HealthPAC Formulary Current as of January 2016

Transcription

1 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 Spironolatone 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 Alphagan Brimonidine tartrate solution 0.2% Ophthalmic Glaucoma Ambien Zolpidem 10 mg tabs Psychiatric Hypnotic Ambien Zolpidem 5 mg tabs Psychiatric Hypnotic Amoxil Amoxicillin 125 mg / 5 cc (80 cc) Antimicrobials Penicillins Amoxil Amoxicillin 250 mg Antimicrobials Penicillins Amoxil Amoxicillin 250 mg / 5 cc (150 cc) Antimicrobials Penicillins Amoxil Amoxicillin 400 mg/ 5 cc 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 25mg 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

2 Apresoline Hydralazine 50 mg Cardiovascular Other Vasodilators Artane Trihexyphenidyl 2 mg Neurologic Parkinson Artane Trihexyphenidyl 2 mg / 5 cc 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 cc (120 ml) 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) 1.0 mg Psychiatric Benzos Ativan Lorazepam (SCH IV) 2.0 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 cc (100 ml) Antimicrobials Penicillins Augmentin Amoxicillin-clavulanate 500 mg-125 mg Antimicrobials Penicillins Augmentin Amoxicillin-clavulanate 875 mg Antimicrobials Penicillins Auralgan Antipyrene, Benzodine, Glycerine dehyd 10 ml drops Otic Aygestin Norethindrone 5 mg Hormone Replacement Progestins Azopt Brinzolamide 1% solution Ophthalmic Glaucoma Azulfidine Sulfasalazine 500 mg GI Anti-inflammatory bowel Bactrim Sulfamethxzl Trimethoprim 40mg / 5ml - 200mg / 5-ml (60 ml) Antimicrobials Sulfas Bactroban Mupirocin 2% ointment Antibiotic Benadryl Diphenhydramine 12.5 mg/ 5ml Cold, Cough, Allergy Antihistamine Benadryl Diphenhydramine 25, 50 mg capsules Cold, Cough, Allergy Antihistamine Benadryl Diphenhydramine 50 mg/cc (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 Biltricide Praziquantel 600 mg Anthelmintics Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 2 of 24

3 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 Calan SR Verapamil SR 120 mg Cardiovascular Calan SR Verapamil SR 180 mg Cardiovascular Calan SR Verapamil SR 240 mg Cardiovascular 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 Cardizem Diltiazem 120 mg Cardiovascular Cardizem CD Diltiazem CD 120 mg Cardiovascular Cardizem CD Diltiazem CD 180 mg Cardiovascular Cardizem CD Diltiazem CD 240 mg Cardiovascular Cardizem CD Diltiazem CD 30 mg Cardiovascular Cardizem CD Diltiazem CD 300 mg Cardiovascular Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 3 of 24

4 Cardizem CD Diltiazem CD 360mg Cardiovascular Cardizem CD Diltiazem CD 60 mg Cardiovascular Cardizem CD Diltiazem CD 90 mg Cardiovascular Cardizem CD, Dilacor Xr, Cartia XL, Dilt-CD Cardizem CD, Dilacor Xr, Cartia XL, Dilt-CD Diltiazem 60 mg Cardiovascular Diltiazem 90 mg Cardiovascular Cardizem LA Dilitiazem HCI 180 mg Cardiovascular Cardizem SR Diltiazem SR 120 mg Cardiovascular Cardizem SR Diltiazem SR 180 mg Cardiovascular Cardizem SR Diltiazem SR 240 mg Cardiovascular Cardizem SR Diltiazem SR 300 mg Cardiovascular 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 Celebrex Celecoxib 400 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

5 Celebrex Celecoxib 50 mg Analgesic NSAID Celexa Citalopram Hydrobromide 10 mg Psychiatric Antidepressant Celexa Citalopram Hydrobromide 10 mg / 5 cc 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 10mg 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/cc (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 Coreg Carvedilol 25 mg Cardiovascular Beta Coreg Carvedilol mg Cardiovascular Beta Coreg Carvedilol 6.25 mg Cardiovascular Beta Cortizone Hydrocortisone cream 2.5% Derm Antiinflammatory Cortizone Hydrocortisone ointment 2.50% Derm Antiinflammatory Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 5 of 24

6 Cortizone Hydrocortisone Suppositories 25 mg GI Antiinflammatory Coumadin Warfarin sodium 1 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 10 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 2 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 2.5 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 3 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 4 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 5 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 6 mg Cardiovascular Anticoagulants Coumadin Warfarin sodium 7.5 mg Cardiovascular Anticoagulants Cozaar Losartan 100 mg Cardiovascular Angiotensin II Blocker Cozaar Losartan 25 mg Cardiovascular Angiotensin II Blocker Cozaar Losartan 50 mg Cardiovascular Angiotensin II Blocker Cymbalta Duloxetine 20 mg Psychiatric Antidepressant Cymbalta Duloxetine 30 mg Psychiatric Antidepressant Cymbalta Duloxetine 40 mg Psychiatric Antidepressant Cymbalta Duloxetine 60 mg Psychiatric Antidepressant Cytotec Misoprostol 100 mg GI Cytotec Misoprostol 200 mg GI Deltasone Prednisone 1 mg Endocrine Glucocorticoids Deltasone Prednisone 10 mg Endocrine Glucocorticoids Deltasone Prednisone 2.5 mg Endocrine Glucocorticoids Deltasone Prednisone 20 mg Endocrine Glucocorticoids Deltasone Prednisone 5 mg Endocrine Glucocorticoids Deltasone Prednisone 50 mg Endocrine Glucocorticoids Depakote DR Divalproex sodium 125 mg Psychiatric Mood Stabilizer Depakote DR Divalproex sodium 250 mg Psychiatric Mood Stabilizer Depakote DR Divalproex sodium 500 mg Psychiatric Mood Stabilizer Depakote ER Divalproex sodium 250 mg Psychiatric Mood Stabilizer Depakote ER Divalproex sodium 500 mg Psychiatric Mood Stabilizer Depo Testosterone Testosterone Inj 100 mg/ml Hormone Replacement Depo Testosterone Testosterone Inj 200mg/ml Hormone Replacement Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 6 of 24

7 Desyrel Trazodone 100 mg Psychiatric Antidepressant Desyrel Trazodone 150 mg Psychiatric Antidepressant Desyrel Trazodone 50 mg Psychiatric Antidepressant Diflucan Fluconazole 100 mg Antimicrobials Antifungals Diflucan Fluconazole 150 mg Antimicrobials Antifungals Diflucan Fluconazole 200 mg Antimicrobials Antifungals Dilantin Phenytoin 100 mg Neurologic Anticonvulsant Dilantin Phenytoin 50 mg Neurologic Anticonvulsant Ditropan Oxybutynin 5 mg Genitourinary Donnatal Belladona alkaloids, phenobarbital 16.2 mg GI Antispasmodics Doryx Vibramycin Doxycycline 100 mg Antimicrobials Tetracyclines Doryx Vibramycin Doxycycline 50 mg Antimicrobials Tetracyclines Duphalac Lactulose 10g/15 ml syrup GI Laxatives Dynapen Dicloxacillin 250 mg Antimicrobials Penicillins Dynapen Dicloxacillin 500 mg Antimicrobials Penicillins Effexor IR Venlafaxine 25 mg Psychiatric Antidepressant Effexor XR Venlafaxine XR 100 mg Psychiatric Antidepressant Effexor XR Venlafaxine XR 37.5 mg Psychiatric Antidepressant Effexor XR Venlafaxine XR 75 mg Psychiatric Antidepressant Elavil Amitriptyline 10 mg Psychiatric Antidepressant Elavil Amitriptyline 100 mg Psychiatric Antidepressant Elavil Amitriptyline 25 mg Psychiatric Antidepressant Elavil Amitriptyline 50 mg Psychiatric Antidepressant Elavil Amitriptyline 75 mg Psychiatric Antidepressant Elimite Permethrin cream 5% (60 Gm) Derm Scabicide and Lice Erygel Erythromycin gel or solution 2% Derm Acne Ery-Tab Erythromycin stearate 250 mg Antimicrobials Macrolides Ery-Tab Erythromycin stearate 333 mg Antimicrobials Macrolides Ery-Tab Erythromycin stearate 500 mg Antimicrobials Macrolides Esidrix Hydrochlorothiazide 25 mg Cardiovascular Diuretics Esidrix Hydrochlorothiazide 50 mg Cardiovascular Diuretics Eskalith CR Lithium carbonate 150 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 7 of 24

8 Eskalith CR Lithium carbonate 300 mg Psychiatric Mood Stabilizer Eskalith SR Lithium carbonate 300 mg Psychiatric Mood Stabilizer Eskalith SR Lithium carbonate 450 mg Psychiatric Mood Stabilizer Estrace Estradiol 0.5 mg Hormone Replacement Estrace Estradiol 1 mg Hormone Replacement Estrace Estradiol 2 mg Hormone Replacement Fioricet Butalbital-APAP-Caffeine 50/325/40 Analgesic Misc Flagyl Metronidazole 250 mg Antimicrobials Misc Flagyl Metronidazole 500 mg Antimicrobials Misc Flexeril Cyclobenzaprine 10 mg Analgesic Muscle Relaxant Flint SSD, Silvadene Silver sulfadiazine 1% crm Derm Other Flomax Tamsulosin 0.4 mg Genitourinary Alpha-blockers Flonase Fluticasone propionate 50 mcg/spray Respiratory Nasal Inhaler Florinef Fludrocortisone 0.1 mg Endocrine Florinef Fludrocortisone 0.2 mg Adrenals Fosamax Alendronate 35 mg Osteoporosis Fosamax Alendronate 70 mg Osteoporosis Garamycin Gentamicin eye drops 0.3% (5 ml) Ophthalmic Glucophage Metformin 1000 mg Diabetes Biguanides Glucophage Metformin 500 mg Diabetes Biguanides Glucophage Metformin 850 mg Diabetes Biguanides Glucophage XR Metformin ER 1000 mg Diabetes Biguanides Glucophage XR Metformin ER 500 mg Diabetes Biguanides Glucophage XR Metformin ER 750 mg Diabetes Biguanides Glucotrol Glipizide 10 mg Diabetes Sulfonylureas Glucotrol Glipizide 5 mg Diabetes Sulfonylureas Grifulvin V Griseofulvin micro liquid 125 mg / 5 ml (120 ml) Antimicrobials Antifungals Grisactin Fulvicin Griseofulvin ultramicro 125 mg Antimicrobials Antifungals Grisactin Fulvicin Griseofulvin ultramicro 250 mg Antimicrobials Antifungals Haldol Haloperidol 0.5 mg Psychiatric Antipsychotic Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 8 of 24

9 Haldol Haloperidol 1 mg Psychiatric Antipsychotic Haldol Haloperidol 10 mg Psychiatric Antipsychotic Haldol Haloperidol 2 mg Psychiatric Antipsychotic Haldol Haloperidol 2 mg / cc (120 cc) Psychiatric Antipsychotic Haldol Haloperidol 2 mg / cc (15 cc) Psychiatric Antipsychotic Haldol Haloperidol 20 mg Psychiatric Antipsychotic Haldol Haloperidol 5 mg Psychiatric Antipsychotic Haldol Haloperidol decanoate 100 mg/cc (inj) Psychiatric Antipsychotic Haldol Haloperidol decanoate 50 mg/cc (inj) Psychiatric Antipsychotic HC Hydrocortisone 10mg Derm Antiinflammatory HC Hydrocortisone 2.5% lotion Derm Antiinflammatory HC Hydrocortisone 20mg Derm Antiinflammatory HC Hydrocortisone 5mg Derm Antiinflammatory Helidac bismuth subsalicylate-metronidazoletetracycline Helicobacter pylori agent Humalog Insulin Lispro 100U/mL Diabetes Insulin Product Humulin N Insulin NPH U100 (10 ml) Diabetes Insulin Product Humulin R Insulin Regular U100 (10 ml) Diabetes Insulin Product Humulin R Insulin Regular U500 Diabetes Insulin Product Humulin, Novolin Insulin 70/30 U100 (10 ml) Diabetes Insulin Product Hytrin Terazosin HCL 1 mg Genitourinary Hytrin Terazosin HCL 10 mg Genitourinary Hytrin Terazosin HCL 2 mg Genitourinary Hytrin Terazosin HCL 5 mg Genitourinary Hyzaar Losartan/Hctz mg Cardiovascular Antihypertensive Hyzaar Losartan/Hctz mg Cardiovascular Antihypertensive Hyzaar Losartan/Hctz mg Cardiovascular Antihypertensive Imdur Isosorbide mononitrate IR, SR 10 mg Cardiovascular Nitrate Vasodilators Imdur Isosorbide mononitrate IR, SR 120 mg Cardiovascular Nitrate Vasodilators Imdur Isosorbide mononitrate IR, SR 20 mg Cardiovascular Nitrate Vasodilators Imdur Isosorbide mononitrate IR, SR 30 mg Cardiovascular Nitrate Vasodilators Imdur Isosorbide mononitrate IR, SR 60 mg Cardiovascular Nitrate Vasodilators Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 9 of 24

10 Imitrex Sumatriptan 100 mg Neurologic Migraine Imitrex Sumatriptan 25 mg Neurologic Migraine Imitrex Sumatriptan 50 mg Neurologic Migraine Imuran Azathioprine 50 mg Immunosupressive Inderal Propranolol HCL 10 mg Cardiovascular Beta Inderal Propranolol HCL 20 mg Cardiovascular Beta Inderal Propranolol HCL 40 mg Cardiovascular Beta Inderal Propranolol HCL 60 mg Cardiovascular Beta Inderal Propranolol HCL 80 mg Cardiovascular Beta Indocin Indomethacin 25 mg Analgesic NSAID Indocin Indomethacin 50 mg Analgesic NSAID INH Isoniazid 10 mg / ml Antimicrobials Antitubercular INH Isoniazid 100 mg Antimicrobials Antitubercular INH Isoniazid 300 mg Antimicrobials Antitubercular Intal Cromolyn inhaler 14.2 Gm Respiratory Isoptin Verapamil 120 mg Cardiovascular Isoptin Verapamil LA 180 mg Cardiovascular Isordil Isosorbide dinitrate 10 mg Cardiovascular Nitrate Vasodilators Isordil Isosorbide dinitrate 20 mg Cardiovascular Nitrate Vasodilators Isordil Isosorbide dinitrate 30 mg Cardiovascular Nitrate Vasodilators Isordil Isosorbide dinitrate 5 mg Cardiovascular Nitrate Vasodilators Keflex Cephalexin 125 mg / 5 ml (200 ml) Antimicrobials Cephalosporins Keflex Cephalexin 250 mg Antimicrobials Cephalosporins Keflex Cephalexin 250 mg / 5 ml (100 ml) Antimicrobials Cephalosporins Keflex Cephalexin 500 mg Antimicrobials Cephalosporins Triamcinolone cream, ointment, or Kenalog, Aristocort lotion 0.025% Derm Antiinflammatory Triamcinolone cream, ointment, or Kenalog, Aristocort lotion 0.10% Derm Antiinflammatory Keppra Levetiracetam 1000 mg Neurologic Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 10 of 24

11 Keppra Levetiracetam 500 mg Neurologic Keppra Levetiracetam 750 mg Neurologic Klonopin Clonazepam (SCH IV) 0.5 mg Psychiatric Benzos Klonopin Clonazepam (SCH IV) 1 mg Psychiatric Benzos Klonopin Clonazepam (SCH IV) 2 mg Psychiatric Benzos K-Tab, K-Dur, Slow-K, Klor-con Potassium chloride tabs 10 meq Cardiovascular Potassium Supplement K-Tab, K-Dur, Slow-K, Klor-con Potassium chloride tabs 20 meq Cardiovascular Potassium Supplement K-Tab, K-Dur, Slow-K, Klor-con Potassium chloride tabs 8 meq Cardiovascular Potassium Supplement Lamictal Lamotrigine 100 mg tab Neurologic Anticonvulsant Lamictal Lamotrigine 150 mg tab Neurologic Anticonvulsant Lamictal Lamotrigine 200 mg tab Neurologic Anticonvulsant Lamictal Lamotrigine 25 mg tab Neurologic Anticonvulsant Lanoxin Digoxin mg Cardiovascular Glycosides Lanoxin Digoxin 0.25 mg Cardiovascular Glycosides Lantus Insulin glargine 100 IU/mL Diabetes Insulin Product Lasix Furosemide 20 mg Cardiovascular Diuretics Lasix Furosemide 40 mg Cardiovascular Diuretics Lasix Furosemide 80 mg Cardiovascular Diuretics Levaquin Levofloxacin 500 mg Antimicrobials Levoxyl Levothyroxine mg Endocrine Thyroid Levoxyl Levothyroxine mg Endocrine Thyroid Levoxyl Levothyroxine mg Endocrine Thyroid Levoxyl Levothyroxine mg Endocrine Thyroid Levoxyl Levothyroxine 0.1 mg Endocrine Thyroid Levoxyl Levothyroxine mg Endocrine Thyroid Levoxyl Levothyroxine mg Endocrine Thyroid Levoxyl Levothyroxine mg Endocrine Thyroid Levoxyl Levothyroxine 0.15 mg Endocrine Thyroid Levoxyl Levothyroxine mg Endocrine Thyroid Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 11 of 24

12 Levoxyl Levothyroxine 0.2 mg Endocrine Thyroid Levoxyl Levothyroxine 0.3 mg Endocrine Thyroid Lidex Fluocinonide 0.05% solution 60ml Derm Antiinflammatory Lidex Fluocinonide 0.05% gel (60gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% cream (30 gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% cream (60 gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% oint (15 gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% oint (30 gm) Derm Antiinflammatory Lidex Fluocinonide 0.05% oint (60 gm) Derm Antiinflammatory Lioresal Baclofen 10 mg Analgesic Muscle Relaxant Lioresal Baclofen 20 mg Analgesic Muscle Relaxant Lipitor Atorvastatin 10 mg Cardiovascular Cholesterol Lowering Agents Lipitor Atorvastatin 20 mg Cardiovascular Cholesterol Lowering Agents Lipitor Atorvastatin 40 mg Cardiovascular Cholesterol Lowering Agents Lipitor Atorvastatin 80 mg Cardiovascular Cholesterol Lowering Agents Lomotil Diphenoxylate-atropine 2.5 mg GI Antidiarrhea Lomotil Diphenoxylate-atropine (SCH V) 2.5 /.025 / 5 (60 ml) GI Antidiarrhea Lopid Gemfibrozil 600 mg Cardiovascular Cholesterol Lowering Agents Lopressor Metoprolol tartrate 100 mg Cardiovascular Beta Lopressor Metoprolol tartrate 25 mg Cardiovascular Beta Lopressor Metoprolol tartrate 50 mg Cardiovascular Beta Loxitane Loxapin 5, 10, 25, 50 mg Psychiatric Antipsychotic Macrobid Nitrofurantoin monohydrate 100 mg Antimicrobials Misc Macrodantin Nitrofurantoin macrocryst 100 mg Antimicrobials Misc Macrodantin Nitrofurantoin macrocryst 50 mg Antimicrobials Misc Maxzide Triamterene hctz 37.5/25 mg Cardiovascular Diuretics Maxzide Triamterene hctz 75 / 50 mg Cardiovascular Diuretics Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 12 of 24

13 Metrocream Metronidazole cream 0.075% Antimicrobials Misc Metrocream Metronidazole cream 0.75% Derm Acne Metrogel Metronidazole topical gel 0.75% Derm Acne Mevacor Lovastatin 10, 20, 40 mg Cardiovascular Cholesterol Lowering Agents Micronase Diabeta Glyburide 1.25 mg Diabetes Sulfonylureas Micronase Diabeta Glyburide 2.5 mg Diabetes Sulfonylureas Micronase Diabeta Glyburide 5 mg Diabetes Sulfonylureas Microzide Hydrochlorothiazide 12.5 mg cap Cardiovascular Diuretics Minipress Prazosin 1 mg Cardiovascular Alpha-blockers Minipress Prazosin 2 mg Cardiovascular Alpha-blockers Minipress Prazosin 5 mg Cardiovascular Alpha-blockers Mix Golytely Polyethylene glycol electrolyte solution 240 g GI Prep Motrin Ibuprofen 400 mg Analgesic NSAID Motrin Ibuprofen 600 mg Analgesic NSAID Motrin Ibuprofen 800 mg Analgesic NSAID MS Morphine sulfate Liquid 20 mg/ 5 ml Analgesic Narcotic MS Morphine sulfate short acting 15,30 mg Analgesic Narcotic Myambutol Ethambutol 100 mg Antimicrobials Antitubercular Myambutol Ethambutol 400 mg Antimicrobials Antitubercular Mysoline Primidone 250 mg Neurologic Anticonvulsant Mysoline Primidone 50 mg Neurologic Anticonvulsant Naprosyn Naproxen 250 mg Analgesic NSAID Naprosyn Naproxen 375 mg Analgesic NSAID Naprosyn Naproxen 500 mg Analgesic NSAID Narcan Naloxone 0.4 mg/ ml Toxicology Agents Opiate Antagonists Narcan Naloxone 1 mg/ ml Toxicology Agents Opiate Antagonists Nasarel Flunisolide 25 mcg/spray (0.025%) Cold, Cough, Allergy Nasal Steroids Navane Thiothixene 1 mg Psychiatric Antipsychotic Navane Thiothixene 10 mg Psychiatric Antipsychotic Navane Thiothixene 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 13 of 24

14 Navane Thiothixene 20 mg Psychiatric Antipsychotic Navane Thiothixene 5 mg Psychiatric Antipsychotic Navane Thiothixene 5 mg/ ml Psychiatric Antipsychotic Neurontin Gabapentin 100 mg Neurologic Anticonvulsant Neurontin Gabapentin 300 mg Neurologic Anticonvulsant Neurontin Gabapentin 400 mg Neurologic Anticonvulsant Neurontin Gabapentin 600 mg Neurologic Anticonvulsant NicoDerm Nicotine Patches- 28 weeks 14 mg Smoking deterrents NicoDerm Nicotine Patches- 28 weeks 21 mg Smoking deterrents NicoDerm Nicotine Patches- 28 weeks 7 mg Smoking deterrents Nitrostat Nitroglycerine SL 0.4 mg Cardiovascular Nitrate Vasodilators Nizoral Ketoconazole 2% crm (15 Gm) Antimicrobials Antifungals Nizoral Ketoconazole 2% crm (30 Gm) Antimicrobials Antifungals Nizoral Ketoconazole 2% crm (60 Gm) Antimicrobials Antifungals Nizoral Ketoconazole 2% shampoo Antimicrobials Antifungals Nizoral Ketoconazole 200 mg (tabs) Antimicrobials Antifungals Norco Acetaminophen/Hydrocodone 325/10 mg Analgesic Narcotic Norco Acetaminophen/Hydrocodone 325/5 mg Analgesic Narcotic Norco Acetaminophen/Hydrocodone 325/7.5 mg Analgesic Narcotic Norvasc Amlodipine 10 mg Cardiovascular Norvasc Amlodipine 2.5 mg Cardiovascular Norvasc Amlodipine 5 mg Cardiovascular Oramorph SR Morphine sulfate SR 100 mg Analgesic Narcotic Oramorph SR Morphine sulfate SR 15 mg Analgesic Narcotic Oramorph SR Morphine sulfate SR 30 mg Analgesic Narcotic Oramorph SR Morphine sulfate SR 60 mg Analgesic Narcotic Pamelor Nortriptyline 10 mg Psychiatric Antidepressant Pamelor Nortriptyline 25 mg Psychiatric Antidepressant Pamelor Nortriptyline 50 mg Psychiatric Antidepressant Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 14 of 24

15 Pamelor Nortriptyline 75 mg Psychiatric Antidepressant Parlodel Bromocriptine 2.5mg Hypoprolactinemic Paxil Paroxetine 10 mg Psychiatric Antidepressant Paxil Paroxetine 10 mg / 5 ml Psychiatric Antidepressant Paxil Paroxetine 20 mg Psychiatric Antidepressant Paxil Paroxetine 30 mg Psychiatric Antidepressant Paxil Paroxetine 40 mg Psychiatric Antidepressant Pepcid Famotidine 20 mg GI H2 Antagonists Pepcid Famotidine 40 mg GI H2 Antagonists Percocet Acetaminophen/Oxycodone 325/5 and 325/10 Analgesic Narcotic Persantine Dipyridamole 25 mg Cardiovascular Anticoagulants Persantine Dipyridamole 50 mg Cardiovascular Anticoagulants Persantine Dipyridamole 75 mg Cardiovascular Anticoagulants Phenergan Promethazine HCI 12.5 mg GI Antiemetic Phenergan Promethazine HCI 12.5 mg supp GI Antiemetic Phenergan Promethazine HCI 25 mg GI Antiemetic Phenergan Promethazine HCI 50 mg GI Antiemetic Phenergan suppositor Promethazine HCI 25 mg supp GI Antiemetic Phenergan syrup Promethazine HCI 6.25 / 5 ml (120 ml) GI Antiemetic Phoslo Calcium acetate 667 mg Phosphate binder Phytonadione Vitamin K 5 mg tab Vitamin Plaquenil Hydroxychloroquine 200 mg Rheumatology Plavix Clopidogrel 75 mg Platelet aggregation inhibitor polyethylene glycol Miralax 238g GI polyethylene glycol Miralax 510g GI Polytrim Polymyxin b- trimethoprim 10 ml drops Ophthalmic Polytrim Polymyxin b- trimethoprim 3.5 gm ointment Ophthalmic Pravachol Pravastatin 20, 40, 80 mg tabs Cardiovascular Cholesterol Lowering Agents Prelone Prednisolone 15mg/5ml oral sol Endocrine Glucocorticoids Premarin Conjugated Estrogen Cream mg/g crm (43 Gm) Hormone Replacement Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 15 of 24

16 Prilosec Omeprazole 20 mg GI PPI Prinivil, Zestril Lisinopril 10 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 2.5 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 20 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 30 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 40 mg Cardiovascular ACE Inhibitor Prinivil, Zestril Lisinopril 5 mg Cardiovascular ACE Inhibitor Procardia, Adalat Nifedipine SR 30 mg Cardiovascular CC, Nifediac Procardia, Adalat Nifedipine SR 60 mg Cardiovascular CC, Nifediac Procardia, Adalat Nifedipine SR 90 mg Cardiovascular CC, Nifediac Prolixin Fluphenazine 0.5 mg/ml Psychiatric Antipsychotic Prolixin Fluphenazine 1 mg Psychiatric Antipsychotic Prolixin Fluphenazine 10 mg Psychiatric Antipsychotic Prolixin Fluphenazine 2.5 mg Psychiatric Antipsychotic Prolixin Fluphenazine 5 mg / cc Psychiatric Antipsychotic Prolixin Fluphenazine decanoate 25 mg/cc (inj) Psychiatric Antipsychotic Proscar Finasteride 5 mg Genitourinary 5-alpha reductase inhibitor Proventil Albuterol solution neb 5 mg/ml (20 ml bottle) Respiratory Nebulizer soln Proventil Albuterol Unit Dose 0.83 mg/ml Respiratory Proventil HFA Albuterol HFA (IDP) tablet, MDI, (IDP) solution, UD 90 mcg Respiratory Inhaler Provera Medroxyprogesterone 10 mg Hormone Replacement Provera Medroxyprogesterone 2.5 mg Hormone Replacement Provera Medroxyprogesterone 5 mg Hormone Replacement Prozac Fluoxetine 10 mg Psychiatric Antidepressant Prozac Fluoxetine 20 mg Psychiatric Antidepressant Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 16 of 24

17 Prozac Fluoxetine 20 mg / 5 ml Psychiatric Antidepressant Prozac Fluoxetine 40 mg Psychiatric Antidepressant PTU Propylthiouracil 50 mg Endocrine Thyroid Pyridium Phenazopyridine HCL 100 mg Genitourinary Pyridium Phenazopyridine HCL 200 mg Genitourinary Qvar Beclomethasone dipropinate 40 mcg Respiratory Steroid inhaler Qvar Beclomethasone dipropinate 80 mcg Respiratory Steroid inhaler Reglan Metoclopramide 10 mg GI Antiemetic Reglan Metoclopramide hcl 5 mg GI Antiemetic Relafen Nabumetone 750 mg Analgesic NSAID Remeron Mirtazapine 15 mg Psychiatric Antidepressant Remeron Mirtazapine 30 mg Psychiatric Antidepressant Remeron Mirtazapine 45 mg Psychiatric Antidepressant Restoril Temazepam (SCH IV) 15 mg Psychiatric Hypnotic Restoril Temazepam (SCH IV) 30 mg Psychiatric Hypnotic Retin-A Tretinoin 0.01%, 0.025%, 0.05%, 0.1% cream, gel Derm Acne Rheumatrex Methotrexate 2.5 mg Chemotherapy Rifadin Rifampin 150 mg Antimicrobials Antitubercular Rifadin Rifampin 300 mg Antimicrobials Antitubercular Risperdal Risperidone 0.5 mg Psychiatric Antipsychotic Risperdal Risperidone 1 mg Psychiatric Antipsychotic Risperdal Risperidone 1 mg/ml solution Psychiatric Antipsychotic Risperdal Risperidone 2 mg Psychiatric Antipsychotic Risperdal Risperidone 3 mg Psychiatric Antipsychotic Risperdal Risperidone 4 mg Psychiatric Antipsychotic Ritalin Methylphenidate short acting 10mg Psychiatric Stimulant Ritalin Methylphenidate short acting 20mg Psychiatric Stimulant Ritalin Methylphenidate short acting 30mg Psychiatric Stimulant Ritalin LA Methylphenidate long-acting 10mg Psychiatric Stimulant Ritalin LA Methylphenidate long-acting 20mg Psychiatric Stimulant Ritalin LA Methylphenidate long-acting 30mg Psychiatric Stimulant Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 17 of 24

18 Ritalin LA Methylphenidate long-acting 40mg Psychiatric Stimulant Robaxin Methocarbamol 500 mg Analgesic Muscle Relaxant Robaxin Methocarbamol 750 mg Analgesic Muscle Relaxant Robitussin AC Guaifenesin + Codeine 100 mg - 10mg / 5 ml Cold, Cough, Allergy Antitussive Rocaltrol Calcitriol 0.25 mcg Vitamin Rocaltrol Calcitriol 0.5mcg Vitamin Selsun Selenium sulfide lotion 2.50% Derm Anti-seborrhea Septra Sulfamethxzl Trimethoprim 80 / 400 mg Antimicrobials Sulfas Septra Sulfamethxzl Trimethoprim DS 160 / 800 mg Antimicrobials Sulfas Serevent Diskus Salmeterol xinafoate 50 mcg Respiratory Asthma Seroquel Quetiapine fumarate 100 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 200 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 25 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 300 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 400 mg Psychiatric Antipsychotic Seroquel Quetiapine fumarate 50 mg Psychiatric Antipsychotic Sinemet Carbidopa - levodopa mg Neurologic Parkinson Sinemet Carbidopa - levodopa mg Neurologic Parkinson Sinemet Carbidopa - levodopa mg Neurologic Parkinson Sinemet CR Carbidopa - levodopa LA mg Neurologic Parkinson Sinemet CR Carbidopa - levodopa LA mg Neurologic Parkinson Sinequan Doxepin HCL 10 mg Psychiatric Antidepressant Sinequan Doxepin HCL 100 mg Psychiatric Antidepressant Sinequan Doxepin HCL 150 mg Psychiatric Antidepressant Sinequan Doxepin HCL 25 mg Psychiatric Antidepressant Sinequan Doxepin HCL 50 mg Psychiatric Antidepressant Sinequan Doxepin HCL 75 mg Psychiatric Antidepressant Singulair Montelukast 10 mg Respiratory Singulair Montelukast 5 mg chew Respiratory Soltamox Tamoxifen 10 mg Hormone Replacement Soma Carisoprodol 250 mg Muscle Relaxant Spectazole Econazole 1% crm 30 Gm (30 Gm) Antimicrobials Antifungals Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 18 of 24

19 Spectazole Econazole 1% crm 85 Gm (85 Gm) Antimicrobials Antifungals Spectazole Econazole 1% crm 15 Gm (15 Gm) Antimicrobials Antifungals Stelazine Trifluoperazine 10 mg Psychiatric Antipsychotic Stelazine Trifluoperazine 2 mg Psychiatric Antipsychotic Stelazine Trifluoperazine 5 mg Psychiatric Antipsychotic Suboxone Buprenorphine/naloxone mg Analgesic Mixed Opiate Agonist/Antagonist Suboxone Buprenorphine/naloxone 8-2 mg Analgesic Mixed Opiate Agonist/Antagonist Subutex Buprenorphine 2 mg Analgesic Opiate Agonist Sulamyd Sulfacetamide sodium eye drop sol 10% Ophthalmic Sulamyd Sulfacetamide sodium eye ointment 10% Ophthalmic Sumycin Tetracycline 250 mg Antimicrobials Tetracyclines Sumycin Tetracycline 500 mg Antimicrobials Tetracyclines Symmetrel Amantadine 100 mg Neurologic Parkinson Symmetrel Amantadine 50 mg / 5 ml (120 ml) Neurologic Parkinson Synalar Fluocinolone acetonide 0.01% cream Derm Antiinflammatory Synalar Fluocinolone acetonide 0.01% ointment Derm Antiinflammatory Synalar Fluocinolone acetonide 0.025% cream Derm Antiinflammatory Synalar Fluocinolone acetonide 0.025% ointment Derm Antiinflammatory Synalar Fluocinolone acetonide 0.025%, 0.01% solution, 60 ml Derm Antiinflammatory Tagamet Cimetidine 400 mg GI H2 blockers Tamiflu Oseltamivir 12mg/ml Antimicrobials Antiviral Tamiflu Oseltamivir 75 mg Antimicrobials Antiviral Tapazole Methimazole 10 mg Endocrine Thyroid Tapazole Methimazole 5 mg Endocrine Thyroid Tegretol Carbamazepine 100 mg Psychiatric Mood Stabilizer Tegretol Carbamazepine 100 mg / 5 cc Psychiatric Mood Stabilizer Tegretol Carbamazepine 200 mg Psychiatric Mood Stabilizer Temovate Clobetasol lotion 0.05% Derm Temovate Clobetasol propionate 0.05% crm (15 Gms) Derm Antiinflammatory Temovate Clobetasol propionate 0.05% oint (15 Gms) Derm Antiinflammatory Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 19 of 24

20 Temovate Clobetasol propionate 0.05% oint (30 Gms) Derm Antiinflammatory Tenormin Atenolol 100 mg Cardiovascular Beta Tenormin Atenolol 25 mg Cardiovascular Beta Tenormin Atenolol 50 mg Cardiovascular Beta Thalitone Chlorthalidone 25mg Cardiovascular Diuretics Thalitone Chlorthalidone 50 mg Cardiovascular Diuretics Theo-Dur Theophylline 200 mg Respiratory Theo-Dur Theophylline 300 mg Respiratory Thorazine Chlorpromazine 10 mg Psychiatric Antipsychotic Thorazine Chlorpromazine 100 mg Psychiatric Antipsychotic Thorazine Chlorpromazine 100 mg/ml Psychiatric Antipsychotic Thorazine Chlorpromazine 200 mg Psychiatric Antipsychotic Thorazine Chlorpromazine 25 mg Psychiatric Antipsychotic Thorazine Chlorpromazine 30 mg/ml Psychiatric Antipsychotic Thorazine Chlorpromazine 50 mg Psychiatric Antipsychotic Ticlid Ticlopidine 250 mg Platelet aggregation inhibitor Tofranil Imipramine 10 mg Psychiatric Antidepressant Tofranil Imipramine 25 mg Psychiatric Antidepressant Tofranil Imipramine 50 mg Psychiatric Antidepressant Toprol XL Metoprolol succinate 100 mg Cardiovascular Beta Toprol XL Metoprolol succinate 25 mg Cardiovascular Beta Toprol XL Metoprolol succinate 50 mg Cardiovascular Beta Trandate Labetalol HCL 100 mg Cardiovascular Beta Trandate Labetalol HCL 200 mg Cardiovascular Beta Trandate Labetalol HCL 300 mg Cardiovascular Beta Trental Pentoxifylline ER 400 mg Hemorrheologic Agents Tricor Fenofibrate 145 mg Cardiovascular Cholesterol Lowering Agents Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 20 of 24

21 Tricor Fenofibrate 48 mg Cardiovascular Cholesterol Lowering Agents Trilafon Perphenazine 16 mg Psychiatric Antipsychotic Trilafon Perphenazine 16 mg / 5 cc (120 ml) Psychiatric Antipsychotic Trilafon Perphenazine 2 mg Psychiatric Antipsychotic Trilafon Perphenazine 4 mg Psychiatric Antipsychotic Trilafon Perphenazine 8 mg Psychiatric Antipsychotic Tylenol Acetaminophen 325 mg Analgesic Acetaminophen Tylenol Acetaminophen 500 mg Analgesic Acetaminophen Tylenol Acetaminophen 650 mg Analgesic Acetaminophen Tylenol #3 Acetaminophen/Codeine #3 300 / 30 mg Analgesic Narcotic Ultram, Rybix Tramadol 50 mg Analgesic Misc Valium Diazepam (SCH IV) 10 mg Psychiatric Benzos Valium Diazepam (SCH IV) 2 mg Psychiatric Benzos Valium Diazepam (SCH IV) 5 mg Psychiatric Benzos Vaseretic Enalapril maleate/hctz mg Cardiovascular Antihypertensive Vaseretic Enalapril maleate/hctz mg Cardiovascular Antihypertensive Vasotec Enalapril maleate 10 mg Cardiovascular ACE Inhibitor Vasotec Enalapril maleate 2.5 mg Cardiovascular ACE Inhibitor Vasotec Enalapril maleate 20 mg Cardiovascular ACE Inhibitor Vasotec Enalapril maleate 5 mg Cardiovascular ACE Inhibitor Veetids Penicillin VK 250 mg Antimicrobials Penicillins Ventolin, Proventil Albuterol liquid 2 mg / 5 cc (120 ml) Respiratory Vicodin Acetaminophen/Hydrocodone bitartrate 500 mg - 5 mg Analgesic Narcotic Vitamin B5 Pyridoxine 25 mg Vitamin Vitamin B6 Pyridoxine 100 mg Vitamin Voltaren Diclofenac 50 mg Analgesic NSAID Voltaren Diclofenac 75 mg Analgesic NSAID Vosol Acetic acid 15 ml drops Otic Vosol HC Acetic acid/hydrocortisone 2%-1% Otic Wellbutrin SR Buproprion IR, SR 100 mg Psychiatric Antidepressant Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 21 of 24

22 Wellbutrin SR Buproprion IR, SR 150 mg Psychiatric Antidepressant Wellbutrin SR Buproprion IR, SR 200 mg Psychiatric Antidepressant Wellbutrin SR Buproprion IR, SR 300 mg Psychiatric Antidepressant Wellbutrin SR Buproprion IR, SR 75 mg Psychiatric Antidepressant Wellbutrin XL Bupropion XL 150 mg, 300 mg Psychiatric Antidepressant Xalatan Latanoprost 0.005% Ophthalmic Zantac Ranitidine 150 mg GI H2 blockers Zantac Ranitidine 300 mg GI H2 blockers Zaroxolyn Metolazone 10 mg Cardiovascular Diurectics Zaroxolyn Metolazone 2.5 mg Cardiovascular Diurectics Zaroxolyn Metolazone 5 mg Cardiovascular Diurectics Zestoretic Lisinopril/Hctz mg Cardiovascular Antihypertensive Zestoretic Lisinopril/Hctz mg Cardiovascular Antihypertensive Zestoretic Lisinopril/Hctz mg Cardiovascular Antihypertensive Zithromax Azithromycin 250 mg Antimicrobials Macrolides Zocor Simvastatin 10 mg Cardiovascular Cholesterol Lowering Agents Zocor Simvastatin 20 mg Cardiovascular Cholesterol Lowering Agents Zocor Simvastatin 40 mg Cardiovascular Cholesterol Lowering Agents Zoloft Sertraline 100 mg Psychiatric Antidepressant Zoloft Sertraline 20 mg/ml Psychiatric Antidepressant Zoloft Sertraline 25 mg Psychiatric Antidepressant Zoloft Sertraline 50 mg Psychiatric Antidepressant Zovirax Acyclovir 200 mg Antimicrobials Antiviral Zovirax Acyclovir 400 mg Antimicrobials Antiviral Zovirax Acyclovir 800 mg Antimicrobials Antiviral Zyloprim Allopurinol 100 mg Gout Zyloprim Allopurinol 300 mg Gout Zyprexa Olanzapine 2.5mg Psychiatric Antipsychotic Zyprexa Olanzapine 5 mg Psychiatric Antipsychotic Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 22 of 24

23 Aspirin (acetylsalicylic acid, ASA) 325 mg Analgesic Salicylates Aspirin (acetylsalicylic acid, ASA) 81 mg Analgesic Salicylates Capsaicin 0.025% cream Derm Analgesic Capsaicin 0.075% cream Derm Analgesic Capsaicin 0.1% cream Derm Analgesic Cortisporin otic soln 1%-0.35%-10000u/mL (10 ml) Otic Cortisporin otic susp drops (10 ml) Otic Diabetes supplies - glucometer Diabetes Diabetes supplies - lancets Diabetes Diabetes supplies - syringes/needles Diabetes Diabetes supplies - test strips Diabetes Diabetes supplies - testing control solution Diabetes Erythromycin eye ointment 5 mg / Gm (3.5 Gm) Ophthalmic Folic Acid 800 MicroGrams Vitamin Lidocaine 4% cream Derm Anesthetic Lidocaine 4% solution Derm Anesthetic Lidocaine 5% cream Derm Anesthetic Lidocaine 5% ointment Derm Anesthetic Methadone 10 mg Analgesic Narcotic Methadone 5 mg Analgesic Narcotic Niacin IR & ER tabs only 100 mg Cardiovascular Niacin IR & ER tabs only 250 mg Cardiovascular Niacin IR & ER tabs only 500 mg Cardiovascular Nicotine Gum 2 mg Smoking deterrents Nicotine Gum 4 mg Smoking deterrents Nicotine Lozenge 2 mg Smoking deterrents Nicotine Lozenge 4 mg Smoking deterrents Nystatin (cream or ointment) Derm Antifungals Nystatin oral suspension 100,000 units/ml Antimicrobials Antifungals Penicillin VK 125 mg / 5 cc (200 cc) Antimicrobials Penicillins Penicillin VK 250 mg / 5 cc (100 cc) Antimicrobials Penicillins Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 23 of 24

24 Penicillin VK 250 mg / 5 cc (150 cc) Antimicrobials Penicillins Penicillin VK 500 mg Antimicrobials Penicillins Phenobarbital (SCH IV) 100 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 15 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 30 mg Neurologic Anticonvulsant Phenobarbital (SCH IV) 60 mg Neurologic Anticonvulsant Potassium chloride 10% (480 cc) Cardiovascular Potassium Supplement Prednisolone ophth solu or susp 1% Ophthalmic Promethazine/VC/DM Cold, Cough, Allergy Antitussive Pyrazinamide 500 mg Antimicrobials Antitubercular Salsalate 500 mg Analgesic Salicylates Salsalate 750 mg Analgesic Salicylates Timolol Maleate eye drops 0.25% Ophthalmic Glaucoma Timolol Maleate eye drops 0.5% Ophthalmic Glaucoma Tobramycin ophthal soln. 0.30% Ophthalmic Vitamin B6 50 mg Vitamin Disclaimer: Doses / routes of administration are the responsibility of the prescribing provider based on the medical home's practice guidelines. Page 24 of 24