Microsoft word - medication formulary april 2011.doc

Dear Prescribers,
April 2011
Welcome to the Saint Vincent Healthcare Medication Formulary. This formulary was designed to provide you with the most current information possible pertaining to Formulary listings and drug-related policies. Please review this booklet at your leisure so you are familiar with which drugs are approved for use at Saint Vincent
HOW TO USE THIS BOOKLET

Drug Listings

The drugs are listed using the American Hospital Formulary Service (AHFS) classification system. Each drug entry lists the generic name, strengths and formulations available, and common brand names.
Drug-Related Policies

Selected policies have been included to assist you in ordering medications and understanding the Formulary
PLEASE NOTE
It is possible there are a few omissions due to human error which will be corrected in future versions. Please do not panic if something common is not listed! Please call the Pharmacy with questions and concerns. If a desired item was purposefully left off the Formulary, it can be acquired as a non-formulary drug request.
UPDATES TO THE FORMULARY
Updates to the Formulary will be distributed to the medical and hospital staff as drugs are added and deleted from the Formulary. An electronic copy of the formulary may be found on the Communicator. TITLE: PHARMACY & THERAPEUTICS COMMITTEE POLICY NO. 200.40.010

PURPOSE OF THE COMMITTEE

1. Policy Development: The Pharmacy and Therapeutics Committee formulates policies regarding evaluation, selection, & therapeutic use of
drugs for Saint Vincent Hospital and Health Center.
2. Advisory/Educational: The Pharmacy and Therapeutic Committee recommends & formulates programs designed to meet the needs of the
professional staff (physicians, nurses, pharmacists, and other health care practitioners) for complete current knowledge on matters related to drugs and drug use.
FUNCTIONS AND SCOPE OF THE COMMITTEE
The multiplicity of drugs available and the complexities surrounding their safe and effective use make it necessary for hospitals to have an organized,
sound program for maximizing rational drug use. The Pharmacy and Therapeutics Committee is the organizational keystone of this program.
The Pharmacy and Therapeutics Committee is an advisory group of the Medical Staff and serves as the organizational line of communication
between the Medical Staff and the Department of Pharmacy Services. The Pharmacy and Therapeutics Committee is a policy-recommending body
to the Medical Staff and the Administration of the Hospital on matters related to use of drugs.
The Pharmacy and Therapeutics Committee shall be responsible for the development and surveillance of all drug usage policies and practices at
Saint Vincent Hospital and Health Center in order to assure optimum clinical results. The Committee will formulate professional policies regarding
the evaluation, selection, procurement, storage, distribution, use, safety, and all other matters relating to drug usage. It will perform the following
specific functions:
1. Serve in an advisory capacity to the Medical Staff and Hospital Administration in all matters pertaining to the use of drugs (including
2. Develop a Formulary of drugs acceptable for use in the Hospital and provide for its ongoing review and revision as indicated. The selection of items to be of Formulary status will be based on objective evaluation of their relative therapeutic merits, safety, and cost. The Committee will minimize duplication of the same basic drug type, drug entity or drug product. 3. Establish programs and procedures that help ensure safe & effective drug therapy. 4. Establish programs adn procedures that help ensure cost-effective drug therapy. 5. Establish or plan suitable educational programs for the Hospital professional staff on matters related to drug use. 6. Participate in continuous quality improvement activities related to procurement, prescribing, distribution, administration, and monitoring of medications. As indicated by review findings, the Committee will make recommendations to the Medical Executive Committee for appropriate action. 7. Monitor & evaluate adverse drug reactions occurring in the Hospital. 8. Initiate and/or direct medication-use review programs and studies. The Committee will review the results of such activities and make 9. Advise the Pharmacy in the implementation of effective drug distribution and control procedures. 10. Make recommendations concerning drugs to be stocked in Hospital patient-care areas. 11. Evaluate clinical data concerning new drugs or preparations requested for use in the Hospital. 12. Recommend policies regarding the safe use of investigational and hazardous drugs. THE FORMULARY – Policy TX-100.12

Definition and Composition

The Formulary is a compilation of all drug products approved for use by the medical staff which are considered most useful in patient care. The Formulary System is a method whereby the Medical Staff of the Hospital, working through the Pharmacy and Therapeutics Committee, evaluates, appraises, and selects from among the numerous available drug entities and drug products those that are considered most useful in patient care. The Formulary System is thus an important tool for assuring the quality of drug use. A. The Pharmacy & Therapeutics (P&T) Committee shall be responsible for the development and management of a medication formulary for use in the hospital. Only those medications selected are routinely available from the B. The P&T Committee whall be responsible for reviewing and approving all changes to the formulary including: The addition and deletion of medications The use of generic and therapeutically equivalent products C. The Medical Executive Committee shall be responsible for the review and approval of all actions in relation to
Procedures
A. Evaluation and Approval of Medications 1.1 Evaluates & appraises selected medication(s) & medication classes for formulary inclusion. 1.2 Approves all changes to the hospital formulary. a. Add to the formulary with no restrictions. 1.) These are medications approved for use by any member of the medical staff. b. Add to the formulary with restrictions 1.) These are medications approved for use in specific patient care. 2.) These medications may be restricted to use by a specific service or for a specific indication of use. 1.) Includes medications in which the Committee feels that additional information is required to 2.) Provisionally approved medications are reconsidered by the Committee after 6 months of use. 1.4 Forwards formulary recommendations to the Medical Executive Committee for review & final approval. 2.1 Reviews and approves formulary recommendations. 3.1 Requests the addition of a medication not included on the formulary by submitting a completed "Request for Formulary Addition" form. NOTE: Any member of the medical staff may make a formulary request 4.1 Schedules medications for review by the P&T Committee. Medications for review include: a. Medications recently approved by the FDA. b. Medications requested by members of the medical staff. c. Medications or medication classes in which duplication is felt to exist. 4.2 Prepares a formulary evaluation of the medication(s) scheduled for review by the P&T Committee. a. Summarizes clinical information related to a medication(s) safety & efficacy. b. Provides cost information. NOTE: Cost will only be used as a basis for formulary selection when the Committee feels that two or more medications are clinically equivalent. 4.3 Presents above information to the P&T Committee 4.4 Communicates information regarding formulary decisions to the medical staff. 4.5 Obtains, stores, & distributes, all medications on the formulary. 4.6 Ensures the maintenance and distribution of the printed formulary. 4.7 Publishes a printed formulary every year. a. All patient care areas in the hospital If the medication is given provisional approval: 4.10 Gathers & reviews any new information 4.11 Solicits information & opinions from practitioners who have had experience with the medication. 4.12 Presents above information to the P&T Committee so that a determination may be made concerning full 1.1 Contacts physician when a non-formulary medication is ordered. NOTE: If the physician determines that the non-formulary medication is necessary for the patient then the pharmacy will obtain a supply of the medication to meet the anticipated needs of the patient. 1.2 Notifies the prescriber and nursing unit caring for the patient if the non-formulary medication cannot be 1.3 Documents any changes to the medication order in the patient's medical record as authorized by the GENERIC/THERAPEUTIC INTERCHANGE POLICY
To define the use of generic and therapeutically equivalent drugs within at Saint Vincent Healthcare. Therapeutic interchange of selected drug products will be accomplished according to drug specific guidelines as outlined in this policy. Patient safety and product quality will be the guiding principle in the use of generic and therapeutically equivalent drugs. Medical, pharmacy, government and industry literature will be continually scrutinized to ensure the efficacy of drug products contained on the hospital formulary.
DEFINITIONS:
Generic Interchange: Involves the interchange among nonpropriety and propriety drugs having the same chemical Therapeutic Interchange: Is the selection of a chemically different drug that is considered by the Pharmacy and Therapeutics Committee to be a therapeutic alternative with a comparable effect.
PROCEDURE:

Pharmacy and Therapeutics Committee
1.0 Review and approve all changes to the hospital formulary which includes the addition of new and deletion of old drugs, and the use of generic and therapeutically equivalent products.
Pharmacist

1.1 Generic equivalent substitution is approved for drugs deemed to be bioequivalent, and may be applied to all
products on the hospital formulary. Criteria used in the selection of generic products will include: the annual Approved Drug Products with Therapeutic Equivalence Evaluations published by the Food and Drug Administration; affiliation with a major pharmacy buying group; and appropriate medical literature and physician feedback. Generic substitution will not be applied if the prescriber has written on the order, “Do not 1.2 Class equivalent substitutions are approved for the following product classes unless specified by the prescriber. In these situations, the pharmacist may dispense a product deemed to be therapeutically equivalent by the Twice weekly, transdermal estradiol patches 1st Generation Cephalosporins (Injectable) THERAPEUTIC INTERCHANGE POLICY APPENDIX
IF THIS IS ORDERED
THIS IS
EFFECTIVE
SUBSTITUTED
DATE
Antacids
ANALGESICS
HCTZ/Triamterene Combinations
Antibiotics
Multivitamins
IF THIS IS ORDERED
THIS IS SUBSTITUTED EFFECTIVE
DATE
H2 Antagonists
Famotidine 20mg IV bolus, followed Feb. 99 by CI QUINOLONES
IF THIS IS ORDERED
THIS IS SUBSTITUTED
EFFECTIVE
DATE
Proton Pump Inhibitors
Hydrocodone/APAP combinations
Rapid Acting Insulin Analogs (Humalog/Novolog)
Diltiazem Extended-Release Products
Generic diltiazem ER (dose for dose) 1/2004 IF THIS IS ORDERED
THIS IS SUBSTITUTED EFFECTIVE
DATE
Ambien/Ambien CR
Twice Weekly Transdermal Estradial Patches
Oral Nitrofurantoin Products
Fosphenytoin/Phenytoin Injection
4:00 ANTIHISTAMINE DRUGS
Amphotericin B, liposomal inj (AMBISOME) Brompheniramine Maleate/ Phenyl-propanolamine Nystatin tab, susp, vag tab (MYCOSTATIN) Posaconazole Oral Susp. 40 mg/mL (NOXAFIL) Chlorpheniramine maleate tab. (CHLORTRIMETON) 8:12.06 Cephalosporins
DRYL); elixir 12.5 mg/5mL (alcohal free) Promethazine tab 25 mg; soln 6.25 mg/5mL; Promethazine syrup 6.25mg/5mL (PHENERGAN) 8:12.07 Miscellaneous Beta-Lactam Antibiotics
8:00 ANTI-INFECTIVE AGENTS
8:12.08 Chloramphenicol cap 250 mg, inj,
8:04 AMEBICIDES
8:12.12 Macrolides
Azithromycin cap 250 mg, Inj – 1Gm. (ZITHROMAX) 8:08 ANTHELMINTICS
8:12 ANTIBIOTICS
8:12.02 Aminoglycosides
8:12.16 Penicillins
Dicloxacillin cap 250, 500 mg; susp (DYNAPEN) Penicillin G Benzathine inj 600,000 units, 1.2 mu, Penicillin V K tab 250, 500 mg (PEN-VEE-K, 8:12.04 Antifungal Antibiotics
Penicillin G Procaine inj 600,000 units, 1.2 mu, 8:22 QUINOLONES
Ciprofloxacin tab 250, 500, 750 mg, inj (CIPRO) Levofloxacin tab 250, 500 mg, 500 mg, 750 mg inj 25mg/mL, 8:24 SULFONAMIDES
Sulfabenzamide/Sulfacetamide/Sulfathiozole 250 mg, 500 mg, susp 200mg/5 mL, 400mg/5mL, 600 mg/5mL; chew tabs 250 mg (AUGMENTIN) (AUGMENTIN Sulfisoxazole/Erythromycin Ethylsuccinate Sulfamethoxazole tab 500 mg, susp 500 mg/5 mL Sulfisoxazole tab 500 mg, susp 500 mg/5 mL 8:36 URINARY ANTI-INFECTIVES
Piperacillin/tazobactam inj 2.25, 3.375, 4.5 g (ZOSYN) 8:12.24 Tetracyclines
8:40 MISCELLANEOUS ANTI-INFECTIVES
Doxycycline cap 50, 100 mg (VIBRAMYCIN), Tetracycline cap 250 mg, 500 mg (SUMYCIN) Metronidazole tab 250, 500 mg, inj 500 mg (FLAGYL) 8:12.28 Miscellaneous Antibiotics
10:00 ANTI-NEOPLASTIC AGENTS
Clindamycin cap 150, inj 300, 600, 900 mg Linezolid tab 600 mg, 2 mg/ml inj (ZYVOX)- restricted Cyclophosphamide tab 50 mg; inj (CYTOXAN) 8:16 ANTI-TUBERCULOSIS AGENTS
8:18 ANTI-VIRAL AGENTS
Gemcitabine inj. 200 mg; 1 Gm inj (GEMZAR) lamivudine 150 mg/zidovudine 300 mg tab(COMBIVIR) Rimantadine tab 100 mg, syrup 50 mg/5 mL 8:20 ANTI-MALARIAL AGENTS
Megestrol Acetate oral susp., 40 mg/mL, (MEGACE), 12:12 SYMPATHOMIMETIC (ADRENERGIC)
Methotrexate tab 2.5 mg, inj 50 mg (MTX) (ADVAIR) Fluticasone/salmeterol oral inhaler Albuterol oral inhaler, SR tab 4 mg, tab 2, 4 mg, soln, powder & soln for inhalation Epinephrine inj, topical soln (ADRENALIN) Ipratropium bromide oral inhaler, soln (ATROVENT) Levalbuterol HCl inhalation 0.63 mg/3ml and 1.25 mg/3 ml 12:00 AUTONOMIC DRUGS
12:04 PARASYMPATHOMIMETIC (CHOLINERGIC)
Metaproterenol Sulfate soln, oral inhaler, oral Bethanechol Chloride tab 10, 25, 50 mg, inj Norepinephrine Bitartrate inj (LEVOPHED) Phenylephrine drops 0.12, 0.25, 0.5, 1%, 0.5% nasal spray,1%/Lidocaine 4%, inj 1% Pirbuterol acetate oral inhaler (MAXAIR) Physostigmine Salicylate inj (ANTILIRIUM) Terbutaline Sulfate tab 2.5, 5 mg, inj 1 mg Rivastigmine cap 1.5, 3, 4.5, 6 mg (EXELON) 12:08 ANTICHOLINERGIC AGENTS
12:16 SYMPATHOLYTIC AGENTS
12:08.04 ANTIPARKINSONIAN AGENTS
Ergotamine tartrate tab SL 2 mg (ERGOSTAT) Benztropine Mesylate tab 0.5, 1, 2 mg, inj Selegiline hydrochloride tab 5mg (ELDEPRYL) 12:20 SKELETAL MUSCLE RELAXANTS
12:08.08 ANTIMUSCARINICS/ANTISPASMODICS
Dantrolene Sodium cap 25 mg; inj (DANTRIUM) Methocarbamol tab 500, 750 mg, inj (ROBAXIN) 12:92 MISCELLANEOUS AUTONOMIC DRUGS
16:00 BLOOD DERIVATIVES
Plasma Protein Fraction inj (PLASMANATE) 20:00 BLOOD FORMATION AND COAGULATION
20:04.04 IRON PREPARATIONS
Ferrous Sulfate tab 200 mg, SR cap 159 mg, Propranolol tab 10, 20, 40, 60, 80 mg, LA elixir (FEOSOL), tab 325 mg, syrup (FER- 20:12.04 ANTICOAGULANTS
Warfarin Sodium tab 1, 2, 2.5, 5, 7.5, 10 mg Clevidipine Butyrate Inj 0.5 mg/mL; 50 mL (CLEVIPREX 20:12.08 ANTI-HEPARIN AGENTS
20:12.16 HEMOSTATICS
Antihemophilic Factor VIII inj., recombinant Nifedipine cap 10 mg, CC tab 30, 60, 90 mg Antihemophilic Factor IX inj., recombinant (BENEFIX) Von Willebrand Factor VIII inj. (HUMATE-P) Verapamil tab 40, 80, 120 mg, inj (ISOPTIN), Antihemophilic Factor VIIa inj., (NOVOSEVEN) Aminocaproic Acid tab 500 mg, inj (AMICAR) Microfibrillar Collagen Hemostat (AVITENE) Candesartan Cilexetil tab 16 mg (ATACAND) 20:16 HEMATOPOIETIC AGENTS
Darbopoeitin alfa, Inj, 100 mcg/mL, 300 mcg/mL vial Epoetin Alfa inj 2,000 u, 3000 u, 4000 u, 10,000 u, 20,000 u Enalapril tab 2.5, 5, 10, 20 mg (VASOTEC) 20:24 HEMORRHEOLOGIC AGENTS
20:40 THROMBOLYTIC AGENTS
24:04:08 CARDIAC DRUGS
Candesartan tab. 4, 8, 16, 32 mg (ATACAND) Carvedilol 3.125 mg, 6.25 mg, 12.5 mg, 25 mg tabs. (COREG); 10 mg, 20 mg, 40 mg extended release tablets Disopyramide cap 100, 150 mg, CR cap 100, Dofetilide 125 mcg, 250 mcg caps (TIKOSYN) Mexiletine cap 150, 200, 250 mg (MEXITIL) Choline Magnesium Trisalicylate tab 500, Ibuprofen tab 200, 300, 400, 600, 800 mg (MOTRIN, Indomethacin cap 25, 50 mg, SR cap 75 mg, rectal supp 50 Aliskiren tab., 150 mg, 300 mg (TEKTURNA) Clonidine tab 0.1, 0.2, 0.3 mg (CATAPRES), Ketorolac Tromethamine tab 10 mg, inj 15, 30 mg 28:08.08 OPIATE AGONISTS
24:06 ANTILIPEMIC AGENTS
Atorvastatin tab. 10, 20, 40, 80 mg (Lipitor) Cholestyramine Resin granules (QUESTRAN) Fentanyl Citrate transdermal 12.5, 25, 50, 75 Simvastatin tab 10, 20, 40, 80 mg (ZOCOR) 24:12 VASODILATING AGENTS
Hydrocodone Bitartrate/Acetaminophen tab Hydrocodone Bitartrate/Acetaminophen tab Isosorbide Dinitrate tab 5, 10, 20, 40 mg, Nitroglycerin lingual aerosol 0.4 mg/spray Nitroglycerin Transdermal 0.1, 0.2, 0.3, 0.4, Morphine sulfate inj. 0.5 mg/mL, 1 mg/mL 28:00 CENTRAL NERVOUS SYSTEM AGENTS
28:08 ANALGESICS AND ANTIPYRETICS
28:08.04 NON-STEROIDAL ANTI-INFLAMMATORY
Oxycodone/Aspirin tab 5/325 mg (PERCODAN) Aspirin tab 325, 650 mg, chewtab 81 mg, EC tab 325 mg Propoxyphene H Cl cap 65 mg (DARVON PULVULES) Propoxyphene Napsylate/Acetaminophen tab 28:08.12 OPIATE PARTIAL AGONISTS
Desvenlafaxine Succinate tab 50 mg ER Tab PRISTIQ Pentazocine tab 50 mg; inj 30 mg, 60 mg (TALWIN) 28:08.92 MISCELLANEOUS ANALGESICS AND
ANTIPYRETICS
Acetaminophen tab 325, 500 mg, supp 120, 325, 650 mg; Imipramine Hydrochloride tab 10, 25, 50 mg Acetaminophen/Isometheptane Mucate/Dichloralphenazone Ziconotide Inj. 25 mcg/mL, 20 mL vial (PRIALT)
Paroxetine tab 10, 20, 30, 40 mg (PAXIL) Restricted to Northern Rockies Pain Clinic
28:10 OPIATE ANTAGONISTS
Venlafaxine, tab 37.5, 75, 150 mg, tab (EFFEXOR XR) 28:12 ANTICONVULSANTS
28:16.08 TRANQUILIZERS
Chlorpromazine Hydrochloride soln, tab 10, 25, 100 mg, inj Phenobarbital tab 15, 30, 60, 100 mg elixir 4 mg/mL, inj Fluphenazine Hydrochloride tab 1, 2.5, 5 mg, Prochlorperazine rectal supp 2.5, 5, 25 mg (COMPAZINE) Phenytoin chew tab 50 mg, susp 30 mg/5ml, 125 mg/5 ml Thioridazine Hydrochloride tab 10, 25, 50, 100 mg, soln Phenytoin Sodium SR cap 30 mg, 100 mg, 300 mg Fosphenytoin Inj. 150mg/2mL, 750mg/10mL (Cerebyx) 150 mg fosphenytoin equivalent to 100 mg phenytoin sodium. Haloperidol tab 0.5, 1, 2, 5, 10 mg, soln, inj (HALDOL) Carbamazepine tab 100 mg (chewable), 200 mg, susp Quetiapine 25, 100 mg tabs (SEROQUEL ) (SEROQUEL) Levetiracetam tabs., 500 mg; Inj 500 mg/5mL vial Risperidone 0.25, 0.5, 1, 2 mg tabs (RIS:ERDAL) Thiothixene cap 1, 2, 5, 10 mg; inj (NAVANE) Oxcarbazepine tab 150, 300, 600 mg (TRILEPTAL) 28:20 RESPIRATORY AND CEREBRAL
STIMULANTS
Valproic Acid cap 250 mg; liq 250 mg/5 mL (DEPAKENE) Divalproex Sodium cap 125 mg, tab 250, 500 mg Divalproex Sodium tab 500 mg (DEPAKOTE ER) Methylphenidate tab 5, 10, 20 mg (RITALIN) 28:16.04 ANTIDEPRESSANTS
28:24.04 BARBITURATES
Amitriptyline tab 10, 25, 50, 75, 100, 150 mg (ELAVIL) 28:24.08 BENZODIAZEPINES
36:84 TUBERCULOSIS
40:04 ACIDIFYING AGENTS
Chlordiazepoxide/Amitriptyline tab 5/12.5, 10/25 mg 40:08 ALKALINIZING AGENTS
Diazepam tab 2, 5, 10 mg, inj (VALIUM), rectal gel Lorazepam tab 0.5, 1, 2 mg, inj (ATIVAN) 40:10 AMMONIA DETOXICANTS
28:24.92 MISCELLANEOUS ANXIOLYTICS,
SEDATIVES, AND HYPNOTICS
40:12 REPLACEMENT PREPARATIONS
Choral hydrate syrup 500 mg/5mL, cap 500 mg (NOCTEC) Dexmedetomidine inj 200 mg/2 ml (PRECEDEX) Hydroxyzine HCl tab 10, 25, 50 mg, syrup 10 mg/5mL; inj Hydroxyzine Pamoate susp 25 mg/5 mL, cap 25, 50, 100 mg, Potassium Phosphate/Sodium Phospate mixture (NEUTRA- Promethazine tab 25 mg, supp 12.5, 25 mg, syrup 28:28 ANTIMANIC AGENTS
Lithium Carbonate SR tab 300 mg, (LITHOBID), 36:00 DIAGNOSTIC AGENTS
40:18 POTASSIUM-REMOVING RESINS
Sodium Polystyrene Sulfonate/Sorbitol susp, 40:28 DIURETICS
Thiazides
36:04 ADRENOCORTICAL INSUFFICIENCY
Chlorothiazide tab 250, 500 mg; inj; susp (DIURIL) Hydrochlorothiazide tab 25, 50 mg, HCTZ) Hydrochlorothiazide/Triamterene cap 25/37.5, 50/75 mg Metolazone tab 2.5, 5, 10 mg (ZAROXOLYN, DIULO) 36:26 DIABETES MELLITUS
Loop Diuretics
Bumetanide tab 0.5, 1, 2 mg, inj (BUMEX) Osmotic Diuretics
36:40 KIDNEY FUNCTION
Potassium-Sparing Diuretics
36:56 MYASTHENIA GRAVIS
36:68 ROENTGENOGRAPHY
Spironolactone/HCTZ tab 25mg/25mg, 50mg/50mg Polymyxin/Trimethoprim oph soln (10,000 u/ Oxytetracycline/Polymyxin B oph oint (0.5%/ 40:36 IRRIGATING SOLUTIONS
Aminoacetic Acid irr soln 1.5% (GLYCINE) 52:04.06 ANTI-VIRALS
40:40 URICOSURIC AGENTS
52:04.08 SULFONAMIDES
44:00 Enzymes
Sulfacetamide/Prednisolone oph susp 10%/ 48:08 ANTITUSSIVES
52:08 ANTI-INFLAMMATORY AGENTS
Beclomethasone dipropionate nasal aerosol Beclomethasone dipropionate monohydrate nasal susp Dextromethorphan/Guaifenesin syrup 10/100 oph oint, susp 0.1/0.5%/10,000 u/g or ml 48:16 EXPECTORANTS
48:24 MUCOLYTICS
Acetylcysteine sodium soln 10%, 20% MUCOMYST) Flunisolide nasal soln 0.025% (NASALIDE) 52:00 EYE, EAR, NOSE AND THROAT
PREPARATIONS
Hydrocortisone/Neomycin/Polymyxin B otic 52:04.04 ANTIBIOTICS
Hydrocortisone/Colistin/Neomycin/Thonzoni- Chloramphenicol oph oint 1% CHLOROMYCETIN, Chloramphenicol opth soln 0.5% CHLOROPTIC) Gentamicin Sulfate oph soln, oint 0.3% GENOPTIC) Sulfacetamide/Prednisolone oph oint, susp 52:10 CARBONIC ANHYDRASE INHIBITORS
Neomycin/Colistin/Hydrocortisone/Thonzonium 52:16 LOCAL ANESTHETICS
Benzocaine/Antipyrine otic soln 1.4/5.4% Tetracaine oph oint, soln 0.5% PONTOCAINE) 56:04 ANTACIDS AND ABSORBENTS
52:20 MIOTICS
Carbachol oph soln 0.75, 1.5, 3%(ISOPTO-CARBACHOL) Echothiophate Iodide oph soln 0.06, 0.125% Pilocarpine oph soln 0.25, 0.5, 1, 2, 4, 6% Magraldate susp 400 mg/5mL (RIOPAN PLUS) 52:24 MYDRIATICS
Atropine oph oint 1%, soln 1% (ATROPISOL, 56:08 ANTIDIARRHEA AGENTS
Diphenoxylate/Atropine Sulfate 2.5/0.025 Diphenoxylate/Atropine Sulfate 2.5/0.025 mg Homatropine oph soln 2, 5% (ISOPTO-HOMATROPINE) 56:10 ANTIFLATULENTS
52:32 VASOCONSTRICTORS
Epinephrine nasal soln 0.1% (ADRENALIN)
Naphazoline/Pheniramine Maleate oph soln Naphazoline/Antazoline oph soln 0.05/0.5% 56:12 CATHARTICS AND LAXATIVES
Senna/Docusate tab 187 mg/50 mg (SENOKOT-S) 52:36 MISCELLANEOUS EENT DRUGS
Polyvinyl alcohol oph soln 1.4% (DRY EYES) Magnesium Hydroxide susp (MILK OF MAGNESIA) Phosphate soln (FLEET PHOSPHO SODA oral soln) Dexamethasone 0.5, 0.75, 1.5, 2, 4 mg tab inj, liq 0.5 mg/5 Fludrocortisone Acetate tab 0.1 mg (FLORINEF) Hydrocortisone 5, 10, 20 mg tab; (CORTEF) Methylprednisolone 4, 8, 16 mg tab (MEDROL) Methylprednisolone Sodium Succinate inj (SOLU- 56:16 DIGESTANTS
Prednisone tab 1, 2.5, 5, 10, 20, 50 mg (ORASONE, Pancrealipase cap (ULTRASE MT-12), (ULTRASE MT20), (PANGESTYNE MT10), (LIPRAM 20 PN), (LIPRAM 10 Triamcinolone Acetonide inj (KENALOG-10, KENALOG-40), oral inhaler 100 mcg/spray 56:20 EMETICS
Triamcinolone Diacetate inj (ARISTOCORT) 56:22 ANTIEMETICS
68:08 ANDROGENS
68:16 ESTROGENS
Prochlorperazine tab 5, 10 mg, supp 25 mg. (COMPAZINE) Triethylperazine maleate tab 10 mg, supp 10 mg, inj Estradiol transdermal 0.05, 0.1 mg/24 hr (VIVELLE DOT) Trimethobenzamide cap 100, 250 mg, inj., supp 100, 200 mg Estradiol valerate inj (DELESTROGEN) Estrogens, conjugated tab 0.3, 0.625, 0.9, 1.25 mg, vag 56:36: ANTI-INFLAMMATORY AGENTS (GI
68:20.08 INSULINS
56:92 MISCELLANEOUS GI DRUGS
Alvimopan Caps. 12 mg (ENTEREG)
Insulin detemir 100 units/mL Inj. (DETEMIR) Insulin, human regular 100 units/mL; 500 units/mL Lansoprazole 15 mg Solutab (PREVACID)
Metoclopramide 5, 10 mg tab, soln, inj (REGLAN) Insulin, Ultra-lente (HUMULIN ULTRALENTE) Pantoprazole tab 40 mg, Inj. 40 mg (PROTONIX) 64:00 HEAVY METAL ANTAGONISTS
68:20.20 SULFONYLUREAS
68:04 ADRENAL CORTICOSTEROIDS
Beclomethasone dipropionate oral inhaler Glipizide XL tab 5, 10 mg (GLUCOTROL XL) 80:04 SERUMS
68:20.92 MISCELLANEOUS ANTIDIABETIC
80:08 TOXOIDS
Sitagliptan 50 mg, 100 mg tabs. (JANUVIA) 68:24 PARATHYROID AGENTS
80:12 VACCINES
68:28 PITUITARY AGENTS
Haemophilus B conjugate vaccine (HibTITER) Meningococcal vaccine Inj. (MENOMUNE, MENACTRA) Pneumococcal Vaccine Polyvalent (PNEUMOVAX 23) Poliovirus Vaccine Live Oral Rabies Vaccine (IMOVAX 68:32 PROGESTINS
Medroxyprogesterone acetate tab 2.5, 5, 10 Tetanus/diphtheria/acellular/pertussis vaccine (ADACEL) Varicella Zoster Vaccine Inj. (ZOSTAVAX) 68:36.04 THYROID AGENTS
Varicella virus vaccine live, attenuated, Inj. (VARIVAX) Levothyroxine sodium tab 25, 50, 75, 88,100, 125, 150, 200, 84:00 SKIN AND MUCOUS MEMBRANE
Liothyronine sodium tab 25 mcg (CYTOMEL) 84:04.04 ANTIBIOTICS
68:36.08 ANTI-THYROID AGENTS
Clindamycin gel, lotion, soln 1% (CLEOCIN-T) 72:00 LOCAL ANESTHETICS
Neomycin/Bacitracin Zinc/Polymyxin B oint 0.5, 0.75% (MARCAINE & EPI) Chloroprocaine inj 1, 2, 3 84:04.06 ANTIVIRALS
84:04.08 ANTIFUNGALS
76:00 OXYTOCICS
Methylergonovine maleate tab 0.2 mg, inj (METHERGINE) Nystatin cream, oint, powder 100,000 u/g 84:04.12 SCABICIDES AND PEDICULICIDES
84:32 KERATOPLASTIC AGENTS
84:04.16 MISCELLANEOUS LOCAL ANTI-
84:36 MISCELLANEOUS SKIN AND MUCOUS
INFECTIVES
MEMEBRANE AGENTS
Silver Sulfadiazine cream 1% (SILVADENE) 84:06 ANTI-INFLAMMATORY AGENTS
Dextranomer topical beads 4 g (DEBRISAN) Alclometasone Dipropionate cream 0.05% oint 0.05% Fibrinolysin/Desoxyribonuclease oint 1/666.6u/g (ELASE) Fibrinolysin/Desoxyribonuclease/Chloram- Betamethasone Dipropionate cream, lotion, Betamethasone/Clotrimazole cream 0.05/1% (LOTRISONE) Chlorhexidine Gluconate oral rinse 0.12% (PERIDEX) Clobetasol Propionate cream, oint 0.05% (TEMOVATE) Lidocaine jelly 2%, oint 2.5, 5% (XYLOCAINE) Lidocaine/Procaine cream 2.5/2.5% (EMLA) Desoximetasone cream 0.05, 0.25%, gel 0.05%, oint 0.25% Permethrin 1% rinse (NIX), cream 5% (ELIMITE) Fluocinolone Acetonide cream 0.01%, soln 0.01% Fluocinonide cream, oint, gel, soln 0.05% (LIDEX) Hydrocortisone cream 0.5, 1, 2.5%, lotion 1%, oint 0.5, 1% 86:12 GENITOURINARY SMOOTH MUSCLE
RELAXANTS
Oxybutynin Chloride tab 5 mg, syrup (DITROPAN), Hydrocortisone Acetate/Neomycin/Polymyxin Triamcinolone Acetonide cream 0.025, 0.1, 0.5%, oint 0.1% 86:16 RESPIRATORY SMOOTH MUSCLE
(KENALOG), paste 0.1% (KENALOG IN ORABASE) RELAXANTS
Aminophylline inj, tab 100, 200 mg
84:08 ANTIPRURITICS AND LOCAL
ANESTHETICS
Theophylline SR tab 100, 200, 300, 400 mg , SR cap 75 mg Phenazopyridine tab 100, 200 mg (PYRIDIUM) 88:00 VITAMINS

84:16 CELL STIMULANTS AND
88:08 VITAMIN B COMPLEX
Folic Acid tab 1 mg, soln, inj (FOLVITE)
PROLIFERANTS
Tretinoin cream 0.025, 0.05, 0.1%, gel 0.01, 0.025% (RETIN- 84:24 EMOLLIENTS, DEMULCENTS, AND
PROTECTANTS
88:12 VITAMIN C
88:16 VITAMIN D
84:28 KERATOLYTIC AGENTS
88:20 VITAMIN E
Vitamin E cap 400 IU, drops (AQUASOL E)
Salicylic Acid wart remover 17% (DUOFILM)
88:24 VITAMIN K ACTIVITY
Phytonadione tab 5 mg (MEPHYTON), inj (AQUA-MEPHYTON)
88:28 MULTIVITAMIN PREPARATIONS
Multivitamin inj (Adult, Pediatric)
Therapeutic Multivitamin tab
Therapeutic Multivitamin with Minerals tab
NEPHROCAPS
STUART PRENATAL tab

92:00 UNCLASSIFIED THERAPEUTIC

AGENTS
Allopurinol tab 100, 300 mg (ZYLOPRIM)
Anagrelide cap 0.5 mg (AGRYLIN)
Aprotinin inj (TRASYLOL)
Azathioprine tab 50 mg, inj (IMURAN)
Beractant susp (SURVANTA)
Bromocriptine Mesylate tab 2.5 mg (PARLODEL)
Carboprost
Clopidogrel tab 75 mg (PLAVIX)
Colchicine tab 0.6 mg
Cromolyn Sodium nasal soln
(NASALCROM), oral inhaler, powder & soln for
nebulization (INTAL)
Cyclosporine soln (SANDIMMUNE)
Dexrazoxane inj. 500 mg vial/kit (TOTECT)
Drotrecogin alfa inj (XIGRIS)
Etidronate Disodium inj (DIDRONEL)
Finasteride tab 5 mg (PROSCAR)
Flumazenil inj (ROMAZICON)
Glucosamine tab 500 mg (GLUCOSAMINE)
Glucosamine/Chondroitin tab 250/200 mg
(GLUCOSAMINE/CHONDROITIN)
Fomepizole sln for inj (1g/mL) 1.5 mL vial (ANITZOL)
Leucovorin Calcium tab 5 mg;
inj (WELLCOVORIN)
Carbidopa/Levodopa tab 10/100, 25/100, 25/250, SR tab
50/200 mg (SINEMET)
Carbidopa/Levodopa CR tab 50mg/200mg (SINEMET CR)
Methylene Blue inj
Montelukast Sodium tab 10 mg
SINGULAIR)
Melatonin 3 mg Cap (MELATONIN)
Natalizumab Inj., 300 mg vial (TYSABRI) - Restricted
Octreotide Acetate inj (SANDOSTATIN)
Pamidronate Disodium inj (AREDIA)
Palivizumab inj 100 mg/vial (SYNAGIS)
Sumatriptan inj (IMITREX)
Tamsulosin cap 0.4 mg (FLOMAX)
Talc powder, 5 Gm sterile
Ticlopidine tab 250 mg (TICLID)
Zoledronic acid inj.,
4 mg/5mL (ZOMETA)
Aluminum Hydroxide/ Magnesium Hydroxide/ Simethicone, 18 Aluminum Hydroxide/Magnesium Trisalicylate, 18 Acetaminophen/Isometheptane Mucate/Dichloralphenazone, 15 Benzocaine/Antipyrine/Phenylephrine otic, 18 Benzocaine/Cetylpyridinium anesthetic lozenges, 18 Benztropine Mesylate, 12
Atracurium Besylate, 12
Atropine Sulfate/Hyoscyamine/Phenobarbital/Scopolamine, 12 Brompheniramine Maleate/ Phenylpropanolamine, 10 Beclomethasone dipropionate monohydrate, 17 Beclomethasone dipropionate nasal aerosol, 17 Beclomethasone dipropionate oral inhaler, 19 Calcium Carbonate, 16, 18
Carbinoxamine Maleate/Pseudoephedrine, 10 Carbinoxamine Maleate/Pseudoephedrine/Dextromethorphan, 10 Clotrimazole/Betamethasone Dipropionate, 20 Codeine Phosphate/Aspirin/Butalbital/Caffeine, 14 Chloramphenicol, 10
Desvenlafaxine Succinate tab 50 mg ER Tab, 15 Dexamethasone Sodium Phosphate cream, 21 Dibasic Na Phosphate with Monobasic Na Phosphate soln, 18 Dihydoergotamine Mesylate, 12
Diphtheria and Tetanus Toxoids Absorbed Adult, 20 Diphtheria and Tetanus Toxoids Absorbed Ultrafined Pediatric, 20 Diphtheria and Tetanus Toxoids and Pertussis Vaccine, 20 ENTEREG, 19
Epoetin Alfa, 13
Estradiol cypionate/testosterone cypionate, 19 Fibrinolysin/Desoxyribonuclease/Chloramphenicol, 21 Guaifenesin/Phenylephrine/Phenylpropanolamine, 17 Hepatitis B Virus vaccine inactivated, 20 Insulin, human regular/isophane 30/70, 19 Hydrocodone Bitartrate/Acetaminophen, 14 Hydrocortisone/Bacitracin Zinc/Neomycin/Polymyxin B, 21 Hydrocortisone/Colistin/Neomycin/Thonzonium otic, 17 Hydrocortisone/Neomycin/Polymyxin B otic, 17 Measles, Mumps and Rubella Virus Vaccine Live, 20 Methyltestosterone/esterified estrogens, 19 Neomycin/Bacitracin Zinc/Polymyxin B, 17 Neomycin/Bacitracin Zinc/Polymyxin B oint, 20 Neomycin/Colistin/Hydrocortisone/Thonzonium, 17 Neomycin/Gramicidin/Polymyxin B oph soln, 17 Neomycin/Hydrocortisone/Polymyxin B/Bacitracin Zinc, 17 MYCAMINE, 10
Pentoxifylline, 13
Petrolatum/Mineral Oil/Shark Liver Oil/Phenylephrine, 21 Phenylephrine/Sulfacetamide oph soln, 18 Oxytetracycline/Polymyxin B oph oint, 17 Promethazine/Phenylephrine/Codeine, 10, 17 Propoxyphene Napsylate/Acetaminophen, 14 Protamine Sulfate, 13
Prednisolone/Neomycin/Polymyxin B oph, 17 PREVACID, 19
PRIALT, 15
Sodium Bicarbonate, 16
Sodium Polystyrene Sulfonate, 16
Sulfabenzamide/Sulfacetamide/Sulfathiozole, 11 Sulfacetamide/Phenylephrine oph soln, 17 Sulfisoxazole/Erythromycin Ethylsuccinate, 11 Tetanus/diphtheria/acellular/pertussis vaccine, 20 Therapeutic Multivitamin with Minerals, 22 VERSED, 16
VIBRAMYCIN, 11
VICODIN, 14
Vidarabine, 17
Vinblastine Sulfate, 12
VINCASAR PFS, 12
Vincristine Sulfate, 12
VIRA-A, 17
VIRAZOLE, 11
VISTARIL, 16
VIT B-1, 21
VIT B-12, 21
VIT B-6, 21
Vitamin E, 21
VIT-C, 21
VIVELLE DOT, 19
VOLTAREN, 14
Von Willebrand Factor VIII inj, 13
VOSOL, 18
VP-16, 11
Warfarin Sodium, 13
WELLCOVORIN, 22
White Petrolatum/Mineral Oil oph oint, 18
Witch Hazel/Glycerin pads, 21
WYCILLIN, 10
WYDASE, 17
XANAX, 16
Xopenex, 12
XYLOCAINE, 13, 20, 21
XYLOCAINE w EPI, 20

Source: http://www.stvincenthealthcare.org/Workfiles/Formulary2011.pdf

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