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. Generic Name Brand Name Drug Classification Tier Acetazolamide Diamox CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Acetic Acid Vosol Otic Anti-Infectives 1 Acetic Acid/HC Vosol HC Otic Anti-Infectives 1 Al, Mg, Simethicone Mylanta DS Gastrointest/Antacid 1 Albuterol tab Ventolin Respiratory, Cough & Cold Allergy/BetaAgonist Oral 1 Allopurinol Zyloprim Misc/Other 1 Alpha-Linoleic Acid Omega 3 Antihyperlipidemic Agents- Dietary Source 1 Amiiodarone Cordarone Cardiac & Anti-Hypertensive/Antiarrythmic 1 Ammonium lact Lac-Hydrin Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Amoxicillin Amoxil Antiinfectives/Antiviral/Antibacterial 1 Amoxicillin/Clavulanate Potassium Augmentin Antiinfectives/Antiviral/Antibacterial 1 Artificial tears Tearisol Ophthalmic/Misc/Other 1 Aspirin Clopidogrel *Aspirin may only be dispensed with Clopidogrel Plavix Cardiac & Anti-Hypertensive/Antiplatelet 1 Baclofen Lioresal CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1 Benzonatate Tessalon Antitussives 1 Benztropine Cogentin CNS, Anxiety, Psych, Neuro, & Autonomic/Misc 1 Betamethasone Diprosone Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Betaxolol Betoptic S Ophthalmic/Betablocker 1 Bimatoprost Lumigan Ophthalmic/Glaucoma 1 B-Plex with C Antioxidant Vitamins & Nutritional/Vitamins 1 Brimonide Alphagan Ophthalmic/Glaucoma 1 Brinzolamide Azopt Ophthalmic/Glaucoma 1 Budesonide Rhinocort Nasal 1 Bumetanide Bumex Cardiac & Anti-Hypertensive/Diuretic 1 Buspirone Buspar CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1 Butalbitol/Acetaminophen/Caffeine Fioricet CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1 Calcium Acetate Calcium Minerals, Electrolytes/Phosphate Binders 1 Carbamazepine Tegretol CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Carbamide Peroxide Debrox Otic 1 Carbidopa/Levodopa Sinemet CNS, Anxiety, Psych, Neuro, & Autonomic/Antiparkinson 1 Carbinoxamine/Pseudoephedrine Cardec, Cardec DM, Cardec S Respiratory, Cough & Cold Allergy/Antihist/Decongestant 1 Carisoprodol Soma CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1 Carvedilol Coreg Cardiac & Anti-Hypertensive/AlphaBeta Blocker 1 Cefdinir Omnicef Antiinfectives/Antiviral/Antibacterial 1 Ceftriaxone INJ Rocephin Antiinfectives/Antiviral/Antibacterial 1 Cefuroxime Ceftin Antiinfectives/Antiviral/Antibacterial 1 Generic Name Brand Name Drug Classification Tier Celebrex Celecoxib CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1 Cephalexin Keflex Antiinfectives/Antiviral/Antibacterial 1 Chlorhexidine 12% Solution Peridex Oral Rinse Misc/Other 1 Chlorpromazine Thorazine CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1 Ciprofloxacin Ciloxin Ophthalmic/Antibiotic 1 Ciprofloxacin Cipro Antiinfectives/Antiviral/Antibacterial 1 Ciprofloxacin/Hydrocortisone Cipro HC Otic Steroids 1 Clindamycin Cleocin Antiinfectives/Antiviral/Antibacterial 1 Clindamycin Cleocin Vag Topical, Dermatology, Rectal, Vaginal/Antibacterial 1 Clobetasol Temovate Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Clonazepam Klonopin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Clonidine Catapres Cardiac & Anti-Hypertensive/Alpha Blockers 1 Colchicine Colchicine Misc/Other 1 Cyclobenzaprine Flexeril CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1 Cycloserine Seromycin Antiinfectives/Antitubercular 1 Cyproheptadine Periactin Wasting 1 Danocrine Danazol Misc/Other 1 Dexamethasone Decadron Antiinfectives/Antiinflammatory 1 Dexamethasone/Neomycin/ Polymyxin B Dexacidin Ophthalmic/Antibiotic 1 Diazepam Valium CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1 Diclofenac Topical Voltaren (gel) Topical Non-Steroidal Anti-Inflammatories 1 Dicyclomine Bentyl Gastrointest/Antispasmotic 1 Diflorasone Psorcon Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Docusate sodium Colace Gastrointest/Laxative 1 Docusate/Casanth Peri-Colace Gastrointest/Laxative 1 Dorzolamide+Timolol Cosopt Ophthalmic/Glaucoma 1 Doxycycline Vibramycin Antiinfectives/Antiviral/Antibacterial 1 Dutasteride Avodart 5-Alpha-Reductase Inhibitors/BPH 1 Erythomycin / Benzoyl perox Benzagel Topical, Dermatology, Rectal, Vaginal/Antibacterial 1 Erythromycin E-Mycin Ophthalmic/Antibiotic 1 Erythromycin base Ery-tab Antiinfectives/Antiviral/Antibacterial 1 Estrogen Conjugated Premarin GYN/OB 1 Ethinyl Estradiol/Norgestimate Ortho-Tricyclen 28 GYN/OB 1 Ethinyl Estradiol/Norgestrel Lo-Ovral 28 GYN/OB 1 Ethosuximide Zarontin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Ferrous Sulfate/Fumerate Feosol Vitamins & Nutritional/Vitamins 1 Fiberlax Fibercon Gastrointest/Laxative 1 Fluocinolone Dermasmoothe Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Generic Name Brand Name Drug Classification Tier Fluorometholone FML Ophthalmic/Steroid 1 Formoterol/Mometasone Dulera Bronchodilator Combinations 1 Guaifen/Codeine/Pseudoephedrine Robitussin DAC Respiratory, Cough & Cold Allergy/Antitussive 1 Guaifen/Dextromethorphan Robitussin DM Respiratory, Cough & Cold Allergy/Antitussive 1 Guaifenesin Robitussin Respiratory, Cough & Cold Allergy/Antitussive 1 Guaifenesin/Codeine Robitussin AC Respiratory, Cough & Cold Allergy/Antitussive 1 Haloperidol Haldol CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1 HCTZ HydroDiuril Cardiac & Anti-Hypertensive/Diuretic 1 HCTZ/Triamterene Dyazide Cardiac & Anti-Hypertensive/Diuretic 1 Hydrocodone/Acetaminophen Vicodin,VicodinES CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Hydrocortisone Cream Hytone Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Hydrocortisone Suppository Anusol-HC Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Hydroxyzine Vistaril,Atarx CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1 Irbesartan Avapro Cardiac & Anti-Hypertensive/Angiotensin Receptor Blocker (ARB) 1 Isoniazid/Rifampin Rifamate Antiinfectives/Antitubercular 1 Isosorbide Mononitrate Imdur Cardiac & Anti-Hypertensive/Nitrates 1 Labetalol Normodyne Cardiac & Anti-Hypertensive/Beta Blockers 1 Lansoprazole Prevacid Gastrointest/PPI 1 Latanoprost Xalatan Ophthalmic/Glaucoma 1 Leuprolide Lupron Gonadotropin Releasing Hormones 1 Lindane Kwell Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Lithium Carb Lithonate CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1 Lodoxamide Alomide Ophthalmic/Misc/Other 1 Loperamide Paregoric Imodium Gastrointest/Antidiarrheal 1 Lorazepam Ativan CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1 MAGIC Mouthwash MAGIC Mouthwash Misc/Other 1 Methadone Methadone CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Methocarbamol Robaxin Skeletal Muscle Relaxants 1 Methyprednisolone Medrol dosepak Antiinfectives/Antiinflammatory 1 Montileukast Singulair Respiratory, Cough & Cold Allergy/Other 1 MSContin, MSIR Morphine CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Mupirocin Bactroban Topical Antibiotic 1 Naphazoline Vasocon Ophthalmic/Misc/Other 1 Neo/Gramic/Poly Neosporin Topical, Dermatology, Rectal, Vaginal/Antibacterial 1 Neo/Poly/Bacit Neosporin Ophthalmic/Antibiotic 1 Neomycin / HC Cortisporin Otic 1 Neurontin Gabapentin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Nitrofurantoin Macrodantin Antiinfectives/Antiviral/Antibacterial 1 Generic Name Brand Name Drug Classification Tier Nystatin Mycostatin Topical, Dermatology, Rectal, Vaginal/Antifungal 1 Nystatin/Triamcin Mycolog Topical, Dermatology, Rectal, Vaginal/Antifungal 1 Olopatadine Ophthalmic Pataday Ophthalmic Antihistamines and Decongestants 1 Oxybutinin Ditropan Misc/Other 1 Oxycodone/Acet Percocet CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Oxycodone/ASA Percodan CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Pancrealipase Ultrace MT Gastrointest/Digestive Enzyme 1 Paromomycin Humatin Antiinfectives/Other 1 Pen Needles Pen Needles *for Lantus/Levemir Medication Administration 1 Penicililn VK PenVK Antiinfectives/Antiviral/Antibacterial 1 Penicillin Benzath Bicillin LA Antiinfectives/Antiviral/Antibacterial 1 Permethrin Elimite Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Perphenazine Trilafon CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1 Phenazopyridine Pyridium Misc/Other 1 Phenobarbital Phenobarbital CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Phenytoin Dilantin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Pilocarpine Pilocar Ophthalmic/Miotic 1 Podophilox Condylox Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Polyethylene Glycol Electrolyte GoLytely/Colyte Gastrointest/Misc/Other 1 Pramipexole Mirapex Dopaminergic Antiparkinaonism Agents 1 Prednisolone Pred Forte Ophthalmic/Steroid 1 Prednisone Deltasone Antiinfectives/Antiinflammatory 1 Promethazine Suppos Promethazine Suppos Gastrointest/Antiemetic 1 Propranolol Inderal Cardiac & Anti-Hypertensive/Beta Blockers 1 Pseudoephedrine Sudafed Respiratory, Cough & Cold Allergy/Antihist/Decongestant 1 Rivaroxaban Xarelto Anticoagulant/Factor Xa Inhibitors 1 Salmeterol Discus Serevent Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled 1 Selenium Selsun Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Simethicone Mylicon Gastrointest/Antiflatulant 1 Sodium Chloride Ocean Nasal Nasal 1 Sodium Chloride for Irrigation Normal Saline Misc/Other 1 Spironolactone