| NOTCH 340B FORMULARY
Updated 6/10/05 |
| CLASSIFICATION |
NAME |
| ANTI-INFECTIVES |
| Antifungals |
Nystatin Oral Susp (60ml) |
| Antivirals |
Acyclovir 400mg tablet |
| |
Amantadine 100mg capsule |
| |
VALTREX (Valacyclovir) 500mg tablet |
| Cephalosporins |
Cefadroxil 500mg capsule |
| |
Cefuoxime 250mg tablet |
| |
Cephalexin 250mg/5ml & 500mg capsule |
| Erythromycins and other
Macrolides |
BIAXIN 500mg tablet (Clarithromycin) |
| |
Erythromycin 333mg tablet |
| |
ZITHROMAX 250mg & 500mg tablet & 200mg/5ml |
| Penicillins |
Amoxicillin 125mg/5ml susp & 250mg/5ml susp |
| |
Amoxicillin 250mg chewable tablet & 500mg capsule |
| |
Amoxicillin/Clavulanate 875mg tablet |
| |
AUGMENTIN XR (Amoxicillin/Clavulanate 1000/62.5) |
| |
Penicillin VK 500mg tablet |
| Quinolones |
LEVAQUIN (Levofloxacin) 500mg tablet |
| Sulfas |
Sulfamethoxazole/Trimethoprim DS (800/160) tablet |
| |
Sulfamethoxazole/Trimethoprim Susp (200mg/40mg per 5ml) |
| Tetracyclines |
Doxycycline 100mg capsule |
| Urinary Tract Agents |
MACROBID (Nitrofurantoin macrocrystal) 100mg capsule |
| Misc |
Metronidazole 500mg tablet |
| AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH |
| Analgesics (Narcotic) |
Acetaminophen w/Codeine 300/30 tablet |
| |
Acetaminophen w/Codeine Liquid 120/12mg per 5ml |
| |
DURAGESIC PATCH 25,50,75 & 100mcg/hr |
| |
Fentanyl Patch 25,50,75 & 100mcg/hr |
| |
Hydrocodone/Acetaminophen 10/650 & 5/500 tablet |
| |
Oxycodone/Acetaminophen 5/325 & 10/325 tablet
(Roxicet) |
| |
OXYCONTIN 10mg tablet (Oxycodone CR) |
| |
Propoxyphene N 100 tablet |
| |
Tramadol 50mg tablet |
| Analgesics (Non-Narcotic) |
CELEBREX 100mg & 200mg capsule (Celecoxib) |
| |
Ibuprofen 800mg tablet |
| |
Sulindac 200ml |
| Anticonvulsants |
Gabapentin 300mg & 600mg Capsule |
| |
NEURONTIN (Gabapentin) 300mg & 600mg capsule |
| Antiverigo &
Antiemetic Drugs |
Meclizine 12.5mg tablet |
| Migraine & Cluster
Headache Therapy |
Butalbital/APAP/Caffeine tablet |
| |
IMITREX (Sumatriptan) 100mg tablet |
| |
RELPAX (Eletriptan) 40mg tablet |
| Misc. Neurological
Therapy |
ARICEPT 5mg & 10mg tablet (Donepezil) |
| Muscle Relaxants &
Antispasmodic Therapy |
COPAXONE 20MG INJECT. |
| |
Cyclobenzaprine 10mg tablet |
| |
DETROL (Tolterodine) LA 2mg & 4mg capsule |
| Psychotherapeutic Drugs |
|
| Antidepressant Agents |
Amitriptyline 10mg, 25mg & 100mg tablet |
| |
Amitriptyline 25mg tablet |
| |
Bupropion SR 75mg, 100mg & 150mg |
| |
Citalopram 10mg, 20mg & 40mg |
| |
Effexor XR 75mg & 150mg |
| |
Trazodone 50mg tablet |
| AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (Continued) |
| Antipsychotics |
RISPERDAL (Risperidone) 0.25mg & 0.5mg tablet |
| |
ZYPREXA (Olanzapine) 2.5mg, 5mg & 10mg tablet |
| Anxiolytics |
Alprazolam 0.5mg tablet |
| |
Buspirone 15mg tablet |
| |
Diazepam 5mg tablet |
| |
Lorazepam 0.5mg & 1mg tablet |
| Hypnotic Agents |
AMBIEN (Zolpidem) 10mg tablet |
| SSRIs |
Fluxotine 20mg & 40mg capsule |
| |
LEXAPRO 10mg & 20mg tablet |
| |
PAXIL (Paroxetine) CR 10mg, 12.5mg, 25mg & 37.5mg
tablet |
| |
ZOLOFT (Sertraline) 50mg & 100mg tablet |
| CARDIOVASCULAR, HYPERTENSION & LIPIDS |
| Antiarrhythmic
Agents |
Sotaolol 80mg |
| Antihypertensive Therapy |
|
| Ace Inihibitors |
ALTACE 2.5mg, 5mg & 10mg |
| |
Enalapril 2.5mg, 5mg & 10mg tablet |
| |
Lisinopril 5mg, 10mg & 20mg tablet |
| Andrenergic Antagonists
& Related Drugs |
|
| Angiotensin II Receptor
Blockers (ARBs) |
AVALIDE 300/12.5 |
| |
AVAPRO 150mg & 300mg |
| |
COZAAR (Losartan) 50mg & 100mg tablet |
| |
HYZAAR 100/25 (Losartan/HCTZ) tablet |
| Beta Blockers |
Atenolol 25mg, 50mg & 100mg tablet |
| |
Bisoprolol 5-6.25 |
| |
Metoprolol 25mg, 50mg & 100mg tablet |
| |
Propranolol 80mg |
| |
TOPROL XL (Metoprolol) 50mg & 100mg tablet |
| Calcium Channel Blockers |
Diltiazem ER 180mg, 240mg & 300mg capsule |
| |
NORVASC (Amlodipine) 5mg & 10mg tablet |
| Thiazine & Related
Diuretics |
Furosemide 20mg & 40mg tablet |
| |
Hydrochlorothiazide 25mg & 50mg tablet |
| |
Spironolactone 25mg tablet |
| |
Triamterene/Hctz 37.5/25 |
| Cardiac Glycosides |
Lanoxin 250mcg |
| Coagulation Therapy |
PLAVIX (Clopidogrel) 75mg tablet |
| |
Warfarin 1mg, 4mg & 5mg tablet |
| Lipid/Cholesterol
Lowering Agents |
Gemfibrozil 600mg tablet |
| |
LESCOL (FLUVASTATIN) XL 80mg tablet |
| |
LIPITOR (Atorvastatin) 10mg, 20mg, 40mg & 80mg tablet |
| |
Lovastatin 20mg & 40mg |
| |
ZETIA 10mg |
| |
ZOCOR (Simvastatin) 20mg, 40mg & 80mg tablet |
| Nitrates |
Isosorbide Mononitrate 30mg & 60mg tablet |
| |
Nitroglycerin 0.1mg Patch |
| |
Nitroglycerin 0.4mg SL tablet |
| DERMATOLOGICALS/TOPICAL THERAPY |
| |
Betamethasone .1% Cream |
| |
Clotrimazole Cream 15g |
| |
Clotrimazole/Betamethasone Dipropionate Cream 15mg
(Lotrisone) |
| |
Desonide .05% Cream |
| |
Hydrocortisone 1% & 2.5% Cream 30mg |
| |
Ketoconazole Cream 15mg |
| |
Nystatin Ointment 15mg |
| |
Triamcinolone 0.5% Cream 15g |
| THYROID |
| |
LEVOXYL 0.05mcg, 0.075mcg,
0.1mcg, 0.125mcg & 0.15mcg |
| DIABETES |
| Insulin
Therapy |
|
| Oral Hypoglycemic Agents |
ACTOS (Ploglitazone) 30mg & 45mg tablet |
| |
AVANDIA (Rosiglitazone) 4mg & 8mg tablet |
| |
Glyburide 2.5mg & 5mg tablet |
| |
Metformin 500mg & 1000mg tablet |
| GASTROENTEROLOGY |
| Ulcer Therapy |
ACIPHEX 20mg |
| |
NEXIUM (ESOMEPRAZOLE) 40mg |
| |
PREVACID (Lansoprazole) 15mg & 30mg |
| |
PROTONIX (Pantoprazole) 40mg |
| |
Ranitidine 150mg tablet |
| MUSCULOSKELELTAL & RHEUMATOLOGY |
| Corticosteroids |
Methylprednisolone 4mg tablet (21) |
| |
Prednisone 5mg & 10mg tablet |
| Gout Therapy |
Allopurinol 100mg & 300mg tablet |
| NSAID Agents |
Nabumetone 500mg |
| |
Naproxen 500mg |
| Osteoporosis Therapy |
EVISTA (Raloxifene) 60mg tablet |
| |
FOSAMAX (Alendronate) 10mg & 70mg tablet |
| OBSTETRICS & GYNECOLOGY |
| Anti Estrogens |
TAMOXIFEN 20mg |
| Estrogens &
Progestins |
PREMARIN (Conjugated Estrogens) 0.3mg & 0.625mg
tablet |
| |
PREMARIN VAGINAL CREAM |
| |
PREMPRO 0.625/2.5mg tablet |
| Oral Contraceptives &
Related Agents |
Alesse-28 |
| |
Cryselle-28 |
| |
DEPO-PROVERA 150mg/m |
| |
LEVLITE |
| |
Lo/Ovral-28 |
| |
LOW-OGESTREL |
| |
ORTHO-MICRONOR |
| |
Ortho-Novum 777 |
| |
ORTHO TRI-CYCLEN |
| |
Medroxyprogesterone 150mg |
| |
Tri-Levelen |
| Misc. |
DIFLUCAN (Fluconazole) 150mg tablet |
| OPHTHALMOLOGY |
| |
Gentamicin oph soln |
| |
Prednisolone 1% oph susp (Pred-Forte) |
| |
Trimethoprim/Polymyxin B oph soln (Polytrim) |
| PULMONARY |
| Antihistamines |
ALLEGRA (Fexofenadine) 60mg &
180mg tablet |
| |
ZYRTEC (Cetirizine) 10mg tablet |
| |
ZYRTEC D |
| Antitussives |
Benzonatate 100mg capsule |
| |
Bromophed DX Cough Syrup (Dimetane DX) |
| |
Guaifenesin/Codeine Syrup (Robitussin AC) |
| |
Guaifenesin/Codeine/Pseudoephedrine Syrup (Robitussin
DAC) |
| Combinations |
ALLEGRA D (Fexodenadine/Pseudoephedrine 60/120) tablet |
| |
Guaifenesin/Pseudoephedrine (250/120) capsule (Guaifed) |
| Intranasal Steriods |
FLONASE (Fluticasone) NS |
| Pulmonary Agents |
ADVAIR DISKUS 100/50, 250/50 & 500/50 |
| |
Albuterol 0.083% vials for nebulizer |
| |
Albuterol MDI |
| |
COMBIVENT MDI (Albuterol/Ipratropium) |
| |
FLOVENT 110 |
| |
Ipratropium 0.02% vials for nebulizer |
| |
SINGULAR (Montelukast) 10mg tablet |
| Topical Otic |
Neomycin/Polymyxin B/Hydrocortisone Otic Susp
(Cortisporin Otic) |
| UROLOGICALS |
| |
Doxazosin 4mg tablet |
| |
FLOMAX (Tamsulosin) 0.4mg capsule |
| |
Terazosin 10mg |
| ELECTROLYTES |
| |
Klor-con 8meq, 10meq & 20meq |
| |
Potassium 10% liquid |
| |
Potassium 10meq & 20meq tablet |
| GLAUCOMA AGENTS/MIOTICS |
| |
XALATAN OPHTH SOLN 2.5ml |
|
|