MAJOR HEALTH PARTNERS MEDICATION FORMULARY ALPHABETICAL
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1 GENERIC NAME TRADE NAME STRENGTH UNITS Disp Qty FORM Max Qty AGAMATRIX PRESTO METER PRESTO METER 1 EA 1 meter ALBUTEROL NEB SOLN UD VENTOLIN, PROVENTIL 2.5 MCG/3 ML 90 ML 90 days ALCOHOL SWABS ALCOHOL SWABS 70% 100 EA 100 days ALENDRONATE TAB WEEKLY PACK FOSAMAX 70 MG 4 TAB 12 tabs ALLOPURINOL TAB ZYLOPRIM MG 100 TAB 100 days 300 MG 100 TAB 100 days ALUMINUM CHLORIDE TOPICAL SOLN DRYSOL 20% 60 ML 60ml/30 days AMIODARONE TAB CORDARONE 200 MG 60 TAB 90 days AMITRIPTYLINE TAB ELAVIL 100 MG 100 TAB 100 days 10 MG 100 TAB 100 days AMLODIPINE TAB NORVASC 2.5 MG 90 TAB 90 days 10 MG 90 TAB 90 days 5 MG 90 TAB 90 days AMOX TR-POT CLAV SUSP AUGMENTIN MG/5 ML 100 ML 14 days MG/5 ML 100 ML 10 days MG/5 ML 200 ML 10 days AMOX/ POT CLAVULANATE TAB AUGMENTIN MG 20 TAB 14 days MG 20 TAB 14 days AMOXICILLIN CAP AMOXIL 500 MG 30 CAP 90 days AMOXICILLIN SUSP AMOXIL 250 MG/5 ML 150 ML 14 days 400 MG/5 ML 100 ML 14 days AMOXICILLIN TAB AMOXIL 875 MG 20 TAB 90 days ATENOLOL TAB TENORMIN 100 MG 100 TAB 100 days ATENOLOL/CHLORTHALIDONE TAB TENORETIC ATORVASTATIN TAB LIPITOR 10 MG 90 TAB 90 days 20 MG 90 TAB 90 days AZITHROMYCIN SUSP ZITHROMAX 100 MG/5 ML 15 ML 6 days 200 MG/5 ML 30 ML 6 days AZITHROMYCIN TAB DOSE PAK Z-PACK (ZITHROMAX) 250 MG 6 TAB 6 days BACLOFEN TAB LIORESAL 10 MG 100 TAB 100 days BENAZEPRIL TAB LOTENSIN 10 MG 100 TAB 100 days BENZONATATE CAP TESSALON PERLES 100 MG 30 CAP 90 days 200 MG 30 CAP 90 days BISOPROLOL/HCTZ TAB ZIAC BRIMONIDINE OPTH SOLN ALPHAGAN 0.2% 5 ML 90 days BUPROPION TAB SR WELLBUTRIN SR 150 MG (2X/DAY) 60 TAB 90 days BUPROPION TAB XL WELLBUTRIN XL 300 MG (1X/DAY) 90 TAB 90 days 150 MG (1X/DAY) 90 TAB 90 days BUSPIRONE TAB BUSPAR 10 MG 100 TAB 100 days 5 MG 100 TAB 100 days 15 MG 100 TAB 100 days CARBIDOPA-LEVODOPA TAB SINEMET 25/100 MG 100 TAB 100 days CARVEDILOL TAB COREG MG 100 TAB 100 days CEFDINIR CAP OMNICEF 300 MG 20 CAP 10 days CEFDINIR SUSP OMNICEF 250 MG/5 ML 60 ML 10 days 100 ML 10 days 125 MG/5 ML 100 ML 10 days CEFUROXIME TAB CEFTIN 500 MG 20 TAB 10 days CELECOXIB CELEBREX 100 MG 100 CAP 100 days 200 MG 100 CAP 100 days CEPHALEXIN CAP KEFLEX 500 MG 40 CAP 90 days CEPHALEXIN SUSP KEFLEX 250 MG/5 ML 200 ML 14 days CETIRIZINE HCL TAB ZYRTEC 10 MG 100 TAB 100 days CETIRIZINE SYRUP ZYRTEC 5 MG/5 ML 120 ML 90 days CHANTIX MAINTENANCE PACK CHANTIX 1 MG 56 TAB 1 box CHANTIX STARTER PACK CHANTIX 0.5/1 MG 53 TAB 1 box CHANTIX TAB CHANTIX 0.5 MG 56 TAB 1 bottle/28 days CIPROFLOXACIN TAB CIPRO 500 MG 20 TAB 14 days Page 1 of 5 Revised 7/01/2016
2 CITALOPRAM TAB CELEXA 10 MG 100 TAB 100 days CLARITHROMYCIN TAB BIAXIN 500 MG 20 TAB 14 days CLINDAMYCIN CAP CLEOCIN 300 MG 40 CAP 14 days 150 MG 40 CAP 14 days CLONIDINE TAB CATAPRES 0.1 MG 100 TAB 100 days 0.2 MG 100 TAB 100 days 0.3 MG 100 TAB 100 days CLOPIDOGREL TAB PLAVIX 75 MG 90 TAB 90 days CLOTRIMAZOLE-BETAMETHASONE CRM LOTRISONE 1%-0.5% 45 GM 1 tube/14 days CYCLOBENZAPRINE TAB FLEXERIL 10 MG 30 TAB 90 days DIGOXIN TAB LANOXIN 0.1 DILTIAZEM CD CAP CARDIZEM CD 300 MG 90 CAP 90 days 120 MG 90 CAP 90 days 180 MG 90 CAP 90 days 240 MG 90 CAP 90 days TIAZAC 360 MG 90 CAP 90 days DIMAPHEN DM DIMETAPP COLD & COUGH MULTI INGR. 118 ML 236 ml DIPHENHYDRAMINE CAP BENADRYL 25 MG 24 CAP 24 caps DOXAZOSIN TAB CARDURA 1 MG 100 TAB 100 days 4 MG 100 TAB 100 days DOXYCYCLINE HYCLATE CAP 50 MG ANY CAP 90 days DOXYCYCLINE HYCLATE TAB VIBRAMYCIN 100 MG 20 CAP 90 days DOXYCYCLINE MONOHYDRATE CAP MONODOX 100 MG ANY CAP 90 days 50 MG ANY CAP 90 days DULOXETINE CAP CYMBALTA 30 MG 90 CAP 90 days 60 MG 90 CAP 90 days ESCITALOPRAM TAB LEXAPRO 10 MG 100 TAB 100 days FENOFIBRATE TAB TRICOR 48 MG 90 TAB 100 days 145 MG 90 TAB 100 days FEXOFENADINE TAB ALLEGRA 180 MG 100 TAB 100 days FLUCONAZOLE TAB DIFLUCAN 100 MG ANY TAB 90 days 200 MG ANY TAB 90 days 150 MG ANY TAB 90 days FLUOXETINE CAP PROZAC 10 MG 100 CAP 100 days 20 MG 100 CAP 100 days FLUTICASONE NASAL SPRAY FLONASE 50 MCG 16 GM 3 bottles/90 days FOLIC ACID TAB FOLIC ACID 1 MG 100 TAB 100 days FUROSEMIDE TAB LASIX 80 MG 100 TAB 100 days GABAPENTIN CAP NEURONTIN 100 MG 100 CAP 100 days 300 MG 100 CAP 100 days 400 MG 100 CAP 100 days GABAPENTIN TAB NEURONTIN 600 MG 100 TAB 100 days 800 MG 100 TAB 100 days GEMFIBROZIL TAB LOPID 600 MG 60 TAB 90 days GLIMEPIRIDE TAB AMARYL 4 MG 100 TAB 100 days 2 MG 100 TAB 100 days GLYBURIDE/METFORMIN TAB GLUCOVANCE 2.5/500 MG 100 TAB 100 days 5/500 MG 100 TAB 100 days HYDROCHLOROTHIAZIDE CAP HYDRODIURIL 12.5 MG 100 CAP 100 days HYDROCHLOROTHIAZIDE TAB HYDRODIURIL HYDROXYZINE HCL TAB ATARAX 10 MG ANY TAB 100 days 25 MG 30 TAB 100 days HYDROXYZINE PAM CAP VISTARIL 25 MG ANY CAP 100 days IBUPROFEN TAB MOTRIN 600 MG ANY TAB 30/10 days 800 MG 30 TAB 30/10 days INSULIN PEN NEEDLES (EASY TOUCH) 29 GAUGE, 1/2 INCH 100 EA 100 days 31 GAUGE, 5/16 INCH 100 EA 100 days 32 GAUGE, 3/16 INCH 100 EA 100 days INSULIN SYRINGES (EASY TOUCH) 1 ML 100 EA 100 days INSULIN SYRINGES LO-DOSE (EASY TOUCH) 0.5 ML 100 EA 100 days IPRATROPIUM ALBUTEROL INH SOLN DUONEB MG/3 ML 90 ML 90 days IPRATROPIUM NASAL SPRAY ATROVENT 0.03% 30 ML 3 bottles/90 days 0.06% 15 ML 3 bottles/90 days Page 2 of 5 Revised 7/01/2016
3 IRBESARTAN TAB AVAPRO 300 MG 90 TAB 90 days 150 MG 90 TAB 90 days 75 MG 90 TAB 90 days IRBESARTAN/HCTZ TAB AVALIDE 150/12.5 MG 90 TAB 90 days ISOSORBIDE MONONITRATE TAB IMDUR 10 MG 100 TAB 100 days 1 30 MG 100 TAB 100 days 60 MG 100 TAB 100 days LAMOTRIGINE TAB LAMICTAL 100 MG 100 TAB 100 days 200 MG 60 TAB 90 days 150 MG 60 TAB 90 days LANCET DEVICE, EASY TOUCH 1 EA 1 device LANCETS, EASY TOUCH N/A 30 GAUGE 100 EA 100 days LANCETS, TECHLITE N/A 25 GAUGE 100 EA 100 days LANSOPRAZOLE CAP PREVACID 30 MG 90 CAP 90 days LANTUS SOLOSTAR PEN LANTUS 100 UNITS/ML 45 ML 6 wks LANTUS VIAL LANTUS 100 UNITS/ML 10 ML 6 wks LATANOPROST OPTH SOLN XALATAN 2.5% 2.5 ML 1 bottle LEVOFLOXACIN TAB LEVAQUIN 500 MG ANY TAB 14 days 250 MG ANY TAB 14 days 750 MG ANY TAB 14 days LEVOTHYROXINE TAB SYNTHROID 100 MCG 100 TAB 100 days 200 MCG 100 TAB 100 days 25 MCG 100 TAB 100 days 50 MCG 100 TAB 100 days 150 MCG 100 TAB 100 days 125 MCG 100 TAB 100 days 75 MCG 100 TAB 100 days 88 MCG 100 TAB 100 days 112 MCG 100 TAB 100 days 137 MCG 100 TAB 100 days 175 MCG 100 TAB 100 days LISINOPRIL TAB PRINIVIL - ZESTRIL 10 MG 100 TAB 100 days 5 MG 100 TAB 100 days 30 MG 100 TAB 100 days LISINOPRIL/HCTZ TAB PRINZIDE - ZESTORETIC 10/12.5 MG 100 TAB 100 days 20/12.5 MG 100 TAB 100 days 20/ LORATADINE TAB CLARITIN 10 MG 100 TAB 100 days LORATADINE/PSEUDOEPHEDRINE TAB CLARITIN-D 24-HOUR 10/240 MG 10 TAB 30 days LOSARTAN TABS COZAAR 100 MG 90 TAB 90 days 25 MG 90 TAB 90 days 50 MG 90 TAB 90 days LOSARTAN/HCTZ TAB HYZAAR 50/12.5 MG 90 TAB 90 days 100/25 MG 90 TAB 90 days LOVASTATIN TAB MEVACOR MELOXICAM TAB MOBIC 15 MG 100 TAB 100 days 7.5 MG 100 TAB 100 days METFORMIN TAB GLUCOPHAGE 500 MG 100 TAB 100 days MG 100 TAB 100 days METFORMIN TAB ER GLUCOPHAGE XR 500 MG 100 TAB 100 days 7 METHOTREXATE TAB N/A 2.5 MG 100 TAB 100 days METHYLPREDNISOLONE DOSEPACK MEDROL DOSPAK 4 MG 21 TAB 2 packs/30 days METOPROLOL SUCC TAB ER TOPROL XL 100 MG 100 TAB 100 days 200 MG 100 TAB 100 days METOPROLOL TARTRATE TAB LOPRESSOR 100 MG 100 TAB 100 days METRONIDAZOLE TAB FLAGYL 500 MG ANY TAB 14 days Page 3 of 5 Revised 7/01/2016
4 MONTELUKAST TAB SINGULAIR 10 MG 90 TAB 90 days MONTELUKAST TAB CHEWABLE SINGULAIR 5 MG 90 TAB 90 days 4 MG 90 TAB 90 days MUPIROCIN OINTMENT BACTROBAN 2% 22 GM 3 tubes/30 days NABUMETONE TAB RELAFEN 500 MG 100 TAB 100 days 7 NAPROXEN TAB NAPROSYN 500 MG 100 TAB 100 days MG 100 TAB 100 days NEO/POLY/HC OTIC SOLN CORTISPORIN MULTI INGR. 10 ML 1 bottle/14 days NEO/POLY/HC OTIC SUSP CORTISPORIN MULTI INGR. 10 ML 1 bottle/14 days NITROFURANTOIN MACRO CAP MACROBID 100 MG 20 CAP 14 days NOVOLIN 70/30 VIAL NOVOLIN 100 UNITS/ML 10 ML 6 wks NOVOLIN N VIAL NOVOLIN N 100 UNITS/ML 10 ML 6 wks NOVOLIN R VIAL NOVOLIN R 100 UNITS/ML 10 ML 6 wks NOVOLOG 70/30 VIAL NOVOLOG 70/ UNITS/ML 10 ML 6 wks NOVOLOG FLEXPEN NOVOLOG FLEX PEN 100 UNITS/ML 45 ML 6 wks NOVOLOG VIAL NOVOLOG 100 UNITS/ML 10 ML 6 wks OMEPRAZOLE CAP PRILOSEC (Rx) 20 MG 100 CAP 100 days 40 MG 100 CAP 100 days ONDANSETRON ODT ZOFRAN ODT 4 MG 10 TAB 30 days 8 MG ANY TAB 30 days ONDANSETRON TAB ZOFRAN 4 MG ANY TAB 30 days OPTICHAMBER N/A 1 EA 2/180 days ORPHENADRINE TAB ER NORFLEX 100 MG 100 TAB 100 days PANTOPRAZOLE TAB PROTONIX PAROXETINE TAB PAXIL 10 MG 90 TAB 90 days 20 MG 90 TAB 90 days 30 MG 90 TAB 90 days PHENAZOPYRIDINE TAB PYRIDIUM 100 MG ANY TAB 7 days 200 MG 10 TAB 7 days PIOGLITAZONE TAB ACTOS 15 MG 90 TAB 90 days 30 MG 90 TAB 90 days 45 MG 90 TAB 90 days POLYETHYLENE GLYCOL MIRALAX/GLYCOLAX GM 90 days 527 GM 90 days POLYMIXIN/TRIMETHOPRIM OPTH SOLN POLYTRIM MULTI INGR. 10 ML 1 bottle/14 days POTASSIUM CL CAP ER MICRO-K 10 MEQ 100 CAP 100 days POTASSIUM CL TAB ER K-DUR 20 MEQ 100 TAB 100 days KLOR-CON 10 MEQ 100 TAB 100 days PRAVASTATIN TAB PRAVACHOL 20 MG 90 TAB 90 days PREDNISOLONE ORAL SOLN PRELONE 15 MG/5 ML ANY ML 14 days PREDNISONE TAB DELTASONE 10 MG 100 TAB 100 days 5 MG ANY TAB 100 days 50 MG ANY TAB 10 days 20 MG ANY TAB 100 days 1 MG ANY TAB 100 days PREDNISONE TAB UD DELTASONE 10 MG 18 TAB 18 PRESTO TEST STRIPS AGAMATRIX PRESTO 100 EA 100 days PROMETHAZINE DM SYRUP PHENERGAN DM MULTI INGR. 118 ML 236 ml PROMETHAZINE TAB PHENERGAN 25 MG 30 TAB 100 days RANITIDINE TAB ZANTAC 1 SERTRALINE TAB ZOLOFT 100 MG 100 TAB 100 days SIMVASTATIN TAB ZOCOR 20 MG 90 TAB 90 days SPIRONOLACTONE TAB ALDACTONE SPIRONOLACTONE/HCTZ TAB ALDACTAZIDE 25/ SUCRALFATE 1GM TAB CARAFATE 1 GRAM 100 TAB 100 days SULFAMETHOXAZOLE/TMP SUSP SEPTRA, BACTRIM 200/40 MG/5 ML ANY ML 14 days SULFAMETHOXAZOLE/TMP TAB DS SEPTRA DS, BACTRIM DS 160/80 MG 20 TAB 14 days SUMATRIPTAN TAB IMITREX 100 MG 9 TAB 27 tabs/30 days 25 MG 9 TAB 27 tabs/30 days 50 MG 9 TAB 27 tabs/30 days Page 4 of 5 Revised 7/01/2016
5 TAMSULOSIN 0.4MG CAP FLOMAX 0.4 MG 100 CAP 100 days TIZANIDINE TAB ZANAFLEX 4 MG 150 TAB 100 days TOBRAMYCIN OPTH SOLN TOBREX 0.3% 5 ML 1 bottle/14 days TOPIRAMATE TAB TOPAMAX 100 MG 60 TAB 90 days 200 MG 60 TAB 90 days 25 MG 60 TAB 90 days 50 MG 60 TAB 90 days TRAZODONE TAB DESYREL 100 MG 100 TAB 100 days TRIAMCINOLONE CREAM ARISTOCORT CREAM 0.1% 80 GM 1 tube/30 days TRIAMTERENE/HCTZ TAB MAXZIDE VENLAFAXINE CAP XR EFFEXOR XR 150 MG 90 CAP 90 days 75 MG 90 CAP 90 days 37.5 MG 90 CAP 90 days VENTOLIN HFA INHALER PROAIR HFA 90 MCG 18 GM 2 inhalers/30 days VERAPAMIL TAB SR CALAN SR 120 MG 100 CAP 100 days 180 MG 100 TAB 100 days Page 5 of 5 Revised 7/01/2016
Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70 mg Fosamax Arthritis
Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
School Corp Formulary Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70
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Penicillin VK Vcillin K 250gm/5ml Penicillin VK Vcillin K 250mg Sulfameth/Trimeth Bactrim 400/80mg Sulfameth/Trimeth Bactrim/Septra DS 800/160mg
Antibiotic Amoxicillin Amoxil 250mg Amoxicillin Amoxil 500mg Amoxicillin Amoxil 125mg/5ml Amoxicillin Amoxil 250mg/5ml Amoxicillin Bid Amoxil 400mg/5ml Amoxicillin Bid Amoxil 200mg/5ml Ampicillin Polycillin
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Antibiotic Amoxicillin Amoxil 250mg Amoxicillin Amoxil 500mg Amoxicillin Amoxil 125mg/5ml Amoxicillin Amoxil 250mg/5ml Amoxicillin Bid Amoxil 400mg/5ml Amoxicillin Bid Amoxil 200mg/5ml Ampicillin Polycillin
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The Society of St. Vincent de Paul Charitable Pharmacy is a fully licensed pharmacy operating on a stand-alone basis and providing prescribed medications at no charge to those low-income individuals who
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Acyclovir Capsules 200mg Viruses 30 90 Albuterol Syrup 2mg/5ml Asthma 120 360 Albuterol Sulfate Solution 0.05% * Asthma ----- ----- 20 60 Albuterol Sulfate Solution 0.083% Asthma ----- ----- 75 225 Alendronate
Riesbeck's Pharmacy Reward Club Generic Medication List October 2017
Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
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Drug Category Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Riesbeck's Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml 2160ml Hydroxyzine
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Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
AMANTADINE 50 MG/5 ML SYRUP ACYCLOVIR 200 MG CAPSULES ACYCLOVIR 400 MG TABLETS ACYCLOVIR 800 MG TABLETS 30 90
Antibiotics Qty* DRUG NAME $0.00 Copay $ 4.00 $ 10.00 AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE) 150 AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE) 100 AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE) 80 AMOXICILLIN 200 MG/5
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1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL
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Antibiotics Antifungal Antiviral Arthritis/ Pain 30 Day Qty* Free AMOXICILLIN 125 MG/5 ML (150 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (100 ML BOTTLE) AMOXICILLIN 125 MG/5 ML (80 ML BOTTLE) AMOXICILLIN 200
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Allergies & Cold and Flu $4, 30-day $10, 90-day Benzonatate 100mg cap 14 42 Loratadine 10mg tab 30 90 Promethazine DM syrup 120ml 360ml Antibiotic Treatments Amoxicillin 125mg/5ml susp (80ml bottle) 1
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Allergies & Cold and Flu Benzonatate 100mg 14 42 Ceron DM syrup 120ml 360ml Ceron drops* 30ml 90ml Dec-Chlorphen drops* 30ml 90ml Dec-Chlorphen DM syrup* 118ml 354ml Loratadine 10mg 30 90 Promethazine
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Acetaminophen 325 mg (MaPap, Q-Pap) Analgesic Tylenol Acyclovir 400 mg Antiviral Zovirax AirDuo Respiclick 55 mg/14 Inhalation Fluticasone, Respiratory mg Powder salmeterol Albuterol Soln for Nebulizer
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DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M %
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DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 702 M %
December 16 No Category M changes so the reductions imposed in May which were only supposed to last until September continue As in November, most changes are Category A lines with a few Category C. Significant
DT Description Price Category Price change
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