TE 4 Medicines (Formulary).pdf

ITEM MEDICATION

INDICATION

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

498713 ANALGESICS;

ANTIPYRETIC

325mg 24 tablets per bottle

995478 ANALGESICS;

ANTIPYRETIC

325mg 2 tablets per packet/250 packets per box

1111736 ANALGESICS;

ANTIPYRETIC

325mg 2 tablets per packet/250 packets per box

787649 ANALGESICS;

ANTIPYRETIC

500mg 24 caplets per bottle

260632 ANALGESICS;

ANTIPYRETIC

500mg 2 tablets per packet/250 packs per box

1111741 NSAIDS 325MG 2 tablets per packet/250 packets per box

555693 NSAIDS 81MG 36 tablets per bottle

1067537 ANTIVIRAL 400mg 30 tablets per bottle

706567 SYMPATHOMIMETIC(ADR

ENERGIC) AGENT

2.5mg / 3mL 2.5mg / 3mL per vial, 30 vials per

1126224 BRONCHODIALATOR 90 mcg 200 doses per MDI

701695 BRONCHODIALATOR 90 mcg 60 doses per MDI

633796

GASTROINTESTINAL

AGENTS’ ANTACIDS

200mg Aluminum Hydroxide / 200mg Magnesium Hydroxide / 20mg Simethicone per 5mL 12 fl. oz per bottle

1090715

GASTROINTESTINAL

AGENTS’ ANTACIDS

200 mg/200mg/25 mg Chewable Tablets

100 tablets per bottle; Aluminum hydroxide- magnesium hydroxide with simethicone is provided in blister packs of 10 each per pack x 10 packs

1042405 ANTIHYPERTENSIVE 5mg 90 tablets per bottle

1170619 ANTI-INFECTIVE AGENTS 875mg 20 tablets per bottle

1192499 ANTI-INFECTIVE AGENTS 875mg /125mg 20 tablets per bottle

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

ORAL (PO) & INHALANT MEDICATIONS

acetaminophen TABLET acetaminophen TABLET acetaminophen TABLET acetaminophen Extra Strength CAPLETS acetaminophen Extra Strength TABLET acetysalicylic acid TABLET acetysalicylic acid CHEWABLE

TABLET

acyclovir TABLET albuterol neb sol 0.083% INHALANT albuterol sulfate AEROSOL albuterol sulfate AEROSOL aluminum hydroxide/magnesium hydroxide w/simethicone

LIQUID

aluminum hydroxide/magnesium hydroxide w/simethicone

TABLET

amLODIPine TABLET amoxicillin TABLET amoxicillin/potassium clavulanate FILM COATED

TABLET

Health Services Contract Section J, Technical Exhibit 4

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

1211583 ANTIBIOTIC 250 mg 6 tablets per box/3 boxes

989808 ANTIBIOTIC 250 mg 6 tablets per box

852678 ANTISEPTIC 15mg Benzocaine \ 4mg Menthol

18 lozenges per box

851616 ANTISEPTIC 7.5 mg/5mg 16 lozenges per box

835277 SORE THROAT RELIEF benzocaine 15mg menthol 2.6mg

16 lozenges per box

851616 SORE THROAT RELIEF Benzocain 7.5mg dextromethorphan 5mg

16 lozenges per box

1067530 NON-NARCOTIC

ANTITUSSIVE

100mg 15 tablets per bottle

1111737 ANTIDIARRHEALS 262 mg per tablet 2 tablets per packet / 100 packets per box

1111738 ANTACIDS 420 mg 2 tablets per packet / 250 packets per box

1111738 ANTI-INFECTIVE AGENTS 500mg 20 capsules per bottle

305791 ANTI-INFECTIVE AGENTS 500mg 40 capsules per bottle

1235078 ANTIHISTAMINE DRUG

2nd GENERATION

10mg 14 tablets per box

305285 ANTIHISTAMINE DRUG

1ST GENERATION

4 mg 1 tablet per packet/250 packets per box

1067557 ANTI-INFECTIVE AGENTS 500mg 10 tablets per bottle

1067519 ANTI-INFECTIVE AGENTS 150mg 30 capsules per bottle

570795 ORAL ANTIBIOTIC 300mg 16 capsules per bottle

313517 SKELETAL MUSCLE

RELAXANT

10mg 10 tablets per bottle

1158844 ANTISPASMODIC 10mg 100/blister pack

498724

ANTIHISTAMINE DRUGS- FIRST

GENERATION 25mg 24 caplets per box

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

ORAL (PO) & INHALANT MEDICATIONS

azithromycin TABLET azithromycin TABLET benzocaine/menthol LOZENGE benzocaine/menthol LOZENGE

Cepacol® benzocaine/menthol Honey Lemon

LOZENGE

Cepacol® benzocaine/menthol Mixed Berry

LOZENGE

benzonatate TABLET bismuth subsalicylate TABLET calcium carbonate TABLET cephalexin CAPSULE cephalexin CAPSULE cetrizine hcl TABLET chlorpheniramine maleate TABLET ciprofloxacin TABLET clindamycin hcl CAPSULE clindamycin CAPSULE cyclobenzaprine hcl TABLET dicyclomine (bentyl) CAPSULE diphenhydrAMINE hcl po

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

406725

ANTIHISTAMINE DRUGS- FIRST

GENERATION 25 mg 200 per box

468232 ANTI-INFECTIVE AGENTS 100mg 20 capsules per bottle

769437 H2 BLOCKER ANTACID 20mg 25 tablets per box

1067560 ANTIFUNGAL AGENT 150mg 1 tablet per bottle

1127722 ORAL ANTI-

HYPOGLYCEMIC

15 gm/tube 15 gm per tube/3 tubes per pk

580125 ORAL ANTI-

HYPOGLYCEMIC

15 gm/tube 15 gm per tube/3 tubes per pk

1112075 discontinued

ORAL ANTI- HYPOGLYCEMIC

15 gm/tube 15 gm per tube/3 tubes per pk

1231470 ORAL ANTI-

HYPOGLYCEMIC

15 gm/tube 15 gm per tube/3 tubes per pk

1112076 ORAL ANTI-

HYPOGLYCEMIC

15 gm/tube 15 gm per tube/3 tubes per pk

1113777 discontinued but still part of clinic stock ANTI-HYPOGLYCEMIC 24 grams

24 grams per tube 3 tubes per packet

1235101 Expectorant 600 mg Extended Release 20 tablets per box

1076735 EXPECTORANT 200mg/10ml unit dose 100/CS

973234 EXPECTORANT

100 mg guaifenesin /10 mg dextromethorphan per 5mL

4 oz per bottle

718856 EXPECTORANT 600mg/30mg 20 tables per box

1111735 NSAID 200mg 2 per pack, 200 per box

305771 NSAID 400mg 30 tablets per bottle

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

ORAL (PO) & INHALANT MEDICATIONS

diphenhydrAMINE hcl po

TABLET

doxyclycline CAPSULE famotidine TABLET

Diflucan® fluconazole - Hazardous TABLET glucose gel - grape-glutose 15™ GEL glucose gel - lemon glutose 15™ GEL glucose gel - cherry transcend™ GEL glucose gel - strawberry transcend™ GEL glucose gel - orange transcend™ GEL glucose gel GEL guaiFENesin (Foster & Thrive) Tablet guaiFENesin LIQUID guaiFENesin/dextromethorphan

GuaiasorbDM® LIQUID guaiFENesin/dextromethorphan (Mucinex®)

TABLET

iburprofen TABLET iburprofen TABLET

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

1067126 NSAID 600mg 21 tablets per bottle

1067502 NSAID 800mg 21 tablets per bottle

1205151 BRONCHODIALATOR 0.02% (0.5 mg/2.5ml) 30 per package

1067544 ANTIHYPERTENSIVE ACE

INHIBITOR

10mg 30 tablets per bottle

1179456 ANTIDIARRHEAL 2 mg 2 mg tab per packet/Box 24 packets Unit Dose

1238948 ANTIDIARRHEAL 2m 2 mg caplet, 12 per box

1111728

ANTIHISTAMINE DRUGS-

SECOND GENERATION

DRUGS

10mg 1 10 mg tab per packet/ 50 packets per box

1235075

ANTIHISTAMINE DRUGS-

SECOND GENERATION DRUGS 10mg 90 tablets per bottle

1235098 ANTIEMETIC 25mg 8 tables per box

1111732 COUGH SUPPRESSANT 7.6 mg Box of 300 Lozenges

1111731 COUGH SUPPRESSANT 7.6 mg Box of 300 Lozenges

798209 SORE THROAT 7.6 mg individually wrapped/ 600 lozenges/box

1168233 GLUCOCORTICOIDS 4mg 21 tablets dose pack

421788 ANTACID LAXATIVE 400 mg Magnesium Hydroxide per 5 mL

30mL per unit dose cup, 10- unit dose cups per case

*new* 720751

LAXATIVE POWDER 17 gm strength 24 individual packets of powder per box

1067524 NSAID 500mg 14 tablets per bottle

1194961 NSAID 220mg 24 tablets per bottle

1010184 OPIATE ANTAGONIST 4mg single dose device 0.1ml

1239547 OPIATE ANTAGONIST 4mg single dose device 0.1ml/box of 2

1192762 ANTIANGINAL;

VASODILATOR

0.4 mg 25 sublingual tablets per bottle

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

ORAL (PO) & INHALANT MEDICATIONS

iburprofen TABLET iburprofen TABLET ipratropium bromide inhalation solution liquid solution lisinopril TABLET loperamide hcl TABLET loperamide hcl (Foster & Thrive) Caplet loratadine

TABLET

loratadine (Foster & Thrive)

TABLET

meclizine (Foster & Thrive) TABLET menthol lozenges - cherry flavor LOZENGE menthol lozenges - menthol flavor LOZENGE menthol lozenges cough drop COUGH DROP methylPREDNISolone TABLET milk of magnesia LIQUID

MiraLAX® Polyethylene Glycol Powder

POWDER

naproxen sodium TABLET naproxen sodium (Aleve Brand) TABLET narcan – naloxone hcl SPRAY narcan – naloxone hcl SPRAY nitroglycerin SUBLINGUAL (SL)

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

1087051

ANTI-ANGINAL/

VASODILATOR 0.4 mg/tab one box of 4 bottles each containing 25 tablets of 0.4/mg per tab

842418 ANTIEMETIC 4mg 30 tablets per blister pack

496508 HYPOXIA N/A 6LPM – 30 minutes

N/A HYPOXIA N/A Refillable Tank

788102 NASAL DECONGESTANT 10 mg 1 per packet / 100 per box

779223 GLUCOCORTICOIDS 10mg 21 tablets dose pack

1206901 GLUCOCORTICOIDS 10mg 48 tablets per dose pack

1067511

ANTIEMETICS

ANTIHISTAMINE - 1st

GENERATION

25mg 10 tablets per bottle

305714

ANTIBIOTIC

COMBINATION

800mg Sulfamethoxazole / 160mg Trimethoprim 6 tablets per blister pack

305713

ANTIBIOTIC

COMBINATION

800mg Sulfamethoxazole / 160mg Trimethoprim 28 tablets per bottle

566163 ANTI-INFECTIVE AGENTS 1 gram Ceftriaxone Sodium per 15 mL

15mL per vial, 10 vials per box

1169103

ALLERGIC

REACTION/ANTIHISTAMI

NE

50 mg/mL 1 mL per SDV /

246042 ALLERGIC REACTION 50 mg/mL 1 mL per SDV /

1169101 ALLERGIC REACTION 1 mg/mL (1:1000) 1 mL per SDV /

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

ORAL (PO) & INHALANT MEDICATIONS

nitroglycerin TABLET ondansetron Oral Distenigrating Tablet (ODT) oxygen INHALE oxygen tank refill INHALE phenylephrine hcl TABLET predniSONE TABLET predniSONE TABLET promethazine hcl - HIGH ALERT

MED TABLET

sulfamethoxazole / trimethoprim TABLET sulfamethoxazole / trimethoprim TABLET

INTRAMUSCULAR (IM) INTRADERMAL (ID)/INTRAVENOUS (IV) SUBCUTANEOUS (SQ,) MEDICATIONS FLUID RESUSCITATION cefTRIAXone INJECTABLE diphenhydrAMINE hcl im

INJECTABLE

diphenhydrAMINE hcl im INJECTABLE

EPINEPHrine - HIGH ALERT INJECTABLE

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

1124578 alternate only when item $1169101 is out of stock

ALLERGIC REACTION 1 mg/mL (1:1000) one time use kit includes:

•one vial of epinephrine 1mg/ml •two ea - 1 ml epinephrine syringes w/ markings •two ea - 23 gauge needles •four alcohol pads

1124578 alternate only when item $1169101 is out of stock

ALLERGIC REACTION 1 mg/mL (1:1000) one time use kit includes:

•one vial of epinephrine 1mg/ml •two ea - 1 ml epinephrine syringes w/ markings •two ea - 23 gauge needles •four alcohol pads

1185593 ANTI-HYPOGLYCEMIC 1 mg/mL

1mg glucagon for injection (as a sterile, lyophilized white to off- white powder) in a single- dose vial and 1 mL of diluent for glucagon in a prefilled syringe

1169097 NSAID 60mg per 2mL 2 mL per vial, One vial

1151516 NSAID 60mg per 2mL 2 mL per vial, 25 vials per box

186662 INTRAVENOUS FLUID

RESCUSCITATION

Isotonic buffered solution 1000mL per bag

899363 AMIDE LOCAL

ANESTHETIC

1% (10mg / mL) 2 mL per SDV, 10 vials per box

747065 AMIDE LOCAL

ANESTHETIC

1% Lidocaine HCL/ EPINEPHrine 1:100,000

20 mL per vial, 25 vials per box

1169094 GLUCOCORTICOIDS 125mg per 2 mL 2 mL per SDV, one SDV per box

310000 GLUCOCORTICOIDS 125mg per 2 mL

2 mL per SDV, 25 SDV per box

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

INTRAMUSCULAR (IM) INTRADERMAL (ID)/INTRAVENOUS (IV) SUBCUTANEOUS (SQ,) MEDICATIONS FLUID RESUSCITATION

EPINEPHrine - HIGH ALERT INJECTABLE

EPINEPHrine - HIGH ALERT INJECTABLE glucagon human recombinant INJECTABLE ketorolac tromethamine INJECTABLE ketorolac tromethamine INJECTABLE lactated ringers INTRAVENOUS lidocaine hcl 1% - HIGH ALERT INJECTABLE lidocaine 1% with EPINEPHrine -

HIGH ALERT

INJECTABLE

SOLU-Medrol® methylPREDNISolone sodium succinate

INJECTABLE

SOLU-Medrol® methylPREDNISolone sodium succinate (Preservative Free) INJECTABLE

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

665326 ANTIHISTAMINE 25mg / mL 1 mL per vials per pack

208816

INTRAVENOUS FLUID

RESCUSCITATION 0.9% Sodium Chloride 500mL per bag

208830

INTRAVENOUS FLUID

RESCUSCITATION 0.9% Sodium Chloride 1000mL per bag

441379 IV FLUSH 0.9% Sodium Chloride 10CC prefilled syringe, 30 per box

949873

AGENTS FOR MIGRANE,

SELECTIVE SEROTONIN

AGONIST

6 mg / 0.5 mL 0.5mL per vial, 5 vials per box

*new* 1242306

TOPICAL PAIN RELIEF 1% Strength 1% Strength/100 gm weight tube

498019 ANTI-BACTERIAL 500 IU/GM 0.9 grams per packet/144 packets per box

1220888 ANTI-BACTERIAL 500 IU/GM 0.9 grams per packet/144 packets per box

1111727 DENTAL ANESTHETIC 20% Benzocaine 0.75 grams per packet/75 packets per box

810181 d/c'd repl acement 1257996

DERMATOLOGICAL

20% Benzocaine/1% Menthol

0.6 mL per ampule/10 ampules per box

121158 DERMATOLOGICAL 20% Benzocaine/1% Menthol

0.6 mL per ampule/10 ampules per box

135754 TOPICAL ANTISEPTIC 10% Benzoin Tincture 0.6 mL per ampule (2/3 mL), 40 ampules per box

1117102 CORTICOSTERIODS

TOPICAL

0.1 percent (%) 15 grams per tube

850077 TOPICAL SKIN

PROTECTANT

8% Calamine/ 8% Zinc Oxide

6 fl. oz per bottle

919150

TOPICAL SKIN

PROTECTANT

1% pramoxine hydrochloride/0.1% Zinc

Acetate 6 fl. oz per bottle

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

INTRAMUSCULAR (IM) INTRADERMAL (ID)/INTRAVENOUS (IV) SUBCUTANEOUS (SQ,) MEDICATIONS FLUID RESUSCITATION promethazine hcl - HIGH

ALERT MED

INJECTABLE

sodium chloride 0.9% intravenous solution (normal saline) INTRAVENOUS sodium chloride 0.9% intravenous solution (normal saline) INTRAVENOUS sodium chloride INTRAVENOUS

SUMAtriptan succinate INJECTABLE (Subcutaneous)

TOPICALS AND IRRIGATION

diclofenac sodium gel 1% GEL bacitracin zinc OINTMENT bacitracin zinc OINTMENT benzocaine GEL benzocaine/menthol SWABS/ AMPULE benzocaine/menthol SWABS/ AMPULE benzoin tincture, compound SWABS/ AMPULE betamethaosone valerate CREAM calamine/ zinc oxide LOTION caladryl clear LOTION

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

81473 ANTI-INFECTIVE AGENTS 4% Chlorhexidine gluconate

4 fl. oz per bottle

807853 TOPICAL SKIN BARRIER 0.36mL 0.36mL per applicator, 12 applicators per box

1174598 LOCAL ANESTHETIC

TOPICAL

1% Dibucaine 28 grams per tube

436675 ALLERGIC REACTION 1% Diphenhydramine HCL 1 oz per tube

1188885 OPTHALMALIC

IRRIGATION

98.3% purified water 4 oz per bottle

1057131 CORTICOSTERIODS

TOPICAL

0.05% fluocinonide 15 grams per tube

796007 LOCALIZED RASH 1% Hydrocortisone 0.9 gram per packet / 144 packets per box

852692 LOCALIZED RASH 1% Hydrocortisone 1 oz tube

141564 TOPICAL ANTISEPTIC 3% 4 oz per bottle, 24 bottles per case

470440 ANTISPETIC 5% Iodoform 5 yards per bottle

1029889 TOPICAL ANTISEPTIC 3.5 percent (%) 3mL per packet, 100 packets per box

830993 ANTI-FUNGAL CREAM 2 percent (%) 5 gram individual packet/144 per box

1016329 ANTIBACTERIAL/DERMAT

OLOGICAL

2 percent (%) 22-gram tube

386810

ANTIBIOTIC

COMBINATION

3.5 mg Neomycin /5,000 IU Polymyxin B, 400 IU Bacitracin per gram

0.5 oz tube/ 6 tubes per pack

769307

ANTIBIOTIC

COMBINATION

3.5 mg Neomycin /5,000 IU Polymyxin B, 400 IU Bacitracin per gram

0.9 grams per packet, 144 packets per box

234397 ANTI-BACTERIAL 1% Silver Sulfadiazine 20 grams tube

1184125 CAUSTIC 75%/25% 100 vials

520118 IRRIGATION SOLUTION 0.9% Sodium Chloride 250 mL per bottle

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

TOPICALS AND IRRIGATION

chlorhexidine gluconate (surgical scrub hibiclens)

LIQUID

dermabond skin adhesive (2-octyl cyanoacrylate)

ADHESIVE

dibucaine ointment 1% OINTMENT diphenhydramine 1% CREAM eye wash, buffer, sterile, iso, saline LIQUID fluocinonide .05% CREAM hydrocortisone 1% CREAM hydrocortisone 1% CREAM hydrogen peroxide LIQUID iodoform 1/4 wound packing strips STRIPS menthol 3.5 % topical gel GEL miconazole nitrate 2% CREAM mupirocin OINTMENT neomycin/polymyxin b/bacitracin OINTMENT neomycin/polymyxin b/bacitracin OINTMENT silver sulfadiazine 1% CREAM silver nitrate sticks STICK sodium chloride irrigation 0.9% LIQUID

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

161735 IRRIGATION SOLUTION 0.9% Sodium Chloride 500 mL per bottle

161734 IRRIGATION SOLUTION 0.9% Sodium Chloride 1000mL per bottle

997422 ANTIFUNGAL TOPICAL 1% 15 grams per tube

689164 ANTIFUNGAL TOPICAL 1% 45 grams per packet

1110249 CORTICOSTERIODS

TOPICAL

0.1 percent (%) 15 grams per tube

865270 ANTI-INFECTIVE AGENTS

TOPICAL

3% Bismuth Tribromophenate

2 x 2-inch gauze square, 25 gauze squares per box

865271

ANTI-INFECTIVE AGENTS

TOPICAL

3% Bismuth Tribromophenate

4 X 4 inch gauze square, 25 gauze squares per box

1129811 CERUMEN (EAR WAX)

IMPACTION

6.5% carbamide peroxide 15mL per bottle

575831 or 1050950 d/c'd

CERUMEN (EAR WAX)

IMPACTION 6.5% carbamide peroxide 15mL per bottle

533185 OPHTHALMIC

ANTIBIOTIC

5mg/gram 0.5%-gram tube

3.5-gram tube

767037 ANTIHISTAMINE 60mg 12 per box

761236

OPHTHALMIC DIAGNOSTIC

PRODUCTS 1mg 1mg per strip, 100 strips per box

798118

OPHTHALMIC DIAGNOSTIC

PRODUCTS 1mg 1mg per strip, 300 strips per box

721880 NASAL STEROID 50 mcg 16-gram bottle

1066698 LUBRICANT FOR

NOSTRILS

50 mcg lubericating jelly 3 grams per packet 144 packets per box

1172403 OTIC ANTIBIOTIC 0.3 percent (percent) 5ml bottle

1104711 OPHTHALMIC

ANTIHISTAMINE

0.1% Olopatadine HCL 5 mL per bottle

525939 OPHTHALMIC

ANTIBIOTIC

10,000/ml 0.1gtts 10ml bottle

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

TOPICALS AND IRRIGATION

sodium chloride irrigation 0.9% LIQUID sodium chloride irrigation 0.9% LIQUID tolnaftate CREAM tolnaftate POWDER triamcinolone acetonide CREAM xerofoam petrolatum dressing 2 x 2 inch

GAUZE DRESSING

xerofoam petrolatum dressing 4x 4 inch

GAUZE DRESSING

EARS, EYES, AND NOSE

carbamide peroxide otic 6.5% LIQUID carbamide peroxide otic 6.5% LIQUID erythromycin OINTMENT fexofenadine (allegra®) TABLET fluorescein sodium STRIPS fluorescein sodium STRIPS fluticasone - propionate LIQUID lubricant, surgical, sterile LUBRICATING

JELLY

ofloxacin drops DROPS olopatadine hcl LIQUID ophthalmic polymyxin b sulfate/trimethoprim (polytrim)

DROPS

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

1125414 479744

DECONGESTANT 0.05% 1 oz bottle

256783 EYE LUBRICANT /

ARTIFICIAL TEARS

1.4% Polyvinyl Alcohol 0.01 fl oz per single- use container /50 per box

1103954

MISCELLANEOUS EENT

DRUGS - NASAL DECONGESTANT 0.6% Povidone 44 mL per bottle

552028 discontinued

MILD EYE ITCHING, REDNESS,

IRRITATION 0.5% Tetrahydrozoline 15mL per bottle replacement 1245002 currently on b.o.

MILD EYE ITCHING, REDNESS,

IRRITATION

0.5% Tetrahydrozoline 15mL per bottle

677862 replacement

MILD EYE ITCHING,

REDNESS, IRRITATION

0.5% Tetrahydrozoline 15mL per bottle

1041544 OPHTHALMIC LOCAL

ANESTHETICS

0.50% 15mL per bottle 12 bottles per box

874444

GASTROINTESTINAL AGENTS

ANORECTAL

PREPARATIO

25mg 25mg per suppository, 12 suppositories per box

564474 ANTI-FUNGAL-Vaginal 2 percent (%) 100mg Cream

7 doses/tube

775102 CATHARTICS & LAXATIVES 19 grams Monobasic Sodium Phosphate / 7 grams

Dibasic Sodium Phosphate

4.5 oz per enema, one enema

776922 CATHARTICS & LAXATIVES 19 grams Monobasic Sodium Phosphate / 7 grams Dibasic Sodium Phosphate

7.8 oz per enema, one enema

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

EARS, EYES, AND NOSE

oxymetazoline (Afrin) SPRAY polyvinyl alcohol/povidone DROPS sodium choloride nasal solution NASAL SPRAY tetrahydrozoline hcl ophth sol,0.05%, DROPS tetrahydrozoline hcl ophth sol,0.05%, DROPS tetrahydrozoline hcl ophth sol,0.05%, DROPS tetracaine hcl LIQUID

SUPPOSITORIES AND ENEMAS

hydrocortisone acetate rectal suppository

SUPPOSITORY

miconazole nitrate 2% VAGINAL

SUPPOSITORY

monobasic sodium phosphate / dibasic sodium phosphate ENEMA

ENEMA

monobasic sodium phosphate / dibasic sodium phosphate enema

ENEMA

STRENGTH

(ml,mcg,mg,gm, etc.)

UNIT DOSE QUANTITY PER PACKAGE

VACCINES

772679

PREVENTATIVE

VACCINATION FOR

HEPATITIS A VIRUS

1440 EL.U./mL 1 mL per SDV / 10 SDV per box

769341

PREVENTATIVE

VACCINATION FOR

HEPATITIS B VIRUS

20 mcg/mL 1 mL per SDV / 10 SDV per box

Seasonal PREVENTATIVE FOR

INFLUENZA

0.5 mL 10 dose multi-dose vial per manufacturer availability

795825 PREVENTATIVE FOR

TETANUS

5Lf (T) -2Lf (d) 0.5mL per SDV / 10 SDV per box

562083 PREVENTATIVE FOR TETANUS,

WHOOPING COUGH

5Lf (T) -2Lf (d)-2.5mcg (PT)

0.5 mL

0.5mL per SDV /5 SDV per box OR 10 SDV per box

162671

SCREENING FOR TUBERCULOSIS

EXPOSURE 5 units (TU) / 0.1 mL

0.1 mL per dose /10 doses per 1mL vial / 50 doses per 5mL vial

530841

PREVENTATIVE AGAINST

TYPHOID FEVER 25mcg/0.5mL

0.5mL pre-filled syringe / OR one 20-dose vial (10mL)

Unavailable PREVENTATIVE YELLOW

FEVER VIRUS

4.74 log 10 PFU 0.5mL per SDV /5 SDV per box OR one 5- dose vial per box

GENERIC NAME FORM (Tablet, Cream, Serum, Injectable, etc.)

hepatitis a vaccine INJECTABLE

Engerix-B® hepatitis b vaccine INJECTABLE yellow fever INJECTABLE influenza virus vaccine INJECTABLE tetanus-diphtheria toxoid (Td) INJECTABLE tetanus-diphtheria toxoid with acellular pertusis (Tdap)

INJECTABLE

tuberculin purified protein derivative PPD (mantoux) INJECTABLE typhoid vi polysaccharide vaccine INJECTABLE

Table 1