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Cleveland pharmacy formulary

CLEVELAND COUNTY EMPLOYEE PHARMACY PROGRAM- CATEGORY I FORMULARY
NO CHARGE FOR INSURED EMPLOYEES/SPOUSES AND DEPENDENTS
***NOTE: FORMULARY SUBJECT TO CHANGE BASED ON DRUG COST AND AVAILABILITY***

1. ANTIBIOTICS/ ANTIFUNGALS/ ANTIVIRALS
 PENICILLIN VK LIQUID 250MG/5ML, 250MG AND 500MG TABS
 AMOXICILLIN LIQUID 200MG/5ML, 400MG/5ML, 250MG, 500MG CAPS and 875MG TABS
 AMOXICILLIN/POT CLAV 200 MG/28.5MG/5ML AND 400MG/57MG/5ML SUSPENSION
 AMOXICILLIN/POT CLAV ES 600MG/42.9MG/5ML SUSPENSION
 AMPICILLIN 500MG CAPS
 AZITHROMYCIN 250MG-5 DAY PACKS AND 500MG- 3 DAY PACKS, SUSPENSION
 CEFADROXIL 500MG CAPS
 CEFUROXIME (CEFTIN) 500MG TABS
 CEPHALEXIN SUSPENSION 250MG/5ML
 CEPHALEXIN 250MG AND 500MG CAPS
 CIPROFLOXACIN 500MG TABS
 CLINDAMYCIN 150MG CAPS
 TRIMETHOPRIM/SULFA (SEPTRA,BACTRIM) DS TABS, SUSPENSION
 DOXYCYCLINE 50MG TABS AND 100MG TABS AND CAPS
 ERYTHROMYCIN STEARATE 250MG TABS
 NITROFURANTOIN (MACRODANTIN) 50MG CAPS (UTI PROPHYLAXIS)
 METRONIDAZOLE 500MG TABS
 NYSTATIN ORAL SUSPENSION
 FLUCONAZOLE 100MG, 150MG, AND 200MG TABS
 KETOCONAZOLE 200MG TABS
 ACYCLOVIR 400MG AND 800MG TABS
 FAMCICLOVIR 500MG TABS
2. BLOOD MODIFIERS
 DIPYRIDAMOLE 25MG AND 75MG TABS  ASPIRIN 81MG EC TABS, EC 325MG TABS  PHENTOXIFYLLINE ER 400MG TAB  CLOPIDOGREL (PLAVIX) 75MG TABS  WARFARIN 1MG, 2MG, 2 1/2MG, 3MG, 5MG, 7.5MG 3. LIPID LOWERING AGENTS
 FISH OIL 1000MG CAPS
 GEMFIBROZIL 600MG TABS
 NIACIN TIMED-RELEASE 500MG TABS
 LOVASTATIN (MEVACOR) 10MG, 20MG, AND 40MG TABS
 SIMVASTATIN (ZOCOR) 10MG, 20MG, 40MG, AND 80MG TABS
 PRAVASTATIN (PRAVACHOL) 20MG AND 40MG TABS
 ATORVASTATIN (LIPITOR) 10MG, 20MG, 40MG, AND 80MG TABS
4. CARDIAC DRUGS AND ANTIHYPERTENSIVES
 DIGOXIN 0.125MG AND 0.25MG TABS  AMIODARONE 200MG TABS  SOTALOL 80MG TABS  FLECAINIDE ACETATE 100MG AND 150MG TABS B. DIURETICS  HCTZ (HYDROCHLOROTHIAZIDE) 12.5MG CAPS, 25MG AND 50MG TABS  SPIRONOLACTONE 25MG AND 100MG TABS  FUROSEMIDE 20MG AND 40MG TABS  TRIAMTERENE/HCTZ 37.5/25MG AND 75/50MG TABS  INDAPAMIDE 1.25MG AND 2.5MG TABS  METOLAZONE 2.5MG TABS C. BETA BLOCKERS  PROPRANOLOL 10MG, 20MG, 40MG, ER 60MG, ER 80MG, ER 120MG  METOPROLOL 25MG AND 50MG TABS  ATENOLOL 25MG AND 50MG TABS  NADOLOL 20MG AND 80MG TABS  BISOPROLOL 5MG AND 10MG TABS D. CALCIUM CHANNEL BLOCKERS  VERAPAMIL 120MG SR CAPS, 180MG SR AND 240MG SR TABS  AMLODIPINE 2.5MG, 5MG, AND 10MG E. CENTRALLY ACTIVE AGENTS AND VASODILATORS  CLONIDINE 0.1MG AND 0.2MG TABS  HYDRALAZINE 10MG, 25MG, AND 50MG TABS  METHYLDOPA 250MG AND 500MG TABS  TERAZOSIN 1MG, 2MG, 5MG, AND 10MG CAPS  DOXAZOSIN 2MG AND 4MG TABS F. ACE INHIBITORS  CAPTOPRIL 25MG AND 50MG TABS  ENALAPRIL 2.5MG, 5MG, 10MG, AND 20MG TABS  LISINOPRIL 5MG , 10 MG, AND 20MG TABS  BENAZEPRIL 10MG, 20MG, AND 40MG TABS  RAMIPRIL 5MG AND 10 MG CAPSULES G. ANGIOTENSIN II RECEPTOR ANTAGONISTS  LOSARTAN 25MG, 100MG TABS  LOSARTAN/ HCTZ 50/12.5MG, 100/12.5MG, 100/25MG TABS H. ANTI-ANGINALS  ISOSORBIDE MONONITRATE ER 30MG AND 60MG TABS  NITROGLYCERIN SUBLINGUAL 0.4MG TABS  NITROGLYCERIN 0.4MG/HR TRANSDERMAL PATCHES I. ANTIHYPERTENSIVE COMBINATIONS  BISOPROLOL/HCTZ 2.5/6.25MG, 5/6.25MG, 10/6.25MG TABS  LISINOPRIL/HCTZ 10/12.5MG TABS J. APLHA/BETA ADRENERGIC BLOCKING AGENTS  LABETALOL 200MG TABS  CARVEDILOL 3.125 MG, 6.25MG, 12.5MG, AND 25MG TABS  IBUPROFEN 600MG AND 800MG TABS
 NAPROXEN 375MG AND 500MG TABS
 INDOMETHACIN 25MG AND 50MG CAPS
 DICLOFENAC SODIUM 50MG, 75MG AND 100MG ER TABS
 MELOXICAM 7.5MG AND 15MG TABS
 ETODOLAC 400MG TABS
 UTI ANALGESIC- PHENAZOPYRIDINE 200MG TABS
 TRAMADOL HCL 50MG TABS
 TRAMADOL/ACETAMINOPHEN 37.5MG/325MG TABS
 ACETAMINOPHEN W/CODIENE 300MG/30MG TABS (GENERIC TYLENOL #3)
 HYDROCODONE/ACETAMINOPHEN 5/325MG, 7.5/325MG, AND 10/325MG TABS
 BULTALBITAL/ACETAMINOPHEN/CAFFEINE 50/325/40MG TABS (GENERIC FIORICET)
6. ANTICONVULSANTS
 CARBAMAZEPINE 200MG TABS
 GABAPENTIN 100MG, 300MG, 400MG CAPS AND 600MG, 800MG TABS
 PRIMIDONE 50MG TABS
 ZONISAMIDE 100MG CAPS
 OXCARBAZEPINE 300MG TABS
 LAMOTRIGINE 200MG TABS
 TOPIRAMATE 25MG, 50MG, AND 100MG TABS
 DIVALPROEX SODIUM ER 250MG AND DR 500MG TABS
7. ANTIDEPRESSANTS/ ANTIPSYCOTICS
 AMITRIPTYLINE 10MG, 25MG, AND 50MG TABS  IMIPRAMINE 25MG AND 50 MG TABS  TRAZODONE 50MG, 100MG, AND 150MG TABS  PAROXETINE 20MG, 40MG TABS  NORTRIPTYLINE 25MG AND 50MG CAPS  DOXEPIN 25MG AND 50MG CAPS  FLUOXETINE (PROZAC) 10MG TABS AND 20MG CAPS  CITALOPRAM (CELEXA) 10MG, 20MG, AND 40MG TABS  ESCITALOPRAM (LEXAPRO) 10MG AND 20MG TABS  SERTRALINE (ZOLOFT) 50MG AND 100MG TABS  VENLAFAXINE (EFFEXOR) 37.5MG ER, 75MG ER, AND 150MG ER CAPS  BUPROPION (WELLBUTRIN) SR 150MG TABS  RISPERIDONE 2MG TABS  OLANZAPINE 7.5 MG TABS
8. ANTIANXIETY/ SLEEP
 HYDROXYZINE PAMOATE 25MG CAPS  BUSPIRONE 10MG TABS  ALPRAZOLAM 0.5MG AND 1MG TABS  CLONAZEPAM 0.5MG, 1MG, 2MG TABS  LORAZEPAM 1MG TABS  DIAZEPAM 5MG AND 10MG TABS  ZOLPIDEM 5MG AND 10MG TABS 9. OPHTHALMIC/ OTIC MEDS
 SULFACETAMIDE 10%/ PREDNISOLONE 0.2% OPHTH OINTMENT (BLEPHAMIDE) 3.5GM  GENTAMYCIN 0.3% OPHTH SOLUTION 5ML  ERYTHROMYCIN 0.5% OPHTH OINTMENT 3.5GM  TOBRAMYCIN OPHTH SOLN 0.3% 5ML  TIMOLOL MALEATE OPHTH SOLN 0.5% 5ML  PREDNISOLONE ACETATE 1% OPHTH SOLN 5ML  KETOTIFEN 0.025% OPHTH SOLN (ZADITOR, ALAWAY) 5ML  FLUOROMETHOLONE 0.1% OPHTH SOLN 5ML  FLUOROMETHOLONE 0.1% OPHTH OINTMENT 3.5GM  LATANOPROST (XALATAN) 0.005% OPHTH SOLN 2.5ML  CORTISPORIN OTIC SUSPENSION OR EQUIVALENT 10ML  CORTISPORIN OTIC SOLUTION OR EQUIVALENT 10ML  OFLOXACIN (FLOXIN) 0.3% OTIC SOLUTION  ANTIPYRINE/BENZOCAINE (SIMILAR TO AURALGAN) OTIC SOLN 15ML
10. GASTROINTESTINAL
 METOCLOPRAMIDE 10MG TABS  DICYCLOMINE 10MG AND 20MG CAPS  PROMETHAZINE 25MG TABS  ONDANSETRON 4MG, 8MG TABS AND 4MG ODT, 8MG ODT  MECLIZINE 25MG TABS  OMEPRAZOLE 20MG CAPS  PANTOPRAZOLE 40MG TABS  FAMOTIDINE 20MG TABS  RANITIDINE 150MG TABS AND 15MG/ML SYRUP  ANUSOL HC SUPPOSITORY/ GENERIC  BISACODYL 5MG TABS  PEG 3350 (MIRALAX) POWDER FOR SOLUTION 238 GM-14 DOSES (COLONOSCOPY PREP)  COLYTE 4 LITER (COLONOSCOPY PREP)
11. STEROIDS
 PREDNISONE 5MG, 10MG, AND 20MG TABS  PREDNISOLONE 15MG/5ML SYRUP
12. ORAL HYPOGYCEMICS
 GLIPIZIDE 2.5MG, 5MG, AND 10MG TABS  GLIPIZIDE ER 5MG AND 10MG TABS  GLYBURIDE 5MG TABS  METFORMIN 500MG, 850MG, AND 1000MG TABS AND METFORMIN XR 500MG  METFORMIN/GLYBURIDE 2.5/500 AND 5/500 TABS  GLIMEPIRIDE 4MG TABLETS
13. THYROID
 SYNTHROID BRAND 0.025MG, 0.88MG, 0.1MG, 0.112MG, 0.125MG, AND 0.15MG TABS  METHIMAZOLE 10MG TABS
14. TOPICALS/ VAGINAL

 TRIAMCINOLONE 0.1% CREAM, 15 GM, 80GM
 HYDROCORTISONE 1% CREAM 20 GM AND 2.5% 20GM
 CLOTRIMAZOLE CREAM 1% 30GM AND VAGINAL 45GM
 NYSTATIN CREAM 15GM
 MUPIROCIN 2% OINTMENT 22GM
 MOMETASONE FUROATE 0.1% (ELOCON) 45GM
 SILVER SULFADIAZINE CREAM 1% 20GM
 CONDYLOX 0.5% GEL 3.5GM
 FLUTICASONE PROPIONATE 0.05% CREAM (CUTIVATE) 15GM
 FLUOCINONIDE 0.05% OINTMENT (LIDEX) 30GM
 LUBRIDERM ADVANCED SKIN THERAPY LOTION FOR EXTRA DRY SKIN (3 OZ)
 CLOBETASOL 0.05% OINTMENT 45GM
 METRONIDAZOLE 0.75% VAGINAL GEL 70GM
 CLINDAMYCIN 2% VAGINAL CREAM 40GM
15. RESPIRATORY
 ALBUTEROL HFA INHALER (1 INHALER- 60 INHALATIONS)
 ALBUTEROL INHALATION SOLN 0.083% (1 BOX- 25 VIALS)
 IPRATROPIUM BROMIDE 0.02% INHALATION SOLN (1 BOX- 30 VIALS)
 IPRATROPIUM 0.03% AND 0.06% NASAL SPRAY
 SPACER (TO BE USED IN CONJUNCTION WITH INHALER)

16. ANTIHISTAMINES

 HYDROXYZINE HCL 10MG TABS, 25MG TABS, 10MG/ML SYRUP
 DIPHENHYDRAMINE 50MG CAPS
 LORATADINE 10MG TABS
 CETIRIZINE 10MG TABS
 FEXOFENADINE 60MG AND 180MG TABS
 AZELASTINE 137MCG NASAL SPRAY
17. MISCELLANEOUS COUGH AND COLD
 PSEUDOEPHEDRINE 30MG AND 60MG TABS  GUAIFENESIN/CODEINE SYRUP 100MG/10MG- 5ML  GUAIFENESIN 400MG TABS  BENZONATATE 100MG AND 200MG CAPS (GENERIC TESSALON PERLE)  PROMETHAZINE WITH DEXTROMETHORPHAN SYRUP 6.25MG/15MG- 5ML  NEO DM SYRUP: 5ML-DEXTROMETHORPHAN 30MG/PSEUDOEPHEDRINE 50MG/
18. MISCELLANEOUS ARTHRITIC TREATMENTS
 HYDROXYCHLOROQUINE 200MG TABS (PLAQUENIL)
 LEFLUNOMIDE 20MG TABS
 METHOTREXATE 2.5MG TABS
19. MUSCLE RELAXANTS

 CYCLOBENZAPRINE 5MG AND 10MG TABS  TIZANIDINE 2MG AND 4MG TABS
20. HORMONES

 MEDROXYPROGESTORONE 2.5MG, 5MG, AND 10MG TABS  ESTRADIOL 0.5MG AND 1MG TABS  ESTROGENS/ METHYLTESTOSTERONE 1.25/2.5MG AND 0.625/1.25MG TABS (GENERIC 21. VITAMIN/MINERAL SUPPLEMENTS
 FERROUS SULFATE 325MG TABS
 FERRAPLUS 90 TABS
 KCL 10MEQ AND 20MEQ TABS
22. ORAL CONTRACEPTIVES
 AVIANE (GENERIC ALESSE)
 SEASONALE
 MIRCETTE
 LO-OVRAL
 ORTHO TRI CYCLEN
 ORTHO CYCLEN
 ORTHO NOVUM 1/35
 ORTHO NOVUM 777
 YASMIN

23. ANTI-NEOPLASTIC AGENTS
 TAMOXIFEN 20MG TABS
 LETROZOLE (FEMARA) 2.5MG TABS

24. BISPHOSPHONATES

 ALENDRONATE SODIUM 35MG AND 70MG TABS

25. BPH
 FINASTERIDE 5MG TABS
 TAMSULOSIN 0.4MG CAPS
 DOXAZOSIN 2MG AND 4MG TABS
 TERAZOSIN 1MG, 2MG, 5MG, AND 10MG CAPS
26. MIGRAINE
 SUMATRIPTAN (IMITREX) TABS 50MG AND 100MG TABS
27. GOUT

 ALLOPURINOL 100MG AND 300MG TABS
28. INCONTINENCE
 OXYBUTYNIN 5MG TABS

29. RESTLESS LEG SYNDROME
 ROPINIROLE (REQUIP) 0.5MG, 1MG, 2MG, 3MG, 4MG, AND 5MG TABS

Source: http://clevelandcounty.com/cchd/wp-content/uploads/2013/09/Formulary-Category-1.pdf

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