Attachment 2 - IHSC Medication Formulary for Non-IHSC staffed detention facilities.pdf

ICE HEALTH SERVICE CORPS

FY 2021 Medication Formulary for non-IHSC Staffed Detention Facilities

This formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs.

Brand names with generic equivalents are considered non-formulary. * Changes from FY2020. Last revised 9/30/2020

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Drug Category Formulary Agents: generics, BRANDS Anti-Infectives

Antifungal clotrimazole, fluconazole, griseofulvin, ketoconazole, terbinafine Anthelmintic albendazole, ivermectin, *mebendazole Anti-herpetic acyclovir, acyclovir cream, famciclovir Anti-influenza amantadine, TAMIFLU

Antimycobacterial ethambutol, isoniazid, pyrazinamide, rifampin, streptomycin, rifapentine Antiretrovirals All agents are formulary Cephalosporins cefaclor, cefadroxil, cefprozil, cefuroxime, cephalexin, ceftriaxone

Ketolides All agents require an approved Non-Formulary Request Macrolides azithromycin, clarithromycin, clindamycin, ERY-TAB, Miscellaneous antibiotics metronidazole, sulfamethoxazole/trimethoprim, nitrofurantoin Penicillins amoxicillin, amoxicillin/clavulanate, BICILLIN-LA, dicloxacillin, penicillin VK

Quinolones ciprofloxacin, moxifloxacin, ofloxacin Tetracyclines doxycycline, minocycline

Cardiovascular

ACE inhibitor benazepril, captopril, enalapril, fosinopril, quinapril, ramipril Alpha & Beta Blockers carvedilol, labetalol

Alpha2-Adrenergic Agonist clonidine, methyldopa Angiotensin Receptor Blockers (ARBs) losartan, valsartan

Anti-arrhythmic amiodarone, ranolazine ER Anticoagulants apixaban, enoxaparin, rivaroxaban, warfarin

Anti-hypertensive combos All agents require an approved Non-Formulary Request Beta blockers, nonselective nadolol, propranolol, sotalol/-AF, pindolol, timolol Beta-1 blockers, selective acebutolol, atenolol, betaxolol, bisoprolol, metoprolol

Cardiotonic digoxin CCB – non-dihydropyridine CARTIA XT, DILTIA XT, diltiazem HCl, diltiazem ER, verapamil SR

CCB – dihydropyridine amlodipine, felodipine, nicardipine, nifedipine, nifedipine XL

Diuretic bumetanide, chlorthalidone, furosemide, hydrochlorothiazide, metolazone, spironolactone, triamterene/hydrochlorothiazide

HMG-CoA reductase inhibitors atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin Cholesterol – other cholestyramine, fenofibrate, gemfibrozil

Nitrates isosorbide dinitrate, isosorbide mononitrate, nitroglycerin SL tabs Phosphodiesterase-5 Enzyme Inhibitor ADCIRCA, REVATIO

Platelet Aggregation Inhibitors clopidogrel

Central Nervous System

Alzheimer’s/ Dementia donepezil, *memantine Anti-Anxiety alprazolam, buspirone, chlordiazepoxide, clorazepate, diazepam, lorazepam, oxazepam

Anticholinergic benztropine

Anticonvulsant carbamazepine, clonazepam, divalproex, gabapentin, levetiracetam, phenobarbital, phenytoin, topiramate, valproic acid

Antidepressant – SSRI citalopram, escitalopram, fluoxetine, paroxetine, sertraline Antidepressant – Tricyclic amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline

Antidepressant – other bupropion HCl, bupropion SR, duloxetine, mirtazapine, nefazodone, trazadone, venlafaxine Antiemetic dimenhydrinate, meclizine, ondansetron + ODT, promethazine

Antimigraine sumatriptan Anti-Parkinson/Dopamine Agonist *carbidopa/levodopa, *pramipexole

Antipsychotic – 1st gen chlorpromazine, fluphenazine, haloperidol - PO, lactate, & decanoate, loxapine, perphenazine, thioridazine, thiothixene, trifluoperazine

Antipsychotic – 2nd gen aripiprazole, clozapine, lurasidone, risperidone, olanzapine, ziprasidone, paliperidone Antimanic lithium

Antihistamine hydroxyzine Stimulants/ ADHD All agents require an approved Non-Formulary Request

This formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs.

Brand names with generic equivalents are considered non-formulary. * Changes from FY2020. Last revised 9/30/2020

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Dermatologic

Acne Products benzoyl peroxide, clindamycin lotion, erythromycin gel, tretinoin Eczema clobetasol, fluocinonide, hydrocortisone, betamethasone valerate, triamcinolone

Antibiotics gentamicin, metronidazole cream, mupirocin Antifungals clotrimazole, nystatin, terbinafine

Pediculicides permethrin cream, ivermectin

Endocrine/ Hormone Contraceptives levonorgestrel/ethinyl estradiol, medroxyprogesterone inj, norethindrone/ethinyl estradiol, norethindrone, norgestrel/ethinyl estradiol, norgestimate/ethinyl estradiol

Emergency Contraceptive, oral levonorgestrel emergency contraceptive 0.75mg, ELLA, MY WAY, PLAN B, PLAN B ONE-STEP, OPCICON ONE-STEP

Osteoporosis alendronate Estrogens, oral depo-estradiol, estradiol, PREMARIN

Estrogens, injectable estradiol valerate Estrogen, combinations All agents require an approved Non-Formulary Request

Estrogen, topical All agents require an approved Non-Formulary Request Pituitary disorders cabergoline, bromocriptine

Insulin HUMULIN, HUMALOG, LANTUS, NOVOLOG, NOVOLIN Progesterones medroxyprogesterone, DEPO-PROVERA

Diabetes – sulfonylureas glimepiride, glipizide, glipizide ER, glyburide, glyburide micronized, tolazamide Diabetes – biguanides metformin, metformin ER Diabetes – glitazones AVANDIA - Restricted access, pioglitazone

Diabetes – meglitinides All agents require an approved Non-Formulary Request Diabetes – alpha-glucosidase inhibitors All agents require an approved Non-Formulary Request

Corticosteroids dexamethasone, *fludrocortisone, methylprednisolone, hydrocortisone, prednisolone, prednisone, triamcinolone IM inj

Thyroid levothyroxine, thyroid Testosterone testosterone cypionate injectable

Gastrointestinal

Antidiarrheal diphenoxylate/atropine, loperamide Antispasmodic dicyclomine, hyoscyamine

Anti-ulcer sucralfate Enzymes pancrelipase - Restricted to most cost-effective agent

Histamine 2 antagonists cimetidine, famotidine, ranitidine IBS agents All agents require an approved Non-Formulary Request Laxative *polyethylene glycol 3350, *polyethylene glycol w/ electrolytes

Proton Pump Inhibitors omeprazole, pantoprazole Stimulants metoclopramide

Ulcerative colitis sulfasalazine, mesalamine - All formulations covered

Musculoskeletal, Analgesics

Opioids, long acting All agents require an approved Non-Formulary Request Opioids, short acting codeine/acetaminophen, hydrocodone/acetaminophen, oxycodone/acetaminophen, tramadol

Opioids, partial agonist SUBOXONE - For short term use less than 15 days and by physician initiation only.

NSAIDs, nonselective aspirin, diclofenac, etodolac, ibuprofen, indomethacin + SR, ketoprofen, ketorolac, meloxicam, nabumetone, naproxen + NA, oxaprozin, piroxicam, salsalate, sulindac

COX-2, selective *celecoxib Local anesthetic *lidocaine

Skeletal Muscle Relaxants baclofen, cyclobenzaprine, methocarbamol

This formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs.

Brand names with generic equivalents are considered non-formulary. * Changes from FY2020. Last revised 9/30/2020

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Ophthalmic

Anti-infectives ciprofloxacin, erythromycin ointment, gentamicin, sulfacetamide, tobramycin, neomycin/polymyxin/dexamethasone

Allergic Conjunctivitis ketotifen Glaucoma brimonidine, carteolol, dorzolamide, dorzolamide/timolol, latanoprost, timolol

Anti-inflammatory ketorolac, prednisolone acetate

Otic

Anti-Infective neomycin/polymyxin/hydrocortisone, ofloxacin

Respiratory, Allergy

Beta agonist albuterol, levalbuterol inhaler, metaproterenol solution, PRO AIR, PROVENTIL HFA, SEREVENT, VENTOLIN HFA

Inhaled Steroids FLOVENT HFA, PULMICORT, QVAR Inhaled Steroid/ Beta agonist combo fluticasone/salmeterol, SYMBICORT

Leukotriene montelukast Nasal steroids flunisolide, fluticasone, triamcinolone (OTC formulations approved) Antihistamine chlorpheniramine CR, clemastine, cyproheptadine, diphenhydramine, loratadine OTC

Antitussive benzonatate Xanthine derivatives theophylline

Genitourinary

BPH doxazosin, finasteride (5mg only), prazosin, tamsulosin, terazosin Erectile dysfunction All agents require an approved Non-Formulary Request

Antispasmodic Oxybutynin, *tolterodine Analgesic phenazopyridine

Alkalizing agent potassium citrate

Miscellaneous

Vitamins calcitriol, cholecalciferol, cyanocobalamin, ergocalciferol, leucovorin, prenatal vitamins, pyridoxine, renal vitamins, Gout allopurinol, colchicine Potassium binders sodium polystyrene Phosphate binders RENAGEL, RENVELA, calcium acetate, lanthanum Myasthenia gravis pyridostigmine

DMARDs hydroxychloroquine, hydroxyurea, methotrexate Dental chlorhexidine gluconate (alcohol free), triamcinolone paste

Laxative lactulose, polyethylene glycol w/ electrolytes Minerals & electrolytes potassium chloride, sodium bicarbonate, sodium chloride - All formulations covered.

Gallstone Dissolution Agent ursodiol Immunosuppressant mycophenolate, tacrolimus

Vaccines

All FDA-approved vaccinations are covered by ICE except varicella (herpes) zoster (Shingrix/Zostavax).