UWSP Student Health Service Pharmacy Formulary updated: 1/2017
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1 UWSP Student Health Service Pharmacy Formulary updated: 1/2017 Medication Name Strength DosageForm Route Acetaminophen 325 MG Tablet Oral Acetaminophen-Codeine # MG Tablet Oral Acetaminophen-Codeine # MG Tablet Oral AcetaZOLAMIDE 125 MG Tablet Oral Acyclovir 400 MG Tablet Oral Acyclovir 800 MG Tablet Oral Albuterol Sulfate (2.5 MG/3ML) 0.083% Nebulization Solution Inhalation Amitriptyline HCl 10 MG Tablet Oral Amitriptyline HCl 25 MG Tablet Oral Amoxicillin 250 MG Capsule Oral Amoxicillin 500 MG Capsule Oral Amoxicillin-Pot Clavulanate MG Tablet Oral Antacid Liquid MG/5ML Suspension Oral Anucort-HC 25 MG Suppository Rectal Apri MG-MCG Tablet Oral Assess Full Range Peak Meter (peak flow meter) Device Atovaquone-Proguanil HCl MG Tablet Oral Aviane MG-MCG Tablet Oral Azithromycin 250 MG Tablet Oral Azithromycin 500 MG Tablet Oral Bacitracin 500 UNIT/GM Ointment External Bactrim DS MG Tablet Oral Benzocaine-Menthol MG Lozenge Mouth/Throat Benzonatate 100 MG Capsule Oral Benzoyl Peroxide 5% Gel External Betamethasone Dipropionate 0.05% Cream External Betamethasone Dipropionate Aug 0.05% Cream External Betasept Surgical Scrub 4% Liquid External Bismatrol (bismuth subsalicylate) 262 MG Tablet Chewable Oral Breathe Right Large Strip Breathe Right Small/Medium Strip BuPROPion HCl ER (SR) 100 MG Tablet Extended Release 12 Hr Oral BuPROPion HCl ER (SR) 150 MG Tablet Extended Release 12 Hr Oral BuPROPion HCl ER (XL) 150 MG Tablet Extended Release 24 Hr Oral BuPROPion HCl ER (XL) 300 MG Tablet Extended Release 24 Hr Oral BusPIRone HCl 15 MG Tablet Oral Camila 0.35 MG Tablet Oral Cefuroxime Axetil 250 MG Tablet Oral Cefuroxime Axetil 500 MG Tablet Oral Cepacol Sore Throat MG Lozenge Mouth/Throat Cephalexin 250 MG Capsule Oral Cephalexin 500 MG Capsule Oral CeraORS 75 Natural (oral rehydration) Packet Oral
2 Cetirizine HCl 10 MG Tablet Oral Ciprofloxacin HCl 0.3% Solution Ophthalmic Ciprofloxacin HCl 250 MG Tablet Oral Ciprofloxacin HCl 500 MG Tablet Oral Citalopram Hydrobromide 20 MG Tablet Oral Clindamycin HCl 150 MG Capsule Oral Clindamycin Phosphate 1% Gel External ClonazePAM 0.5 MG Tablet Oral Clotrimazole 1% Cream External Clotrimazole 1% Cream Vaginal Clotrimazole 10 MG Troche Mouth/Throat Clotrimazole 2% Cream Vaginal Condoms Miscellaneous Cough Drops Menthol Lozenge Mouth/Throat Cryselle MG-MCG Tablet Oral Cyclobenzaprine HCl 10 MG Tablet Oral Cyclobenzaprine HCl 5 MG Tablet Oral Deep Sea Nasal Spray 0.65% Solution Nasal Depo-Provera 150 MG/ML Suspension Intramuscular Dexamethasone 4 MG Tablet Oral Dexamethasone Sod Phosphate PF 10 MG/ML Solution Injection Dicloxacillin Sodium 250 MG Capsule Oral Dicloxacillin Sodium 500 MG Capsule Oral Dicyclomine HCl 20 MG Tablet Oral DiphenhydrAMINE HCl 25 MG Capsule Oral Docusate Sodium 100 MG Capsule Oral Domeboro 25% Packet External Doxycycline Monohydrate 100 MG Capsule Oral Drysol 20% Solution External Ella 30 MG Tablet Oral Epinephrine 0.3 MG inj Pen injector Intramuscular Erythromycin 5 MG/GM Ointment Ophthalmic Estradiol 2 MG Tablet Oral Estradiol Valerate 200 MG/ML Solution Intramuscular Famotidine 20 MG Tablet Oral Ferrous Gluconate 324 (37.5 Fe) MG Tablet Oral Ferrous Sulfate 325 (65 Fe) MG Tablet Oral Fluconazole 150 MG Tablet Oral Fluorouracil 5% Cream External FLUoxetine HCl 10 MG Capsule Oral FLUoxetine HCl 10 MG Tablet Oral FLUoxetine HCl 20 MG Capsule Oral Fluticasone Propionate 50 MCG/ACT Suspension Nasal Gianvi MG Tablet Oral GuaiFENesin 100 MG/5ML Liquid Oral Guaifenesin-DM MG/5ML Liquid Oral Halls Cough Drops 5.8 MG Lozenge Mouth/Throat Hibiclens 4% Liquid External
3 Hydrocodone-Acetaminophen MG Tablet Oral Hydrocortisone 1% Cream External Hydrocortisone 1% Ointment External Hydrocortisone Acetate 25 MG Suppository Rectal Hydrogen Peroxide 3% Miscellaneous External Hydroxychloroquine Sulfate 200 MG Tablet Oral HydrOXYzine HCl 10 MG Tablet Oral Hypercare 20% Solution External Ibuprofen 200 MG Tablet Oral Ibuprofen 600 MG Tablet Oral Imiquimod 5% Cream External Iron 325 (65 Fe) MG Tablet Oral Jolessa MG Tablet Oral Junel FE 1.5/ MG-MCG Tablet Oral Junel FE 1/ MG-MCG Tablet Oral Kariva /0.01 MG (21/5) Tablet Oral Kelnor 1/ MG-MCG Tablet Oral Ketoconazole 2% Cream External Ketoconazole 2% Shampoo External Ketorolac Tromethamine 30 MG/ML Solution Injection Ketotifen Fumarate 0.025% Solution Ophthalmic LamoTRIgine 100 MG Tablet Oral LamoTRIgine 25 MG Tablet Oral Levofloxacin 500 MG Tablet Oral Lidocaine HCl 2% Gel External Lidocaine Viscous 2% Solution Mouth/Throat Lomedia 24 FE 1-20 MG-MCG(24) Tablet Oral Loperamide HCl 2 MG Capsule Oral Loratadine 10 MG Tablet Oral Malarone MG Tablet Oral Meclizine HCl 25 MG Tablet Chewable Oral Mediplast 40% Miscellaneous External MedroxyPROGESTERone Acetate 10 MG Tablet Oral MedroxyPROGESTERone Acetate 150 MG/ML Suspension Intramuscular Mefloquine HCl 250 MG Tablet Oral Melatonin Maximum Strength 5 MG Tablet Oral MetroNIDAZOLE 0.75% Gel Vaginal MetroNIDAZOLE 500 MG Tablet Oral Minocycline HCl 100 MG Capsule Oral Minocycline HCl 50 MG Capsule Oral Mirtazapine 15 MG Tablet Oral Montelukast Sodium 10 MG Tablet Oral Mupirocin 2% Ointment External Naproxen Sodium 220 MG Tablet Oral Naproxen Sodium 500 MG Tablet Oral Nasal Decongestant Spray 0.05% Solution Nasal Neomycin-Polymyxin-HC Suspension Otic Nicotine Polacrilex 2 MG Gum Mouth/Throat
4 Nicotine Polacrilex 4 MG Gum Mouth/Throat Nicotine Step 1 21 MG/24HR Patch 24 Hour Transdermal Nicotine Step 2 14 MG/24HR Patch 24 Hour Transdermal Nicotine Step 3 7 MG/24HR Patch 24 Hour Transdermal Nitrofurantoin Monohyd Macro 100 MG Capsule Oral Nortrel 1/35 (28) 1-35 MG-MCG Tablet Oral NuvaRing MG/24HR Ring Vaginal Ocella MG Tablet Oral Ofloxacin 0.30% Solution Ophthalmic Ofloxacin 0.30% Solution Otic Omeprazole 20 MG Capsule Delayed Release Oral Ondansetron ODT 4 MG Tablet Dispersible Oral Ortho Tri-Cyclen Lo Tablet Oral Oseltamivir 75 MG Tablet Oral Oxymetazoline HCl 0.05% Solution Nasal Pantoprazole Sodium 20 MG Tablet Delayed Release Oral Penicillin V Potassium 500 MG Tablet Oral Pepto-Bismol 262 MG Tablet Chewable Oral Permethrin 5% Cream External Petrolatum Ointment External Phenazopyridine HCl 95 MG Tablet Oral Phenol 1.40% Liquid Mouth/Throat Pill Splitter Miscellaneous Plan B One-Step 1.5 MG Tablet Oral Pocket Chamber (MDI spacer) Device Polymyxin B-Trimethoprim UNIT/ML-% Solution Ophthalmic Portia MG-MCG Tablet Oral PrednisoLONE Acetate 1% Suspension Ophthalmic PredniSONE 20 MG Tablet Oral PredniSONE 50 MG Tablet Oral Prenatal Plus 27-1 MG Tablet Oral Promethazine HCl 12.5 MG Suppository Rectal Promethazine HCl 12.5 MG Tablet Oral Propranolol HCl 10 MG Tablet Oral Propranolol HCl 20 MG Tablet Oral QUEtiapine Fumarate 100 MG Tablet Oral QUEtiapine Fumarate 25 MG Tablet Oral Ranitidine HCl 150 MG Tablet Oral Reclipsen MG-MCG Tablet Oral Ricola Lozenge Mouth/Throat Ricola Cherry Honey Herb 2 MG Lozenge Mouth/Throat Ricola Honey Herb 2 MG Lozenge Mouth/Throat Ricola Lemon Mint 1.5 MG Lozenge Mouth/Throat Rifampin 300 MG Tablet Oral Rizatriptan 10 MG Tablet Oral Saline 0.65% Solution Nasal Seasonique &0.01 MG Tablet Oral Selenium Sulfide 2.50% Lotion External
5 Sertraline HCl 100 MG Tablet Oral Sertraline HCl 50 MG Tablet Oral Silver Sulfadiazine 1% Cream External Singulair 10 MG Tablet Oral Sinus Rinse Bottle Kit Packet Nasal Sinus Wash Salt Crystals Nasal SMZ-TMP DS MG Tablet Oral Sore Throat MG Lozenge Mouth/Throat Sore Throat Spray 1.40% Liquid Mouth/Throat Spironolactone 25 MG Tablet Oral Spironolactone 100mg Tablet Oral Sprintec MG-MCG Tablet Oral SSD 1% Cream External SudoGest 30 MG Tablet Oral SudoGest 60 MG Tablet Oral Sudogest PE 10 MG Tablet Oral SUMAtriptan Succinate 100 MG Tablet Oral SUMAtriptan Succinate 50 MG Tablet Oral SUMAtriptan Succinate 6 MG/0.5ML Solution Subcutaneous Tamiflu 75 MG Capsule Oral Terbinafine HCl 1% Cream External Terbinafine HCl 250 MG Tablet Oral Terconazole 0.80% Cream Vaginal Testosterone cypionate 200 MG/ML Solution Intramuscular Thera-M (multi-vitamin) Tablet Oral TraZODone HCl 50 MG Tablet Oral Tretinoin 0.01% Gel External Tretinoin 0.025% Cream External Tri-Sprintec Tablet Oral Triamcinolone Acetonide 0.10% Cream External Triamcinolone Acetonide 0.10% Ointment External Triamcinolone Acetonide 0.10% Paste Mouth/Throat Ulipristal Acetate 30 MG Tablet Oral Ultrathon Insect Repellent 34.34% Lotion External Ultrathon Permethrin Spray0.5% Urinary Pain Relief 95 MG Tablet Oral ValACYclovir HCl 1 GM Tablet Oral Ventolin HFA 108 (90 Base) MCG/ACT Aerosol Solution Inhalation Visc Lido2%/Benadryl/Maalox 1:1:1 Suspension Oral Vitamin D 1000 UNIT Tablet Oral Vivotif Berna Vaccine Capsule Delayed Release Oral White Petrolatum Ointment Zarah MG Tablet Oral
UWSP Student Health Service Pharmacy Formulary 1/22/2015
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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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Packing List SS#: From: HEALTH PARTNERS INTERNATIONAL 2907 PORTLAND DRIVE OAKVILLE ON CANADA L6H 5S4. Ship to: Carrier:
30 907 PORTLAND DRIVE OAKVILLE ON CANADA LH S4 PHONE:(90) 70-990 X FAX:(90) 70-74 ShipDate: /9/ Shipper# PTP30- Bott/0ml 0 TUBE/7G Tube/30g Box/ Box/ Kaopectate OS 70mg/mL, Bottle/0mL 790043 Attapulgite
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Name of Policy:PolicyNumber: PRN Indications }-.+-`-+,tr---fi::-'..1- :-` -.,-_ -` E-..,',,=.:~1,EffectiveDate:9/1/2018 Department: ApprovlnResponslScope: g Officer:bleAgent: 3364-133-103 Pharmacy Chief
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calcium chloride 100 mg/ml (10 %) intravenous solution,calcium chloride 100 mg/ml (10 %) $ 60.00
Px Code Generic Name CPT(R)/ HCPCS NDC Unit Price 2500000200 insulin human U-100 NPH-regulr 70-30 mix 100 J1815 00002871517 $ 223.05 2500000200 labetalol 5 mg/ml intravenous solution 00409226720 $ 60.00
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