HealthPAC Formulary Current as of July 2017 Brand Name Generic Name Strength Class I Class II Aclovate Alclometasone Cream 45 gm Anti-inflammatory Agents Aclovate Alclometasone Ointment 45 gm Anti-inflammatory Agents Actigall Ursodiol 300 mg GI Actos Pioglitazone hydrochloride 15 mg Diabetes Thiazolidinediones Actos Pioglitazone hydrochloride 30 mg Diabetes Thiazolidinediones Actos Pioglitazone hydrochloride 45 mg Diabetes Thiazolidinediones Adderall XR Dextroamphetamine/amphetamine 10 mg Psychiatric Stimulant Adderall XR Dextroamphetamine/amphetamine 15 mg Psychiatric Stimulant Adderall XR Dextroamphetamine/amphetamine 20 mg Psychiatric Stimulant Adderall XR Dextroamphetamine/amphetamine 30 mg Psychiatric Stimulant Alaway Ketotifen 0.025% Ophthalmic Aldactone Spironolactone 25 mg Cardiovascular Diuretics Aldactone Spironolactone 50 mg Cardiovascular Diuretics Aldactone Spironolactone 100 mg Cardiovascular Diuretics Aldomet Methyldopa 250 mg Cardiovascular Central Alpha Agonist Aldomet Methyldopa 500 mg Cardiovascular Central Alpha Agonist Alphagan Brimonidine tartrate solution 0.2% Ophthalmic Glaucoma Amikin Amikacin 1000 mg/4 ml (4 cc) Antimicrobials Aminoglycoside Amikin Amikacin 500 mg/2 ml (2 cc) Antimicrobials Aminoglycoside Ambien Zolpidem 10 mg Psychiatric Hypnotic Ambien Zolpidem 5 mg Psychiatric Hypnotic Amoxil Amoxicillin 125 mg/5 ml (80 cc) Antimicrobials Penicillins Amoxil Amoxicillin 250 mg Antimicrobials Penicillins Amoxil Amoxicillin 250 mg/5 ml (150 cc) Antimicrobials Penicillins Amoxil Amoxicillin 400 mg/5 ml Antimicrobials Penicillins Amoxil Amoxicillin 500 mg Antimicrobials Penicillins Anafranil Clomipramine 25 mg Psychiatric Antidepressant Anafranil Clomipramine 50 mg Psychiatric Antidepressant Anafranil Clomipramine 75 mg Psychiatric Antidepressant Antivert Meclizine 25 mg tabs Neurologic Misc Apresoline Hydralazine 10 mg Cardiovascular Other Vasodilators Apresoline Hydralazine 100 mg Cardiovascular Other Vasodilators Apresoline Hydralazine 25 mg Cardiovascular Other Vasodilators Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 1 of 24 HealthPAC Formulary Current as of July 2017 Brand Name Generic Name Strength Class I Class II Apresoline Hydralazine 50 mg Cardiovascular Other Vasodilators Artane Trihexyphenidyl 2 mg Neurologic Parkinson Artane Trihexyphenidyl 2 mg/5 ml Neurologic Parkinson Artane Trihexyphenidyl 5 mg Neurologic Parkinson Asacol Mesalamine 400 mg GI Anti-inflammatory bowel Atarax Hydroxyzine HCL 10 mg Cold, Cough, Allergy Antihistamine Atarax Hydroxyzine HCL 10 mg/5 ml (120 cc) Cold, Cough, Allergy Antihistamine Atarax Hydroxyzine HCL 25 mg Cold, Cough, Allergy Antihistamine Atarax Hydroxyzine HCL 50 mg Cold, Cough, Allergy Antihistamine Ativan Lorazepam (SCH IV) 0.5 mg Psychiatric Benzos Ativan Lorazepam (SCH IV) 1 mg Psychiatric Benzos Ativan Lorazepam (SCH IV) 2 mg Psychiatric Benzos Atrovent Ipratropium MDI 18mcg/dose MDI (14gm) Respiratory Asthma Atrovent Inh Sol Ipratropium bromide 0.02% 500 mcg (3 cc/amp) Respiratory Nebulizer soln Augmentin Amoxicillin-clavulanate 200 mg/5 ml (100 cc) Antimicrobials Penicillins Augmentin Amoxicillin-clavulanate 500 mg-125 mg Antimicrobials Penicillins Augmentin Amoxicillin-clavulanate 875 mg-125 mg Antimicrobials Penicillins Antipyrene, Benzocaine, Glycerine Auralgan 10 ml drops Otic dehyd Avelox Moxifloxacin 400 mg Antimicrobials Quinolones Aygestin Norethindrone 5 mg Hormone Replacement Progestins Azopt Brinzolamide 1% suspension Ophthalmic Glaucoma Azulfidine Sulfasalazine 500 mg GI Anti-inflammatory bowel 40mg / 5ml - 200mg / 5- Bactrim Sulfamethxzl Trimethoprim Antimicrobials Sulfas ml (60 ml) Bactroban Mupirocin 2% ointment Derm Antimicrobial Benadryl Diphenhydramine 12.5 mg/ 5ml Cold, Cough, Allergy Antihistamine Benadryl Diphenhydramine 25, 50 mg capsules Cold, Cough, Allergy Antihistamine Benadryl Diphenhydramine 50 mg/ml (inj) Cold, Cough, Allergy Antihistamine Benemid Probenecid 500 mg Gout Bentyl Dicyclomine 10 mg GI Antispasmodics Bentyl Dicyclomine 20 mg GI Antispasmodics Biaxin Clarithromycin 500 mg Antimicrobials Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 2 of 24 HealthPAC Formulary Current as of July 2017 Brand Name Generic Name Strength Class I Class II Biltricide Praziquantel 600 mg Anthelmintics BuSpar Buspirone HCI 10 mg Psychiatric Other BuSpar Buspirone HCI 15 mg Psychiatric Other BuSpar Buspirone HCI 30 mg Psychiatric Other BuSpar Buspirone HCI 5 mg Psychiatric Other Butrans Buprenorphine 10 mcg/hr Analgesic Opiate Agonist Butrans Buprenorphine 15 mcg/hr Analgesic Opiate Agonist Butrans Buprenorphine 5 mcg/hr Analgesic Opiate Agonist Butrans Buprenorphine 7.5 mcg/hr Analgesic Opiate Agonist Byetta Exenatide 10 mcg/0.04 mL (2.4 mL) Diabetes GLP-1 Receptor Agonist Byetta Exenatide 5 mcg/0.02 mL (1.2 mL) Diabetes GLP-1 Receptor Agonist Calcium Channel Calan SR Verapamil SR 120 mg Cardiovascular Blockers Calcium Channel Calan SR Verapamil SR 180 mg Cardiovascular Blockers Calcium Channel Calan SR Verapamil SR 240 mg Cardiovascular Blockers Calciferol Vitamin D 50,000 units Vitamin Capoten Captopril 100 mg Cardiovascular ACE Inhibitor Capoten Captopril 12.5 mg Cardiovascular ACE Inhibitor Capoten Captopril 25 mg Cardiovascular ACE Inhibitor Capoten Captopril 50 mg Cardiovascular ACE Inhibitor Carafate Sucralfate 1 Gm GI Calcium Channel Cardizem Diltiazem 120 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 120 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 180 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 240 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 30 mg Cardiovascular Blockers Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 3 of 24 HealthPAC Formulary Current as of July 2017 Brand Name Generic Name Strength Class I Class II Calcium Channel Cardizem CD Diltiazem CD 300 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 360 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 60 mg Cardiovascular Blockers Calcium Channel Cardizem CD Diltiazem CD 90 mg Cardiovascular Blockers Cardizem CD, Calcium Channel Dilacor Xr, Cartia Diltiazem 60 mg Cardiovascular Blockers XL, Dilt-CD Cardizem CD, Calcium Channel Dilacor Xr, Cartia Diltiazem 90 mg Cardiovascular Blockers XL, Dilt-CD Calcium Channel Cardizem LA Dilitiazem HCI 180 mg Cardiovascular Blockers Calcium Channel Cardizem SR Diltiazem SR 120 mg Cardiovascular Blockers Calcium Channel Cardizem SR Diltiazem SR 180 mg Cardiovascular Blockers Calcium Channel Cardizem SR Diltiazem SR 240 mg Cardiovascular Blockers Calcium Channel Cardizem SR Diltiazem SR 300 mg Cardiovascular Blockers Cardura Doxazosin mesylate 1 mg Cardiovascular Alpha-1 blocker Cardura Doxazosin mesylate 2 mg Cardiovascular Alpha-1 blocker Cardura Doxazosin mesylate 4 mg Cardiovascular Alpha-1 blocker Cardura Doxazosin mesylate 8 mg Cardiovascular Alpha-1 blocker Catapres Clonidine HCI tabs 0.1 mg Cardiovascular Central Alpha Agonist Catapres Clonidine HCI tabs 0.2 mg Cardiovascular Central Alpha Agonist Catapres Clonidine HCI tabs 0.3 mg Cardiovascular Central Alpha Agonist Celebrex Celecoxib 100 mg Analgesic NSAID Celebrex Celecoxib 200 mg Analgesic NSAID Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 4 of 24 HealthPAC Formulary Current as of July 2017 Brand Name Generic Name Strength Class I Class II Celebrex Celecoxib 400 mg Analgesic NSAID Celebrex Celecoxib 50 mg Analgesic NSAID Celexa Citalopram Hydrobromide 10 mg Psychiatric Antidepressant Celexa Citalopram Hydrobromide 10 mg/5 ml Psychiatric Antidepressant Celexa Citalopram Hydrobromide 20 mg Psychiatric Antidepressant Celexa Citalopram Hydrobromide 40 mg Psychiatric Antidepressant Ciloxan Ciprofloxacin eye drop 0.3% Ophthalmic Cipro Ciprofloxacin 250 mg Antimicrobials Quinolones Cipro Ciprofloxacin 500 mg Antimicrobials Quinolones Claritin Loratadine 10 mg Antihistamine Cleocin Clindamycin 150 mg Antimicrobials Misc Cleocin Clindamycin 300 mg Antimicrobials Misc Cleocin Clindamycin topical gel, lotion 1% Derm Acne Cleocin-T Clindamycin topical solution 1% (60 ml) Derm Acne Clinoril Sulindac 150 mg Analgesic NSAID Clinoril Sulindac 200 mg Analgesic NSAID Cogentin Benztropine mesylate 0.5 mg Neurologic Parkinson Cogentin Benztropine mesylate 1 mg Neurologic Parkinson Cogentin Benztropine mesylate 1 mg/ml (inj) Neurologic Parkinson Cogentin Benztropine mesylate 2 mg Neurologic Parkinson Colcrys Colchicine 0.6 mg Gout Combivent MDI Albuterol-ipratropium Inhaler Respiratory Compazine Prochlorperazine 10 mg GI Antiemetic Compazine Prochlorperazine 25 mg supp GI Antiemetic Compazine Prochlorperazine 5 mg GI Antiemetic Cordarone Amiodarone 200 mg Cardiovascular Antiarrythmic Cordarone Amiodarone 400 mg Cardiovascular Antiarrythmic Coreg Carvedilol 12.5 mg Cardiovascular Beta Blockers Coreg Carvedilol 25 mg Cardiovascular Beta Blockers Coreg Carvedilol 3.125 mg Cardiovascular Beta Blockers Coreg Carvedilol 6.25 mg Cardiovascular Beta Blockers Cortizone Hydrocortisone cream 2.5% Derm Antiinflammatory Cortizone Hydrocortisone ointment 2.5% Derm Antiinflammatory Disclaimer: Doses / routes of administration are the responsibility of the prescribing