PRIOR ADAP FORMULARY - RX OPTIONS

Transcription

1 PRIOR ADAP FORMULARY - RX OPTIONS Created by Care Directions Case Manageent MEDICATION Pharacies ALLERGY/COUGH/COLD DIPHENHYDRAMINE 50 MG FLUTICASONE $35 HYDROXYZINE 25 MG, 50 MG X LORATIDINE 10 MG Wal-Mart Only X PROMETHAZINE/CODEINE 6.25 MG/10 MG/L PSEUDOEPHEDRINE 30 MG ANALGESICS ACETAMINOPHEN/CODEINE 30/300 MG NO ACETAMINOPHEN/HYDROCODONE 5/500 MG, 7.5/500 MG NO ACETAMINOPHEN/OXYCODONE 5/325 MG X CHLORALPHENAZONE/ISOMETHEPTENE/ ACETAMINOPHEN (FOR MIGRAINE) 100/65/325 MG NO IBUPROFEN 800 MG X X METHADONE (FOR PAIN) 10MG NO MORPHINE SULFATE IMMEDIATE RELEASE 15MG, 30 MG X MORPHINE SULFATE SUSTAINED RELEASE 30 MG, 60 MG, 100 MG X NAPROXEN 500 MG X X OXYCODONE IMMEDIATE RELEASE 5 MG, 15 MG X? ANTIBACTERIALS AMOXICILLIN 500 MG X X AMOXICILLIN/CLAVULANATE 500/125 MG, 875/125 MG X CEFPODOXIME 100 MG, 200 MG NO CEPHALEXIN 250 MG, 500 MG X X DICLOXACILLIN 250 MG, 500 MG NO DOXYCYCLINE 100 MG X X METRONIDAZOLE 250 MG, 500 MG X X MOXIFLOXACIN 400 MG X PENICILLIN VK 500 MG X X ANTI-ACID OMEPRAZOLE (PRILOSEC) 10 MG, 20 MG CAPSULES X $35 RANITIDINE 150 MG, 300 MG TABLETS X X

2 Pharacies ANTICOAGULANTS WARFARIN ALL S X X ANTIDIARRHEALS DIPHENOXYLATE/ATROPINE 2.5 MG TABLETS $35 LOPERAMIDE 2 MG CAPSULES X ANTIEMETICS METOCLOPRAMIDE 5 MG, 10 MG TABLETS X X PROCHLORPERAZINE 5 MG, 10 MG TABLETS X $20 PROMETHAZINE 25 MG, 50 MG TABLETS X X ANTIFUNGAL TERBINAFINE 250 MG X X ELECTROLYTES/NUTRITION FERROUS SULFATE 325 MG FOLIC ACID 1 MG X X MULTIVITAMIN WITH 1 MG FOLATE X X MAGNESIUM OXIDE 400 MG Not Walgreens X POTASSIUM CHLORIDE 10MEQ, 20 MEQ (LIQUID AND SUSTAINED RELEASE) X X GASTROINTESTINAL DICYCLOMINE 10 MG, 20 MG X X OPIUM TINCTURE 10% NO PANCRELIPASE (ULTRASE MT) 12,000 UNITS, 20,000 UNITS X HEPATITIS B TREATMENT *ENTECAVIR (BARACLUDE).05 MG, 1 MG TABLETS X HEPATITIS C TREATMENT ADVERSE SIDE EFFECTS **EPOETIN ALFA (PROCRIT) **FILGRASTIM (NEUPOGEN) 40,000 UNITS/L SINGLE DOSE VIAL (4 X 1 L VIAL) X 300MCG/0.5 L SYRINGE (10 X 0.5 L SYRINGE) X

3 Pharacies HORMONAL/METABOLIC AGENTS ESTRADIOL 0.5 MG, 1.0 MG TABLETS X X ESTROGEN CONJUGATED (PREMARIN) 0.3 MG, MG TABLETS X INSULINS - REGULAR, LISPRO, 70/30, GLARGINE, NPH LEVOTHYROXINE LEVOXYL AND SYNTHROID (DO NOT SUBSTITUTE) ALL S X X MEDROXYPROGESTERONE 5 MG, 10 MG TABLETS X X MEGESTROL (MEGACE) ES ORAL SOLUTION (625g/5L) X NANDROLONE DECANOATE 100 g/l 10 x 2 L VIAL NO NIACIN SUSTAINED RELEASE (NIASPAN OR EQUIVALENT) 500 MG, 1 G X PREDNISONE 5 MG, 10 MG, 20 MG X X TESTOSTERONE ENANTHATE 200 g/l 5 L VIAL NO TESTOSTERONE GEL (ANDROGEL) 1% - 30 X 5 GM PACKETS X TESTOSTERONE GEL (TESTIM) 1% - 30 X 5 GM TUBES X HUMAN PAPILLOMAVIRUS IMIQUIMOD CREAM (ALDARA) 5% - 12 X.25 GM PACKETS X? PODOFILOX SOLUTION (CONDYLOX) 5% L BOTTLE NO HYPERTENSION AMLODIPINE 2.5 MG, 5 MG, 10 MG X $25 ATENOLOL 50 MG, 100 MG X X BENAZEPRIL 10 MG, 20 MG X X DILTIAZEM SUSTAINED RELEASE 120 MG, 180 MG, 240 MG X X DOXAZOSIN 1 MG, 2 MG, 4 MG X X ENALAPRIL 5 MG, 10 MG X X FUROSEMIDE 20 MG, 40 MG X X HCTZ 25 MG, 50 MG X X HCTZ/TRIAMTERENE 37.5 MG, 75MG X X LISINOPRIL 10 MG, 20 MG, 40 MG X X LOSARTAN 25 MG, 50 MG, 100 MG X? METOPROLOL 50 MG, 100 MG X X SPIRONOLACTONE 50 MG, 100 MG X X INFLUENZA ANTIVIRALS OSELTAMIVIR PHOSPHATE (TAMIFLU) 75 MG CAPSULES

4 Pharacies METABOLIC SYNDROME AGENTS ATORVASTATIN (LIPITOR) 10, 20, 40, 80 MG TABLETS X EZETIMIBE (ZETIA) 10 MG X GEMFIBROZIL 600 MG TABLETS $30 GLIPIZIDE 5 MG, 10 MG TABLETS X X GLYBURIDE 2.5 MG, 5 MG TABLETS X X METFORMIN 500 MG, 850 MG TABLETS X X PRAVASTATIN (PRAVACHOL) 10, 20, 40, 80 MG TABLETS X $20 ROSIGLITAZONE (AVANDIA) 2, 4, 8 MG TABLETS X MUSCLE RELAXANTS CYCLOBENZAPRINE 10 MG X X PERIPHERAL NEUROPATHY CARBAMAZEPINE 100 MG CHEWABLE, 200 MG TABLETS X X DESIPRAMINE 25, 50 75, 100 MG TABLETS NO GABAPENTIN (NEURONTIN) 100, 300, 400 MG CAPSULES $35 *PREGABALIN (LYRICA) ALL S X NORTRIPTYLINE 10, 25, 50, 75 MG CAPSULES X X PSYCHOTROPICS/NEUROLOGIC ANTIANXIETY/HYPNOTICS DIAZEPAM 5 MG, 10 MG $35 LORAZEPAM 0.5 MG, 1 MG $35 TEMAZEPAM 15 MG, 30 MG $35 ZOLPIDEM 5 MG, 10 MG $35 ANTICONVULSANTS CLONAZEPAM 1 MG, 2 MG $35 DIVALPROEX (VALPROIC ACID) 250 MG, 500 MG $45 PHENYTOIN 100 MG $45

5 Pharacies ANTIDEPRESSANTS AMITRIPTYLINE 25 MG X X BUPROPION SR (WELLBUTRIN) 100, 150, 200 MG TABLETS Target Only CITALOPRAM (CELEXA) 10, 20, 40 MG TABLETS X X DESIPRAMINE 25, 50, 75, 100 MG TABLETS NO ESCITALOPRAM (LEXAPRO) 5, 10, 20 MG TABLETS X FLUOXETINE 20 MG, 40 MG X X MIRTAZAPINE 15 MG, 30 MG Walgreens Only X NORTRIPTYLINE 10, 25, 50, 75 MG CAPSULES X X PAROXETINE 10, 20, 30, 40 MG Not Wal-Mart X SERTRALINE (ZOLOFT) 25, 50, 100 MG TABLETS X TRAZODONE 50 MG, 100 MG, 150 MG X X VENLAFAXINE XR 75 MG, 150 MG $45 ANTIPSYCHOTICS ARIPIPRAZOLE (ABILIFY) 10 MG, 15 MG, 20 MG X OLANZAPINE (ZYPREXA) 5, 7.5, 10, 15 MG X RISPERIDONE 0.5 MG, 1 MG, 2 MG X MOOD STABILIZERS LITHIUM CARBONATE 150 MG, 300 MG X X STIMULANTS METHYLPHENIDATE (RITALIN) 10 MG, 20 MG X PULMONARY ALBUTEROL METERED-DOSE INHALER (MDI) 17 G X X FLUNISOLIDE MDI 7 G X IPRATROPIUM HFA 12.9 G X TOPICALS CHLORHEXIDINE MOUTHWASH NO FLUOCINONIDE CREAM/OINTMENT 0.05% X X HYDROCORTISONE CREAM/OINTMENT 2.50% X X KETOCONAZOLE CREAM, SHAMPOO 2% NO MUPIROCIN OINTMENT 2% NO SELENIUM SULFIDE 2.50% X X TRIAMCINOLONE CREAM/OINTMENT 0.025%, 0.1%, 0.5% X X

6 Pharacies All of the inforation provided is subject to change and should be confired with the pharacy providing edications DISCOUNT STORES/PHARMACIES: Target: $4/30 day - $10/90 day Wal-Mart: $4/30 day - $10/90 day Walgreens: $12/90 day - $20 ebership fee Not all strengths available through all stores - check with specific store for details Other stores ay also have siilarly priced forularies COPA CARE: $4/30 day - $12/90 day **Must be an MIHS patient to utilize www. Price listed is for 90 day supply - check website for current details Go to website for links to patient assistance progras for specific edication Other Resources: