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Pharmacy formulary – eff

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Pharmacy Formulary
340B Pharmaceutical Assistance for Migrant & Seasonal Farmworkers
NC Farmworker Health Program (NCFHP)
Updated 09/15/2013

REMINDERS: Prescribe or dispense the drug form, dosage, and type (generic vs. name
brand) AS IT APPEARS on the formulary. In most cases the generic form is the lowest-
priced version of a medication but there are some exceptions, with the name-brand
having a 340B price lower than generics. If you need to prescribe or dispense a drug or
dosage not listed on the formulary, please NOTIFY your local health outreach staff.

Drug Name
Drug Category
Drug Class
Anti-microbials
Antibiotics
Amoxicillin (tabs/caps, liquid) Augmentin (500 & 875mg tabs & 400/5, 600/5 Susp) Azithromycin (250mg) Ceftin (500mg) Cephalexin (tabs/caps, liquid) Ciprofloxacin (500mg tabs) Clarithromycin (500mg IR dosing only) Clindamycin (caps only) Dicloxacillin (caps only) Doxycycline (tabs only) Erythromycin (tabs/caps, liquid, opth) Gentamicin (opth only) Nitrofurantoin (100mg BID dosing only) Omnicef 125/5ml liquid Penicillin (tabs, liquid) Rocephin (inj) Septra ( DS tabs and liquid) Tetracycline (caps only) Antifungals
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Anti-microbials
Antifungals (cont.) Terazol-7 vaginal
Anthelmintics
Antivirals
Acyclovir (caps only) Amantadine Tamiflu (pills/liquid) Cardiovascular
Anti-anginals
Beta Blockers
Atenolol (90 day supply allowed per co-pay) Carvedilol (Coreg) Labetalol (100mg, 200mg) Metoprolol (tabs/caps) Propranolol (tabs/caps) Calcium Channel
Blockers
ACE inhibitors
Antihypertensives/ Clonidine (tabs/caps)
Combination
Products
Hydralazine (tabs/caps) Lisinopril Lisinopril/HCTZ Methyldopa Diuretics
Furosemide (90 day supply) (tabs/caps) HCTZ (90 day supply) Spironolactone (tabs/caps) Triamterene/HCTZ (90 day supply) Antiarrhythmics
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hyperlipidemics
Cardiovascular
Drugs (cont.)
hyperlipidemics
Oral anticoagulant Warfarin
CNS Agents
Anticonvulsants
Carbamazepine (tabs/caps) Gabapentin (tabs/caps) Phenobarbital (tabs/caps) Phenytoin (tabs/caps) Valproic Acid (250mg) Benzodiazepines
Clonazepam (0.5mg and 1mg) Diazepam (tabs) Lorazepam (tabs/caps) Tricyclic
antidepressants
antidepressants
Citalopram Fluoxetine Paroxetine Trazodone Zoloft (Sertraline )(50mg and 100mg) Antipsychotic/
Anxiolytics
Chlorpromazine (tabs) Haloperidol (tabs) Lithium (tabs/caps) Sedative/Hypnotics Zolpidem (Ambien) 5mg and 10mg
Stimulants
Adderall 5mg (immediate release only) Methylphenidate (immediate release only) Page 4 of 15
Antiparkinsons
Sinemet (immediate release only) Trihexyphenidyl (tabs) CNS Agents
Narcotic analgesics Acetaminophen w/ codeine
(tabs/caps) Hydrocodone/APAP (5/500) Hydrocodone/APAP ES (7.5/750) Analgesics
Diclofenac Sulindac (150 and 200mg tabs/caps) Toradol (in-clinic injection only) Cold,Cough,
Anaphylaxis
injector/Epipen) Epinephrine 0.15mg (auto-injector/Epipen Jr.) Antitussive/
expectorant
Mucinex-DM Tessalon perles Tussionex (limit 120ml/dispensing) Antihistamines
Cetirizine (10mg tabs) Hydroxyzine (tabs, liquid) Loratadine (tabs/caps, liquid) Meclizine (tabs) Antihistamine/
decongestant
(liquid,syrup,tabs/caps) Triprolidine/pseudoephedrine (liquid, syrup, tabs) Decongestant/
expectorant
Diabetic agents
Lantus (100U/vial) Novolin N Novolin R Novolin 70/30 pre-mix Humalog Oral Diabetic
Glyburide Metformin (500mg/1000mg) Page 5 of 15
Glucose elevating
Dextrose (tabs/ inj – office use only) Diabetic supplies
Strips (Prodigy, TrueTest, or TrueTrack) Antidiarrheals
Loperamide (Imodium) (tabs/caps, liquid) Lomotil Laxatives
Polyethylene Glycol/Miralax (limit 1 bottle/copay) Golytely (1 time use bottles) Lactulose Acid lowering
agents/ulcer
protectants
Prevacid Ranitidine (tabs) Sucralfate (tabs only) Antispasmodic
Bentyl 10mg and 20mg Donnatal (tabs and liquid) Antiemetics
Meclizine (tabs/caps) Metoclopramide (tabs) Promethazine (tabs and supp) Anorectal
Anusol HC cream (2.5%) Anusol HC suppositories Genitourinary
Hormones
Adrenal steroids
Prednisone Prednisolone liquid Solu-medrol (INJ ONLY) Page 6 of 15
Hormones (cont.)
BCPs (cont.)
Menest (60 day supply) Premarin vaginal cream Provera (60 day supply) Cancer tx
Thyroid agents
Musculoskeletal
Ibuprofen (600 and 800mg tabs/caps) Indomethacin (tabs/caps) Meloxicam (Mobic) (tabs) Naproxen (tabs) Sulindac (150 and 200mg tabs) Gout therapy
Allopurinol (60 day supply) Probenecid Indomethacin (tabs/caps) Prednisone Muscle relaxants
Cyclobenzaprine Diazepam (tabs) Methocarbamol (tabs) Page 7 of 15
Opthalmics
Anti-infective
Bacitracin/polymixin B (oint, drops) Ciprofloxacin (drops, sol) Cortisporin opth (susp) Erythromycin (oint) Gentamicin (drops) Ocuflox (drops, sol) Polymyxin/trimethoprim (drops, sol) Sulfacetamide (oint, drops) Respiratory
Respiratory
Asthma (cont.)
QVAR (HFA/inhaler) Albuterol (neb ONLY) Serevent diskus Theophylline (tabs/caps) Nasal steroid
Nicotine
Cessation
Replacement
Benzoyl peroxide 10% gel, 10% cream Clindamycin 1% topical sol Erythromycin 2% topical gel Retin-A cream/gel Antibiotics
Antifungal
Ketoconazole 2% cream and shampoo Miconazole (cream, oint) Nystatin cream and oint Selenium sulfide (cream, oint) Corticosteroids
Clobetasol (Temovate) cream and oint Hydrocortisone 2.5% cream Page 8 of 15
Triamcinolone (0.1% and 0.5% cream) Triamcinolone 0.1% dental paste Pediculocides/
scabicides
Keratolytics
Moisturizers
Combinations
Vitamins/Minerals
Vitamins/Minerals
Infant vitamin drops One a day MVI Prenatal vitamins (limit #100/copay) Page 9 of 15
Alphabetical Listing
Drug Name
Drug Category
Drug Class
Augmentin (500 & 875mg tabs & 400/5, Vitamins/Minerals -
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Dextrose (tabs/ inj – office use only) Page 11 of 15
Vitamins/Minerals -
Vitamins/Minerals -
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Loperamide (Imodium) (tabs/caps, liquid) Methylphenidate (immediate release only) TrueTrack, TrueTest) Mucinex-D (600mg/60mg) (limit 18/co- Page 13 of 15
Vitamins/Minerals -
Vitamins/Minerals -
Page 14 of 15
Strips (Prodigy, TrueTest, or TrueTrack) Page 15 of 15

Source: http://www.ncfhp.org/Data/Sites/1/ncfhp-pharmacy-formulary_09_15_-13-w-alphbet-list.pdf

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