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Dhs _primary care formulary_list september 12 2011.xlsx

DHS PRIMARY CARE FORMULARY‐ NOV 2011 ‐ BY DRUG NAME
Bolded and italicized denote Patient Assistance Program (PAP) availability

Additional
Medication Therapeutic
PAP Availability
Information
Acetaminophen/ Butalbital/ Caffeine (Fioricet) Acetaminophen/ Hydrocodone 325mg/10mg (Norco) Arthritis & Pain Acetaminophen/ Oxycodone 325/5mg (Percocet) Acetaminophen/Codeine 300mg/30mg (Tylenol #3) tabletAcetaminophen/Hydrocodone 500mg/5mg (Vicodin) Amphetamine/ Dextroamphetamine Salts 5mg tab Antipyrine/Benzocaine (Auralgan) otic solution Aspirin 325mg (with or w/o enteric coating) Aspirin 81mg (with or w/o enteric coating) Connection to Care
Atorvastatin 80mg tablet
Cholesterol
1
NO
Pfizer
Bacitracin, neomycin, polymyxin B ointment/cream Bismuth Subsalicylate (Pepto-Bismol) 262mg/15mL Bismuth Subsalicylate (Pepto-Bismol) 262mg tablet Blood Glucose Meter
Diabetes
                  PAP Legend: 1=Very Accessible, no SSN required 2=Accessible requires SSN  3=Less Accessible, requires SSN and additional information DHS PRIMARY CARE FORMULARY‐ NOV 2011 ‐ BY DRUG NAME
Bolded and italicized denote Patient Assistance Program (PAP) availability

Additional
Medication Therapeutic
PAP Availability
Information
Calcium Carbonate 600mg +Vitamin D 400 Units Carbamide Peroxide (Debrox) 6.5% Otic drop Chlorhexidine Gluconate 0.12% oral solution BMS Patient Assistance
Clopidogrel 75mg tablet
Heart Health & Blood Pressure
1
YES
Foundation
Colchicine/ probenecid 0.5mg/500mg tablet Abbott Patient
Divalproex ER 250mg tablet
Anticonvulsant
3
YES
Assistance Foundation
Abbott Patient
Divalproex ER 500mg tablet
Anticonvulsant
3
YES
Assistance Foundation
1
YES
Ergocalciferol 50,000 International Units Estrogen conjugated 0.3mg tablet
Women's Health
Pfizer
1
NO
                  PAP Legend: 1=Very Accessible, no SSN required 2=Accessible requires SSN  3=Less Accessible, requires SSN and additional information DHS PRIMARY CARE FORMULARY‐ NOV 2011 ‐ BY DRUG NAME
Bolded and italicized denote Patient Assistance Program (PAP) availability

Additional
Medication Therapeutic
PAP Availability
Information
Estrogen conjugated 0.625mg tablet
Women's Health
Pfizer
1
NO
Estrogen conjugated 0.625mg/gm vaginal cream Wyeth Pharmaceutical
Estrogen conjugated/Medroxyprogesterone
Women's Health
Patient Assistance
0.3/1.5mg tablet (Prempro)
Foundation
1
NO
Wyeth Pharmaceutical
Estrogen conjugated/Medroxyprogesterone
Women's Health
Patient Assistance
0.625/2.5mg tablet (Prempro)
Foundation
1
NO
Wyeth Pharmaceutical
Estrogen conjugated/Medroxyprogesterone
Women's Health
Patient Assistance
1
NO
0.625/5mg tablet
Foundation
Merck Patient
Ezetimibe 10mg tablet
Cholesterol
2
NO
Assistance Program
Merck Patient
Ezetimibe/Simvastatin 10/20mg tablet
Cholesterol
2
NO
Assistance Program
Merck Patient

Ezetimibe/Simvastatin 10/40mg tablet
Cholesterol
2
NO
Assistance Program
Abbott Patient
Fenofibrate 145mg (Tricor)
Cholesterol
Assistance Foundation
3
YES
Abbott Patient
Fenofibrate 48mg (Tricor)
Cholesterol
Assistance Foundation
3
YES
GlaxoSmithKline Bridges
Fluticasone 50mcg nasal spray
Allergies & Cold and Flu
1
NO
to Access
Guaifenesin/ Dextromethorphan 100mg-10mg/5mL                   PAP Legend: 1=Very Accessible, no SSN required 2=Accessible requires SSN  3=Less Accessible, requires SSN and additional information DHS PRIMARY CARE FORMULARY‐ NOV 2011 ‐ BY DRUG NAME
Bolded and italicized denote Patient Assistance Program (PAP) availability

Additional
Medication Therapeutic
PAP Availability
Information
Hydrocortisone 2.5% Rectal Cream (Proctozone HC) Other Medical Conditions Sanofi-Aventis U.S.
Insulin glargine 100units/ml vial
Diabetes
10mL
Patient Assistance
1
YES
Program
Insulin NPH/Regular 70/30 100units/ml vial Boehringer Ingelheim
Ipratropium HFA 17mcg inhaler
Asthma/COPD
12.9gm
1
YES
Cares Foundation, Inc.
GlaxoSmithKline Bridges
Lamotrigine 100mg tablet
Anticonvulsant
1
NO
to Access
GlaxoSmithKline Bridges
Lamotrigine 25mg tablet
Anticonvulsant
1
NO
to Access
Diabetes
Magnesia) oral suspensionMagnesium hydroxide/ aluminum hydroxide/                   PAP Legend: 1=Very Accessible, no SSN required 2=Accessible requires SSN  3=Less Accessible, requires SSN and additional information DHS PRIMARY CARE FORMULARY‐ NOV 2011 ‐ BY DRUG NAME
Bolded and italicized denote Patient Assistance Program (PAP) availability

Additional
Medication Therapeutic
PAP Availability
Information
Merck Patient
Mometasone/Formoterol (Dulera) 100mcg/5mcg
Asthma/COPD
13Gm
2
YES
Assistance Program
Merck Patient
Mometasone/Formoterol (Dulera) 200mcg/5mcg
Asthma/COPD
13Gm
2
YES
Assistance Program
Merck Patient
Montelukast 10mg tablet
Asthma/COPD
2
NO
Assistance Program
(MS Contin) 60mgMorphine Sulfate Extended-Release (MS Contin) 15mgMorphine Sulfate Extended-Release (MS Contin) 30mg Naphazoline HCl 0.025%/ Pheniramine Maleate Niacin-controlled released (Slo Niacin) 500mg tablet Nystatin/Triamcinolone cream/ointment (Mycolog II)                   PAP Legend: 1=Very Accessible, no SSN required 2=Accessible requires SSN  3=Less Accessible, requires SSN and additional information DHS PRIMARY CARE FORMULARY‐ NOV 2011 ‐ BY DRUG NAME
Bolded and italicized denote Patient Assistance Program (PAP) availability

Additional
Medication Therapeutic
PAP Availability
Information
Takeda Pharmaceuticals
Pioglitazone 15mg tablet
Diabetes
America Patient
1
YES
Assistance Program
Polymyxin Sulfate/TMP (Polytrim) ophthalmic solution Glaucoma & Eye Care Merck Patient
Rizatriptan 10mg
CNS Agents/ Sedative Hypnotic
2
YES
Assistance Program
Sulfacetamide Sodium 10% ophthalmic solution Tobramycin/ Dexamethasone ophthalmic drop                   PAP Legend: 1=Very Accessible, no SSN required 2=Accessible requires SSN  3=Less Accessible, requires SSN and additional information DHS PRIMARY CARE FORMULARY‐ NOV 2011 ‐ BY DRUG NAME
Bolded and italicized denote Patient Assistance Program (PAP) availability

Additional
Medication Therapeutic
PAP Availability
Information
Triamterene/HCTZ 37.5/25mg capsule/tablet                   PAP Legend: 1=Very Accessible, no SSN required 2=Accessible requires SSN  3=Less Accessible, requires SSN and additional information

Source: http://ladhs.com/wps/PA_1_QDN2DSD3005DD02DJ6VQC830G3/DhsSite/AmbulatoryCare/pdf/DHS_Primary_Care_Formulary_List.pdf

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