Aldactone Spironolactone 1 Cardiac & Anti-Hypertensive/Diuretic Bumex Bumetanide 1 Cardiac & Anti-Hypertensive/Diuretic Dyazide HCTZ/Triamterene 1 Cardiac & Anti-Hypertensive/Diuretic HydroDiuril HCTZ 1 Cardiac & Anti-Hypertensive/Nitrates Imdur Isosorbide Mononitrate 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic Celecoxib Celebrex 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic Fioricet Butalbitol/Acetaminophen/Caffeine 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic Tramadol Ultram 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic Ativan Lorazepam 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic Restoril Temazepam 1 Autonomic/Antianxiety/Hypnotic Valium Diazepam 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic Vistaril,Atarx Hydroxyzine 1 CNS, Anxiety, Psych, Neuro, & Acetazolamide Autonomic/Anticonvulsant Diamox 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Dilantin Phenytoin 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Gabapentin Neurontin 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Klonopin Clonazepam 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Phenobarbital Phenobarbital 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Tegretol Carbamazepine 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Topamax Topiramate 1 Drug Classification Brand Name Generic Name Tier CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant Zarontin Ethosuximide 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Bupropion Wellbutrin 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Buspar Buspirone 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant Lithonate Lithium Carb 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antimigraine Imitrex (Oral Only) Sumatriptan 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antiparkinson Sinemet Carbidopa/Levodopa 1 Autonomic/Antipsychotic Haldol Haloperidol 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic Thorazine Chlorpromazine 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic Trilafon Perphenazine 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Misc Cogentin Benztropine 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant Flexeril Cyclobenzaprine 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant Lioresal Baclofen 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant Soma Carisoprodol 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Methadone Methadone 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Morphine MSContin, MSIR 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Percocet Oxycodone/Acet 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Percodan Oxycodone/ASA 1 CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic Vicodin,VicodinES Hydrocodone/Acetaminophen 1 Dopaminergic Antiparkinaonism Agents Mirapex Pramipexole 1 Gastrointest/Antacid Mylanta DS Al, Mg, Simethicone 1 Gastrointest/Antidiarrheal Imodium Loperamide Paregoric 1 Gastrointest/Antiemetic Promethazine Suppos Promethazine Suppos 1 Drug Classification Brand Name Generic Name Tier Gastrointest/Antiflatulant Mylicon Simethicone 1 Gastrointest/Antispasmotic Bentyl Dicyclomine 1 Gastrointest/Digestive Enzyme Ultrace MT Pancrealipase 1 Gastrointest/Laxative Colace Docusate sodium 1 Gastrointest/Laxative Fibercon Fiberlax 1 Gastrointest/Laxative Peri-Colace Docusate/Casanth 1 Gastrointest/Misc/Other Carafate Sucralfate 1 Gastrointest/Misc/Other GoLytely/Colyte Polyethylene Glycol Electrolyte 1 Gastrointest/PPI Prevacid Lansoprazole 1 Gonadotropin Releasing Hormones Lupron Leuprolide 1 GYN/OB Lo-Ovral 28 Ethinyl Estradiol/Norgestrel 1 GYN/OB Ortho-Tricyclen 28 Ethinyl Estradiol/Norgestimate 1 GYN/OB Premarin Estrogen Conjugated 1 Medication Administration Pen Needles *for Lantus/Levemir Pen Needles 1 Minerals, Electrolytes/Phosphate Binders Calcium Calcium Acetate 1 Misc/Other Colchicine Colchicine 1 Misc/Other Danazol Danocrine 1 Misc/Other Ditropan Oxybutinin 1 Misc/Other MAGIC Mouthwash MAGIC Mouthwash 1 Misc/Other Normal Saline Sodium Chloride for Irrigation 1 Misc/Other Peridex Oral Rinse Chlorhexidine 12% Solution 1 Misc/Other Pyridium Phenazopyridine 1 Misc/Other Zyloprim Allopurinol 1 Nasal Ocean Nasal Sodium Chloride 1 Nasal Rhinocort Budesonide 1 Ophthalmic Antihistamines and Decongestants Pataday Olopatadine Ophthalmic 1 Ophthalmic/Antibiotic Ciloxin Ciprofloxacin 1 Ophthalmic/Antibiotic Dexacidin Dexamethasone/Neomycin/ Polymyxin B 1 Ophthalmic/Antibiotic E-Mycin Erythromycin 1 Ophthalmic/Antibiotic Neosporin Neo/Poly/Bacit 1 Ophthalmic/Antibiotic Sulamyd Sulfacetamide 1 Ophthalmic/Antibiotic Tobrex Tobramycin 1 Ophthalmic/Betablocker Betoptic S Betaxolol 1 Ophthalmic/Betablocker Timoptic Timolol 1 Ophthalmic/Glaucoma Alphagan Brimonide 1 Ophthalmic/Glaucoma Azopt Brinzolamide 1 Ophthalmic/Glaucoma Cosopt Dorzolamide+Timolol 1 Drug Classification Brand Name Generic Name Tier Ophthalmic/Glaucoma Lumigan Bimatoprost 1 Ophthalmic/Glaucoma Xalatan Latanoprost 1 Ophthalmic/Miotic Pilocar Pilocarpine 1 Ophthalmic/Misc/Other Alomide Lodoxamide 1 Ophthalmic/Misc/Other Tearisol Artificial tears 1 Ophthalmic/Misc/Other Vasocon Naphazoline 1 Ophthalmic/Misc/Other Viroptic Trifluridine 1 Ophthalmic/Steroid FML Fluorometholone 1 Ophthalmic/Steroid Pred Forte Prednisolone 1 Opportunistic Infections (OIs) TMP-SMX ds TMP-SMX ds 1 Otic Cortisporin Neomycin / HC 1 Otic Debrox Carbamide Peroxide 1 Otic Anti-Infectives Vosol Acetic Acid 1 Otic Anti-Infectives Vosol HC Acetic Acid/HC 1 Otic Steroids Cipro HC Ciprofloxacin/Hydrocortisone 1 Respiratory, Cough & Cold Allergy/Antihist/Decongestant Cardec, Cardec DM, Cardec S Carbinoxamine/Pseudoephedrine 1 Respiratory, Cough & Cold Allergy/Antihist/Decongestant Sudafed Pseudoephedrine 1 Respiratory, Cough & Cold Allergy/Antitussive Robitussin Guaifenesin 1 Respiratory, Cough & Cold Allergy/Antitussive Robitussin AC Guaifenesin/Codeine 1 Respiratory, Cough & Cold Allergy/Antitussive Robitussin DAC Guaifen/Codeine/Pseudoephedrine 1 Respiratory, Cough & Cold Allergy/Antitussive Robitussin DM Guaifen/Dextromethorphan 1 Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled Serevent Salmeterol Discus 1 Respiratory, Cough & Cold Allergy/BetaAgonist Oral Ventolin Albuterol tab 1 Respiratory, Cough & Cold Allergy/Other Singulair Montileukast 1 Respiratory, Cough & Cold Allergy/Xanthine Theo-Dur Theophylline 1 Skeletal Muscle Relaxants Robaxin Methocarbamol 1 Topical Antibiotic Bactroban Mupirocin 1 Topical Non-Steroidal Anti-Inflammatories Voltaren (gel) Diclofenac Topical 1 Drug Classification Brand Name Generic Name Tier Topical, Dermatology, Rectal, Lidocaine , Xylocaine Oint, Jelly, Visc, Vaginal/Anaesthetic Patch Xylocaine/Lidocaine 1 Vaginal/Antibacterial Benzagel Erythomycin / Benzoyl perox 1 Topical, Dermatology, Rectal, Vaginal/Antibacterial Cleocin Vag Clindamycin 1 Vaginal/Antibacterial Neosporin Neo/Gramic/Poly 1 Topical, Dermatology, Rectal, Vaginal/Antifungal Kenalog Triamcinolone 1 Topical, Dermatology, Rectal, Vaginal/Antifungal