Indiana DOC Formulary 08.28.26.pdf

Formulary Drug List Indiana Department of Correction

Adult/Juvenile

Grouped by Therapy Class

August 2026

Rev. 02/27/2025 Adult/Juvenile

Table of Contents

1. Analgesics and Anti-Inflammatories Acetaminophen Agents (01.01) Anti-Gout Agents (01.02) Anti-Migraine Agents (01.03) Narcotic Analgesics/Antagonists (01.04) Neuropathic Pain Agents (01.05) Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) (01.06) Salicylates (01.07) Skeletal Muscle Relaxants (01.08) Other Analgesics and Anti-Inflammatories (01.09)

2. Antihistamines/Decongestants/Antitussives/ Expectorants 1st Generation Antihistamines (02.01) 2nd Generation Antihistamines (02.02) Antitussives (02.03) Expectorants (02.04) Decongestants (02.05) Combination Products (02.06)

3. Anti-Infectives Aminoglycosides (03.01) Antifungals (03.02) Antihelmintics (03.03) Antimalarials (03.04) Antituberculars (03.05) Antivirals (non-HIV) (03.06) Cephalosporins (03.07) Fluoroquinolones (03.08) Hepatitis Medications – Hepatitis B Agents (03.08.01) Hepatitis Medications – Hepatitis C Agents (03.08.02) HIV Agents - Integrase Inhibitors (03.09.02) HIV Agents - Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) (03.09.03) HIV Agents - Nucleos(t)ide Reverse Transcriptase Inhibitors (NRTIs) (03.09.04) HIV Agents - Protease Inhibitors (03.09.05) HIV Agents - Combination Products (03.09.06) Listed as Brand Name ONLY HIV Agents - Supportive Agents (03.09.07)

Macrolides/Azalides/Lincosamides/Oxazolidinones (03.10) Penicillins (03.11) Sulfonamides (03.12) Tetracyclines (03.13) Other Anti-Infectives (03.14)

4. Cancer-Related Agents Antineoplastics (04.01)

5. Cardiovascular Agents Alpha-adrenergic Blockers (05.01) Angiotensin-Converting Enzyme Inhibitors (ACE) (05.02) Angiotensin Receptor Blockers (ARBs) (05.03) Antidysrhythmics - Type 1a (05.04.01) Antidysrhythmics - Type 1b (05.04.02) Antidysrhythmics - Type 1c (05.04.03) Antidysrhythmics - Type III (05.04.04) Antilipidemics - HMG-Coenzyme A Reductase Inhibitors (05.05.01) Antilipidemics - Other Antilipidemics (05.05.02) Beta-Adrenergic Blockers - Selective Agents (05.06.01) Beta-Adrenergic Blockers-Non-Selective Agents (05.06.02) Beta-Adrenergic Blockers - a,ß Antagonists (05.06.03) Calcium Channel Blockers - Dihydropyridine (05.07.01) Nifedipine XL 60 mg tablets Procardia XL Calcium Channel Blockers - Non-Dihydropyridine (05.07.02) Cardiac Glycosides (05.08) Centrally Acting Antihypertensives (05.09) Diuretics (05.10) Hemorrheologic Agents (05.11) Vasodilators - Nitrates (05.12.01) Vasodilators - non-nitrates (05.12.02) Combination Agents (05.13) Other CV Agents (05.14)

6. Central Nervous System Agents Antidepressants (06.01) Antidepressants - Tricyclic Antidepressants (06.01.01) Antidepressants - Serotonin +/- Norepinephrine Reuptake Inhibitors (SSRI / SNRI) (06.01.02) Antidepressants - Other Antidepressants (06.01.03) Antipsychotic Agents (06.02) Antipsychotic Agents - 1st Generation Agents (06.02.01)

Antipsychotic Agents - 2nd Generation Agents (06.02.02) Barbiturates (06.03) Cerebral Stimulants (06.04) Mood Stabilizers (06.05) Sedatives / Hypnotics (06.06) Benzodiazepine (06.06.01) Other Agents (06.06.02) Anxiolytic (06.07) Other CNS Agents (6.08)

7. Dental Agents Dental Agents (07.01)

8. Dermatological Agents Anti-Acne Products (08.01) Antifungals (08.02) Anti-Infectives (08.03) Antipsoriatics (08.04) Antipruritic & Local Anesthetics (08.05) Moisturizing and Barrier Agents (08.06) Scabicides (08.07) Steroid Anti-Inflammatories - Very High Potency (08.08.01) Steroid Anti-Inflammatories - High Potency (08.08.02) Steroid Anti-Inflammatories - Medium Potency (08.08.03) Steroid Anti-Inflammatories - Low Potency (08.08.04) Other Derm Agents (08.09)

9. Diagnostics and Supplies Diagnostics and Supplies (09.01)

10. Emergency Medications Emergency Medications (10.01)

11. Endocrine – Metabolic Agents Androgens (11.01) Estrogens – Progestins (11.02) Insulins (11.03) Hypoglycemics - Sulfonylureas (11.04.01) Hypoglycemics - Biguanides (11.04.02) Hypoglycemics – DPP-4 Inhibitor (11.04.03) Hypoglycemics - Incretin Mimetics (11.04.04) Hypoglycemics - Combination Agents (11.04.05)

Hypoglycemics – SGLT2 Inhibitors (11.04.06) Thyroid Agents (11.05) Adrenal Corticosteroids (11.06) Osteoporosis Agents (11.07) Other Endocrine - Metabolic Agents (11.08)

12. Gastrointestinal Agents Aminosalicylates (12.01) Tumor Necrosis Factor (12.02) Anti-Diarrheals (12.03) Anti-Emetics (12.04) Cathartics / Laxatives (12.05) Digestive Enzymes (12.06) GI Motility Agents (12.07) Histamine – 2 Receptor Antagonists (H2RAs) (12.09) Proton Pump Inhibitors (PPIs) (12.10) Other GI Agents (12.11) Hemorrhoidal Agents (12.12)

13. Genitourinary Agents Benign Prostatic Hypertrophy Agents (13.01) Other GU Agents (13.02)

14. Hematological Agents Hematological Agents (14.01) Sickle Cell Agents (14.02)

15. Immunosuppressants Immunosuppressants (15.01) Antirheumatic Agents (15.02)

16. Neurological Agents Alzheimer’s Agents (16.01) Anticonvulsants (16.02) Anti-Parkinsons Agents (16.03) Myasthenia Gravis (16.04) (Cholinesterase inhibitor) Multiple Sclerosis Agents (16.041) Other Neuro Agents (16.05)

17. Obstetric – Gynecologic Agents Contraceptives (17.01) Anti-Infectives (17.02)

18. Ophthalmic – Otic Preparations Anti-Glaucoma Agents (18.01) Antihistamines / Decongestants (18.02) Anti-Infective Agents (18.03) Anti-Inflammatory Agents (18.04) Otic Preparations (18.05) Other Ophthalmic-Otic Agents (18.06)

19. Respiratory Agents Anticholinergics (19.01) Beta Agonists (19.02) Inhaled Oral Steroids (19.03) Nasal Steroid Sprays (19.04) Combination Products (19.05) Other Respiratory Agents (19.06)

20. Vaccines Vaccines - (20.01)

21. Vitamins – Minerals – Dietary Supplements Vitamins – Minerals – Dietary Supplements (21.01)

22. Miscellaneous and Unclassified Agents Miscellaneous and Unclassified Agents (22.01)

23. Preferred Agents Still Needing Formulary Exception Request Preferred Agents Still Needing Formulary Exception Request

1. Analgesics and Anti-Inflammatories Acetaminophen Agents (01.01)

Apap - box /24 protocol 325 mg tablet Tylenol Acetaminophen 325 mg tablet (limit 60 doses per 30 days) Tylenol Acetaminophen 500 mg tablet (limit 60 doses per 30 days) Tylenol Acetaminophen 325 mg rectal suppository Tylenol supp Acetaminophen 650 mg rectal suppository Tylenol supp

Anti-Gout Agents (01.02) Allopurinol 100 mg and 300mg tablet Zyloprim Probenecid 500 mg tablet Benemid

Anti-Migraine Agents (01.03) Sumatriptan all Strengths (Max dose 9 tabs per month) Imitrex

Narcotic Analgesics/Antagonists (01.04) Acetaminophen/Codeine 120-12 mg/5 ml elixir Tylenol/cod elix Acetaminophen/Codeine/ 300-30 mg tablet 7 day max every 180 days Tylenol #3 Nalbuphine 10 mg/ml injection Nubain Nalbuphine 20 mg/ml injection Nubain Tramadol 50mg 7 day max every 180 days Ultram

Neuropathic Pain Agents (01.05) Duloxetine capsule all strengths Cymbalta Nortriptyline 10 mg capsule Pamelor Nortriptyline 25 mg capsule Pamelor Nortriptyline 50 mg capsule Pamelor Nortriptyline 75 mg capsule Pamelor

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) (01.06) Diclofenac gel 1% Voltaren Ibuprofen max 1200mg/day max 7-day order/30 days Motrin Ketorolac Trometh 15 mg and 30mg/ml injection Toradol Inj.

Meloxicam 7.5mg and 15mg Mobic Naproxen 500mg/2 daily max 7-day order/30 days Aleve/anaprox

Salicylates (01.07) Asa 325mg ec 325 mg tab ec Ecotrin Aspirin - film coat 325 mg tablet Asa fc Aspirin ec 81 mg tab ec Ecotrin Aspirin fc box/24 protocol 325 mg tablet Aspirin

Skeletal Muscle Relaxants (01.08) Cyclobenzaprine 5 mg tablet (7 days use per 180 days) Flexeril Cyclobenzaprine 10 mg tablet (7 days use per 180 days) Flexeril

Other Analgesics and Anti-Inflammatories (01.09)

2. Antihistamines/Decongestants/Antitussives/ Expectorants 1st Generation Antihistamines (02.01)

Diphenhydramine vial 50 mg/ml injection for mental health emergent use Benadryl Diphenhydramine oral/liquid for emergent use (mild allergic reactions) Benadryl (oral diphenhydramine max 30 count card stock only)

2nd Generation Antihistamines (02.02) Loratadine 10mg tablet (Juvenile Only) Claritin

Antitussives (02.03)

Expectorants (02.04)

Decongestants (02.05)

Combination Products (02.06)

3. Anti-Infectives Aminoglycosides (03.01)

Antifungals (03.02) Clotrimazole 10 mg mucous membrane troche Mycelex Fluconazole 50mg tablet (limit to 30-day treatment/180 day) Diflucan Fluconazole 100 mg tablet (limit to 30-day treatment/180 day) Diflucan Fluconazole 150 mg tablet (limit to 30-day treatment/180 day) Diflucan Fluconazole 200 mg tablet (limit to 30-day treatment/180 day) Diflucan Nystatin 100,000 u/ml oral suspension Mycostatin Terbinafine HCL 250 mg tablet Lamisil

Antihelmintics (03.03)

Antimalarials (03.04) Hydroxychloroquine 200 mg Plaquenil Pyrimethamine 25 mg tablet Daraprim

Antituberculars (03.05) Ethambutol HCL 100 mg tablet Myambutol Ethambutol HCL 400 mg tablet Myambutol Isoniazid 100 mg tablet Inh Isoniazid 300 mg tablet Inh Pyrazinamide 500 mg tablet Pyrazinamide Rifampin 150 mg capsule Rifadin Rifampin 300 mg capsule Rifadin Rifapentine 150mg tablet limited to 84 days every 365 days Priftin Streptomycin 1gm injection Streptomycin

Antivirals (non-HIV) (03.06) Acyclovir 200 mg capsule Zovirax

Acyclovir 400 mg tablet Zovirax Acyclovir 800 mg tablet Zovirax Amantadine HCL 100 mg capsule Symmetrel Amantadine HCL 50 mg/5 ml oral solution Symmetrel Ganciclovir 500 mg/250ml iv Cytovene inj.

Cephalosporins (03.07) Cefazolin 500 mg injection Kefzol Cefazolin 1 gm injection Ancef Ceftriaxone 250 mg injection Rocephin inj.

Ceftriaxone 500 mg injection Rocephin inj.

Ceftriaxone 1g injection Rocephin inj.

Ceftriaxone 2g injection Rocephin inj.

Cephalexin 250 mg capsule Keflex Cephalexin 500 mg capsule Keflex Cephalexin susp 250 mg/5 ml suspension Keflex susp

Fluoroquinolones (03.08)

Hepatitis Medications – Hepatitis B Agents (03.08.01) Tenofovir DF 300mg Viread Entecavir 0.5 and 1mg Baraclude Lamivudine 100 mg tablet Epivir HBV

Hepatitis Medications – Hepatitis C Agents (03.08.02)

HIV Agents - Integrase Inhibitors (03.09.02) Dolutegravir 10 mg tablet Tivicay Dolutegravir 25 mg tablet Tivicay Dolutegravir 50 mg tablet Tivicay Raltegravir 400 mg tablet Isentress

HIV Agents - Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) (03.09.03) Etravirine 100 mg tablet Intelence Etravirine 200 mg tablet Intelence Rilpivirine 25mg tablet Endurant

HIV Agents - Nucleos(t)ide Reverse Transcriptase Inhibitors (NRTIs) (03.09.04) Abacavir 300 mg tablet Ziagen Emtricitabine 200 mg capsule Emtriva Emtricitabine 200mg /Tenofovir Disoproxil Combo 300 mg tablet Truvada Lamivudine 150 mg tablet Epivir Lamivudine 300 mg tablet Epivir Lamivudine- 10 mg/ml oral solution Epivir Tenofovir DF 300 mg tablet Viread

HIV Agents - Protease Inhibitors (03.09.05) Darunavir Ethanolate 600 mg tablet Prezista Darunavir Ethanolate 800 mg tablet Prezista

HIV Agents - Combination Products (03.09.06) Listed as Brand Name ONLY Abacavir 600 mg/Dolutegravir 50 mg/Lamivudine 300 mg Triumeq

Atazanavir 300 mg/Cobicistat 150 mg Evotaz Cobicistat 150 mg/Darunavir 800 mg/Emtricitabine 200 mg/Tenofovir AF 10 mg Symtuza Cobicistat 150 mg/Darunavir 675 or 800 mg Prezcobix Cobicistat 150 mg/Elvitegravir 150 mg/Emtricitabine 200 mg/Tenofovir AF 10 mg Genvoya Cobicistat 150 mg/Elvitegravir 150 mg/Emtricitabine 200 mg/Tenofovir DF 300 mg Stribild Dolutegravir 50 mg/Rilpivirine 25 mg Juluca Doravirine 100 mg/Lamivudine 300 mg/Tenofovir DF 300 mg Delstrigo Emtricitabine 200 mg/Rilpivirine 25 mg/Tenofovir AF 25 mg Odefsey Emtricitabine 200 mg/Rilpivirine 25 mg/Tenofovir DF 300 mg Complera Emtricitabine 200 mg/Tenofovir AF 25 mg Descovy

HIV Agents - Supportive Agents (03.09.07) Azithromycin 600 mg tablet Zithromax

Macrolides/Azalides/Lincosamides/Oxazolidinones (03.10) Azithromycin 250 mg tablet Zithromax Azithromycin 600 mg tablet Zithromax Azithromycin Z-Pak 250 mg tablet Zithromax Clarithromycin 500mg tablet Biaxin Clindamycin HCL 150 mg capsule Cleocin Clindamycin HCL 300 mg capsule Cleocin Clindamycin phosphate 150mg/ml injection Cleocin Clindamycin phosphate 300 mg/2ml injection Cleocin Clindamycin phosphate 600 mg/4ml injection Cleocin Clindamycin phos 900 mg/8ml injection Cleocin

Penicillins (03.11) Amoxicillin 250 mg capsule Amoxil Amoxicillin 250 mg/5 ml suspension Amoxil Amoxicillin 500 mg capsule Amoxil Amoxicillin/clav 875-125 mg tablet Augmentin Dicloxacillin 250 mg capsule Dynapen Dicloxacillin 500 mg capsule Dynapen Nafcillin 1gm injection Nafcil Nafcillin 2gm injection Nafcil Penic g procaine 600,000 units injection Wycillin Penicillin v Potassium 250 mg tablet Pen-VK Penicillin v Potassium 500 mg tablet Pen-VK Penicillin v Potassium 250mg/5 ml oral reconst sol Pen-VK oral Penicillin-g Potassium 5mu injection Penicillin Inj.

Penicillin-g Benzathine Bicillin LA inj Piperacillin/Tazobactam Injection all doses Zosyn

Sulfonamides (03.12) Sulfameth-Trimeth 800-160 mg tablet Bactrim DS / Septra Sulfameth/Trimeth 400/80 mg tablet Bactrim/Septra Sulfameth/Trimeth 400/80 mg/5ml injection Bactrim Inj.

Sulfameth/Tri 200-40 mg/5 ml oral suspension Bactrim/Septra

Tetracyclines (03.13) Doxycycline Hyclate 50 mg Vibramycin Doxycycline Hyclate 100 mg capsule Vibramycin

Other Anti-Infectives (03.14) Dapsone 25 and 100 mg Dapsone Metronidazole 250 and 500mg Flagyl Metronidazole/nacl 500 mg/100 ml IVPB Flagyl IVPB Nitrofurantoin monohydrate 100mg capsule Macrobid (Restricted to use in female patients) Linezolid 600mg Zyvox Linezolid injection Zyvox Vancomycin HCL 500 mg injection Vancocin Vancomycin HCL 750 mg injection Vancocin Vancomycin HCL 1000 mg injection Vancocin

4. Cancer-Related Agents Antineoplastics (04.01)

Hydroxyurea 500 mg capsule Hydrea Tamoxifen Citrate 10 mg tablet Nolvadex Tamoxifen Citrate 20 mg tablet Nolvadex

5. Cardiovascular Agents Alpha-adrenergic Blockers (05.01)

Doxazosin 1 mg tablet Cardura Doxazosin 2 mg tablet Cardura Doxazosin 4 mg tablet Cardura Doxazosin 8mg tablet Cardura Terazosin 1 mg capsule Hytrin Terazosin 2 mg capsule Hytrin Terazosin 5 mg capsule Hytrin Terazosin 10 mg capsule Hytrin

Angiotensin-Converting Enzyme Inhibitors (ACE) (05.02) Benazepril 5 mg tablet Lotensin Benazepril 10 mg tablet Lotensin Benazepril 20 mg tablet Lotensin Benazepril 40 mg tablet Lotensin Lisinopril 2.5 mg tablet Zestril/Prinivil Lisinopril 5 mg tablet Zestril/Prinivil Lisinopril 10 mg tablet Zestril/Prinivil Lisinopril 20 mg tablet Zestril Lisinopril 30 mg tablet Zestril/Prinivil Lisinopril 40 mg tablet Zestril/Prinivil

Angiotensin Receptor Blockers (ARBs) (05.03) Losartan 25 mg tablet Cozaar Losartan 50 mg tablet Cozaar Losartan 100 mg tablet Cozaar Olmesartan all strengths Benzicar

Antidysrhythmics - Type 1a (05.04.01) Disopyramide Phos 100 mg capsule Norpace

Disopyramide Phos 150 mg capsule Norpace Disopyramide Phos 150 mg cap extended release Norpace CR Quinidine Sulfate 200 mg tablet

Antidysrhythmics - Type 1b (05.04.02)

Antidysrhythmics - Type 1c (05.04.03)

Antidysrhythmics - Type III (05.04.04) Amiodarone HCL 100 And 200mg Tablet Cordarone

Antilipidemics - HMG-Coenzyme A Reductase Inhibitors (05.05.01) Atorvastatin 10 mg tablet Lipitor Atorvastatin 20 mg tablet Lipitor Atorvastatin 40 mg tablet Lipitor Atorvastatin 80 mg tablet Lipitor Rosuvastatin 5 mg tablet Crestor Rosuvastatin 10 mg tablet Crestor Rosuvastatin 20 mg tablet Crestor Rosuvastatin 40 mg tablet Crestor Simvastatin 5 mg tablet Zocor Simvastatin 10 mg tablet Zocor Simvastatin 20 mg tablet Zocor Simvastatin 40 mg tablet Zocor

Antilipidemics - Other Antilipidemics (05.05.02) Cholestyramine/Aspar powder Questran light Cholestyramine/Aspartame pack Questran light Ezetimibe 10 mg tablet Zetia Gemfibrozil 600 mg tablet Lopid Niacin- 250 mg extended release tablet Slo-Niacin Niacin- 500 mg extended release tablet Slo-Niacin Niacin 750 mg extended release Slo-Niacin

Beta-Adrenergic Blockers - Selective Agents (05.06.01) Atenolol 25 mg tablet Tenormin Atenolol 50 mg tablet Tenormin Atenolol 100 mg tablet Tenormin Metoprolol Tart 25/50/75/100mg tablet Lopressor Metoprolol Succ 25/50/100/200mg tablet Toprol XL

Beta-Adrenergic Blockers-Non-Selective Agents (05.06.02) Propranolol 10 mg tablet Inderal Propranolol 20 mg tablet Inderal Propranolol 40 mg tablet Inderal Propranolol 60 mg tablet Inderal Propranolol 80 mg tablet Inderal

Beta-Adrenergic Blockers - a,ß Antagonists (05.06.03) Carvedilol 3.125 mg tablet Coreg Carvedilol 6.25 mg tablet Coreg Carvedilol 12.5 mg tablet Coreg Carvedilol 25 mg tablet Coreg

Labetalol 100 mg tablet Trandate Labetalol 200 mg tablet Trandate Labetalol 300 mg tablet Trandate

Calcium Channel Blockers - Dihydropyridine (05.07.01) Amlodipine 2.5 mg tablet Norvasc Amlodipine 5 mg tablet Norvasc Amlodipine 10mg tablet Norvasc Nifedipine XL 30 mg tablets Procardia XL Nifedipine XL 60 mg tablets Procardia XL Nifedipine XL 90 mg tablets Procardia XL

Calcium Channel Blockers - Non-Dihydropyridine (05.07.02) Diltiazem HCL120 mg cap extended release 24 hr controlled Dilacor XR Diltiazem HCL 180 mg cap extended release 24 hr controlled Dilacor XR Diltiazem HCL 240 mg cap extended release 24 hr controlled Dilacor XR Diltiazem HCL 300 mg cap extended release 24 hr controlled Cardizem cd Diltiazem HCL 360 mg cap extended release 24 hr controlled Cardizem cd Diltiazem HCL 30 mg tablet Cardizem Diltiazem HCL 60 mg tablet Cardizem Diltiazem HCL 90 mg tablet Cardizem Diltiazem HCL 120 mg tablet Cardizem Verapamil 40 mg tablet Calan Verapamil 80 mg tablet Calan Verapamil 120 mg tablet Calan Verapamil120 mg tab extended release Calan SR Verapamil180 mg tab extended release Calan SR Verapamil 240 mg tab extended release Calan SR

Cardiac Glycosides (05.08) Digoxin 125 mcg tablet Lanoxin Digoxin 250 mcg tablet Lanoxin Digoxin 250 mcg/ml injection Lanoxin Inj.

Centrally Acting Antihypertensives (05.09) Clonidine all strengths for dialysis/juvenile patients only Catapress Methyldopa 250 and 500mg tablet Aldomet

Diuretics (05.10) Acetazolamide 250 mg tablet Diamox Acetazolamide 500 mg cap extended-release Diamox Sequel Chlorthalidone 25 mg Hygroton Chlorthalidone 50 mg Hygroton Eplerenone all strengths Inspra Furosemide 20 mg tablet Lasix Furosemide 40 mg tablet Lasix Furosemide 80 mg tablet Lasix Furosemide 10mg/ml injection Lasix Hydrochlorothiazide 12.5mg cap/tab HCTZ Hydrochlorothiazide 25 mg tablet HCTZ Hydrochlorothiazide 50 mg tablet Hydrodiuril Spironolactone 12.5mg Aldactone

Spironolactone 25 mg tablet Aldactone Spironolactone 50 mg tablet Aldactone Spironolactone 100mg tablet Aldactone Torsemide 5 mg tablet Demadex Torsemide 10 mg tablet Demadex Torsemide 20 mg tablet Demadex Triamterene/Hydrochlorothiazide 37.5-25 mg tablet Maxzide 25 Triamterene/Hydrochlorothiazide 75-50 mg tablet Maxzide

Hemorrheologic Agents (05.11) Apixiban 2.5 mg tablet Eliquis Apixiban 5 mg tablet Eliquis Clopidogrel 75 mg Plavix Dipyridamole 25 mg tablet Persantine Dipyridamole 50 mg tablet Persantine Dipyridamole 75 mg tablet Persantine Enoxparin injections - all strengths Lovenox Heparin sodium 1,000 u/ml injection Heparin Heparin sodium 5,000 u/ml injection Heparin Heparin sodium mdv 10,000 u/ml injection Heparin Heparin lock flush 10 u/ml iv sol Hep lock Heparin lock flush 100 u/ml iv sol Hep lock Heparin lock flush pf syringe 10 u/ml Heparin lock Rivaroxaban 10 mg tablet Xarelto Rivaroxaban 15 mg tablet Xarelto Rivaroxaban 20 mg tablet Xarelto Warfarin sod 1 mg tablet Jantoven Warfarin sod 2 mg tablet Jantoven Warfarin sod 2.5 mg tablet Jantoven Warfarin sod 3 mg tablet Jantoven Warfarin sod 4 mg tablet Jantoven Warfarin sod 5 mg tablet Jantoven Warfarin sod 6 mg tablet Jantoven Warfarin sod 7.5mg tablet Jantoven Warfarin sod 10 mg tablet Jantoven

Vasodilators - Nitrates (05.12.01) Isosorbide-Mononit 10 mg tablet Monoket Isosorbide-Mononit 20 mg tablet Monoket Isosorbide-Mononit 30 mg tab sr 24 hr Imdur Isosorbide-Mononit 60 mg tab sr 24 hr Imdur Isosorbide-Mononit 120 mg tab sr 24 hr Imdur Nitroglycerin SL 1/150 (0.4mg) tab subl Nitrostat

Vasodilators - non-nitrates (05.12.02) Guanfacine 1 and 2mg tablets (Juvenile Only) Tenex Hydralazine HCL 10 mg tablet Apresoline Hydralazine HCL 25 mg tablet Apresoline Hydralazine HCL 50 mg tablet Apresoline Hydralazine HCL 100 mg tablet Apresoline Minoxidil 2.5 mg tablet Loniten Minoxidil 10 mg tablet Loniten

Combination Agents (05.13) Sacubitril/Valsartan 24mg-26mg tablet Entresto Sacubitril/Valsartan 49mg-51mg tablet Entresto Sacubitril/Valsartan 97mg-103mg tablet Entresto

Other CV Agents (05.14)

6. Central Nervous System Agents Antidepressants (06.01)

Antidepressants - Tricyclic Antidepressants (06.01.01) Nortriptyline 10 mg capsule Pamelor Nortriptyline 25 mg capsule Pamelor Nortriptyline 50 mg capsule Pamelor Nortriptyline 75 mg capsule Pamelor

Antidepressants - Serotonin +/- Norepinephrine Reuptake Inhibitors (SSRI / SNRI) (06.01.02) Citalopram 10 mg tablet Celexa Citalopram 20 mg tablet Celexa Citalopram 40 mg tablet Celexa Citalopram oral 10 mg/5 ml solution Celexa Oral Soln Duloxetine 20 mg capsule, delayed release Cymbalta Duloxetine 30 mg capsule, delayed release Cymbalta Duloxetine 40 mg capsule, delayed release Cymbalta Duloxetine 60 mg capsule, delayed release Cymbalta Escitalopram 5mg, 10mg, 20mg tablets Lexapro Fluoxetine 10 mg capsule Prozac Fluoxetine 20 mg capsule Prozac Fluoxetine 40 mg capsule Prozac Fluoxetine soln 20 mg/5 ml oral solution Prozac Fluvoxamine 25mg, 50mg, 100mg tablets (IR only) Luvox Paroxetine all strengths regular release Paxil Sertraline HCL 25 mg tablet Zoloft Sertraline HCL 50 mg tablet Zoloft Sertraline HCL 100 mg tablet Zoloft Sertraline oral conc 20 mg/ ml concentrate Zoloft Oral Conc

Antidepressants - Other Antidepressants (06.01.03)

Antipsychotic Agents (06.02)

Antipsychotic Agents - 1st Generation Agents (06.02.01) Fluphenazine tablets 1mg,2.5mg,5mg,10mg Prolixin Fluphenazine Dec vl 25 mg/ml injection Prolixin Decanoate Fluphenazine HCL vl 2.5 mg/ml injection sol Prolixin Inj..

Haloperidol 0.5 mg tablet Haldol Haloperidol 1 mg tablet Haldol Haloperidol 2 mg tablet Haldol Haloperidol 5 mg tablet Haldol Haloperidol 10 mg tablet Haldol Haloperidol 20mg tablet Haldol

Haloperidol Dec 50 mg/ml im injection Haldol Decanoate Haloperidol Dec 100 mg/ml im injection Haldol Decanoate Haloperidol Lact 5 mg/ml injection Haldol Haloperidol lactate 2 mg/ml oral concentrate Haldol Loxapine succinate 5 mg capsule Loxitane Loxapine succinate 10 mg capsule Loxitane Loxapine succinate 25 mg capsule Loxitane Loxapine succinate 50 mg capsule Loxitane Perphenazine 2 mg tablet Trilafon Perphenazine 4 mg tablet Trilafon Perphenazine 16 mg tablet Trilafon Perphenazine 8 mg tablet Trilafon Thiothixene 1 mg capsule Navane Thiothixene 2 mg capsule Navane Thiothixene 5 mg capsule Navane Thiothixene 10 mg capsule Navane Trifluoperazine HCL 1 mg tablet Stelazine Trifluoperazine HCL 2 mg tablet Stelazine Trifluoperazine HCL 5 mg tablet Stelazine Trifluoperazine HCL 10 mg tablet Stelazine

Antipsychotic Agents - 2nd Generation Agents (06.02.02) Aripiprazole 2 mg tablet Abilify Aripiprazole 5 mg tablet Abilify Aripiprazole 10 mg tablet Abilify Aripiprazole 15 mg tablet Abilify Aripiprazole 20 mg tablet Abilify Aripiprazole 30 mg tablet Abilify Lurisidone 20mg, 40mg, 60mg, 80mg, 120mg tabs Latuda Olanzapine 2.5 mg tablet Zyprexa Olanzapine 5 mg tablet Zyprexa Olanzapine 7.5 mg tablet Zyprexa Olanzapine 10 mg tablet Zyprexa Olanzapine 15 mg tablet Zyprexa Olanzapine 20 mg tablet Zyprexa Risperidone 0.25 mg tablet Risperdal Risperidone 0.5 mg tablet Risperdal Risperidone 1mg tablet Risperdal Risperidone 2 mg tablet Risperdal Risperidone 3 mg tablet Risperdal Risperidone 4 mg tablet Risperdal Risperidone 1 mg / ml solution Risperdal Soln Ziprasidone HCL 20 mg capsule Geodon Ziprasidone HCL 40 mg capsule Geodon Ziprasidone HCL 60 mg capsule Geodon Ziprasidone HCL 80 mg capsule Geodon

Barbiturates (06.03)

Cerebral Stimulants (06.04) Amphetamine all strengths (Juvenile Only) Adderall Methylphenidate all strengths (Juvenile Only) Ritalin

Mood Stabilizers (06.05) Divalproex Sodium 125 mg tab Depakote Divalproex Sodium 250 mg tab Depakote Divalproex Sodium 500 mg tab Depakote Lamotrigine 25 mg tablet Lamictal Lamotrigine 100 mg tablet Lamictal Lamotrigine 150 mg tablet Lamictal Lamotrigine 200 mg tablet Lamictal Lithium Carbonate 150 mg capsule Eskalith Lithium Carbonate 300 mg capsule Eskalith Lithium Citrate 300mg (8meq)/5ml syrup Lithium Citrate Valproic Acid 250 mg capsule Depakene

Sedatives / Hypnotics (06.06)

Benzodiazepine (06.06.01)

Other Agents (06.06.02)

Anxiolytic (06.07)

Other CNS Agents (6.08) Naltrexone 50 mg tablet Depade/Revia (Use limited to addiction recovery treatment) Prazosin 1 mg capsules Minipress Prazosin 2 mg capsules Minipress Prazosin 5 mg capsules Minipress (Prazosin limited to treatment of PTSD related nightmares and sleep disturbances)

7. Dental Agents Dental Agents (07.01)

Benzocaine 20 % mucous membrane liquid Anbesol max strength Chlorhexidine Gluc 0.12% mucous membrane mwash Peridex Sore Throat lozenge (mucous membrane lozenge) Cepacol

8. Dermatological Agents Anti-Acne Products (08.01)

Benzoyl Peroxide 5 and10% Topical Gel Persagel

Antifungals (08.02) Miconazole Nitrate Topical 2% Cream Micatin Cream Clotrimazole 1% Topical Cream Lotrimin AF Nystatin 100,000 u/gm topical cream Mycostatin Nystatin 100,000 u/gm topical ointment Mycostatin

Anti-Infectives (08.03) Bacitracin Ointment Bacitracin Bacitracin/Polymyxin B 500-10,000u/G Topical Ointment Polysporin Silver Sulfadiazine 1% Topical Cream Silvadene

Antipsoriatics (08.04) Adalimumab (Biosimilar to Humira) Yusimry

Antipruritic & Local Anesthetics (08.05)

Moisturizing and Barrier Agents (08.06) Minerin Cream Minerin Zinc Oxide Ointment 20% Ointment Zinc Oxide

Scabicides (08.07) Ivermectin 3 mg Tablet Stromectal Permethrin 5% Cream Elimite Permethrin 1% Topical Liquid Nix Cream Rinse

Steroid Anti-Inflammatories - Very High Potency (08.08.01) Clobetasol 0.05% Topical Ointment Temovate Clobetasol 0.05% Topical Cream Temovate Clobetasol 0.05% Soln Temovate

Steroid Anti-Inflammatories - High Potency (08.08.02) Betamethasone Dipropionate 0.05% aug. Cream Diprolene AF Triamcinolone Acetonide 0.5% Topical Cream Kenalog Triamcinolone Acetonide 0.5% Topical Ointment Kenalog

Steroid Anti-Inflammatories - Medium Potency (08.08.03) Triamcinolone 0.1% Topical Cream and Ointment Kenalog

Steroid Anti-Inflammatories - Low Potency (08.08.04) Hemorrhoidal Hc 1% Cream Preparation H w/Hydrocortisone Hydrocortisone 1% Topical Cream and Ointment Hytone

Other Derm Agents (08.09) Calcium Acet/Alum So4 Pack Domeboro Ferric Subsulf Solution 259mg/G Topical Solution Monsels Solution Imiquimod 5% Cream Aldara Salicylic Acid 17% Topical Liquid Duofilm Salicylic Acid 40% Topical Plaster Mediplast Patch Silver Nitrate Appl 75-25% Topical Stick Silver Nitrate

9. Diagnostics and Supplies Diagnostics and Supplies (09.01)

Candida Albicans Skin Test Dextrose 5% in Water (D5w) D5-W Dextrose 50% in Water Iv Syringe D-50w D5%-0.45% Sodium Chloride Intravenous Parenteral Solution D5-1/2ns 1000ml Lactated Ringers Intravenous Parenteral Solution Lactated Ringers Potassium Chloride 20meq/L--O.45% Nacl IV Parenter Soln Sodium Chloride 0.45% + KCL Potassium Chlorid-D5-0.45%Nacl+20meq/L IV Parenter Soln D5-1/2ns + KCL Sod Chloride 0.9% Inj. Normal Saline Tuberculin Ppd Vl 5tu/0.1 ml Inj. Aplisol

Water for Inj. Sterile Water for Inj.

10. Emergency Medications Emergency Medications (10.01)

Atropine 0.1 mg/ml Inj. Syringe Atropine Sulfate Atropine 0.4 mg/ml Inj. Solution Atropine Inj.

Calcium Gluconate 100mg/ml 10% Intravenous Sol Ca Gluconate Charcoal + Sorbitol 50 Gm/240 ml Suspension Charcoal Charcoal 25gm Liquid Charcoal Charcoal 50gm Liquid Charcoal Dexamethasone 4 mg/ml Inj. Solution Decadron Inj.

Diphenhydramine Inj for emergent mental health use Benadryl Diphenhydramine oral for emergent use (mild allergic reactions) Benadryl (oral diphenhydramine max 30 count card stock only) Epinephrine 1mg/ml (1:1000) Inj. Solution (1ml) Adrenalin Epinephrine 1mg/ml (1:1000) Inj. Solution Vial Adrenalin Fluphenazine HCL 2.5 mg/5ml Elixir Prolixin Elixir Fluphenazine HCL 5 mg/ml Oral Concentrate Prolixin Oral Fluphenazine HCL 2.5 mg/ml Inj. Solution Prolixin Inj.

Furosemide Vial 10 mg/ ml Inj. Lasix Haloperidol Lact 5 mg/ml Inj. Solution Haldol Ketorolac 15 mg/ml Inj. Solution Toradol Inj.

Ketorolac 30 mg/ml Inj. Solution Toradol Inj.

Labetalol 100 mg Tablet Trandate Labetalol 200 mg Tablet Trandate Labetalol 300 mg Tablet Trandate Lidocaine 10mg/ml (1%) Inj. Solution Xylocaine Methylpred Acetate 40 mg/ml Inj. Susp Depo-Medrol Methylpred Acetate 80 mg/ml Inj. Susp Depo-Medrol Methylpred Sod Succ 40mg Inj. Solu-Medrol Methylpred Sod Succ 125 mg Inj. Solu-Medrol Methylpred Sod Succ 500 mg Inj. Solu-Medrol Naloxone 0.4 mg/ml Inj. Narcan Naloxone Syringe 2 mg/2 ml Inj. Narcan Naloxone Nasal Spray Nasal Narcan Nitroglycerin 1/150 (0.4mg) Tab Subl Nitrostat Phenytoin Sod Vial 50 mg/ ml Inj. Dilantin Phytonadione Amp 10 mg/ml Inj. Aqua-Mephyton Potassium Cl 40meq/15 ml Oral Liquid Kaon-Cl Potassium Cl 10 Meq/100 ml IVPB Inj. Potassium Chloride Potassium Cl 20 Meq/100 ml IVPB Inj. Potassium Chloride SOD Bicarbonate (1meq/ml) 8.4 % IV Soln Sodium Bicarbonate SOD Polysty Sulf Oral Powder Kayexalate Powder SOD Polysty Sulf 15gm/60 ml Oral Suspension Kayexalate Susp Thiamine HCL 50 mg Tablet Vitamin B-1 Thiamine HCL 100 mg Tablet Vitamin B-1 Thiamine HCL 100 mg/ml Inj. Soln Vitamin B-1

11. Endocrine – Metabolic Agents Androgens (11.01)

Estrogens – Progestins (11.02) Estradiol 0.5 mg Tablet Estrace Estradiol 1 And 2mg Tablet Estrace

Insulins (11.03) Insulin Hum NPH Vl 100 U/ml Inj. Novolin NPH Insulin Hum Reg Vl 100 U/ml Inj. Novolin Reg Insulin Glargine 100 Units/ml Semglee/Lantus

Hypoglycemics - Sulfonylureas (11.04.01) Glimepiride 1 mg Tablet Amaryl Glimepiride 2 mg Tablet Amaryl Glimepiride 4 mg Tablet Amaryl Glipizide 5 mg Tablet Glucotrol Glipizide 10 mg Tablet Glucotrol

Hypoglycemics - Biguanides (11.04.02) Metformin 500mg tablet Glucophage Metformin 850 mg tablet Glucophage Metformin 1000 mg tablet Glucophage Metformin 500 mg tab extended release 24 hr Glucophage XR Metformin 750 mg tab extended release 24 hr Glucophage XR

Hypoglycemics – DPP-4 Inhibitor (11.04.03) Saxagliptin all strengths Onglyza

Hypoglycemics - Incretin Mimetics (11.04.04)

Hypoglycemics - Combination Agents (11.04.05)

Hypoglycemics – SGLT2 Inhibitors (11.04.06) Empagliflozin 10 mg Tablet Jardiance Empagliflozin 25 mg Tablet Jardiance Dapagliflozin 5 mg tablet Farxiga Dapagliflozin 10 mg tablet Farxiga

Thyroid Agents (11.05) Levothyroxine 25 Mcg Tablet Synthroid Levothyroxine 50 Mcg Tablet Synthroid Levothyroxine 75 Mcg Tablet Synthroid Levothyroxine 88 Mcg Tablet Synthroid Levothyroxine 100 Mcg Tablet Synthroid Levothyroxine 112 Mcg Tablet Synthroid Levothyroxine 125 Mcg Tablet Synthroid Levothyroxine 137 Mcg Tablet Synthroid Levothyroxine 150 Mcg Tablet Synthroid Levothyroxine 175 Mcg Tablet Synthroid Levothyroxine 200 Mcg Tablet Synthroid

Levothyroxine 300 Mcg Tablet Synthroid Methimazole 5 mg Tablet Tapazole Methimazole 10 mg Tablet Tapazole

Adrenal Corticosteroids (11.06) Dexamethasone 0.5 mg Tablet Decadron Dexamethasone 0.5 mg/5 ml Oral Elixir Decadron Dexamethasone 0.75 mg Tablet Decadron Dexamethasone 1 mg Tablet Decadron Dexamethasone 1.5 mg Tablet Decadron Dexamethasone 2 mg Tablet Decadron Dexamethasone 4 mg Tablet Decadron Dexamethasone 6 mg Tablet Decadron Hydrocortisone 5 mg Tablet Cortef Hydrocortisone 10 mg Tablet Cortef Hydrocortisone 20 mg Tablet Cortef Methylprednisolone 2 mg Tablet Medrol Methylprednisolone 4 mg Tablet Medrol Methylprednisolone 4 mg Tablets, Dose Pack Medrol Dosepak Prednisone 1 mg Tablet Deltasone Prednisone 2.5 mg Tablet Deltasone Prednisone 5 mg Tablet Deltasone Prednisone 10 mg Tablet Deltasone Prednisone 20 mg Tablet Deltasone Prednisone 50 mg Tablet Deltasone Prednisone 5 mg Tablets, Dose Pack Prednisone Prednisone 10 mg Tablet Tablets, Dose Pack Prednisone Triamcinolone Acet 40 mg/ml Inj. Suspension Kenalog

Osteoporosis Agents (11.07) Alendronate 35 mg Tablet Fosamax Alendronate 70 mg Tablet Fosamax

Other Endocrine - Metabolic Agents (11.08) Calcitriol 0.25 Mcg Capsule Rocaltrol Calcitriol 0.5 Mcg Capsule Rocaltrol Cinacalcet 30 mg Tablet Sensipar Cinacalcet 60 mg Tablet Sensipar Cinacalcet 90 mg Tablet Sensipar Glucose 40% Oral Gel Glutose Paricalcitol Vial 2 Mcg/ml Inj. Zemplar Paricalcitol Vial 5 Mcg/ml Inj. Zemplar

12. Gastrointestinal Agents Aminosalicylates (12.01)

Balsalazide 750 mg Capsule Colazal Sulfasalazine 500 mg Tablet Azulfidine

Tumor Necrosis Factor (12.02) Adalimumab (Biosimilar to Humira) Yusmiry

Anti-Diarrheals (12.03) Loperamide 2 mg Tablet (24 doses/30-day limit) Imodium Pink Bismuth 262 mg Tab Chew Pepto-Bismol

Anti-Emetics (12.04) Ondansetron 4 mg Tablet (7 days max every 180 days) Zofran Ondansetron 8 mg Tablet (7 days max every 180 days) Zofran Ondansetron HCL Vial 2 mg/ml Inj. (7 days max every 180 days) Zofran Sdv 4mg Ondansetron 4 mg, Tablet Disintegrating (7 days max every 180 days) Zofran ODT Ondansetron 8 mg Tablet Disintegrating (7 days max every 180 days) Zofran ODT Prochlorperazine Maleate 5 mg Tablet (3 days max every 180 days) Compazine Prochlorperazine Maleate 10 mg Tablet (3 days max every 180 days) Compazine Prochlorperazine 25 mg Rectal Suppository (3 days max every 180 days) Compazine Promethazine HCL 25 mg/ml Inj. Soln (3 days max every 180 days) Phenergan Promethazine HCL 50 mg/ml Inj. Soln (3 days max every 180 days) Phenergan Promethazine- 25 mg Rectal Suppository (3 days max every 180 days) Phenergan Promethazine- 50 mg Rectal Suppository (3 days max every 180 days) Phenergan

Cathartics / Laxatives (12.05) Bisacodyl 10 mg Rectal Suppository (7 days max every 180 days) Dulcolax Supp Bisacodyl 5 mg Tab, Delayed Release (Dr/Ec) (7 days max every 180 days) Dulcolax Bisacodyl 5 mg Tablet (7 days max every 180 days) Dulcolax Calcium Polycarbophil 625mg Tablets Fibercon Docusate Sodium-100mg (Limited pre and post-partum patients) Colace Glycerin Adult Rectal Suppository Glycerin Supp Lactulose 10gm/15 ml Oral Solution Chronulac Magnesium Citrate Solution Citrate of Mag Milk of Mag Susp 80meq/30 ml Suspension Limited to Clinic Stock Only MOM Peg 3350/Electrolytes 227.1-21.5-6.36g Oral Powder Golytely Sodium Phosphate 19.7g/119ml Rectal Enema Fleet Enema

Digestive Enzymes (12.06) Lactase 3000 Units Tablets Lactaid

GI Motility Agents (12.07) Polyethylene Glycol Miralax

Histamine – 2 Receptor Antagonists (H2RAs) (12.09) Famotidine 10 mg tablet Pepcid Famotidine 20 mg tablet Pepcid Famotidine 40 mg Tablet Pepcid

Proton Pump Inhibitors (PPIs) (12.10) Omeprazole 10 mg capsule Prilosec Omeprazole 20 mg capsule Prilosec Omeprazole 40 mg capsule Prilosec

Other GI Agents (12.11) Lactobacillus Acidophilus (Restricted to use in female patients) Lactinex Sevelamer Carbonate 800 mg tablet Renvela Sucralfate 1gm tablet Carafate

Hemorrhoidal Agents (12.12) Dibucaine 1% rectal ointment Nupercainal Hemorrhoidal hc 1% cream Preparation H w/Hydrocort Hemorrhoidal supp (phenylephrine) 0.25% rectal Preparation H Hydrocortisone CR 1% Hytone Hydrocortisone enema 100mg/60ml enema Cortenema (Search as brand in NextGen) Hydrocortisone ointment 1% Hytone

13. Genitourinary Agents Benign Prostatic Hypertrophy Agents (13.01)

Doxazosin 1 mg Tablet Cardura Doxazosin 2 mg Tablet Cardura Doxazosin 4 mg Tablet Cardura Doxazosin 8mg Tablet Cardura Finasteride 1 and 5mg Proscar Tamsulosin 0.4 mg Cap Extended Release 24 Hr Flomax Terazosin 1 mg Capsule Hytrin Terazosin 2 mg Capsule Hytrin Terazosin 5 mg Capsule Hytrin Terazosin 10 mg Capsule

Other GU Agents (13.02) Bethanechol 50 mg Tablet Urecholine Sod Bicarbonate 325 mg Tablet Sodium Bicarb Sod Bicarbonate 650 mg Tablet Sodium Bicarb

14. Hematological Agents Hematological Agents (14.01)

Methoxy PEG Epoetin Beta (Preferred) Mircera Epoetin Alfa Retacrit Immune Globulin D (Limited to Iwp) Rhogam

Sickle Cell Agents (14.02) Hydroxyurea 500 mg Capsule Hydrea

15. Immunosuppressants Immunosuppressants (15.01)

Azathioprine 50 mg Tablet Imuran Cyclosporine 25 mg Capsule Sandimmune Cyclosporine 100 mg Capsule Sandimmune Cyclosporine Modified 25 mg Capsule Neoral/Gengraf Cyclosporine Modified 100 mg Capsule Neoral/Gengraf Cyclosporine Modified 100 mg/ml Solution Neoral Solution Tacrolimus 0.5 mg Capsule Prograf Tacrolimus 1 mg Capsule Prograf Tacrolimus 5 mg Capsule Prograf

Antirheumatic Agents (15.02) Hydroxychloroquine Sulfate 200 mg Plaquenil Methotrexate 2.5 mg Tablet Trexall Methotrexate 25mg/ml Inj. Trexall Adalimumab (Biosimilar to Humira) Yusimry

16. Neurological Agents Alzheimer’s Agents (16.01)

Anticonvulsants (16.02) Divalproex 125 mg Tab Depakote Divalproex 250 mg Tab Depakote Divalproex 500 mg Tab Depakote Lamotrigine 25 mg Tablet Lamictal Lamotrigine 100 mg Tablet Lamictal Lamotrigine 150 mg tablet Lamictal Lamotrigine 200 mg tablet Lamictal Levetiracetam 250 mg IR/ER Tablet Keppra Levetiracetam 500 mg IR/ER Tablet Keppra Levetiracetam 750 mg IR/ER Tablet Keppra Levetiracetam 1000 mg IR/ER Tablet Keppra Phenytoin 125 mg/5 ml Oral Suspension Dilantin-125 Phenytoin 50 mg Tablet Chewable Dilantin Infatab Phenytoin Sod *Ext* 30 mg Capsule Dilantin Phenytoin Sod *Ext* 100 mg Capsule Dilantin Valproic Acid 250 mg Capsule Depakene Valproic Acid 250 mg/5 ml Oral Solution Depakene Syrup

Anti-Parkinsons Agents (16.03) Amantadine HCL 100 mg Capsule Symmetrel Amantadine HCL 50 mg/5 ml Oral Solution Symmetrel Benztropine 0.5 mg Tablet Cogentin Benztropine 1 mg Tablet Cogentin Benztropine 2 mg Tablet Cogentin Benztropine 2mg/2ml Inj. Cogentin Inj.

Bromocriptine 2.5 mg Tablet Parlodel Bromocriptine 5 mg Capsule Parlodel Carbidopa/Levodopa 10-100 mg Tablet Sinemet Carbidopa/Levodopa 25-100 mg Tablet Sinemet Carbidopa/Levodopa 25-250 mg Tablet Sinemet

Myasthenia Gravis (16.04) (Cholinesterase inhibitor) Pyridostigmine all strengths Mestinon

Multiple Sclerosis Agents (16.041) Fingolimod 0.5 mg capsule Gilenya Teriflunomide 14mg Tablet Aubagio Teriflunomide 7mg Tablet Aubagio Dimethyl Fum 120mg DR Cap Tecfidera Dimethyl Fum 240mg DR Cap Tecfidera

Other Neuro Agents (16.05) Meclizine 12.5 mg Tablet Antivert Meclizine 25 mg Tablet Antivert Valproic Acid 250 mg/5 ml Oral Soln Depakene Syrup

17. Obstetric – Gynecologic Agents Contraceptives (17.01)

Noreth/Estrad 1-0.035 mg Tablet Ortho-Novum 1/35 Norgest/Estradiol 0.3/0.03 mg Tablet Lo-Ovral

Anti-Infectives (17.02) Miconazole 2% Vaginal Cream Monistat-7 Other OB Agents (17.03) Medroxyprogesterone 2.5 mg Tablet Provera Medroxyprogesterone 5 mg Tablet Provera Medroxyprogesterone 10 mg Tablet Provera Medroxyprogesterone Acetate 150mg/ml Im Susp (Depo) Depo-Provera

18. Ophthalmic – Otic Preparations

Anti-Glaucoma Agents (18.01) Betaxolol HCL 0.25% Ophthalmic Drops, Susp Betoptic S Betaxolol HCL 0.5% Ophthalmic Drops Betoptic Ophth Brimonidine Soln 0.2% Ophthalmic Drops Alphagan Brimonidine/Timolol 0.2%-0.5% Ophthalmic Drops Combigan Opthalmic drops Dorzolamide 2% Ophthalmic Drops Trusopt Ophth Latanoprost 0.005% Ophthalmic Drops Xalatan Levobunolol 0.5% Ophthalmic Drops Betagan Ophth Pilocarpine HCL 1% Ophthalmic Drops Isopto Carpine Pilocarpine HCL 2% Ophthalmic Drops Isopto Carpine Pilocarpine HCL 4% Ophthalmic Drops Isopto Carpine Timolol 0.25% Ophthalmic Drops Timoptic Timolol 0.5% Ophthalmic Drops Timoptic

Antihistamines / Decongestants (18.02)

Anti-Infective Agents (18.03) Bacitracin/Polymyxin B Ophthalmic Ointment Polysporin Ophth Ciprofloxacin 0.3% Ophthalmic Drops Ciloxan Ophth Erythromycin 0.5% ophthalmic ointment Ilotycin Moxifloxacin 0.5% Opthalmic Drops Vigamox Neomy/Bac/Poly 3.5-400-10,000 mg/Unit/Unit/G Eye Ointment Neosporin Ophth Neomy/Poly B/Gram 1.75mg-10,000u-0.025mg/ml Ophthalmic Drops Neosporin Neomy/Polymyx/Dex Ophthalmic Oint 3.5mg/G-10,000u/G--0.1% Maxitrol Neomy/Polymyx/Dex Ophthalmic Susp 3.5mg/ml -10,000unit/ml-0.1% Maxitrol Neomy/Bac/ Polymx/Hc Ointment 3.5-400-10,000u/G--0.1% Cortisporin Ophth Sulfacet/Pred 10%-0.25% Ophthalmic Drops Vasocidin Sulfacet/Pred 10%/0.2% Ophthalmic Susp Blephamide Ophth Tobramycin Eye Drops 0.3% Ophthalmic Drops Tobrex Ophth Tobramycin Oint 0.3% Ophthalmic Ointment Tobrex

Trifluridine 1% Ophthalmic Drops Viroptic Ophth

Anti-Inflammatory Agents (18.04) Dexamethasone 0.1% Ophthalmic Susp Decadron Ophth Diclofenac 0.1% Opthalmic Drops Voltaren Prednisolone Acet 0.12% Ophthalmic Susp Pred Mild Eye Drops Prednisolone Acet 1% Ophthalmic Susp Pred Forte Susp

Otic Preparations (18.05) Acetic Acid 2% Otic Solution Vosol Acetic Acid/Al Acet Otic 2% Otic Domeboro Otic Neomy/Polymx/Hc 3.5-10,000, 1mg/ml Otic Susp Cortisporin Otic Carbamide Peroxide 6.5% Otic (4 Day max every 30 days) Debrox

Other Ophthalmic-Otic Agents (18.06) Artificial Tears (Polyvin Alc) 1.4% Ophthalmic Drops Liquifilm Tears Atropine Sulfate 1% Ophthalmic Drops Isopto Atropine Atropine Sulfate 1% Ophthalmic Ointment Atropine Ophth Cyclopentolate 0.5% Ophthalmic Drops Cyclogyl Cyclopentolate 1% Ophthalmic Drops Cyclogyl Cyclopentolate 2% Ophthalmic Drops Cyclogyl Eye Wash Irrg Ophthalmic Dacriose Fluorescein/Benoxinate 0.25%-0.4% Ophthalmic Drops Fluress Meningococcal ACWY Menquadfi Meningococcal B Bexsero Fluorescein 1 mg Strip Ful-Glo Homatropine Hbr 5% Ophthalmic Drops Isopto Homatropine Proparacaine HCL 0.5% Ophthalmic Drops Ophthetic Sod Chloride Eye Drops 2% Ophthalmic Muro-128 Ophth Sod Chloride Eye Drops 5% Ophthalmic Muro-128 Ophth Sod Chloride Eye Oint 5% Ointment Muro-128 Ophth Tropicamide 0.5% Ophthalmic Drops Mydriacyl Tropicamide 1% Ophthalmic Drops Mydriacyl

19. Respiratory Agents

Anticholinergics (19.01) Ipratropium 0.02% Nebulization Solution Atrovent Soln Aclidinium Inhaler Tudorza

Beta Agonists (19.02) Albuterol 90 Mcg/Actuation Inhalation Hfa Aerosol Proair Albuterol 2.5mg/3ml (0.083%) Inhalation Sol For Neb Proventil Albuterol 2 mg/5ml Syrup Proventil

Inhaled Oral Steroids (19.03) Ciclesonide 80 mcg Inhaler Alvesco Ciclesonide 160 mcg Inhaler Alvesco

Nasal Steroid Sprays (19.04) Triamcinolone Nasal Inhaler Nasalcort

Combination Products (19.05) Ipratropium-Albuterol 0.5-3 mg/3ml Nebulization Solution Duoneb Fluticasone/Salmeterol Inhaler (Laba) (All Strengths) Airduo Aclidinium/Formoterol inhaler Duaklir

Other Respiratory Agents (19.06) Acetylcysteine Vial 100 mg/ml (Misc Soln) Mucomyst 10% Acetylcysteine Vial 200 mg/ml (Misc Soln) Mucomyst 20% Aminophylline 250 mg/10 ml Inj. Aminophylline Montelukast 10mg (Leukotriene Antagonists) Singulair

20. Vaccines Vaccines - (20.01)

Hepatitis B Vacc Pf 10 mcg/ml Inj. Recombivax Hb Ped Hepatitis-A Vacc 50 U/ml Im Inj. Syringe Vaqta Hepatitis-A Vacc 50 U/ml Inj. Vaqta Influenza Vaccine Fluvirin-AFluria Measles, Mumps, Rubella Vl Inj. MMR Vaccine Papillomavirus HPV Pneumococcal 20 Valent Conj Vaccine Prevnar 20 Pneumococcal 23 Valent Conj Vaccine Pneumovax 23 Shingrix Inj. Shingrix Tetanus Tox Conjugate 10/25 mcg Inj. Hiberix Tetanus-Diphtheria Tox Inj. Decavac/Tenivac Syg Tetanus-Diphtheria Vial Inj. Decavac/Tenivac Vial

21. Vitamins – Minerals – Dietary Supplements Vitamins – Minerals – Dietary Supplements (21.01)

Calcium Acetate 667 mg Tablet Phoslo/ Eliphos Calcium Carbonate / Vitamin D Tablet Various Brand Names Calcium Gluconate 100mg/ml (10%) Iv Soln CA Gluconate Cyanocobalamin 1000 Mcg Tablet Vitamin B12 Cyanocobalamin 1000 Mcg/ml Inj. Vitamin B12 Ferrous Sulfate 325 mg (65mg Iron) Tab, Delayed Rel Dr/Ec Feso4 (65mg Fe} Folic Acid 1 mg Tablet Folic Acid Iron Dextran Comp 50 mg/ml Inj. Soln Infed Lanthanum Carb 500 mg Tab Chewable Fosrenol Lanthanum Carb 1000 mg Tab Chewable Fosrenol Phytonadione Amp 10 mg/ml Inj. Aqua-Mephyton Pot IOD/Iodine Sol 10%-5% Solution Lugol's Solution Potassium Cl 8meq Tab Extended Release Slow-K Potassium Cl 10 Meq Tab/Cap K-DUR/KLOR-Con Potassium Cl 20meq Oral Packet K-LOR Powd Pkt Potassium Cl 20meq Tab Extended Release KLOR-Con M20 Potassium Cl 40meq/15 ml Liquid Kaon-Cl Potassium Cl 10 Meq/100 ml IVPB Inj. Potassium Chloride Potassium Cl 20 Meq/100 ml IVPB Inj. Potassium Chloride Prenatal Vit Tablet Prenatal Vit Pyridoxine Tablet Vitamin B-6

Sod Ferric Gluc Sucrose 62.5 mg/5 ml Iv Sol Ferrlecit Inj.

Thiamine HCL 50 mg Tablet Vitamin B-1 Thiamine HCL 100 mg Tablet Vitamin B-1 Thiamine HCL100 mg/ml Inj. Sol Vitamin B-1 Vitamin B Comp W-C/Fa Tablet Rena-Vite Rx

22. Miscellaneous and Unclassified Agents Miscellaneous and Unclassified Agents (22.01)

Alteplase Cathflo Bupivacaine HCL 0.25% (2.5mg/ml) Inj. Soln Marcaine Bupivacaine HCL 0.5% (5mg/ml) Inj. Soln Marcaine Bupivacaine HCL/Epi Vl 0.5% (1:200,000) Inj. Marcaine Epi Lidocaine 10mg/ml (1%) Inj. Xylocaine Lidocaine Epinephrine 1% (1:100,000) Inj. Soln Xylocaine W/Epi Lidocaine 20 mg/ml (2%) Inj. Xylocaine Lidocaine Epinephrine 2% (1:200,000) Inj. Soln Xylocaine W/Ep

23. Preferred Agents Still Needing Formulary Exception Request Preferred Agents Still Needing Formulary Exception Request

Fluphilia – Pegfilgrastim-jmdb used once per chemo cycle Granix – daily filgrastim agent Suboxone – dissolve tablets preferred product

Formulary Drug List ‐ Indiana Department of Corrections-

Index Product Name Equivalent Brand Name Therapy Section

Rev. 02/27/2025 Adult/Juvenile

1/2ns + KCL 20 Meq Inj. Sodium Chloride 0.45% + KCL 09.01 Abacavir 300 mg Tablet Ziagen 03.09.04 Abacavir 600 mg/Dolutegravir 50 mg/Lamivudine 300 mg Triumeq 03.09.06 Acetaminophen 325 mg Tablet Tylenol 01.01 Acetaminophen 500 mg Tablet Tylenol 01.01 Acetazolamide 250 mg Tablet Diamox 05.10 Acetazolamide 500 mg Cap Cr Diamox Sequel 05.10 Acetic Acid Soln 2% Otic Vosol 18.05 Acetic Acid/Al Acet Otic 2% Otic Domeboro Otic 18.05 Acetylcysteine Vial 100 mg/ml (For Nebulization) Mucomyst 10% 19.06 Acetylcysteine Vial 200 mg/ml (For Nebulization) Mucomyst 20% 19.06 Aclidinium Inhaler Tudorza 19.01 Aclidinium/Formoterol inhaler Duaklir 19.05 Acyclovir 200 mg Capsule Zovirax 03.06 Acyclovir 400 mg Tablet Zovirax 03.06 Acyclovir 800 mg Tablet Zovirax 03.06 Adalimumab-aqvh (Biosimilar to Humira) Yusimry 08.04 Adalimumab-aqvh (Biosimilar to Humira) Yusimry 12.02/15.02 Albuterol HFA Proair 90 mcg Inhaler Proair 19.02 Albuterol 0.083% Nebulization Solution Proventil 19.02 Albuterol Syrup 2 mg/5mi Syrup Proventil 19.02 Alendronate Sodium 35/70mg Tablet Fosamax 11.07 Allopurinol 100 mg Tablet Zyloprim 01.02 Allopurinol 300 mg Tablet Zyloprim 01.02 Alteplase Cathflo 22.01 Amantadine HCL 100 mg Capsule Symmetrel 03.06 Amantadine HCL 100 mg Capsule Symmetrel 16.03 Amantadine HCL 50 mg/5 ml Syrup Symmetrel 03.06 Amantadine HCL 50 mg/5 ml Syrup Symmetrel 16.03 Aminophylline Vl 250 mg/10 ml Inj. Aminophylline 19.06 Amiodarone HCL 100 mg Tablet Cordarone 05.04.04 Amiodarone HCL 200 mg Tablet Cordarone 05.04.04 Amlodipine Besylate 10 mg Tablet Norvasc 05.07.01 Amlodipine Besylate 2.5 mg Tablet Norvasc 05.07.01 Amlodipine Besylate 5 mg Tablet Norvasc 05.07.01 Amoxicillin 250 mg Capsule Amoxil 03.11 Amoxicillin 250 mg/5 ml Suspension Amoxil 03.11 Amoxicillin 500 mg Capsule Amoxil 03.11 Amoxicillin/Clav 875-125 mg Tablet Augmentin 03.11 Amphetamine tablet (Juvenile Only) Adderall 06.04 Apap - Box /24 Protocol 325 mg Tablet Tylenol 01.01 Apap Suppository 325 mg Suppository Tylenol Supp 01.01 Apap Suppository 650 MG Suppository Tylenol Supp 01.01 Apixiban 2.5 mg tablet Eliquis 05.11 Apixiban 5 mg tablet Eliquis 05.11 Aripiprazole 2 mg Tablet Abilify 06.02.02 Aripiprazole 5 mg Tablet Abilify 06.02.02 Aripiprazole 10 mg Tablet Abilify 06.02.02 Aripiprazole 15 mg Tablet Abilify 06.02.02 Aripiprazole 20 mg Tablet Abilify 06.02.02

Product Name Equivalent Brand Name Therapy Section

Rev. 02/27/2025 Adult/Juvenile

Aripiprazole 30 mg Tablet ABILIFY 06.02.02 Artificial Tears 1.4% Ophthalmic Liquifilm Tears 18.06 Asa 325mg Ec 325 mg Tab Ec Ecotrin 01.07 Aspirin - Film Coat 325 mg Tablet Asa FC 01.07 Aspirin Ec 81 mg Tab Ec Ecotrin 01.07 Aspirin FC Box/24 Protocol 325 mg Tablet Aspirin 01.07 Atazanavir 300 mg/Cobicistat 150 mg Evotaz 03.09.06 Atenolol 100 mg Tablet Tenormin 05.06.01 Atenolol 25 mg Tablet Tenormin 05.06.01 Atenolol 50 mg Tablet Tenormin 05.06.01 Atomoxetine all strengths (Juvenile Only) Strattera 06.08 Atorvastatin 10 mg Tablet Lipitor 05.05.01 Atorvastatin 20 mg Tablet Lipitor 05.05.01 Atorvastatin 40 mg Tablet Lipitor 05.05.01 Atorvastatin 80 mg Tablet Lipitor 05.05.01 Atropine Sulfate O/S 1% Ophthalmic Isopto Atropine 18.06 Atropine Sulfate Oint 1% Ophthalmic Atropine Ophth 18.06 Atropine Syringe 0.1 mg/ml Inj. Atropine Sulfate 10.01 Atropine Vial 0.4 mg/ml Inj. Atropine Inj. 10.01 Azathioprine 50 mg Tablet Imuran 15.01 Azithromycin 250 mg Tablet Zithromax 03.10 Azithromycin 600 mg tablet Zithromax 03.09.07 Azithromycin 600 mg Tablet Zithromax 03.10 Azithromycin Z-Pak 250 mg Tablet Zithromax Z-Pak 03.10 Bacitracin Ointment Bacitracin 18.03 Bacitracin/Polymyxin B Ointment Polysporin 18.03 Balsalazide Disodium 750 mg Capsule Colazal 12.01 Benazepril HCL 10 mg Tablet Lotensin 05.02 Benazepril HCL 20 mg Tablet Lotensin 05.02 Benazepril HCL 40 mg Tablet Lotensin 05.02 Benazepril HCL 5 mg Tablet Lotensin 05.02 Benzocaine 20% 20 % Liquid Anbesol Liquid Max 07.01 Benzoyl Peroxide 10% Gel (Jelly) Persagel 08.01 Benztropine Mes 0.5 mg Tablet Cogentin 06.99 Benztropine Mes 0.5 mg Tablet Cogentin 16.03 Benztropine Mes 1 mg Tablet Cogentin 06.99 Benztropine Mes 1 mg Tablet Cogentin 16.03 Benztropine Mes 2 mg Tablet Cogentin 06.99 Benztropine Mes 2 mg Tablet Cogentin 16.03 Benztropine Mes Vl/Amp 1 mg/ml Inj. Cogentin Inj. 06.99 Benztropine Mes Vl/Amp 1 mg/ml Inj. Cogentin Inj. 16.03 Betamethasone- 0.05% Aug Cream Diprolene AF 08.08.02 Betaxolol HCL O/S 0.25% Ophthalmic Betoptic S 18.01 Betaxolol HCL O/S 0.5% Ophthalmic Betoptic Ophth 18.01 Bethanechol 50 mg Tablet Urecholine 13.02 Bisacodyl 10 mg Suppository Dulcolax Supp 12.05 Bisacodyl 5 mg Tab Ec Dulcolax 12.05 Brimonidine Soln 0.2% Ophthalmic Alphagan 18.01 Brimonidine/Timolol 0.2%-0.5% Ophthalmic Combigan Opthalmic Drops 18.01 Bromocriptine Mesy 2.5 mg Tablet Parlodel 16.03

Product Name Equivalent Brand Name Therapy Section

Rev. 02/27/2025 Adult/Juvenile

Bromocriptine Mesylate 5 mg Capsule Parlodel 16.03 Bupivacaine HCL Vl 0.25% Inj. Marcaine 22.01 Bupivacaine HCL Vl 0.5% Inj.