ICE HEALTH SERVICE CORPS

COMMONLY USED DRUGS FORMULARY

Drug Category

Formulary Agents
generics, BRANDS

Non-Formulary Agents
(Not Covered Without Prior Authorization)

ANTI-INFECTIVES
Penicillins
Cephalosporins

Ketolides
Macrolides

amoxicillin, amoxicillin/clavulanate, ampicillin,

dicloxacillin, penicillin-VK, BICILLIN-LA
cefaclor, cefadroxil, cefprozil, cefuroxime axetil,
cephadrine, cephalexin

Quinolones

azithromycin, clarithromycin, clindamycin, ery-tab,

erythromycin base, erythromycin ES
ciprofloxacin, ofloxacin, AVELOX

Tetracyclines

doxycycline, minocycline, tetracycline

Anti-herpetic
Anti-influenza
Antifungals
Antimycobaterial

acyclovir, acyclovir cream, famciclovir

amantadine, rimantadine
fluconazole, griseofulvin, ketoconazole, terbinafine
ethambutol, isoniazid, pyrazinamide, rifampin,
streptomycin
ALL AGENTS ARE ON FORMULARY
metronidazole, sulfamethoxazole/trimethoprim,
mebendazole
nitrofurantoin

Antiretrovirals
Misc. Anti-infectives
Urinary Anti-infective

AMOXIL, AUGMENTIN, AUGMENTIN ES,

AUGMENTIN XR, GEOCILLIN, SPECTROBID
CECLOR-CD, CEDAX, CEFTIN, CEFZIL, DURICEF,
KEFTAB, LORABID, OMNICEF, SPECTRACEF,
SUPRAX, VANTIN
KETEK
BIAXIN, BIAXIN XL, DYNABAC, ERYPED, PCE, TAO,
ZITHROMAX
CIPRO, CIPRO-XR, FLOXIN, LEVAQUIN, MAXAQUIN,
NOROXIN, ZAGAM
ACHROMYCIN-V, ADOXA, DORYX, DYNACIN,
MONODOX, PERIOSTAT
FAMVIR, VALTREX
FLUMADINE, RELENZA, TAMIFLU
DIFLUCAN (QL), LAMISIL, SPORANOX
CAPASTAT, MYCOBUTIN, PRIFTIN, SEROMYCIN,
TRECATOR-SC
FLAGYL, BACTRIM
MACROBID, MACRODANTIN

CARDIOVASCULAR
ACE Inhibitors

benazepril, captopril, enalapril, fosinopril, lisinopril,

quinapril, ramipril

Angiotensin Receptor Blockers

(ARBs)
Anti-hypertensive Combos

losartan, DIOVAN

Beta Blockers

Alpha-Beta Blockers
Calcium Channel Blockers
--Dihydropyridines

Requires Approval

acebutolol, atenolol, betaxolol, bisoprolol, carteolol,

metoprolol, nadolol, pindolol, propranolol, sotalol/-AF,
timolol
carvedilol, labetalol

ACCUPRIL, ACEON, ALTACE, LOTENSIN, MAVIK,

MONOPRIL, PRINIVIL, UNIVASC, VASOTEC,
ZESTRIL
AVAPRO, MICARDIS, TEVETEN
ATACAND-HCT, AVALIDE, BENICAR-HCT, DIOVANHCT, HYZAAR, LISINOPRIL-HCTZ, LOTENSIN-HCT,
LOTREL, MICARDIS-HCT, MONOPRIL-HCT,
PRINZIDE, TARKA, VASERETIC, ZESTORETIC
BETAPACE, BETAPACE-AF, CARTROL, INDERAL
LA, INNOPRAN XL, LEVATOL, , TOPROL XL,
ZEBETA
COREG

HMG-CoA

felodipine, nicardipine, nifedipine, nifedipine XL ,

amlodipine
cartia XT, diltia XT, diltiazem HCl, diltiazem ER,
diltiazem XR, verapamil-SR
clonidine, methyldopa
chlorthalidone, hydrochlorothiazide, bumetanide,
furosemide, triamterene/hydrochlorothiazide,
metolazone, spironolactone
lovastatin, simvastatin, pravastatin, atorvastatin

Cholesterol, other

gemfibrozil, cholestyramine, fenofibrate

Nitrates

isosorbide dinitrate, isosorbide mononitrate,

nitroglycerin SL
digoxin
amiodarone
warfarin
clopidogrel

ISORDIL, IMDUR, NITROSTAT

alprazolam, buspirone, clorazepate, diazepam,

lorazepam, oxazepam, chlordiazepoxide
benztropine

BUSPAR, KLONOPIN WAFER, TRANXENE-SD,

XANAX, XANAX-XR
COGENTIN

clonazepam, carbamazepine, divalproex, gabapentin,

phenytoin, valproic acid, topiramate, levetiracetam

DEPAKOTE, DEPAKOTE ER, DILANTIN, FELBATOL,

GABITRIL, KEPPRA, LAMICTAL, NEURONTIN,
TEGRETOL, TRILEPTAL, ZONEGRAN, KEPPRA XR,
KEPPRA, TOPAMAX

--Non-dihydropyridines
Misc. Anti-hypertensives
Diuretics

Cardiotonics
Anti-arrhythmics
ANTICOAGULANTS
Platelet Aggregation Inhibitors

ADALAT CC, CARDENE SR, DYNACIRC, PLENDIL,

PROCARDIA XL, SULAR, NORVASC
TIAZAC, COVERA-HS, VERELAN-PM
CATAPRES, ALDOMET
EDECRIN, ALDACTONE

ALTOPREV, LESCOL, LESCOL-XR, MEVACOR,

ZOCOR, LIPITOR
ADVICOR, CADUET, TRICOR, WELCHOL, VYTORIN,
ZETIA

LANOXIN
CORDARONE
COUMADIN
PLAVIX

CENTRAL NERVOUS SYSTEM

Antianxiety
Anticholinergic
Anticonvulsants

1
The formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs. Brand name drugs with generic equivalents are considered non-formulary.
Revised 2/5/2013 IHSC Jail Formulary (IGSA) 2.5.2013.doc

Antidepressants
SSRIs

citalopram, fluoxetine, paroxetine, sertraline,

escitalopram

Antidepressants Tricylics
Antidepressants
other
Antiemetics

amitriptyline, doxepin, imipramine, clomipramine,

desipramine, nortriptyline
trazodone, bupropion HCl, bupropion SR, mirtazapine,
nefazodone, venlafaxine
dimenhydrinate, meclizine, promethazine

Antimigraine

sumatriptan

Antipsychotics

chlorpromazine, clozapine, fluphenazine, haloperidol

(including injection), haloperidol decanoate, lithium,
loxapine, perphenazine, risperidone, thioridazine,
thiothixene, trifluoperazine, olanzapine, ziprasidone,
ABILIFY, SEROQUEL, SERENTIL
estazolam, hydroxyzine pamoate, temazepam,
triazolam, phenobarbital
methylphenidate (all oral forms), dextroamphetamine,
ADDERALL XR, CONCERTA, FOCALIN XR,
METADATE-CD, RITALIN LA, STRATTERA

Sedative Hypnotics
Stimulants/ADHD

ASIMIA, CELEXA, PAXIL, PAXIL CR, PEXEVA,

PROZAC, PROZAC-WEEKLY(QL), SARAFEM(QL),
ZOLOFT, LEXAPRO
ELAVIL, SINEQUAN, TOFRANIL, ANAFRANIL,
NORPRAMIN, AVENTYL
CYMBALTA, REMERON, SERZONE, VIVACTIL,
WELLBUTRIN, WELLBUTRIN XL, EFFEXOR XR
ANZEMET(QL), EMEND(QL), KYTRIL(QL),
TRANSDERM-SCOP, ZOFRAN (QL)
AMERGE (QL), AXERT(QL), CAFERGOT, DHE-45,
FROVA (QL), IMITREX(QL), MAXALT(QL), MAXALTMLT(QL), MIDRIN, MIGRANAL(QL), RELPAX(QL),
ZOMIG(QL), ZOMIG ZMT(QL)
FAZACLO, ORAP, RISPERDAL, SYMBYAX,
ZYPREXA, GEODON

AMBIEN, DORAL, LUNESTA, PROSOM, SONATA

pemoline, DEXEDRINE CR, DESOXYN, PROVIGIL

DERMATOLOGIC
Acne Products

benzoyl peroxide, clindamycin lotion, erythromycin

gel, tretinoin

ACCUTANE, BENZACLIN, DIFFERIN, RENOVA,

RETIN-A, RETIN-A MICRO, ZIANA

Agents for Eczema

ELIDEL, PROTOPIC

Anti-infectives

clobetasol, fluocinonide, hydrocortisone,

betamethasone valerate, triamcinolone
gentamicin, metronidazole cream, mupirocin

Anti-fungals
PEDICULICIDES

clotrimazole, nystatin
permethrin cream

MYCELEX, MYCOSTATIN
ELMITE

Antithyroid
Contraceptives, Oral

methimazole, propylthiouracil
Requires Approval

Osteoporosis Agents

alendronate

Estrogens, Oral

PREMARIN

Estrogen combo
Estrogen, topical

Requires Approval
Requires Approval

TAPAZOLE
ALESSE, CYCLESSA, DESOGEN, ESTRASTEP-FE,
LO-OVRAL, LOESTRIN, MICRONOR, MODICON,
NOR-QD, ORTHO-7/7/7, ORTHO-TRI-CYCLEN,
ORTHOCEPT, SEASONALE, TRI-LEVLEN, TRINORINYL, YASMIN
ACTONEL, BONIVA, DIDRONEL, EVISTA, FORTICAL
NASAL SPRAY, FOSAMAX, MIACALCIN NASAL
SPRAY,SKELID
estradiol, estropipate, CENESTIN, STRATAB,
MENEST
ACTIVELLA, FEM-HRT, PREMPHASE, PREMPRO
ALORA, CLIMARA PRO, ESCLIM, ESTROGEL,
ESTRASORB, CLIMARA, MENOSTAR, VIVELLE/DOT

Insulins
Progesterones
Oral Antidiabetic Agents
Sulfonylureas

HUMULIN, HUMALOG, LANTUS, NOVOLOG, NOVOLIN

medroxyprogesterone

BACTROBAN, METROGEL, METROLOTION

ENDOCRINE/HORMONE

Biguanides
Glitazones
Meglitinides
Alpha-glucosidase
inhibitors
Corticosteroids
Thyroid
Testosterones, Topical

glimepiride, glipizide, glipizide ER, glyburide, glyburide

micronized, tolazamide
metformin, metformin ER
pioglitazone, AVANDIA (access restricted)
Requires Approval
Requires Approval

PROMETRIUM
AMARYL, GLUCOTROL XL
FORTAMET, GLUCOPHAGE, GLUCOPHAGE XR,
GLUCOVANCE (combo)
ACTOS
PRANDIN, STARLIX
GLYSET, PRECOSE

prednisone, methylprednisolone, dexamethasone

levothyroxine, thyroid
Requires Approval

DELTASONE, MEDROL, DECADRON

SYNTHROID, ARMOUR THYROID
ANDRODERM, ANDROGEL, STRIANT, TESTIM,
TESTODERM

H2 Antagonists
IBS Agents
Proton Pump Inhibitors

cimetidine, famotidine, ranitidine

Requires Approval
omeprazole, PRILOSEC OTC

Ulcerative Colitis
Antidiarrheal
Antispasmodics
GI Stimulants
Misc. Anti-ulcer

sulfasalazine, mesalamine
diphenoxylate/atropine
dicyclomine, hyoscyamine
metoclopramide
sucralfate

AXID, PEPCID, ZANTAC

LOTRONEX, ZELNORM
ACIPHEX, NEXIUM, PRILOSEC, PREVACID,
PROTONIX
COLAZAL, DIPENTUM, ENTOCORT-EC
LOMOTIL
BENTYL, LEVSIN
REGLAN
CARAFATE

GASTROINTESTINAL

2
The formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs. Brand name drugs with generic equivalents are considered non-formulary.
Revised 2/5/2013 IHSC Jail Formulary (IGSA) 2.5.2013.doc

MUSCULOSKELETAL, ANALGESICS
Opioids, long-acting

Requires Approval

Opioids, short-acting

codeine/acetaminophen, hydrocodone/acetaminophen,
oxycodone/acetaminophen, tramadol
diclofenac, etodolac, ibuprofen, indomethacin/SR,
ketoprofen, ketorolac, meloxicam, nabumetone,
naproxen, naproxen sodium, oxaprozin, piroxicam,
salsalate, sulindac, tolmetin, indomethacin
Requires Approval
baclofen, carisoprodol, cyclobenzaprine,
methocarbamol

NSAIDs

COX-2
Skeletal Muscle Relaxants

methadone, morphine SR, AVINZA, DURAGESIC,

KADIAN, MS CONTIN, ORAMORPH SR, OXYCONTIN
ACTIQ, CAPITOL/CODEINE, NORCO, STADOL NS,
ULTRACET, ULTRAM, VICOPROFEN, DARVOCET-N
ARTHROTEC, DAYPRO, EC-NAPROSYN, LODINE
XL, MOBIC, MOTRIN, NAPRELAN, PONSTEL,
RELAFEN, INDOCIN
CELEBREX
LIORESAL, SOMA, FLEXERIL, ROBAXIN

OPHTHALMICS
Anti-infectives
Agents for allergic conjunctivitis
Agents for glaucoma
Ophthalmic Steroids
Combination Products

ciprofloxacin, gentamicin, sulfacetamide, tobramycin,

erythromycin ointment
ZADITOR
brimonidine, dorzolamide, timolol, timolol GFS,
latanoprost
prednisolone acetate
neomycin/polymyxin/dexamethasone

BLEPH-10, CILOXAN, IQUIX, OCUFLOX, QUIXIN,

SODIUM SULAMYD, VIGAMOX, ZYMAR
ALAMAST, ALOCRIL, ELESTAT, LIVOSTIN,
OPTIVAR, PATANOL
BETIMOL, TIMOPTIC, TIMOPTIC XE, XALATAN
PRED FORTE
MAXITROL

OTICS
Anti-infectives
Otic-Analgesic Combinations

neomycin/polymyxin/hydrocortisone
A/B OTIC, antipyrine-benzocaine

CORTISPORIN

Inhaled Steroids
Leukotriene Modifiers
Nasal Steroids

albuterol, metaproterenol solution, SEREVENT,

PROAIR HFA, PROVENTIL HFA, VENTOLIN HFA
FLOVENT HFA, PULMICORT, QVAR
montelukast
flunisolide, fluticasone

Antihistamine (& Decongestant

Combo)
Xanthine Derivatives

chlorpheneramine CR, clemastine, cyproheptadine,

diphenhydramine, loratadine OTC
theophylline

ADVAIR (combo), ALUPENT, FORADIL, MAXAIR,

SYMBICORT, TORNALATE, XOPENEX
AEROBID, AEROBID-M, AZMACORT, BECLOVENT
ACCOLATE, SINGULAIR
BECONASE, BECONASE-AQ, FLONASE,
NASACORT, NASACORT-AQ, NASALIDE, NASAREL,
NASONEX, RHINOCORT-AQUA, TRI-NASAL,
VERAMYST
ALLEGRA, ALLEGRA-D, CLARINEX, TRINALIN
REPETABS ZYRTEC, ZYRTEC-D
THEO-24, UNIPHYL

RESPIRATORY, ALLERGY
Beta-Agonists

UROLOGIC AGENTS
Agents for BPH

doxazosin, prazosin, terazosin

Agents for erectile dysfunction

Requires Approval

Agents for over active bladder

oxybutynin

Agents for urinary analgesic

phenazopyridine

AVODART, finasteride, FLOMAX, PROSCAR,

UROXATRAL
CAVERJECT, CIALIS, EDEX, LEVITRA, MUSE,
VIAGRA
DETROL, DETROL LA, DITROPAN, DITROPAN XL,
ENABLEX, OXYTROL, SANCTURA, VESICARE

VITAMINS
Vitamins

pyridoxine, prenatal vitamin, nephro-vite, PhosLo,

vitamin D

MISCELLANEOUS
Agents for Gout
Agents for phosphate removing
Antineoplastic agent
Laxative
Minerals and Electrolytes
Mouthwashes and Gargles

allopurinol, colchicine
RENAGEL
HYDREA
Lactulose, GOLYTELY
potassium chloride
chlorhexidine gluconate (alcohol free product)

ZYLOPRIM

3
The formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs. Brand name drugs with generic equivalents are considered non-formulary.
Revised 2/5/2013 IHSC Jail Formulary (IGSA) 2.5.2013.doc