RYAN WHITE PART A PHARMACY FORMULARY - Updated 03/21/12 TIER ONE In order to access Tier One, clients must qualify for the Ryan White Part A eligibility requirements. ANTIINFECTIVES Phenytoin (Dilantin) Angiotensin Receptor HCTZ (HydroDiuril) Laxative BLOOD/BLOOD FORMING Antiviral Primidone (Mysoline) Blocker (ARB) HCTZ/Triamterene (Dyazide) Docusate sodium (Colace) Antibacterial Ferrous sulfate (Feosol) Topiramate (Topamax) Irbesartan (Avapro) Spironolactone (Aldactone) Docusate/Casanth (Peri-Colace) Amoxicillin(Amoxil) Fiberlax (Fibercon) Amoxicill/Clav (Augmentin) CNS, ANXIETY, PSYCH, Analgesic Alpha Blockers Nitrates Lactulose (Enulose) Cefdinir (Omnicef) NEURO, & AUTONOMIC Naproxen (Naprosyn) Clonidine (Catapres) Nitroglycerin (Nitrostat,Nitro- Ceftriaxone INJ (Rocephin) Antianxiety/Hypnotic Butalbi/Acetam/Caff (Fioricet) Terazosin (Hytrin) Dur) PPI Cefuroxime (Ceftin) Diazepam (Valium) Tramadol (Ultram) Isosorbide Mononitrate (Imdur) Lansoprazole (Prevacid) Cephalexin (Keflex) Hydroxyzine (Vistaril,Atarx) AlphaBeta Blocker Ciprofloxacin (Cipro) Lorazepam (Ativan) Narcotic Analgesic Carvedilol (Coreg) DIABETES Misc/Other Clindamycin (Cleocin) Temazepam (Restoril) Codeine/Acetam (Tylenol#3) Insulin Analog (Humalog) GoLytely (Colyte) Doxycycline (Vibramycin) Hydrocodone / Acet Beta Blockers Insulin NPH (Novolin) Metoclopramide (Reglan) Dicloxacillin (Dynapen) Antidepressant (Vicodin,VicodinES) Atenolol (Tenormin) Insulin Regular (Novolin) Sucralfate (Carafate) Buspirone (Buspar) Methadone (Methadone) Labetalol (Normodyne) Insulin Glaritine(Lantus) Erythromycin base (Ery-tab) Citalopram (Celexa) Morphine (MSContin, MSIR) Propranolol (Inderal) Actose (Pioglitazone) GYN/OB Nitrofurantoin (Macrodantin) Doxepin (Sinequan) Oxycodone/ASA (Percodan) Metoprolol (Lopressor) Estrogen Conj (Premarin) Penicillin Benzath (Bicillin LA) Paroxetine (Paxil) Oxycodone/Acet (Percocet) GASTROINTEST Medroxyprogesterone (Provera, Penicililn VK (PenVK) Sertraline (Zoloft) Propox/Acet (Darvocet N-100) Antiarrythmic Antacid Depo-Provera) Primaquine (Primaquine) Trazodone (Desyrel) Amiiodarone (Cordarone) Al, Mg, Simeth (Mylanta DS) Ethinyl estrad/Norgest/placeb (Ortho- Tetracycline (Achromycin) Lithium carb (Lithonate) Muscle Relaxant Tricyclen 28) Trimethoprim (Proloprim) Baclofen (Lioresal) Anticoagulant Antidiarrheal Ethinyl estradiol/ Norgestrel (Lo- Antipsychotic Carisoprodol (Soma) Warfarin (Coumadin) Loperamide (Imodium) Ovral 28) Antifungal Chlorpromazine (Thorazine) Cyclobenzaprine (Flexeril) Paregoric Norethindrone (Micronor 28) AmphoteracinB (Fungizone) Haloperidol (Haldol) Antiplatelet Terbinafine (Lamisil) Perphenazine (Trilafon) Antiparkinson Aspirin* Clopidogrel (Plavix) Antiemetic NASAL Carbidopa/levodop (Sinemet) *Aspirin may only be dispensed with Promethazine (Phenergan) Budesonide (Rhinocort) Antitubercular Misc. Clopidogrel Promethazine Suppos Beclomethasone (Beconase AQ) Cycloserine (Seromycin) Benztropine (Cogentin) Antimigraine Calcium Channel Blocker Sodium Chloride (Ocean Nasl) Furazolidone (Furoxone) Sumatriptan (Imitrex) (Oral Only) Amlodipine (Norvasc) Antiflatulant Isoniazid (INH) Anticonvulsant Butalbi/Acetam/Caff (Fioricet) Diltiazem (Cardizem) Simethicone (Mylicon) OTIC Isoniazid/Rifampn (Rifamate) Acetazolamide (Diamox) Verapamil (Isoptin, Calan) Acetic Acid (Vosol) Pyrazinamide (PZA) Carbamazepine (Tegretol) CARDIAC & ANTI- Nifedepine (Procardia,Adalat) Antispasmotic Acetic Acid / HC (Vosol HC) Rifampin (Rifadin) Clonazepam (Klonopin) HYPERTENSIVE Dicyclomine (Bentyl) Neomycin / HC (Cortisporin) Rifampin / Isoniazid(Rifamate) Ethosuximide (Zarontin) ACE Inhibitor Cardiac Glycoside Ciprofloxacin / HC (Cipro HC) Felbamate (Felbatol)* Enalapril (Vasotec) Digoxin (Lanoxin) Digestive Enzyme Carbamide Peroxide (Debrox) Other Mephobarbital(Mebaral) Lisinopril (Zestril, Prinivil) Pancrealipase (Ultrace MT) Metronidazole (Flagyl) Methsuiximide (Celontin) Diuretic Paromomycin(Humatin) Phenobarbital Bumetanide (Bumex) H2Antagonist Furosemide (Lasix) Ranitidine (Zantac) RYAN WHITE PART A PHARMACY FORMULARY - Updated 03/21/12 TIER ONE In order to access Tier One, clients must qualify for the Ryan White Part A eligibility requirements. OPHTHALMIC Antitussive Corticosteroid Methyprednisolone (Medrol Antibiotic Guaifenesin (Robitussin) Clobetasol (Temovate) dosepak) Ciprofloxacin (Ciloxin) Guaifen / DM (Robitussin DM) Diflorasone (Psorcon) Oxybutinin (Ditropan) Guaifen / Cod (Robitussin AC) Betamethasone (Diprosone) Prednisone (Deltasone) Dexameth/Neo/Poly (Dexacidin) Guaifen /Cod / Pseudoephed Fluocinolone (Dermasmoothe) Probenecid Erythromycin (E-Mycin) Hydrocortisone crm (Hytone) Sodium Chloride for Irrigation Neo/Poly/Bacit (Neosporin) Hydrocortisone Suppos (Anusol- (Normal Saline) Sulfacetamide (Sulamyd) BetaAgonist Oral HC) Phenazopyridine (Pyridium) Tobramycin (Tobrex) Albuterol (Ventolin) tab Triamcinolone crm (Kenalog) Celebrex (Celecoxib) Td (Tetanus/Diptheria Injection) Betablocker BetaAgonist Inhaled Topical: Misc/Other Betaxolol (Betoptic S) Albuterol (Ventolin) Ammonium lact (Lac-Hydrin) OPPORTUNISTIC Timolol (Timoptic) Albuterol / Ipratropium Lindane (Kwell) INFECTIONS (OIs) Metronidazole (Metrogel) TMP-SMX ds Glaucoma Salmeterol Discus (Serevent) Permethrin (Elimite) Dapsone Brimonide (Alphagan) Podophilox (Condylox) Bimatoprost (Lumigan) Corticosteroid Inhaled Selenium (Selsun) Brinzolamide (Azopt) Triamcinolone (Azmacort) Urea, misc (Amino-Cerv) Dorzolamide+Timolol (Cosopt) Latanoprost (Xalatan) Xanthine VACCINES Theophylline (Theo-Dur) Influenza Vaccine (Fluzone) Miotic Pneumovax (Pneumococcal) Pilocarpine (Pilocar) Other Ipratropium (Atrovent) VITAMINS & NUTRITIONAL Steroid Montileukast (Singulair) Vitamins Fluorometholone (FML) Pentamidine (Nebupent) Ferrous sulfate/fumerate Prednisolone (Pred Forte) (Feosol) TOPICAL, DERMATOLOGY, Folic Acid (Folvite) Misc/Other RECTAL, VAGINAL Therapeutic (multivitamins) Artificial tears (Tearisol) Anaesthetic B-Plex with C (antioxidant) Lodoxamide (Alomide) Lidocaine (Xylocaine Oint, Naphazoline (Vasocon) Jelly, Visc, Patch) WASTING Trifluridine (Viroptic) Cyproheptadine (Periactin) Antibacterial RESPIRATORY, COUGH & Clindamycin (Cleocin Vag) OTHER / MISCELLANEOUS Neo/Gramic/Poly (Neosporin) Allopurinol (Zyloprim) Antihistamine Erythomycin / Benzoyl perox Chlorhexidine 12% Solution Loratadine (Claritin) (Benzagel) (Peridex Oral Rinse) Diphenhydramine (Benadryl) Colchicine Antifungal Danocrine (Danazol) Antihist/Decongestant Clotrimazole (Lotrimin) Dexamethasone (Decadron) Bromphen/pseudephed / DM Nystatin / Triamcin (Mycolog) Levothyroxine (Synthroid) (Cardec, Cardec DM, Cardec S) Triamcinolone (Kenalog) MAGIC Mouthwash Pseudoephedrine (Sudafed) Terbinafine (Lamisil) Meclizine (Antivert) Nystatin (Mycostatin) .