HealthPAC Formulary Current as of April 2015

Transcription

1 Acetaminophen/Oxycodone Percocet 325/5 and 325/10 Analgesic Narcotic Acetaminophen/Codeine #3 Tylenol #3 300/30 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325/5 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325/7.5 mg Analgesic Narcotic Acetaminophen/Hydrocodone Norco 325/10 mg Analgesic Narcotic Acetaminophen/Hydrocodone bitartrate Vicodin 500 mg - 5 mg Analgesic Narcotic Acetic acid Vosol 15 ml drops Otic Acetic acid/hydrocortisone Vosol HC 2%-1% Otic Acetylsalicylic acid (ASA) 81, 325 mg Analgesic Salicylates Acyclovir Zovirax 200 mg Antimicrobials Antiviral Acyclovir Zovirax 400 mg Antimicrobials Antiviral Acyclovir Zovirax 800 mg Antimicrobials Antiviral Albuterol HFA (IDP) tablet, MDI, Proventil HFA solution, UD (IDP) 90 mcg Respiratory Inhaler Albuterol liquid Ventolin, Proventil 2 mg / 5 cc (120 ml) Respiratory Albuterol solution neb Proventil 5 mg/ml (20 ml bottle) Respiratory Nebulizer soln Albuterol Unit Dose Proventil 0.83 mg/ml Respiratory Albuterol-ipratropium Inhaler Combivent MDI Respiratory Alclometasone Cream Aclovate 45 gm Anti-inflammatory Agents Alclometasone Ointment Aclovate 45 gm Anti-inflammatory Agents Alendronate Fosamax 70 mg Osteoporosis Alendronate Fosamax 35 mg Osteoporosis Allopurinol Zyloprim 300 mg Gout Allopurinol Zyloprim 100 mg Gout Amantadine Symmetrel 50 mg / 5 ml (120 ml) Neurologic Parkinson Amantadine Symmetrel 100 mg Neurologic Parkinson Amiodarone Cordarone 400 mg Cardiovascular Antiarrythmic Amiodarone Cordarone 200 mg Cardiovascular Antiarrythmic Amitriptyline Elavil 50 mg Psychiatric Antidepressant Amitriptyline Elavil 25 mg Psychiatric Antidepressant Amitriptyline Elavil 10 mg Psychiatric Antidepressant Amitriptyline Elavil 75 mg Psychiatric Antidepressant Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 1 of 22

2 Amitriptyline Elavil 100 mg Psychiatric Antidepressant Amlodipine Norvasc 5 mg Cardiovascular Amlodipine Norvasc 2.5 mg Cardiovascular Amlodipine Norvasc 10 mg Cardiovascular Amoxicillin Amoxil 500 mg Antimicrobials Penicillins Amoxicillin Amoxil 250 mg / 5 cc (150 cc) Antimicrobials Penicillins Amoxicillin Amoxil 250 mg Antimicrobials Penicillins Amoxicillin Amoxil 125 mg / 5 cc (80 cc) Antimicrobials Penicillins Amoxicillin Amoxil 400 mg/ 5 cc Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 500 mg-125 mg Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 875 mg Antimicrobials Penicillins Amoxicillin-clavulanate Augmentin 200 mg / 5 cc (100 ml) Antimicrobials Penicillins Antipyrene, Benzodine, Glycerine dehyd Auralgan 10 ml drops Otic Atenolol Tenormin 50 mg Cardiovascular Beta Atenolol Tenormin 25 mg Cardiovascular Beta Atenolol Tenormin 100 mg Cardiovascular Beta Azathioprine Imuran 50mg Immunosupressive Azithromycin Zithromax 250 mg Antimicrobials Macrolides Baclofen Lioresal 10 mg Analgesic Muscle Relaxant Baclofen Lioresal 20 mg Analgesic Muscle Relaxant Beclomethasone dipropinate Qvar 80 mcg Respiratory Steroid inhaler Beclomethasone dipropinate Qvar 40 mcg Respiratory Steroid inhaler Belladona alkaloids, phenobarbital Donnatal 16.2 mg GI Antispasmodics Benztropine mesylate Cogentin 2 mg Neurologic Parkinson Benztropine mesylate Cogentin 1 mg Neurologic Parkinson Benztropine mesylate Cogentin 0.5 mg Neurologic Parkinson Benztropine mesylate Cogentin 1 mg/cc (inj) Neurologic Parkinson bismuth subsalicylate-metronidazoletetracycline Helidac Helicobacter pylori agent Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 2 of 22

3 Brimonidine tartrate solution Alphagan 0.2% Ophthalmic Glaucoma Brimonidine tartrate solution Alphagan 0.2% Ophthalmic Glaucoma Brinzolamide Azopt 1% solution Ophthalmic Glaucoma Bromocriptine Parlodel 2.5mg Hypoprolactinemic Buprenorphine Butrans 10 mcg/hr Analgesic Opiate Agonist Buprenorphine Butrans 15 mcg/hr Analgesic Opiate Agonist Buprenorphine Butrans 5 mcg/hr Analgesic Opiate Agonist Buprenorphine Butrans 7.5 mcg/hr Analgesic Opiate Agonist Buprenorphine Subutex 2 mg Analgesic Opiate Agonist Buprenorphine/naloxone Suboxone mg Analgesic Mixed Opiate Agonist/Antagonist Buprenorphine/naloxone Suboxone 8-2 mg Analgesic Mixed Opiate Agonist/Antagonist Bupropion XL Wellbutrin XL 150 mg, 300 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 150 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 75 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 100 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 200 mg Psychiatric Antidepressant Buproprion IR, SR Wellbutrin SR 300 mg Psychiatric Antidepressant Buspirone HCI BuSpar 5 mg Psychiatric Other Buspirone HCI BuSpar 10 mg Psychiatric Other Buspirone HCI BuSpar 15 mg Psychiatric Other Buspirone HCI BuSpar 30 mg Psychiatric Other Butalbital-APAP-Caffeine Fioricet 50/325/40 Analgesic Misc Calcitriol Rocaltrol 0.25 mcg Vitamin Calcitriol Rocaltrol 0.5 mcg Vitamin Calcium acetate Phoslo 667mg Phosphate binder Captopril Capoten 50 mg Cardiovascular ACE Inhibitor Captopril Capoten 25 mg Cardiovascular ACE Inhibitor Captopril Capoten 12.5 mg Cardiovascular ACE Inhibitor Captopril Capoten 100 mg Cardiovascular ACE Inhibitor Carbamazepine Tegretol 200 mg Psychiatric Mood Stabilizer Carbamazepine Tegretol 100 mg Psychiatric Mood Stabilizer Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 3 of 22

4 Carbamazepine Tegretol 100 mg / 5 cc Psychiatric Mood Stabilizer Carbidopa - levodopa Sinemet mg Neurologic Parkinson Carbidopa - levodopa Sinemet mg Neurologic Parkinson Carbidopa - levodopa Sinemet mg Neurologic Parkinson Carbidopa - levodopa LA Sinemet CR mg Neurologic Parkinson Carbidopa - levodopa LA Sinemet CR mg Neurologic Parkinson Carisoprodol Soma 250mg muscle relaxant Carvedilol Coreg 6.25 mg Cardiovascular Beta Carvedilol Coreg mg Cardiovascular Beta Carvedilol Coreg 12.5 mg Cardiovascular Beta Carvedilol Coreg 25 mg Cardiovascular Beta Cephalexin Keflex 250 mg / 5 ml (100 ml) Antimicrobials Cephalosporins Cephalexin Keflex 250 mg Antimicrobials Cephalosporins Cephalexin Keflex 125 mg / 5 ml (200 ml) Antimicrobials Cephalosporins Cephalexin Keflex 500 mg Antimicrobials Cephalosporins Chlorpromazine Thorazine 50 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 25 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 200 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 100 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 10 mg Psychiatric Antipsychotic Chlorpromazine Thorazine 30 mg/ml Psychiatric Antipsychotic Chlorpromazine Thorazine 100 mg/ml Psychiatric Antipsychotic Chlorthalidone Thalitone 25mg Cardiovascular Diuretics Chlorthalidone Thalitone 50 mg Cardiovascular Diuretics Cimetidine Tagamet 400 mg GI H2 blockers Ciprofloxacin Cipro 500 mg Antimicrobials Quinolones Ciprofloxacin Cipro 250 mg Antimicrobials Quinolones Ciprofloxacin eye drop Ciloxan 0.3% Ophthalmic Citalopram Hydrobromide Celexa 40 mg Psychiatric Antidepressant Citalopram Hydrobromide Celexa 20 mg Psychiatric Antidepressant Citalopram Hydrobromide Celexa 10 mg Psychiatric Antidepressant Citalopram Hydrobromide Celexa 10 mg / 5 cc Psychiatric Antidepressant Clarithromycin Biaxin 500 mg Antimicrobials Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 4 of 22

5 Clindamycin Cleocin 150 mg Antimicrobials Misc Clindamycin Cleocin 300 mg Antimicrobials Misc Clindamycin topical gel, lotion Cleocin 1% Derm Acne Clindamycin topical solution Cleocin-T 1% (60 ml) Derm Acne Clobetasol lotion Temovate 0.05% Derm Clobetasol propionate Temovate 0.05% crm (15 Gms) Derm Antiinflammatory Clobetasol propionate Temovate 0.05% oint (30 Gms) Derm Antiinflammatory Clobetasol propionate Temovate 0.05% oint (15 Gms) Derm Antiinflammatory Clomipramine Anafranil 75 mg Psychiatric Antidepressant Clomipramine Anafranil 50 mg Psychiatric Antidepressant Clomipramine Anafranil 25 mg Psychiatric Antidepressant Clonazepam (SCH IV) Klonopin 2 mg Psychiatric Benzos Clonazepam (SCH IV) Klonopin 1 mg Psychiatric Benzos Clonazepam (SCH IV) Klonopin 0.5 mg Psychiatric Benzos Clonidine HCI tabs Catapres 0.1 mg Cardiovascular Central Alpha Agonist Clonidine HCI tabs Catapres 0.3 mg Cardiovascular Central Alpha Agonist Clonidine HCI tabs Catapres 0.2 mg Cardiovascular Central Alpha Agonist Clopidogrel Plavix 75 mg Platelet aggregation inhibitor Colchicine Colcrys 0.6 mg Gout Conjugated Estrogen Cream Premarin mg/g crm (43 Gm) Hormone Replacement Cortisporin otic soln 1%-0.35%-10000u/mL (10 ml) Otic Cortisporin otic susp drops (10 ml) Otic Cromolyn inhaler Intal 14.2 Gm Respiratory Cyclobenzaprine Flexeril 10 mg Analgesic Muscle Relaxant Dextroamphetamine/amphetamine Adderall XR 10 mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 15 mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 20 mg Psychiatric Stimulant Dextroamphetamine/amphetamine Adderall XR 30 mg Psychiatric Stimulant Diabetes supplies - glucometer Diabetes Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 5 of 22

6 Diabetes supplies - lancets Diabetes Diabetes supplies - syringes/needles Diabetes Diabetes supplies - test strips Diabetes Diabetes supplies - testing control solution Diabetes Diazepam (SCH IV) Valium 5 mg Psychiatric Benzos Diazepam (SCH IV) Valium 2 mg Psychiatric Benzos Diazepam (SCH IV) Valium 10 mg Psychiatric Benzos Diclofenac Voltaren 50 mg Analgesic NSAID Diclofenac Voltaren 75 mg Analgesic NSAID Dicloxacillin Dynapen 500 mg Antimicrobials Penicillins Dicloxacillin Dynapen 250 mg Antimicrobials Penicillins Dicyclomine Bentyl 20 mg GI Antispasmodics Dicyclomine Bentyl 10 mg GI Antispasmodics Digoxin Lanoxin 0.25 mg Cardiovascular Glycosides Digoxin Lanoxin mg Cardiovascular Glycosides Dilitiazem HCI Cardizem LA 180 mg Cardiovascular Diltiazem Cardizem 120 mg Cardiovascular Diltiazem Cardizem CD, Dilacor Xr, Cartia 90 mg Cardiovascular XL, Dilt-CD Diltiazem Cardizem CD, Dilacor Xr, Cartia XL, Dilt-CD 60 mg Cardiovascular Diltiazem SR Cardizem SR 300 mg Cardiovascular Diltiazem SR Cardizem SR 240 mg Cardiovascular Diltiazem SR Cardizem SR 180 mg Cardiovascular Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 6 of 22

7 Diltiazem SR Cardizem SR 120 mg Cardiovascular Diltiazem CD Cardizem CD 360mg Cardiovascular Diltiazem CD Cardizem CD 90 mg Cardiovascular Diltiazem CD Cardizem CD 60 mg Cardiovascular Diltiazem CD Cardizem CD 300 mg Cardiovascular Diltiazem CD Cardizem CD 30 mg Cardiovascular Diltiazem CD Cardizem CD 240 mg Cardiovascular Diltiazem CD Cardizem CD 180 mg Cardiovascular Diltiazem CD Cardizem CD 120 mg Cardiovascular Diphenhydramine Benadryl 25, 50 mg capsules Cold, Cough, Allergy Antihistamine Diphenhydramine Benadryl 12.5 mg/ 5ml Cold, Cough, Allergy Antihistamine Diphenhydramine Benadryl 50 mg/cc (inj) Cold, Cough, Allergy Antihistamine Diphenoxylate-atropine Lomotil 2.5 mg GI Antidiarrhea Diphenoxylate-atropine (SCH V) Lomotil 2.5 /.025 / 5 (60 ml) GI Antidiarrhea Dipyridamole Persantine 25 mg Cardiovascular Anticoagulants Dipyridamole Persantine 50 mg Cardiovascular Anticoagulants Dipyridamole Persantine 75 mg Cardiovascular Anticoagulants Divalproex sodium Depakote DR 125 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote DR 500 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote DR 250 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote ER 250 mg Psychiatric Mood Stabilizer Divalproex sodium Depakote ER 500 mg Psychiatric Mood Stabilizer Doxazosin mesylate Cardura 8 mg Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 4 mg Cardiovascular Alpha-1 blocker Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 7 of 22

8 Doxazosin mesylate Cardura 2 mg Cardiovascular Alpha-1 blocker Doxazosin mesylate Cardura 1 mg Cardiovascular Alpha-1 blocker Doxepin HCL Sinequan 50 mg Psychiatric Antidepressant Doxepin HCL Sinequan 25 mg Psychiatric Antidepressant Doxepin HCL Sinequan 10 mg Psychiatric Antidepressant Doxepin HCL Sinequan 75 mg Psychiatric Antidepressant Doxepin HCL Sinequan 100 mg Psychiatric Antidepressant Doxepin HCL Sinequan 150 mg Psychiatric Antidepressant Doxycycline Doryx Vibramycin 50 mg Antimicrobials Tetracyclines Doxycycline Doryx Vibramycin 100 mg Antimicrobials Tetracyclines Econazole Spectazole 1% crm 15 Gm (15 Gm) Antimicrobials Antifungals Econazole Spectazole 1% crm 85 Gm (85 Gm) Antimicrobials Antifungals Econazole Spectazole 1% crm 30 Gm (30 Gm) Antimicrobials Antifungals Enalapril maleate Vasotec 5 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 20 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 2.5 mg Cardiovascular ACE Inhibitor Enalapril maleate Vasotec 10 mg Cardiovascular ACE Inhibitor Enalapril Vaseretic mg Cardiovascular Antihypertensive maleate/hydrochlorothiazide Enalapril Vaseretic mg Cardiovascular Antihypertensive maleate/hydrochlorothiazide Erythromycin eye ointment 5 mg / Gm (3.5 Gm) Ophthalmic Erythromycin gel or solution Erygel 2% Derm Acne Erythromycin stearate Ery-Tab 500 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 250 mg Antimicrobials Macrolides Erythromycin stearate Ery-Tab 333 mg Antimicrobials Macrolides Estradiol Estrace 2 mg Hormone Replacement Estradiol Estrace 1 mg Hormone Replacement Estradiol Estrace 0.5 mg Hormone Replacement Ethambutol Myambutol 400 mg Antimicrobials Antitubercular Ethambutol Myambutol 100 mg Antimicrobials Antitubercular Famotidine Pepcid 20 mg GI H2 Antagonists Famotidine Pepcid 40 mg GI H2 Antagonists Finasteride Proscar 5 mg Genitourinary 5-alpha reductase inhibitor Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 8 of 22

9 Fluconazole Diflucan 200 mg Antimicrobials Antifungals Fluconazole Diflucan 150 mg Antimicrobials Antifungals Fluconazole Diflucan 100 mg Antimicrobials Antifungals Fludrocortisone Florinef 0.2 mg Adrenals Fludrocortisone Florinef 0.1 mg Endocrine Flunisolide Nasarel 25 mcg/spray (0.025%) Cold, Cough, Allergy Nasal Steroids Fluocinolone acetonide Synalar 0.025% cream Derm Antiinflammatory Fluocinolone acetonide Synalar 0.01% cream Derm Antiinflammatory Fluocinolone acetonide Synalar 0.025% ointment Derm Antiinflammatory Fluocinolone acetonide Synalar 0.01% ointment Derm Antiinflammatory Fluocinolone acetonide Synalar 0.025%, 0.01% solution, 60 ml Derm Antiinflammatory Fluocinonide Lidex 0.05% gel (60gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% solution 60ml Derm Antiinflammatory Fluocinonide Lidex 0.05% oint (60 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% oint (30 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% oint (15 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% cream (60 gm) Derm Antiinflammatory Fluocinonide Lidex 0.05% cream (30 gm) Derm Antiinflammatory Fluoxetine Prozac 20 mg Psychiatric Antidepressant Fluoxetine Prozac 10 mg Psychiatric Antidepressant Fluoxetine Prozac 40 mg Psychiatric Antidepressant Fluoxetine Prozac 20 mg / 5 ml Psychiatric Antidepressant Fluphenazine Prolixin 5 mg / cc Psychiatric Antipsychotic Fluphenazine Prolixin 0.5 mg/ml Psychiatric Antipsychotic Fluphenazine Prolixin 2.5 mg Psychiatric Antipsychotic Fluphenazine Prolixin 10 mg Psychiatric Antipsychotic Fluphenazine Prolixin 1 mg Psychiatric Antipsychotic Fluphenazine decanoate Prolixin 25 mg/cc (inj) Psychiatric Antipsychotic Fluticasone propionate Flonase 50 mcg/spray Respiratory Nasal Inhaler Folic Acid 800 MicroGrams Vitamin Furosemide Lasix 80 mg Cardiovascular Diuretics Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 9 of 22

10 Furosemide Lasix 40 mg Cardiovascular Diuretics Furosemide Lasix 20 mg Cardiovascular Diuretics Gabapentin Neurontin 300 mg Neurologic Anticonvulsant Gabapentin Neurontin 100 mg Neurologic Anticonvulsant Gabapentin Neurontin 400 mg Neurologic Anticonvulsant Gabapentin Neurontin 600 mg Neurologic Anticonvulsant Gemfibrozil Lopid 600 mg Cardiovascular Cholesterol Lowering Agents Gentamicin eye drops Garamycin 0.3% (5 ml) Ophthalmic Glipizide Glucotrol 5 mg Diabetes Sulfonylureas Glipizide Glucotrol 10 mg Diabetes Sulfonylureas Glyburide Micronase Diabeta 5 mg Diabetes Sulfonylureas Glyburide Micronase Diabeta 2.5 mg Diabetes Sulfonylureas Glyburide Micronase Diabeta 1.25 mg Diabetes Sulfonylureas Griseofulvin micro liquid Grifulvin V 125 mg / 5 ml (120 ml) Antimicrobials Antifungals Griseofulvin ultramicro Grisactin Fulvicin 250 mg Antimicrobials Antifungals Griseofulvin ultramicro Grisactin Fulvicin 125 mg Antimicrobials Antifungals Guaifenesin + Codeine Robitussin AC 100 mg - 10mg / 5 ml Cold, Cough, Allergy Antitussive Haloperidol Haldol 5 mg Psychiatric Antipsychotic Haloperidol Haldol 2 mg Psychiatric Antipsychotic Haloperidol Haldol 1 mg Psychiatric Antipsychotic Haloperidol Haldol 0.5 mg Psychiatric Antipsychotic Haloperidol Haldol 2 mg / cc (15 cc) Psychiatric Antipsychotic Haloperidol Haldol 2 mg / cc (120 cc) Psychiatric Antipsychotic Haloperidol Haldol 10 mg Psychiatric Antipsychotic Haloperidol Haldol 20 mg Psychiatric Antipsychotic Haloperidol decanoate Haldol 50 mg/cc (inj) Psychiatric Antipsychotic Haloperidol decanoate Haldol 100 mg/cc (inj) Psychiatric Antipsychotic Hydralazine Apresoline 50 mg Cardiovascular Other Vasodilators Hydralazine Apresoline 25 mg Cardiovascular Other Vasodilators Hydralazine Apresoline 100 mg Cardiovascular Other Vasodilators Hydralazine Apresoline 10 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 10 of 22

11 Hydrochlorothiazide Esidrix 25 mg Cardiovascular Diuretics Hydrochlorothiazide Esidrix 50 mg Cardiovascular Diuretics Hydrochlorothiazide Microzide 12.5 mg cap Cardiovascular Diuretics Hydrocortisone HC 2.5% lotion Derm Antiinflammatory Hydrocortisone HC 5mg Derm Antiinflammatory Hydrocortisone HC 10mg Derm Antiinflammatory Hydrocortisone HC 20mg Derm Antiinflammatory Hydrocortisone cream Cortizone 2.5% Derm Antiinflammatory Hydrocortisone ointment Cortizone 2.50% Derm Antiinflammatory Hydrocortisone Suppositories Cortizone 25mg GI Antiinflammatory Hydroxychloroquine Plaquenil 200 mg Rheumatology Hydroxyzine HCL Atarax 25 mg Cold, Cough, Allergy Antihistamine Hydroxyzine HCL Atarax 10 mg Cold, Cough, Allergy Antihistamine Hydroxyzine HCL Atarax 10 mg / 5 cc (120 ml) Cold, Cough, Allergy Antihistamine Hydroxyzine HCL Atarax 50 mg Cold, Cough, Allergy Antihistamine Ibuprofen Motrin 400 mg Analgesic NSAID Ibuprofen Motrin 600 mg Analgesic NSAID Ibuprofen Motrin 800 mg Analgesic NSAID Imipramine Tofranil 50 mg Psychiatric Antidepressant Imipramine Tofranil 25 mg Psychiatric Antidepressant Imipramine Tofranil 10 mg Psychiatric Antidepressant Indomethacin Indocin 50 mg Analgesic NSAID Indomethacin Indocin 25 mg Analgesic NSAID Insulin 70/30 Humulin, Novolin U100 (10 ml) Diabetes Insulin Product Insulin glargine Lantus 100 IU/mL Diabetes Insulin Product Insulin Lispro Humalog 100U/mL Diabetes Insulin Product Insulin NPH Humulin N U100 (10 ml) Diabetes Insulin Product Insulin Regular Humulin R U100 (10 ml) Diabetes Insulin Product Ipratropium bromide 0.02% Atrovent Inh Sol 500 mcg (3 cc/amp) Respiratory Nebulizer soln Ipratropium MDI Atrovent 18mcg/dose MDI (14gm) Respiratory Asthma Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 11 of 22

12 Isoniazid INH 300 mg Antimicrobials Antitubercular Isoniazid INH 100 mg Antimicrobials Antitubercular Isoniazid INH 10 mg / ml Antimicrobials Antitubercular Nitrate Isosorbide dinitrate Isordil 5 mg Cardiovascular Vasodilators Nitrate Isosorbide dinitrate Isordil 20 mg Cardiovascular Vasodilators Nitrate Isosorbide dinitrate Isordil 10 mg Cardiovascular Vasodilators Nitrate Isosorbide dinitrate Isordil 30 mg Cardiovascular Vasodilators Nitrate Isosorbide mononitrate IR, SR Imdur 60 mg Cardiovascular Vasodilators Nitrate Isosorbide mononitrate IR, SR Imdur 30 mg Cardiovascular Vasodilators Nitrate Isosorbide mononitrate IR, SR Imdur 10 mg Cardiovascular Vasodilators Nitrate Isosorbide mononitrate IR, SR Imdur 20 mg Cardiovascular Vasodilators Nitrate Isosorbide mononitrate IR, SR Imdur 120 mg Cardiovascular Vasodilators Ketoconazole Nizoral 200 mg (tabs) Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (60 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (30 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% crm (15 Gm) Antimicrobials Antifungals Ketoconazole Nizoral 2% shampoo Antimicrobials Antifungals Ketotifen Alaway 0.025% Ophthalmic Labetalol HCL Trandate 200 mg Cardiovascular Beta Labetalol HCL Trandate 100 mg Cardiovascular Beta Labetalol HCL Trandate 300 mg Cardiovascular Beta Lactulose Duphalac 10g/15 ml syrup GI Laxatives Lamotrigine Lamictal 25 mg tab Neurologic Anticonvulsant Lamotrigine Lamictal 200 mg tab Neurologic Anticonvulsant Lamotrigine Lamictal 150 mg tab Neurologic Anticonvulsant Lamotrigine Lamictal 100 mg tab Neurologic Anticonvulsant Latanoprost Xalatan 0.005% Ophthalmic Levetiracetam Keppra 500 mg Neurologic Levetiracetam Keppra 750 mg Neurologic Levetiracetam Keppra 1000 mg Neurologic Levofloxacin Levaquin 500 mg Antimicrobials Levothyroxine Levoxyl 0.3 mg Endocrine Thyroid Levothyroxine Levoxyl 0.2 mg Endocrine Thyroid Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 12 of 22

13 Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl 0.15 mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl 0.1 mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Levothyroxine Levoxyl mg Endocrine Thyroid Lisinopril Prinivil, Zestril 5 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 20 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 40 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 2.5 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 10 mg Cardiovascular ACE Inhibitor Lisinopril Prinivil, Zestril 30 mg Cardiovascular ACE Inhibitor Lisinopril/Hydrochlorothiazide Zestoretic mg Cardiovascular Antihypertensive Lisinopril/Hydrochlorothiazide Zestoretic mg Cardiovascular Antihypertensive Lisinopril/Hydrochlorothiazide Zestoretic mg Cardiovascular Antihypertensive Lithium carbonate Eskalith CR 300 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith CR 150 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith SR 300 mg Psychiatric Mood Stabilizer Lithium carbonate Eskalith SR 450 mg Psychiatric Mood Stabilizer Loratidine Claritin 10mg Antihistamine Lorazepam (SCH IV) Ativan 2.0 mg Psychiatric Benzos Lorazepam (SCH IV) Ativan 1.0 mg Psychiatric Benzos Lorazepam (SCH IV) Ativan 0.5 mg Psychiatric Benzos Losartan Cozaar 25 mg Cardiovascular Angiotensin II Blocker Losartan Cozaar 50mg Cardiovascular Angiotensin II Blocker Losartan Cozaar 100 mg Cardiovascular Angiotensin II Blocker Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 13 of 22

14 Lovastatin Mevacor 10, 20, 40 mg Cardiovascular Cholesterol Lowering Agents Loxapin Loxitane 5, 10, 25, 50 mg Psychiatric Antipsychotic Meclizine Antivert 25mg tabs Neurologic Misc Medroxyprogesterone Provera 5 mg Hormone Replacement Medroxyprogesterone Provera 2.5 mg Hormone Replacement Medroxyprogesterone Provera 10 mg Hormone Replacement Mesalamine Asacol 400 mg GI Anti-inflammatory bowel Metformin Glucophage 500 mg Diabetes Biguanides Metformin Glucophage 850 mg Diabetes Biguanides Metformin Glucophage 1000 mg Diabetes Biguanides Metformin ER Glucophage XR 500 mg Diabetes Biguanides Metformin ER Glucophage XR 750 mg Diabetes Biguanides Metformin ER Glucophage XR 1000 mg Diabetes Biguanides Methadone 5 mg Analgesic Narcotic Methadone 10 mg Analgesic Narcotic Methimazole Tapazole 5 mg Endocrine Thyroid Methimazole Tapazole 10 mg Endocrine Thyroid Methocarbamol Robaxin 500 mg Analgesic Muscle Relaxant Methocarbamol Robaxin 750 mg Analgesic Muscle Relaxant Methotrexate Rheumatrex 2.5 mg Chemotherapy Methyldopa Aldomet 500 mg Cardiovascular Central Alpha Agonist Methyldopa Aldomet 250 mg Cardiovascular Central Alpha Agonist Methylphenidate long-acting Ritalin LA 10mg Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 20mg Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 30mg Psychiatric Stimulant Methylphenidate long-acting Ritalin LA 40mg Psychiatric Stimulant Methylphenidate short acting Ritalin 10mg Psychiatric Stimulant Methylphenidate short acting Ritalin 20mg Psychiatric Stimulant Methylphenidate short acting Ritalin 30mg Psychiatric Stimulant Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 14 of 22

15 Metoclopramide Reglan 10 mg GI Antiemetic Metoclopramide hcl Reglan 5 mg GI Antiemetic Metolazone Zaroxolyn 5 mg Cardiovascular Diurectics Metolazone Zaroxolyn 10 mg Cardiovascular Diurectics Metolazone Zaroxolyn 2.5 mg Cardiovascular Diurectics Metoprolol succinate Toprol XL 50 mg Cardiovascular Beta Metoprolol succinate Toprol XL 25 mg Cardiovascular Beta Metoprolol succinate Toprol XL 100 mg Cardiovascular Beta Metoprolol tartrate Lopressor 50 mg Cardiovascular Beta Metoprolol tartrate Lopressor 100 mg Cardiovascular Beta Metoprolol tartrate Lopressor 25 mg Cardiovascular Beta Metronidazole Flagyl 250 mg Antimicrobials Misc Metronidazole Flagyl 500 mg Antimicrobials Misc Metronidazole cream Metrocream 0.075% Antimicrobials Misc Metronidazole cream Metrocream 0.75% Derm Acne Metronidazole topical gel Metrogel 0.75% Derm Acne Miralax polyethylene glycol 238g GI Miralax polyethylene glycol 510g GI Mirtazapine Remeron 45 mg Psychiatric Antidepressant Mirtazapine Remeron 30 mg Psychiatric Antidepressant Mirtazapine Remeron 15 mg Psychiatric Antidepressant Misoprostol Cytotec 100mg GI Misoprostol Cytotec 200mg GI Montelukast Singulair 5 mg chew Respiratory Montelukast Singulair 10 mg Respiratory Morphine sulfate Liquid MS 20mg/ 5 ml Analgesic Narcotic Morphine sulfate short acting MS 15,30mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 15 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 30 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 60 mg Analgesic Narcotic Morphine sulfate SR Oramorph SR 100 mg Analgesic Narcotic Mupirocin Bactroban 2%ointment Antibiotic Nabumetone Relafen 750 mg Analgesic NSAID Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 15 of 22

16 Naloxone Narcan 0.4 mg/ ml Toxicology Agents Opiate Antagonists Naloxone Narcan 1 mg/ ml Toxicology Agents Opiate Antagonists Naproxen Naprosyn 250 mg Analgesic NSAID Naproxen Naprosyn 375 mg Analgesic NSAID Naproxen Naprosyn 500 mg Analgesic NSAID Niacin IR & ER tabs only 500 mg Cardiovascular Niacin IR & ER tabs only 100 mg Cardiovascular Niacin IR & ER tabs only 250 mg Cardiovascular Nicotine Patches- 28 weeks NicoDerm 7mg Smoking deterrents Nicotine Patches- 28 weeks NicoDerm 14mg Smoking deterrents Nicotine Patches- 28 weeks NicoDerm 21mg Smoking deterrents Nifedipine SR Procardia, Adalat 90 mg Cardiovascular CC, Nifediac Nifedipine SR Procardia, Adalat 60 mg Cardiovascular CC, Nifediac Nifedipine SR Procardia, Adalat 30 mg Cardiovascular CC, Nifediac Nitrofurantoin macrocryst Macrodantin 50 mg Antimicrobials Misc Nitrofurantoin macrocryst Macrodantin 100 mg Antimicrobials Misc Nitrofurantoin monohydrate Macrobid 100 mg Antimicrobials Misc Nitrate Vasodilators Nitroglycerine SL Nitrostat 0.4 mg Cardiovascular Nortriptyline Pamelor 75 mg Psychiatric Antidepressant Nortriptyline Pamelor 50 mg Psychiatric Antidepressant Nortriptyline Pamelor 25 mg Psychiatric Antidepressant Nortriptyline Pamelor 10 mg Psychiatric Antidepressant Nystatin (cream or ointment) Derm Antifungals Nystatin oral suspension 100,000 units/ml Antimicrobials Antifungals Olanzapine Zyprexa 5 mg Psychiatric Antipsychotic Olanzapine Zyprexa 2.5mg Psychiatric Antipsychotic Omeprazole Prilosec 20 mg GI PPI Oseltamivir Tamiflu 75mg Antimicrobials Antiviral Oseltamivir Tamiflu 12mg/ml Antimicrobials Antiviral Oxybutynin Ditropan 5 mg Genitourinary Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 16 of 22

17 Paroxetine Paxil 40 mg Psychiatric Antidepressant Paroxetine Paxil 20 mg Psychiatric Antidepressant Paroxetine Paxil 30 mg Psychiatric Antidepressant Paroxetine Paxil 10 mg Psychiatric Antidepressant Paroxetine Paxil 10 mg / 5 ml Psychiatric Antidepressant Penicillin VK 500 mg Antimicrobials Penicillins Penicillin VK 250 mg / 5 cc (100 cc) Antimicrobials Penicillins Penicillin VK Veetids 250 mg Antimicrobials Penicillins Penicillin VK 125 mg / 5 cc (200 cc) Antimicrobials Penicillins Penicillin VK 250 mg / 5 cc (150 cc) Antimicrobials Penicillins Pentoxifylline ER Trental 400 mg Hemorrheologic Agents Permethrin cream Elimite 5% (60 Gm) Derm Scabicide and Lice Perphenazine Trilafon 8 mg Psychiatric Antipsychotic Perphenazine Trilafon 4 mg Psychiatric Antipsychotic Perphenazine Trilafon 2 mg Psychiatric Antipsychotic Perphenazine Trilafon 16 mg / 5 cc (120 ml) Psychiatric Antipsychotic Perphenazine Trilafon 16 mg Psychiatric Antipsychotic Phenazopyridine HCL Pyridium 200 mg Genitourinary Phenazopyridine HCL Pyridium 100 mg Genitourinary Phenobarbital (SCH IV) 30 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 100 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 60 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 15 mg Neurologic Anticonvulsant Phenytoin Dilantin 100 mg Neurologic Anticonvulsant Phenytoin Dilantin 50 mg Neurologic Anticonvulsant Pioglitazone hydrochloride Actos 15 mg Diabetes Thiazolidinediones Pioglitazone hydrochloride Actos 30 mg Diabetes Thiazolidinediones Pioglitazone hydrochloride Actos 45 mg Diabetes Thiazolidinediones Polyethylene glycol electrolyte solution Mix Golytely 240g GI Prep Polymyxin b- trimethoprim Polytrim 10 ml drops Ophthalmic Polymyxin b- trimethoprim Polytrim 3.5 gm ointment Ophthalmic Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 17 of 22

18 Potassium chloride 10% (480 cc) Cardiovascular Potassium Supplement Potassium chloride tabs K-Tab, K-Dur, Potassium 8 meq Cardiovascular Slow-K, Klor-con Supplement Potassium chloride tabs K-Tab, K-Dur, Potassium 20 meq Cardiovascular Slow-K, Klor-con Supplement Potassium chloride tabs K-Tab, K-Dur, Potassium 10 meq Cardiovascular Slow-K, Klor-con Supplement Pravastatin Pravachol 20, 40, 80 mg tabs Cardiovascular Cholesterol Lowering Agents Praziquantel Biltricide 600mg Anthelmintics Prazosin Minipress 1 mg Cardiovascular Alpha-blockers Prazosin Minipress 2 mg Cardiovascular Alpha-blockers Prazosin Minipress 5 mg Cardiovascular Alpha-blockers Prednisolone Prelone 15mg/5ml oral sol Endocrine Glucocorticoids Prednisolone ophth solu or susp 1% Ophthalmic Prednisone Deltasone 1 mg Endocrine Glucocorticoids Prednisone Deltasone 2.5 mg Endocrine Glucocorticoids Prednisone Deltasone 5 mg Endocrine Glucocorticoids Prednisone Deltasone 20 mg Endocrine Glucocorticoids Prednisone Deltasone 10 mg Endocrine Glucocorticoids Prednisone Deltasone 50 mg Endocrine Glucocorticoids Primidone Mysoline 50 mg Neurologic Anticonvulsant Primidone Mysoline 250 mg Neurologic Anticonvulsant Probenecid Benemid 500 mg Gout Prochlorperazine Compazine 25 mg supp GI Antiemetic Prochlorperazine Compazine 10 mg GI Antiemetic Prochlorperazine Compazine 5 mg GI Antiemetic Promethazine HCI Phenergan 50 mg GI Antiemetic Promethazine HCI Phenergan suppositor 25 mg supp GI Antiemetic Promethazine HCI Phenergan 25 mg GI Antiemetic Promethazine HCI Phenergan 12.5 mg supp GI Antiemetic Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 18 of 22

19 Promethazine HCI Phenergan syrup 6.25 / 5 ml (120 ml) GI Antiemetic Promethazine HCI Phenergan 12.5 mg GI Antiemetic Promethazine/VC/DM Cold, Cough, Allergy Antitussive Propranolol HCL Inderal 80 mg Cardiovascular Beta Propranolol HCL Inderal 40 mg Cardiovascular Beta Propranolol HCL Inderal 20 mg Cardiovascular Beta Propranolol HCL Inderal 10 mg Cardiovascular Beta Propranolol HCL Inderal 60 mg Cardiovascular Beta Propylthiouracil PTU 50 mg Endocrine Thyroid Pyrazinamide 500 mg Antimicrobials Antitubercular Pyridoxine Vitamin B5 25 mg Vitamin Pyridoxine Vitamin B6 100 mg Vitamin Quetiapine fumarate Seroquel 100 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 200 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 25 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 300 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 400 mg Psychiatric Antipsychotic Quetiapine fumarate Seroquel 50 mg Psychiatric Antipsychotic Ranitidine Zantac 300 mg GI H2 blockers Ranitidine Zantac 150 mg GI H2 blockers Rifampin Rifadin 300 mg Antimicrobials Antitubercular Rifampin Rifadin 150 mg Antimicrobials Antitubercular Risperidone Risperdal 1 mg Psychiatric Antipsychotic Risperidone Risperdal 1 mg/ml solution Psychiatric Antipsychotic Risperidone Risperdal 0.5 mg Psychiatric Antipsychotic Risperidone Risperdal 2 mg Psychiatric Antipsychotic Risperidone Risperdal 3 mg Psychiatric Antipsychotic Risperidone Risperdal 4 mg Psychiatric Antipsychotic Salmeterol xinafoate Serevent Diskus 50 mcg Respiratory Asthma Salsalate 750 mg Analgesic Salicyclates Salsalate 500 mg Analgesic Salicyclates Selenium sulfide lotion Selsun 2.50% Derm Anti-seborrhea Sertraline Zoloft 20 mg/ml Psychiatric Antidepressant Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 19 of 22

20 Sertraline Zoloft 25 mg Psychiatric Antidepressant Sertraline Zoloft 50 mg Psychiatric Antidepressant Sertraline Zoloft 100 mg Psychiatric Antidepressant Silver sulfadiazine Flint SSD, Silvadene 1% crm Derm Other Simvastatin Zocor 40 mg Cardiovascular Cholesterol Lowering Agents Simvastatin Zocor 20 mg Cardiovascular Cholesterol Lowering Agents Simvastatin Zocor 10 mg Cardiovascular Cholesterol Lowering Agents Spironolactone Aldactone 25 mg Cardiovascular Diuretics Spironolactone Aldactone 50 mg Cardiovascular Diuretics Spironolatone Aldactone 100 mg Cardiovascular Diuretics Sucralfate Carafate 1 Gm GI Sulfacetamide sodium eye drop sol Sulamyd 10% Ophthalmic Sulfacetamide sodium eye ointment Sulamyd 10% Ophthalmic Sulfamethxzl Trimethoprim Septra 80 / 400 mg Antimicrobials Sulfas Sulfamethxzl Trimethoprim Bactrim 40mg / 5ml - 200mg / 5-ml (60 ml) Antimicrobials Sulfas Sulfamethxzl Trimethoprim DS Septra 160 / 800 mg Antimicrobials Sulfas Sulfasalazine Azulfidine 500 mg GI Anti-inflammatory bowel Sulindac Clinoril 200 mg Analgesic NSAID Sulindac Clinoril 150 mg Analgesic NSAID Sumatriptan Imitrex 50 mg Neurologic Migraine Sumatriptan Imitrex 25 mg Neurologic Migraine Sumatriptan Imitrex 100 mg Neurologic Migraine Tamoxifen Soltamox 10mg Hormone Replacement Tamsulosin Flomax 0.4 mg Genitourinary Alpha-blockers Temazepam (SCH IV) Restoril 30 mg Psychiatric Hypnotic Temazepam (SCH IV) Restoril 15 mg Psychiatric Hypnotic Terazosin HCL Hytrin 5 mg Genitourinary Terazosin HCL Hytrin 2 mg Genitourinary Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 20 of 22

21 Terazosin HCL Hytrin 1 mg Genitourinary Terazosin HCL Hytrin 10 mg Genitourinary Testosterone Inj Depo Testosterone 100 mg/ml Hormone Replacement Testosterone Inj Depo Testosterone 200mg/ml Hormone Replacement Tetracycline Sumycin 500 mg Antimicrobials Tetracyclines Tetracycline Sumycin 250 mg Antimicrobials Tetracyclines Theophylline Theo-Dur 300 mg Respiratory Theophylline Theo-Dur 200 mg Respiratory Thiothixene Navane 5 mg Psychiatric Antipsychotic Thiothixene Navane 20 mg Psychiatric Antipsychotic Thiothixene Navane 2 mg Psychiatric Antipsychotic Thiothixene Navane 10 mg Psychiatric Antipsychotic Thiothixene Navane 1 mg Psychiatric Antipsychotic Thiothixene Navane 5 mg/ml Psychiatric Antipsychotic Ticlopidine Ticlid 250mg Platelet aggregation inhibitor Timolol Maleate eye drops 0.5% Ophthalmic Glaucoma Timolol Maleate eye drops 0.25% Ophthalmic Glaucoma Tobramycin ophthal soln. 0.30% Ophthalmic Tramadol Ultram, Rybix 50 mg Analgesic Misc Trazodone Desyrel 50 mg Psychiatric Antidepressant Trazodone Desyrel 150 mg Psychiatric Antidepressant Trazodone Desyrel 100 mg Psychiatric Antidepressant Tretinoin Retin-A 0.01%, 0.025%, 0.05%, 0.1% cream, gel Derm Acne Triamcinolone cream, ointment, or lotion Kenalog, Aristocort 0.10% Derm Antiinflammatory Triamcinolone cream, ointment, or lotion Kenalog, Aristocort 0.025% Derm Antiinflammatory Triamterene hctz Maxzide 37.5/25 mg Cardiovascular Diuretics Triamterene hctz Maxzide 75 / 50 mg Cardiovascular Diuretics Trifluoperazine Stelazine 5 mg Psychiatric Antipsychotic Trifluoperazine Stelazine 2 mg Psychiatric Antipsychotic Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 21 of 22

22 Trifluoperazine Stelazine 10 mg Psychiatric Antipsychotic Trihexyphenidyl Artane 5 mg Neurologic Parkinson Trihexyphenidyl Artane 2 mg / 5 cc Neurologic Parkinson Trihexyphenidyl Artane 2 mg Neurologic Parkinson ursodiol Actigall 300mg GI Venlafaxine Effexor IR 25 mg Psychiatric Antidepressant Venlafaxine XR Effexor XR 75 mg Psychiatric Antidepressant Venlafaxine XR Effexor XR 37.5 mg Psychiatric Antidepressant Venlafaxine XR Effexor XR 100 mg Psychiatric Antidepressant Verapamil Isoptin 120 mg Cardiovascular Verapamil LA Isoptin 180 mg Cardiovascular Verapamil SR Calan SR 240 mg Cardiovascular Verapamil SR Calan SR 180 mg Cardiovascular Verapamil SR Calan SR 120 mg Cardiovascular Vitamin B6 50 mg Vitamin Vitamin D Calciferol 50,000 units Vitamin Vitamin K Phytonadione 5mg tab Vitamin Warfarin sodium Coumadin 1 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 10 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 2 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 2.5 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 3 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 4 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 5 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 6 mg Cardiovascular Anticoagulants Warfarin sodium Coumadin 7.5 mg Cardiovascular Anticoagulants Zolpidem Ambien 10 mg tabs Psychiatric Hypnotic Zolpidem Ambien 5 mg tabs Psychiatric Hypnotic Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 22 of 22