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HOSPISCRIPT DIAGNOSIS BASED FORMULARY
The HospiScript Diagnosis Formulary is made up of two components. The Base List includes medications that manage symptoms common to all
diagnoses, while the Diagnosis Specific Category medications are used to manage conditions of a particular disease. Together, these two lists
represent the formulary for each terminal diagnosis.
The medications on the base list were selected to manage the following symptoms:
Agitation
Dry eyes
Gastrointestinal
Pain-Nociceptive
Anorexia
Dry mouth
Hiccups
Potassium depletion
Anxiety
Dry skin
Infection
Pruritus
Chest congestion
Dysphagia
Insomnia
Skin irritation
Constipation
Dyspnea
Muscle spasms
Terminal secretions
Cough
Dysuria
Nausea and Vomiting
Topical infections
Delirium
Fatigue
Oral Candidiasis
Depression
Fever
Pain-Bone
Diarrhea
Fluid retention
Pain-Neuropathic
MST= Multiple Symptom
Therapy
BASE LIST
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM CLASSIFICATION
COMMENTS
AGITATION/DELIRIUM
First line treatment
Haloperidol
Haldol (DECANOATE REQUIRES
AUTH)
Agitation-Typical Antipsychotic
MST: Butyrophenone: Avoid doses
of > 2mg/day in LTCF patients.
Chlorpromazine
Thorazine
Agitation-Typical Antipsychotic
MST: Phenothiazine: Sedating,
avoid doses > 75mg/day in LTCF.
Increased risk of orthostatic
hypotension.
Phenobarbital
ANOREXIA
First line treatment
Luminal
Agitation-Barbiturate
MST: Used for it's sedating affects.
Prednisone
Deltasone
Anorexia-Corticosteroid
Dexamethasone
Decadron
Anorexia-Corticosteroid
Mirtazapine
Remeron
Anorexia-Antidepressant
Metoclopramide
ANXIETY
First line treatment
Reglan
Anorexia-Prokinetic Agent
Lorazepam
Ativan
Anxiety-Benzodiazepine
Alprazolam
Xanax (NO XR OR ODT)
Anxiety-Benzodiazepine
Diazepam
Valium (NO DIASTAT)
Anxiety-Benzodiazepine
Clonazepam
Klonopin
Anxiety-Benzodiazepine
Lorazepam Intensol
Anxiety-Benzodiazepine
MST: Less expensive than
dexamethasone.
MST: More costly but less
mineralcorticoid activity/fluid
retention than prednisone.
Second line treatment
Second line treatment
Lorazepam Concentrated Oral
Soln
HSDBF V1
MST: Increases appetite in doses
7.5 - 15mg.
MST: Tablets are small and can be
given sublingually/rectally.
MST: Rapid onset, can cause end of
dose rebound anxiety.
MST: Long half-life-dose no more
frequently than q8h and avoid in
geriatrics.
MST: Also beneficial for seizure
prevention.
MST: Intensol expensive-tablets can
be given sublingually/rectally.
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM CLASSIFICATION
COMMENTS
Anxiety-Benzodiazepine
MST: Intensol expensive-tablets can
be given sublingually/rectally.
Benadryl
Atarax, Vistaril
Anxiety-Antihistamine
Anxiety-Antihistamine
MST: Use with caution in elderly.
MST: Use with caution in elderly.
Docusate Sodium
Colace
Constipation-Stool Softener
Senna/Docusate Sodium
Senokot S
Constipation-Stimulant and Stool
Softener Combination
Senna
Senokot
Constipation-Stimulant Laxative
Bisacodyl
Dulcolax
Constipation-Stimulant Laxative
Magnesium Citrate
Citroma
Constipation-Osmotic Laxative
Milk of Magnesia
Constipation-Osmotic Laxative
Diazepam Concentrated Oral Soln Diazepam Intensol
Third line treatment
Diphenhydramine
Hydroxyzine
CONSTIPATION
First line treatment
Magnesium Hydroxide
Suspension
Second line treatment
Sorbitol 70% Soln
Sorbitol
Constipation-Osmotic Laxative
Glycerin Suppository
Glycerin Suppository
Constipation-Osmotic Laxative
Mineral Oil Enema
Mineral Oil Enema
Constipation-Lubricant
Sodium Phosphate Enema
Polyethylene Glycol
Fleet Enema
Miralax OTC
Constipation-Osmotic Laxative
Constipation-Osmotic Laxative
Petroleum Jelly
Vaseline
Constipation-Lubricant
Guaifenesin Syrup
Robitussin
Cough-Expectorant
Guaifenesin SR Tablet
Mucinex
Cough-Expectorant
Hydrocodone/Homatropine
Guaifenesin/Dextromethorphan
Guaifenesin/Codeine
Second line treatment
Benzonatate
Hydromet
Robitussin DM
Robitussin AC
Cough-Suppressant
Cough-Expectorant/Suppressant
Cough-Expectorant/Suppressant
Tessalon Perles
Cough-Antitussive
Lidocaine Inj for Nebulization
Xylocaine
Cough-Suppressant
Methylphenidate
Ritalin (NO CR)
Depression-Psychostimulant
Fluoxetine
Prozac (NO WEEKLY)
Depression-Selective Serotonin
Reuptake Inhibitor
Citalopram
Celexa
Sertraline
Zoloft
Not sufficient as a sole agent in
patients on opioids or who do not
have adequate fluid intake.
Maximize dose before adding
additional agents (8 tabs/day).
Maximize dose before adding
additional agents (8 tabs/day).
Maximize dose before adding
additional agents (4 tabs/day).
Saline Laxative-contraindicated in
renal failure.
Saline Laxative-contraindicated in
renal failure.
More cost effective than lactulose
and as effective. Not sufficient as a
sole agent in patients on opioids or
who do not have adequate fluid
intake.
Don't use oral liquid Mineral Oilaspiration risk. Try Vaseline™ Balls
if high or hard impaction present.
Saline Laxative
Give in 4-8 ounces of liquid.
Vaseline™ Balls-Contact
HospiScript for instructions.
COUGH
First line treatment
Encourage fluid intake for maximum
effect.
Encourage fluid intake for maximum
effect.
Schedule V controlled substance.
Do not break or chew capsules.
Do not use Epinephrine containing
dosage form.
DEPRESSION
First line treatment
Depression-Selective Serotonin
Reuptake Inhibitor
Depression-Selective Serotonin
Reuptake Inhibitor
MST: Drug of choice if patient has <
4-6 weeks life expectancy.
Least expensive SSRI: Least likely to
cause withdrawal symptoms when
discontinued abruptly.
Good choice for depression
accompanied by anxiety.
Good choice for depression
accompanied by anxiety.
Second line treatment
Mirtazapine
Remeron
Depression-Atypical
Escitalopram
Lexapro
Depression-Selective Serotonin
Reuptake Inhibitor
HSDBF V1
MST: Sedating in doses of 7.5 15mg.
No benefit over first line citalopram.
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM CLASSIFICATION
COMMENTS
DIARRHEA
First line treatment
Bismuth Subsalicylate
Kaopectate
Loperamide
Imodium
Diphenoxylate/Atropine
Lomotil
Psyllium
DRY EYES
First line treatment
Artificial Tears
Ophthalmic Lubricant
DYSPHAGIA
First line treatment
Thickening Agent
DYSPNEA
First line treatment
Morphine IR
Metamucil
Antisecretory and antimicrobial
action.
Diarrhea-Hypermotility
Available over the counter (OTC).
Schedule V controlled substanceDiarrhea-Hypermotility
prescription only.
Diarrhea-Absorbent-Bulk Laxative For bulking stool
Tears Naturale
Lacri-lube
Dry Eyes-Lubricant
Dry Eyes-Lubricant
Thick-it
Dysphagia
Roxanol, MSIR
Dyspnea-Opioid
Lorazepam
Ativan
Dyspnea-Benzodiazepine
Alprazolam
Xanax (NO XR OR ODT)
Dyspnea-Benzodiazepine
Diarrhea-Absorbent
MST: Also an analgesic.
MST: Treats anxiety component of
dyspnea.
MST: Treats anxiety component of
dyspnea.
Valium (NO DIASTAT)
Dyspnea-Benzodiazepine
MST: Treats anxiety component of
dyspnea. Long half-life-dose, no
more frequently than q8h and avoid
in geriatrics.
Oxyfast (NO SUSTAINED RELEASE)
Dyspnea-Opioid
MST: More expensive than
morphine.
Dyspnea-Opioid
10g/mL injectable expensive but
beneficial for subcutaneous
administration due to its high
potency.
Dyspnea-Benzodiazepine
MST: Expensive-tablets can be
given sublingually/rectally.
Lorazepam Intensol
Dyspnea-Benzodiazepine
MST: Expensive-tablets can be
given sublingually/rectally.
Ritalin (NO CR)
Fatigue-Psychostimulant
Deltasone
Fatigue-Corticosteroid
Decadron
Fatigue-Corticosteroid
MST: More costly but less
mineralocorticoid activity/fluid
retention than prednisone.
Acetaminophen
Tylenol
Fever
MST: Maximum dose = 3
gms/24hrs. Caution for liver patients.
Ibuprofen
Motrin
Fever-Nonsteroidal AntiInflammatory Drug
MST: Maximum dose = 3200
mgs/24hrs. Caution for renal
patients.
Indocin
Fever-Nonsteroidal AntiInflammatory Drug
Potent antipyretic but severe GI and
renal adverse effects with prolonged
use. Maximum dose= 200mg/day.
Lasix
Fluid Retention-Loop Diuretic
Monitor for hypokalemia. Oral
absorption decreases as fluid
overload increases.
Diazepam
Second line treatment
Oxycodone IR
Hydromorphone
Dilaudid (NO XR)
Diazepam Concentrated Oral Soln Diazepam Intensol
Lorazepam Concentrated Oral
Soln
FATIGUE
First line treatment
Methylphenidate
Prednisone
MST: Effect may be short term.
MST: Less expensive than
dexamethasone.
Second line treatment
Dexamethasone
FEVER
First line treatment
Second line treatment
Indomethacin
FLUID RETENTION
First line treatment
Furosemide
HSDBF V1
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM CLASSIFICATION
COMMENTS
Second line treatment
Spironolactone
Aldactone
Fluid Retention-Potassium
Sparing Diuretic
Potassium sparing
Metolazone
Zaroxolyn
Fluid Retention-Thiazide Diuretic
Adjunct to loop diuretics. Monitor for
hypokalemia.
Aluminum/Magnesium Hydroxide
Maalox, Mylanta
Gastrointestinal-Antacid
For PRN use. Can cause rebound
acid production with chronic use.
Aluminum/Magnesium
Hydroxide/Simethicone
Maalox Plus
Gastrointestinal-Antacid
Omeprazole OTC
Prilosec OTC
Famotidine
Ranitidine
Simethicone
Second line treatment
Pepcid (NO ORAL LIQ)
Zantac (NO ORAL LIQ)
Mylicon
Gastrointestinal-Proton Pump
Inhibitor
Gastrointestinal-H2 Antagonist
Gastrointestinal-H2 Antagonist
Gastrointestinal-Gas
Sucralfate
Carafate
Gastrointestinal-Protectant
Take other medication 2 hours
before sucralfate.
Levsin
Genitourinary-Bladder SpasmsAnticholinergic
MST: Liquid is expensive.
GASTROINTESTINAL
First line treatment
For PRN use. Can cause rebound
acid production with chronic use.
Request OTC omeprazole only-not
RX form.
Use with caution in elderly.
Use with caution in elderly.
For relief of gas.
GENITOURINARY
First line treatment
Hyoscyamine
Second line treatment
Genitourinary-Urinary RetentionCholinergic
Genitourinary-Bladder SpasmsAnticholinergic
Bethanechol
Urecholine
Oxybutynin
Ditropan (IR ONLY)
Phenazopyridine
Pyridium
Genitourinary-Urinary Analgesic
Lioresal
Haldol (DECANOATE REQUIRES
AUTH)
Hiccups-Muscle Relaxant
HICCUPS
First line treatment
Baclofen
Haloperidol
Hiccups-Antipsychotic
For urinary retention.
For urinary frequency or spasms:
Use immediate release form.
Urinary analgesic: Use for a
maximum of 3 days.
MST:Antispasmodic
MST:Butyrophenone: Avoid doses of
> 2mg/day in LTCF patients.
Chlorpromazine
Thorazine
Hiccups- Antipsychotic
MST:Phenothiazine Antipsychotic:
Avoid doses > 75mg/day in LTCF.
Increased risk of orthostatic
hypotension.
Metoclopramide
HYPOKALEMIA
First line treatment
Potassium Chloride
INFECTION-BACTERIAL
First line treatment
Amoxicillin
Cephalexin
Doxycycline
Erythromycin
Reglan
Hiccups-Prokinetic
Promotility agent.
Klor-Con, K-Dur
Cardiac-Potassium Supplement
Monitor potassium levels.
Amoxil
Keflex
Vibramycin, Monodox
E-Mycin, Erytab
Infection-Bacterial
Infection-Bacterial
Infection-Bacterial
Infection-Bacterial
Metronidazole
Flagyl
Infection-Bacterial
Sulfamethoxazole/Trimethoprim
Second line treatment
Ciprofloxacin
Azithromycin
Nitrofurantoin
Third line treatment
Levofloxacin
INFECTION-FUNGAL
First line treatment
Nystatin Oral Suspension
Bactrim
Infection-Bacterial
Penicillin
Cephalosporin
Tetracycline
Macrolide
Miscellaneous:May crush tabs and
use topically for wounds.
Sulfonamide
Cipro (NO XR)
Zithromax
Macrodantin, Macrobid
Infection-Bacterial
Infection-Bacterial
Infection-Bacterial
Fluoroquinolone
Macrolide
Miscellaneous
Levaquin
Infection-Bacterial
Fluoroquinolone
Mycostatin
Infection-Fungal
No systemic absorption.
HSDBF V1
GENERIC NAME
Second line treatment
Fluconazole
INFECTION-VIRAL
First line treatment
Acyclovir
INSOMNIA
First line treatment
Temazepam
Trazodone
Second line treatment
Lorazepam
Alprazolam
Diphenhydramine
Mirtazapine
BRAND NAME EXAMPLES
SYMPTOM CLASSIFICATION
COMMENTS
Diflucan
Infection-Fungal
Multiple drug interactions.
Zovirax (ORAL ONLY)
Infection-Viral
Restoril (NO 7.5 OR 22.5MG)
Desyrel (NO XL)
Insomnia-Benzodiazepine
Insomnia-Antidepressant
Duration of action 6-8 hours.
Atypical antidepressant.
Ativan
Xanax (NO XR or ODT)
Benadryl
Insomnia-Benzodiazepine
Insomnia-Benzodiazepine
Insomnia-Anticholinergic
Short duration of action.
Short duration of action.
Use with caution in the elderly.
Remeron
Insomnia-Antidepressant
MST: Sedating in doses 7.5 - 15mg.
Valium (NO DIASTAT)
Muscle Spasm-Benzodiazepine
MST: Long half life-dose, no more
frequently than q8h and avoid in
geriatrics.
Lioresal
Muscle Spasm-Skeletal Muscle
Relaxant
MST:For muscle spasticity.
Muscle Spasm-Benzodiazepine
Intensol expensive-tablets can be
given sublingually/rectally.
Nausea & Vomiting:
Chemoreceptor Trigger Zone
MST: Butyrophenone: Less sedating
than other antiemetics, can use
tablets or liquid PO/SL/PR. Avoid
doses of > 2mg/day in LTCF
patients.
MUSCLE SPASM
First line treatment
Diazepam
Second line treatment
Baclofen
Diazepam Concentrated Oral Soln Diazepam Intensol
NAUSEA & VOMITING
First line treatment
Haloperidol
Haldol (DECANOATE REQUIRES
AUTH)
Prochlorperazine
Compazine
Metoclopramide
Reglan
Lorazepam
Ativan
Meclizine
Antivert
Phenothiazine: More sedating, less
versatile and less cost effective than
haloperidol.
MST:Promotility Agent: Drug of
Nausea & Vomiting-Gastric Stasis
choice for gastric stasis.
MST: Benzodiazepine: For anxiety
Nausea & Vomiting-Anxiety
induced nausea.
Nausea & Vomiting-DismotilityMST:Antihistamine: For movement
Vertigo
induced nausea/vertigo.
Nausea & Vomiting:
Chemoreceptor Trigger Zone
Second line treatment
Nausea & VomitingChemoreceptor Trigger Zone
MST: Phenothiazine: Sedating.
Avoid doses > 75mg/day in LTCF.
Increased risk of orthostatic
hypotension.
Chlorpromazine
Thorazine
Promethazine
Phenergan
Hyoscyamine
Levsin
Alprazolam
Xanax (NO XR OR ODT)
Nausea & Vomiting-Anxiety
Valium (NO DIASTAT)
Nausea & Vomiting-Anxiety
E-Mycin, Erytab
Macrolide antibiotic: If patient can't
Nausea & Vomiting-Gastric Stasis tolerate metoclopramide for gastric
stasis.
Diazepam
Nausea & VomitingChemoreceptor Trigger ZoneAntihistamine
Nausea & VomitingAntispasmodic
More sedating than haloperidol.
Suppositories are expensive.
MST: Anticholinergic: For gastric
colic; constipating.
MST: Benzodiazepine: For anxiety
induced nausea.
MST: Benzodiazepine: For anxiety
induced nausea. Long half-life-dose,
no more frequently than q8h and
avoid in geriatrics unless bed bound.
Third line treatment
Erythromycin
HSDBF V1
GENERIC NAME
Glycopyrrolate
BRAND NAME EXAMPLES
Robinul
SYMPTOM CLASSIFICATION
Nausea & VomitingAntispasmodic
Diazepam Concentrated Oral Soln Diazepam Intensol
Nausea & Vomiting-Anxiety
Lorazepam Concentrated Oral
Soln
Nausea & Vomiting-Anxiety
Scopolamine Patch
Lorazepam Intensol
COMMENTS
MST: Tablets more expensive.
MST: Benzodiazepine: Expensivetablets are well absorbed
sublingually/rectally.
MST: Benzodiazepine: Expensivetablets are well absorbed
sublingually/rectally.
MST: Anticholinergic: For movement
induced nausea/vertigo.
Constipating; onset of action about 4
hrs.
Transderm Scop
Nausea & Vomiting, Secretions
Methadone
Dolophine, Methadose
Neuropathic Pain-Opioid
Desipramine
Norpramin
Nortriptyline
Pamelor
Gabapentin
Neurontin
Neuropathic Pain-Antiepileptic
Divalproex Sodium/Valproic Acid
Depakote/Depakene (NO STAVZOR)
Neuropathic Pain-Antiepileptic
MST: Beneficial for seizure
prevention and as a mood stabilizer.
Doxepin
Third line treatment
Amitriptyline
Sinequan (NO SILENOR)
Neuropathic Pain-Tricyclic
MST: Sedating
Elavil
Neuropathic Pain-Tricyclic
Carbamazepine
Tegretol
Neuropathic Pain-Antiepileptic
Pregabalin
Lyrica
Neuropathic Pain-Antiepileptic
Most severe side effects of TCA's.
MST: IR form is well absorbed
rectally.
Schedule V Controlled Substance.
Useful as an alternative to
gabapentin.
Acetaminophen
Tylenol
Pain-Non-opioid
Ibuprofen
Motrin
Pain-Nonsteroidal AntiInflammatory Drug
Naproxen
Naprosyn (IR ONLY)
Hydrocodone/Acetaminophen
Lortab, Vicodin, Norco
Oxycodone/Acetaminophen
Percocet
NEUROPATHIC PAIN
First line treatment
Neuropathic Pain-Tricyclic
Antidepressant
Neuropathic Pain-Tricyclic
Antidepressant
MST: 1st line when opioid and
neuropathic analgesic required.
Less severe side effects than
amitriptyline.
Less severe side effects than
amitriptyline.
Anticonvulsant of choice for
neuropathic pain.
Second line treatment
PAIN
First line treatment
Pain-Nonsteroidal AntiInflammatory Drug
Nociceptive Pain-Combination
Product
Nociceptive Pain-Combination
Product
Methadone
Roxanol, MS Contin (NO KADIAN or
AVINZA)
Dolophine, Methadose
Lidocaine Oral
Xylocaine Viscous
Pain-Pharyngeal
Choline Magnesium Trisalicylate
Trilisate
Pain-Salicylate Anti-Inflammatory
Prednisone
Deltasone
Pain-Corticosteroid AntiInflammatory
Dexamethasone
Decadron
Pain-Corticosteroid AntiInflammatory
Morphine
MST: Maximum dose = 3
gms/24hrs. Caution for liver patients.
MST: Maximum dose = 3200
mgs/24hrs. Caution for renal
patients.
Maximum dose = 1500mg/24hrs.
Caution for renal patients.
Caution acetaminophen content:
maximum 3gms/24hrs.
Caution acetaminophen content:
maximum 3gms/24hrs.
Pain-Opioid
Pain-Opioid
Watch for aspiration; wait 30 minutes
before eating or drinking.
Second line treatment
Oxycodone IR
Hydromorphone
HSDBF V1
Roxicodone, Oxyfast (NO SUSTAINED
RELEASE)
Dilaudid (NO XR)
Pain-Opioid
Pain-Opioid
Less platelet inhibition than
traditional NSAIDs.
MST: Less expensive than
dexamethasone.
MST: More costly but less
mineralocorticoid activity/fluid
retention than prednisone.
MST: Immediate release opioid:
More expensive than morphine.
MST: Immediate release opioid.
GENERIC NAME
Tramadol
BRAND NAME EXAMPLES
Ultram (REGULAR RELEASE ONLY)
SYMPTOM CLASSIFICATION
COMMENTS
Pain-Opioid
Max dose of 200mg/day in patients
with renal failure.
MST: Use with caution in the elderly.
PARKINSONISM/EXTRAPYRAMIDAL SYMPTOMS
First line treatment
Diphenhydramine
Benadryl
EPS-Anticholinergic
Benztropine
PRURITUS
First line treatment
Cogentin
EPS-Anticholinergic
Diphenhydramine
Benadryl
Pruritus-Antihistamine
Hydroxyzine
Atarax, Vistaril
Pruritus-Antihistamine
Prednisone
Deltasone
Pruritus-Corticosteroid
Dexamethasone
Decadron
Pruritus-Corticosteroid
Doxepin
RESPIRATORY
First line treatment
Sinequan (NO SILENOR)
Pruritis-Tricyclic Antidepressant
Prednisone
Deltasone
Respiratory Anti-InflammatoryCorticosteroid
Dexamethasone
Decadron
Respiratory Anti-InflammatoryCorticosteroid
Albuterol
Proventil, Ventolin
Beta Agonist Bronchodilator
Saline-Nebulized
Respiratory-Humidifier
Use PRN between bronchodilator
doses, Thins secretions & moistens
airways.
Atropine 1% Ophthalmic Soln
Isopto Atropine
Secretions-Anticholinergic
For sublingual use-Do not use in the
EYE.
Second line treatment
Hyoscyamine
Levsin
Secretions-Anticholinergic
Glycopyrrolate
Robinul
Secretions-Anticholinergic
Scopolamine Patch
Transderm Scop
Secretions-Anticholinergic
Lorazepam
Ativan
Seizures-Maintenance and Acute
Treatment
MST: Benzodiazepine: For acute
treatment of seizure
Diazepam
Valium (NO DIASTAT)
Seizures-Maintenance and Acute
Treatment
MST: Benzodiazepine: For acute
treatment of seizure
Phenobarbital
Luminal
Seizures-Maintenance and Acute
Treatment
MST: Benzodiazepine: For acute
treatment of seizure
Clonazepam
Klonopin
Seizures-Maintenance
MST: Benzodiazepine: For acute
treatment of seizure
Phenytoin
Dilantin
Seizures-Maintenance
MST:Antiepileptic: For maintenance
seizure control.
Valproic Acid/Divalproex
Depakote/Depakene (NO STAVZOR)
Seizures-Maintenance
MST: Antiepileptic: For maintenance
seizure control.
Carbamazepine
Tegretol
Seizures-Maintenance
MST: Antiepileptic: For maintenance
seizure control.
Dexamethasone
Decadron
Seizures-Maintenance
MST: Seizures due to intracranial
pressure.
MST: Sedating-Use with caution in
the elderly.
MST: Sedating-Use with caution in
the elderly.
MST: Less expensive than
dexamethasone.
MST: More costly but less
mineralocorticoid activity/fluid
retention than prednisone.
MST: Sedating
MST: Less expensive than
dexamethasone.
MST: More costly but less
mineralocorticoid activity/fluid
retention than prednisone.
Only for wheezing related to terminal
diagnosis.
Second line treatment
Sodium Chloride
SECRETIONS-DRYING AGENT
First line treatment
MST: Liquid is expensive.
MST: Does not cross blood-brain
barrier. Oral dosage form expensive,
injectable preferred.
MST: Only for long term for excess
secretions. Onset of action is 4
hours.
SEIZURES
First line treatment
HSDBF V1
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM CLASSIFICATION
COMMENTS
Second line treatment
Lorazepam Concentrated Oral
Soln
Lorazepam Intensol
Diazepam Concentrated Oral Soln Diazepam Intensol
Seizures-Maintenance and Acute
Treatment
Seizures-Maintenance and Acute
Treatment
TOPICAL
First line treatment
Emollient
Vitamin A & D Cream
Camphor/Menthol Lotion
Hydrocortisone Cream
Bacitracin
Neomycin/Polymyxin/Bacitracin
Nystatin
Myconazole Cream, Powder
Nystatin/Triamcinolone Cream
Thymol/Menthol Ointment
Zinc Oxide Ointment
Eucerin
Sween
Sarna Lotion
Cortaid
Bacitracin
Neosporin
Mycostatin, Nystop
Baza, Zeasorb AF
Mycolog II
Calmoseptine
Desitin
Topical-Emollient
Topical-Emollient
Topical-Antipruritic
Topical-Corticosteroid
Topical-Anti-infective
Topical-Anti-infective
Topical Antifungal
Topical Antifungal
Topical-Antifungal/Corticosteroid
Topical-Protectant
Topical-Protectant
Zinc Oxide + Dimethicone
Baza Protect
Topical-Protectant
MST: Benzodiazepine: Expensivetablets can be given
sublingually/rectally.
MST: Benzodiazepine: Expensivetablets can be given
sublingually/rectally.
Skin barrier
Itching, avoid on broken wounds.
Rash, Itching
Antibiotic
Antibiotic
Good barrier against urine.
Skin barrier
Good barrier against stool and
denuded skin.
Local anesthetic: Localized pain.
Lidocaine Ointment
Lidocaine
Topical-Analgesics
Second line treatment
Silver Sulfadiazine Cream
Silvadene
Topical-Burn & Antibacterial
Anti-infective
XEROSTOMIA (Dry Mouth)
First line treatment
Artificial Saliva
Biotene
Xerostomia (dry mouth)
MISCELLANEOUS
Hep-Lock
Heparin Lock Flush
Intravenous Line Maintenance
Sodium Chloride 0.9%
Sodium Chloride 0.9%
Injection, Irrigation, Nasal Spray
Please Note: Unless otherwise noted, all strengths and dosage forms of listed medications are covered on both the Base List and
Diagnosis Specific Categories.
HSDBF V1
DIAGNOSIS SPECIFIC CATEGORIES - MEDICATION LIST
Hospice Diagnoses
10 = Cancer
20 = Pulmonary
30 = Heart Disease
40 = Stroke/Coma
50 = Liver Disease
60 = Renal Disease
70 = Neuromuscular Diseases (ALS, Parkinson's Disease, etc)
80 = HIV-AIDS
90 = Dementia
95 = Debility Unspecified/Failure to Thrive
GENERIC NAME
THERAPEUTIC CLASS
CANCER (10)
Anticoagulant
Warfarin
Mineral Corticoids
Fludrocortisone
Pancreatic Enzymes
Pancrelipase
Anticonvulsant
Levetiracetam
PULMONARY DISEASE (20)
BRAND EXAMPLE
COMMENTS
Coumadin
Florinef
Pancrease
Keppra (NO XR)
Hypercoagulation due to cancer.
Orthostatic hypotension.
Pancreatic cancer
Seizures. Do not crush.
Ipratropium
Atrovent (ORAL INHALATION ONLY)
Nebulizer more effective in late
stage COPD.
Tiotropium
Spiriva
Beta Adrenergic Agonists
Salmeterol Xinafoate
Serevent Diskus
Beta Adrenergic
Agonist/Corticosteroid
Salmeterol-Fluticasone
Advair
Beta Adrenergic
Agonists/Anticholinergic
Albuterol-Ipratropium
Combivent, Duo-Neb
Corticosteroids - Inhaled
Beclomethasone
Qvar
Xanthines
Theophylline
Theo-Dur (SINGLE AGENT
PRODUCTS ONLY)
Anticholinergics
HEART DISEASE (30)
ACE Inhibitors
Benazepril
Benazepril/Hctz
Captopril
Captopril/Hctz
Enalapril
Enalapril/Hctz
Lisinopril
Lisinopril/Hctz
Quinapril
Quinapril/Hctz
Ramipril
Alpha Adrenergic Agonists
Clonidine
Alpha Adrenergic
Blockers
Angiotensin Receptor
Blockers
Doxazosin
Terazosin
Candesartan
Candesartan Hctz
Irbesartan
Irbesartan/Hctz
HSDBF V1
Nebulizer more effective in late
stage COPD.
Nebulizer more effective in late
stage COPD.
Consider changing to nebulized
albuterol and oral prednisone.
Nebulizer more effective in late
stage COPD. Combination product
more cost effective than using
individual products.
Consider changing to oral
prednisone.
Monitor Theophylline blood levels.
Lotensin
Lotensin HCT
Capoten
Capozide
Vasotec, Enalaprit
Vasoretic
Prinivil, Zestril
Zestoretic, Prinzide
Accupril
Accuretic
Altace
Catapres, Clorpres (NO KAPVAY OR
Patch is expensive.
NEXICLON XR)
Cardura
Hytrin
Atacand
Atacand HCT
Avapro
Avalide
THERAPEUTIC CLASS
Antianginal Agents
Antiarrhythmic Agent
GENERIC NAME
Losartan
Losartan Hctz
Olmesartan
Olmesartan Hctz
Valsartan
Valsartan Hctz
Isosorbide Dinitrate
Isosorbide-Hydralazine
Isosorbide Mononitrate
Amiodarone
Warfarin
Heparin
Aspirin
Atenolol
Atenolol/Chlorthalidone
Bisoprolol
Bisoprolol/Hctz
Carvedilol
Labetalol
Metoprolol
Metoprolol/Hctz
Propranolol
Propranolol/Hctz
Amlodipine
Amlodipine/Benazepril
Amlodipine/Olmesartan
Amlodipine/Olmesartan/Hctz
Amlodipine/Valsartan
Amlodipine/Valsartan/Hctz
Diltiazem
BRAND EXAMPLE
Cozaar
Hyzaar
Benicar
Benicar HCT
Diovan
Diovan HCT
Isordil
Bidil
Monoket, Imdur, Ismo
Cordarone, Pacerone
Nitrostat, Nitro-Bid, Nitro-Dur,
Minitran
Coumadin
Heparin
Aspirin
Tenormin
Tenoretic
Zebeta
Ziac
Coreg (NO CR)
Normodyne
Lopressor, Toprol XL
Lopressor HCT
Inderal
Inderide
Norvasc
Lotrel
Azor
Tribenzor
Exforge
Exforge HCT
Cardizem
Nifedipine
Procardia, Procardia XL, Adalat CC
Felodipine
Verapamil
Digoxin
Chlorthalidone
Hydrochlorothiazide
Bumetanide
Hydralazine
Plendil
Calan, Verelan
Lanoxin
Hygroton
Oretic
Bumex
Apresoline
Benazepril
Benazepril/Hctz
Captopril
Captopril/Hctz
Enalapril
Enalapril/Hctz
Lisinopril
Lisinopril/Hctz
Quinapril
Quinapril/Hctz
Ramipril
Lotensin
Lotensin HCT
Capoten
Capozide
Vasotec, Enalaprit
Vasoretic
Prinivil, Zestril
Zestoretic, Prinzide
Accupril
Accuretic
Altace
Catapres, Clorpres (NO KAPVAY or
NEXICLON XR)
Cardura
Hytrin
Nitroglycerin
Anticoagulants
Antiplatelet
Beta Adrenergic
Blockers
Calcium Channel
Blockers
Cardiac Glycosides
Thiazide Diuretics
Loop Diuretic
Vasodilators
STROKE/COMA (40)
ACE Inhibitors
Alpha Adrenergic Agonists
Clonidine
Alpha Adrenergic
Blockers
Doxazosin
Terazosin
HSDBF V1
COMMENTS
Spray is expensive.
Patch is expensive.
THERAPEUTIC CLASS
Angiotensin Receptor
Blockers
Anticoagulants
Antiplatelet
Beta Adrenergic
Blockers
Calcium Channel
Blockers
Blockers
Thiazide Diuretics
LIVER DISEASE (50)
Beta Adrenergic
Blockers
Coagulants
Vasodilators
Loop Diuretic
Benzodiazepine
Ammonium Detoxicant/Osmotic
Laxative
RENAL DISEASE (60)
GENERIC NAME
Candesartan
Candesartan/Hctz
Irbesartan
Irbesartan/Hctz
Losartan
Losartan/Hctz
Olmesartan
Olmesartan/Hctz
Valsartan
Valsartan/Hctz
Warfarin
Heparin
Aspirin
Atenolol
Atenolol/Chlorthalidone
Bisoprolol
Bisoprolol/Hctz
Carvedilol
Labetalol
Metoprolol
Metoprolol/Hctz
Propranolol
Propranolol/Hctz
Amlodipine
Amlodipine/Benazepril
Amlodipine/Olmesartan
Amlodipine/Olmesartan/Hctz
Amlodipine/Valsartan
Amlodipine/Valsartan/Hctz
Diltiazem
Felodipine
BRAND EXAMPLE
Atacand
Atacand HCT
Avapro
Avalide
Cozaar
Hyzaar
Benicar
Benicar HCT
Diovan
Diovan HCT
Coumadin
Heparin
Aspirin
Tenormin
Tenoretic
Zebeta
Ziac
Coreg (NO CR)
Normodyne
Lopressor, Toprol XL
Lopressor HCT
Inderal
Inderide
Norvasc
Lotrel
Azor
Tribenzor
Exforge
Exforge HCT
Cardizem
Plendil
Nifedipine
Procardia, Procardia XL, Adalat CC
Nisoldipine
Verapamil
Chlorthalidone
Hydrochlorothiazide
Sular
Calan, Verelan
Hygroton
Oretic
Nadolol
Propranolol
Propranolol/Hctz
Vitamin K, Phytonadione
Isosorbide Dinitrate
Isosorbide Mononitrate
Bumetanide
Oxazepam
Corgard
Inderal
Inderide
Mephyton, AquaMephyton
Isordil
Monoket, Imdur, Ismo
Bumex
Serax
Lactulose
Enulose
COMMENTS
For esophageal varices.
For esophageal varices.
For esophageal varices.
No active metabolites.
Consider using Sorbitol for
lowering Ammonia as well.
Base Formulary Only (No additional add on's)
NEUROMUSCULAR DISEASE (70) ALS - PARKINSONS
Antiemetics
Trimethobenzamide
Tigan
Anti-Parkinson's Agents
Amantadine
Entacapone
Levodopa/Carbidopa
Levodopa/Carbidopa/Entacapone
Pramipexole
Ropinirole
Symmetrel
Comtan
Sinemet
Stalevo
Mirapex (NO ER)
Requip (NO XL)
HSDBF V1
Antiemetic of choice in Parkinson's
Disease
May use in Parkinson's Disease.
May use in Parkinson's Disease.
May use in Parkinson's Disease.
May use in Parkinson's Disease.
May use in Parkinson's Disease.
May use in Parkinson's Disease.
GENERIC NAME
THERAPEUTIC CLASS
Antispasmodics
Atypical Antipsychotics
HIV OR AIDS (80)
BRAND EXAMPLE
COMMENTS
Selegiline
Eldepryl (NO EMSAM OR ZELAPAR) May use in Parkinson's Disease.
Trihexyphenidyl
Cyclobenzaprine
Tizanidine
Quetiapine
Artane
Flexeril (5&10MG ONLY)
Zanaflex
Seroquel (NO XR)
May use in Parkinson's Disease.
Skeletal Muscle Relaxant.
Skeletal Muscle Relaxant.
May use in Parkinson's Disease.
Base Formulary Only (No additional add on's)
DEMENTIA (90)
Atypical Antipsychotics
Quetiapine
Seroquel (NO XR)
Risperidone
Risperdal
UNSPECIFIED DIAGNOSIS/DEBILITY UNSPECIFIED/FAILURE TO THRIVE (95)
Base Formulary Only (No additional add on's)
HSDBF V1
Sedating
HospiScript Diagnosis Based Formulary - Alphabetical Listing by Brand/Generic Name
Generic/Brand Drug Name
Generic/Brand Drug Name
Accupril
Accuretic
Acetaminophen
Acyclovir
Quinapril
Quinapril/Hctz
Tylenol
Zovirax (ORAL ONLY)
Advair
Salmeterol-Fluticasone
Albuterol
Proventil, Ventolin
Albuterol-Ipratropium
Combivent, Duoneb
Aldactone
Spironolactone
Alprazolam
Xanax (NO XR OR ODT)
Altace
Ramipril
Aluminum/Magnesium Hydroxide
Maalox, Mylanta, Maalox Plus
Amantadine
Amiodarone
Symmetrel
Cordarone, Pacerone
Amitriptyline
Elavil
Amlodipine
Amlodipine/Benazepril
Amlodipine/Olmesartan
Amlodipine/Olmesartan/Hctz
Amlodipine/Valsartan
Amlodipine/Valsartan/Hctz
Amoxicillin
Amoxil
Norvasc
Lotrel
Azor
Tribenzor
Exforge
Exforge HCT
Amoxil
Amoxicillin
Antivert
Meclizine
Apresoline
Artane
Artificial Saliva
Artificial Tears
Aspirin
Atacand
Atacand HCT
Atarax
Atenolol
Atenolol/Chlorthalidone
Hydralazine
Trihexyphenidyl
Salivart
Lytears
Aspirin
Candesartan
Candesartan/Hctz
Hydroxyzine HCL
Tenormin
Tenoretic
Ativan
Lorazepam
Atropine 1% Ophthalmic Soln
Isopto Atropine
Ipratropium (ORAL INHALATION
ONLY)
Irbesartan
Atrovent
Avapro
HSDBF V1
Indication/Drug Class
Formulary
ACE Inhibitors
ACE Inhibitors
Fever, Pain-Nonopioid
Infection-Viral
Beta Adrenergic
Agonist/Corticosteroid
Beta Agonist Bronchodilator
Beta Adrenergic Agonists/
Anticholinergic
Fluid Retention-Potassium
Sparing Diuretic
Anxiety, Dyspnea, Insomnia,
Nausea & VomitingBenzodiazepine
ACE Inhibitors
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
Gastrointestinal-Antacid
BASE
Parkinson's Disease Agents
Antiarrhythmic Agent
Neuropathic Pain-Tricyclic
Antidepressant
Calcium Channel Blockers
Calcium Channel Blockers
Calcium Channel Blockers
Calcium Channel Blockers
Calcium Channel Blockers
Calcium Channel Blockers
Infection-Bacterial
Infection-Bacterial
Nausea & Vomiting, SecretionsAntihistamine
Vasodilators
Antiparkinson's Agents
Xerostomia (dry mouth)
Dry Eyes-Lubricant
Antiplatelet
Angiotensin Receptor Blockers
Angiotensin Receptor Blockers
Anxiety, Pruritus-Antihistamine
Beta Adrenergic Blockers
Beta Adrenergic Blockers
Anxiety, Dyspnea, Insomnia,
Nausea & Vomiting, SeizuresBenzodiazepine
Secretions-Anticholinergic
NEUROMUSCULAR
CARDIAC
Anticholinergics
PULMONARY
Angiotensin Receptor Blockers
CARDIAC/STROKE
PULMONARY
BASE
PULMONARY
BASE
BASE
CARDIAC/STROKE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
BASE
CARDIAC
NEUROMUSCULAR
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
Generic/Brand Drug Name
Generic/Brand Drug Name
Indication/Drug Class
Formulary
CARDIAC/STROKE
BASE
BASE
BASE
BASE
BASE
BASE
PULMONARY
Avalide
Azithromycin
Bacitracin
Baclofen
Bactrim
Baza Protect
Baza, Zeasorb AF
Beclomethasone
Irbesartan/Hctz
Zithromax
Bacitracin
Lioresal
Sulfamethoxazole/Trimethoprim
Zinc Oxide + Dimethicone
Myconazole Cream, Powder
Qvar
Benadryl
Diphenhydramine
Benazepril
Benazepril/Hctz
Benicar
Benicar HCT
Benzonatate
Benztropine
Bethanechol
Bidil
Biotene
Bisacodyl
Bismuth Subsalicylate
Bisoprolol
Bisoprolol/Hctz
Bumetanide
Bumex
Calan
Calmoseptine
Camphor/Menthol Lotion
Candesartan
Candesartan/Hctz
Capoten
Captopril
Captopril/Hctz
Carafate
Lotensin
Lotensin HCT
Olmesartan
Olmesartan/Hctz
Tessalon Perles
Cogentin
Urecholine
Isosorbide-Hydralazine
Artificial Saliva
Dulcolax
Kaopectate
Zebeta
Ziac
Bumex
Bumetanide
Verapamil
Thymol/Menthol Ointment
Sarna Lotion
Atacand
Atacand HCT
Captopril
Capoten
Capozide
Sucralfate
Carbamazepine
Tegretol
Cardizem
Cardura
Carvedilol
Catapres
Diltiazem
Doxazosin
Coreg (NO CR)
Clonidine
Celexa
Citalopram
Cephalexin
Keflex
Chlorpromazine
Thorazine
Chlorthalidone
Hygroton
Angiotensin Receptor Blockers
Infection-Bacterial
Topical-Anti-infective
Hiccups, Muscle Spasms
Infection-Bacterial
Topical-Protectant
Topical Antifungal
Corticosteroids-Inhaled
Anxiety, Insomnia, EPS, PruritusAntihistamine
ACE Inhibitors
ACE Inhibitors
Angiotensin Receptor Blockers
Angiotensin Receptor Blockers
Cough-Antitussive
EPS-Anticholinergic
Genitourinary-Cholinergic
Antianginal Agents
Xerostomia (dry mouth)
Constipation-Stimulant Laxative
Diarrhea-Absorbent
Beta Adrenergic Blockers
Beta Adrenergic Blockers
Loop Diuretic
Loop Diuretic
Calcium Channel Blockers
Topical-Protectant
Topical-Antipruritic
Angiotensin Receptor Blockers
Angiotensin Receptor Blockers
ACE Inhibitors
ACE Inhibitors
ACE Inhibitors
Gastrointestinal-Protectant
Neuropathic Pain, SeizuresAntiepileptic
Calcium Channel Blockers
Alpha Adrenergic Blockers
Beta Adrenergic Blockers
Alpha Adrenergic Agonists
Depression-Selective Serotonin
Reuptake Inhibitor
Infection-Bacterial
Agitation, Hiccups, Nausea &
Vomiting-Phenothiazine
Thiazide Diuretics
Choline Magnesium Trisalicylate
Trilisate
Pain-Salicylate Anti-Inflammatory
BASE
Cipro
Ciprofloxacin
Ciprofloxacin (NO XR)
Cipro (NO XR)
BASE
BASE
Citalopram
Celexa
Citroma
Clonazepam
Clonidine
Cogentin
Colace
Magnesium Citrate
Klonopin
Catapres
Benztropine
Docusate Sodium
Combivent
Albuterol-Ipratropium
Infection-Bacterial
Infection-Bacterial
Depression-Selective Serotonin
Reuptake Inhibitor
Constipation-Osmotic Laxative
Anxiety, Seizures-Benzodiazepine
Alpha Adrenergic Agonists
EPS-Anticholinergic
Constipation-Stool Softener
Beta Adrenergic Agonists/
Anticholinergic
HSDBF V1
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
BASE
CARDIAC
BASE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/LIVER
CARDIAC/LIVER
CARDIAC/STROKE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
BASE
CARDIAC/STROKE
BASE
BASE
BASE
CARDIAC/STROKE
BASE
BASE
PULMONARY
Generic/Brand Drug Name
Generic/Brand Drug Name
Compazine
Prochlorperazine
Comtan
Cordarone
Coreg
Corgard
Cortaid
Coumadin
Cozaar
Creon
Cyclobenzaprine
Entacapone
Amiodarone
Carvedilol (NO CR)
Nadolol
Hydrocortisone Cream
Warfarin
Losartan
Pancrelipase
Flexeril (5&10 mg ONLY)
Decadron
Dexamethasone
Deltasone
Prednisone
Depakote/Depakene
Divalproex Sodium/Valproic Acid (NO
STAVZOR)
Desipramine
Norpramin
Desitin
Desyrel
Zinc Oxide Ointment
Trazodone (NO XR)
Dexamethasone
Decadron
Diazepam
Valium (NO DIASTAT)
Diazepam Concentrated Oral Soln Diazepam Intensol
Diazepam Intensol
Diazepam Concentrated Oral Soln
Diflucan
Digoxin
Fluconazole
Lanoxin
Dilantin
Phenytoin
Dilaudid
Diltiazem
Diovan
Diovan HCT
Hydromorphone (NO XR)
Cardizem
Valsartan
Valsartan/Hctz
Diphenhydramine
Benadryl
Diphenoxylate/Atropine
Lomotil
Ditropan
Oxybutynin (IR ONLY)
Divalproex Sodium/Valproic Acid
Depakote/Depakene (NO STAVZOR)
Docusate Sodium
Dolophine, Methadose
Doxazosin
Colace
Methadone
Cardura
Doxepin
Sinequan (NO SILENOR)
Doxycycline
Dulcolax
Vibramycin, Monodox
Bisacodyl
Duoneb
Albuterol-Ipratropium
HSDBF V1
Indication/Drug Class
Nausea & Vomiting:
Chemoreceptor Trigger ZonePhenothiazine
Parkinson's Disease Agents
Antiarrhythmic Agent
Beta Adrenergic Blockers
Beta Adrenergic Blockers
Topical-Corticosteroid
Anticoagulants
Angiotensin Receptor Blockers
Pancreatic Enzymes
Antispasmodics
Anorexia, Fatigue, Pain, Pruritus,
Respiratory Anti-Inflammatory,
Seizures-Corticosteroid
Anorexia, Fatigue, Pain, Pruritus,
Respiratory Anti-InflammatoryCorticosteroid
Neuropathic Pain SeizuresAntiepileptic
Neuropathic Pain-Tricyclic
Antidepressant
Topical-Protectant
Insomnia-Antidepressant
Anorexia, Fatigue, Pain, Pruritus,
Respiratory Anti-Inflammatory,
Seizures-Corticosteroid
Anxiety, Dyspnea, Muscle
Spasms, Nausea & Vomiting,
Seizures-Benzodiazepine
Anxiety, Dyspnea, Muscle
Spasms, Nausea & Vomiting,
Seizures-Benzodiazepine
Anxiety, Dyspnea, Muscle
Spasms, Nausea & Vomiting,
Seizures-Benzodiazepine
Infection-Fungal
Cardiac Glycosides
Seizures-MaintenanceAntiepileptic
Dyspnea, Pain-Opioid
Calcium Channel Blockers
Angiotensin Receptor Blockers
Angiotensin Receptor Blockers
Anxiety, Insomnia, EPS, PruritusAntihistamine
Diarrhea-Hypermotility
Genitourinary-Bladder SpasmsAnticholinergic
Formulary
BASE
NEUROMUSCULAR
CARDIAC
CARDIAC/STROKE
LIVER
BASE
CANCER/CARDIAC/STROKE
CARDIAC/STROKE
CANCER
NEUROMUSCULAR
BASE
BASE
BASE
BASE
BASE
BASE
BASE
BASE
BASE
BASE
BASE
CARDIAC
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
BASE
Neuropathic Pain-Antiepileptic
BASE
Constipation-Stool Softener
Neuropathic Pain, Pain-Opioid
Alpha Adrenergic Blockers
Neuropathic Pain, PruritusTricyclic Antidepressant
Infection-Bacterial
Constipation-Stimulant Laxative
Beta Adrenergic Agonists/
Anticholinergic
BASE
BASE
CARDIAC/STROKE
BASE
BASE
BASE
PULMONARY
Generic/Brand Drug Name
Generic/Brand Drug Name
Indication/Drug Class
Formulary
Neuropathic Pain-Tricyclic
Antidepressant
BASE
Parkinson's Disease Agents
NEUROMUSCULAR
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
NEUROMUSCULAR
BASE
Elavil
Amitriptyline
Eldepryl
Selegiline (NO EMSAM OR ZELAPAR)
Emollient
E-Mycin, Erytab
Enalapril
Enalapril/Hctz
Enalaprit
Entacapone
Eucerin
Erythromycin
Vasotec
Vasoretic
Enalapril
Comtan
Enulose
Lactulose
Erythromycin
E-Mycin, Erytab
Escitalopram
Lexapro
Eucerin
Exforge
Exforge HCT
Famotidine
Felodipine
Flagyl
Fleet Enema
Flexeril
Florinef
Fluconazole
Fludrocortisone
Emollient
Amlodipine/Valsartan
Amlodipine/Valsartan/Hctz
Pepcid (NO ORAL LIQ)
Plendil
Metronidazole
Sodium Phosphate Enema
Cyclobenzaprine (5&10 MG ONLY)
Fludrocortisone
Diflucan
Florinef
Fluoxetine
Prozac (NO WEEKLY)
Furosemide
Gabapentin
Glycerin Suppository
Lasix
Neurontin
Glycerin Suppository
Glycopyrrolate
Robinul
Guaifenesin
Guaifenesin/Codeine
Robitussin, Mucinex
Robitussin AC
Topical-Emollient
Infection, Nausea & Vomiting
ACE Inhibitors
ACE Inhibitors
ACE Inhibitors
Parkinson's Disease Agents
Amonium Detoxicant/Osmotic
Laxative
Infection, Nausea & Vomiting
Depression-Selective Serotonin
Reuptake Inhibitor
Topical-Emollient
Calcium Channel Blockers
Calcium Channel Blockers
Gastrointestinal-H2 Antagonist
Calcium Channel Blockers
Infection-Bacterial
Constipation-Osmotic Laxative
Antispasmodics
Mineral corticoids
Infection-Fungal
Mineral corticoids
Depression-Selective Serotonin
Reuptake Inhibitor
Fluid Retention-Loop Diuretic
Neuropathic Pain-Antiepileptic
Constipation-Osmotic Laxative
Nausea & Vomiting, SecretionsAnticholinergic
Cough-Expectorant
Cough-Expectorant/Suppressant
Guaifenesin/Dextromethorphan
Robitussin DM
Cough-Expectorant/Suppressant
Hep-Lock
Heparin
Hydralazine
Hydrochlorothiazide
Haloperidol (DECANOATE REQUIRES
AUTH)
Haldol (DECANOATE REQUIRES
AUTH)
Heparin
Heparin
Apresoline
Oretic
Hydrocodone/Acetaminophen
Lortab,Vicodin, Vicodin ES, Norco
Hydrocodone/Homatropine
Hydrocortisone Cream
Hydromet
Hydromorphone
Hydroxyzine
Hygroton
Hydromet
Cortaid
Hydrocodone/Homatropine
Dilaudid (NO XR)
Atarax, Vistaril
Chlorthalidone
Hyoscyamine
Levsin
Hytrin
Hyzaar
Terazosin
Losartan/Hctz
Ibuprofen
Motrin, Advil
Agitation, Hiccups, Nausea &
Vomiting-Butyrophenone
Agitation, Hiccups, Nausea &
Vomiting-Butyrophenone
Line Maintenance-Anticoagulants
Anticoagulants
Vasodilators
Thiazide Diuretics
Nociceptive Pain-Combination
Opioid/Nonopioid
Cough-Expectorant/Suppressant
Topical-Corticosteroid
Cough-Expectorant/Suppressant
Dyspnea, Pain-Opioid
Anxiety, Pruritus-Antihistamine
Thiazide Diuretics
Genitourinary, Nausea &
Vomiting, SecretionsAnticholinergic
Alpha Adrenergic Blockers
Angiotensin Receptor Blockers
Fever, Pain-Nonsteroidal AntiInflammatory Drug
Haldol
Haloperidol
HSDBF V1
LIVER
BASE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
CARDIAC/STROKE
BASE
BASE
NEUROMUSCULAR
CANCER
BASE
CANCER
BASE
BASE
BASE
BASE
BASE
BASE
BASE
BASE
BASE
BASE
CARDIAC/STROKE
CARDIAC
CARDIAC/STROKE
BASE
BASE
BASE
BASE
BASE
BASE
CARDIAC/STROKE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
Generic/Brand Drug Name
Generic/Brand Drug Name
Imdur
Imodium
Inderal
Inderide
Indocin
Indomethacin
Isosorbide Mononitrate
Loperamide
Propranolol
Propranolol/Hctz
Indomethacin
Indocin
Ipratropium
Atrovent (ORAL INHALATION ONLY)
Irbesartan
Irbesartan/Hctz
Isopto Atropine
Isordil
Isosorbide Dinitrate
Isosorbide Dinitrate/Hydralazine
Isosorbide Mononitrate
Kaopectate
Keflex
Keppra
Klonopin
Klor-Con, K-Dur
Labetalol
Lacrilube
Avapro
Avalide
Atropine 1% Ophthalmic Soln
Isosorbide Dinitrate
Isordil
Bidil
Monoket, Imdur, Ismo
Bismuth Subsalicylate
Cephalexin
Levetiracetam (NO XR)
Clonazepam
Potassium Chloride
Normodyne
Ophthalmic Lubricant
Lactulose
Enulose, Kristalose
Lanoxin
Lasix
Levaquin
Levetiracetam
Levodopa/Carbidopa
Levodopa/Carbidopa/Entacapone
Levofloxacin
Digoxin
Furosemide
Levofloxacin
Keppra (NO XR)
Sinemet
Stalevo
Levaquin
Levsin
Hyoscyamine
Lexapro
Escitalopram
Lidocaine Inj for Nebulization
Lidocaine Ointment
Lidocaine Viscous
Lioresal
Lisinopril
Lisinopril/Hctz
Lomotil
Loperamide
Lopressor
Lopressor HCT
Xylocaine
Lidocaine
Xylocaine Viscous
Baclofen
Prinivil, Zestril
Zestoretic
Diphenoxylate/Atropine
Imodium
Metoprolol
Metoprolol/Hctz
Lorazepam
Ativan
Lorazepam Concentrated Oral
Soln
Lorazepam Intensol
Lorazepam Intensol
Lorazepam Concentrated Oral Soln
Lortab
Hydrocodone/Acetaminophen
Losartan
Cozaar
HSDBF V1
Indication/Drug Class
Formulary
Vasodilators
Diarrhea-Hypermotility
Beta Adrenergic Blockers
Beta Adrenergic Blockers
Fever
Fever
CARDIAC/LIVER
BASE
CARDIAC/STROKE/LIVER
CARDIAC/STROKE/LIVER
BASE
BASE
Anticholinergics
PULMONARY
Angiotensin Receptor Blockers
Angiotensin Receptor Blockers
Secretions-Anticholinergic
Vasodilators
Vasodilators
Antianginal Agents
Vasodilators
Diarrhea-Absorbent
Infection-Bacterial
Anticonvulsant
Anxiety, Seizures-Benzodiazepine
Cardiac-Potassium Supplement
Beta Adrenergic Blockers
Dry Eyes-Lubricant
Amonium Detoxicant/Osmotic
Laxative
Cardiac Glycosides
Fluid Retention-Loop Diuretic
Infection-Bacterial
Anticonvulsant
Parkinson's Disease Agents
Parkinson's Disease Agents
Infection-Bacterial
Genitourinary, Nausea &
Vomiting, SecretionsAnticholinergic
Depression-Selective Serotonin
Reuptake Inhibitor
Cough-Suppressant
Topical-Analgesics
Pain-Pharyngeal
Hiccups, Muscle Spasms
ACE Inhibitors
ACE Inhibitors
Diarrhea-Hypermotility
Diarrhea-Hypermotility
Beta Adrenergic Blockers
Beta Adrenergic Blockers
Anxiety, Dyspnea, Insomnia,
Nausea & Vomiting, SeizuresBenzodiazepine
Anxiety, Dyspnea, Insomnia,
Nausea & Vomiting, SeizuresBenzodiazepine
Anxiety, Dyspnea, Insomnia,
Nausea & Vomiting, SeizuresBenzodiazepine
Nociceptive Pain-Combination
Opioid/Nonopioid
Angiotensin Receptor Blockers
CARDIAC/STROKE
CARDIAC/STROKE
BASE
CARDIAC/LIVER
CARDIAC/LIVER
CARDIAC
CARDIAC/LIVER
BASE
BASE
CANCER
BASE
BASE
CARDIAC/STROKE
BASE
LIVER
CARDIAC
BASE
BASE
CANCER
NEUROMUSCULAR
NEUROMUSCULAR
BASE
BASE
BASE
BASE
BASE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
BASE
BASE
CARDIAC/STROKE
Generic/Brand Drug Name
Losartan/Hctz
Lotensin
Lotensin HCT
Luminal
Lyrica
Lytears
Generic/Brand Drug Name
Maalox
Macrodantin, Macrobid
Magnesium Citrate
Magnesium Hydroxide
Hyzaar
Benazepril
Benazepril/Hctz
Phenobarbital
Pregabalin
Artificial Tears
Aluminum/Magnesium
Hydroxide/Simethicone
Aluminum/Magnesium Hydroxide
Nitrofurantoin
Citroma
Milk of Magnesia
Meclizine
Antivert
Mephyton, AquaMephyton
Metamucil
Methadone
Vitamin K, Phytonadione
Psyllium
Dolophine, Methadose
Methylphenidate
Ritalin (NO CR)
Metoclopramide
Metolazone
Metoprolol
Metoprolol/Hctz
Metronidazole
Milk of Magnesia
Mineral Oil Enema
Miralax OTC
Mirapex
Reglan
Zaroxolyn
Lopressor, Toprol XL
Lopressor HCT
Flagyl
Magnesium Hydroxide Suspension
Mineral Oil Enema
Polyethylene Glycol
Pramipexole (NO ER)
Mirtazapine
Remeron
Monodox
Monoket
MSIR
Doxycycline
Isosorbide Mononitrate
Roxanol, MS Contin, MSIR (NO
KADIAN OR AVINZA)
Morphine ER (NO KADIAN OR
AVINZA)
Morphine IR
Motrin, Advil
Ibuprofen
Mucinex
Mycolog
Myconazole Cream, Powder
Mycostatin
Mylanta
Mylicon
Nadolol
Guaifenesin SR
Nystatin/Triamcinolone Cream
Baza, Zeasorb AF
Nystatin
Aluminum/Magnesium Hydroxide
Simethicone
Corgard
Naprosyn
Naproxen (IR ONLY)
Naproxen
Naprosyn (IR ONLY)
Neomycin/Polymyxin/Bacitracin
Neosporin
Neurontin
Nifedipine
Nisoldipine
Nitrofurantoin
Neosporin
Neomycin/Polymyxin/Bacitracin
Gabapentin
Procardia
Sular
Macrodantin, Macrobid
NitroMist, Nitro-Bid, NitroDur,
Nitrostat
Maalox Plus
Morphine
MS Contin
Nitroglycerin
HSDBF V1
Indication/Drug Class
Formulary
Angiotensin Receptor Blockers
ACE Inhibitors
ACE Inhibitors
Agitation, Seizures-Barbiturate
Neuropathic Pain-Antiepileptic
Dry Eyes-Lubricant
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
BASE
Gastrointestinal-Antacid
BASE
Gastrointestinal-Antacid
Infection-Bacterial
Constipation-Osmotic Laxative
Constipation-Osmotic Laxative
Nausea & Vomiting, SecretionsAntihistamine
Coagulants
Diarrhea-Absorbent-Bulk Laxative
Neuropathic Pain, Pain-Opioid
Depression, FatiguePsychostimulant
Hiccups, Nausea & Vomiting
Fluid Retention-Thiazide Diuretic
Beta Adrenergic Blockers
Beta Adrenergic Blockers
Infection-Bacterial
Constipation-Osmotic Laxative
Constipation-Lubricant
Osmotic Laxative
Parkinson's Disease Agents
Anorexia, Depression, InsomniaAtypical Antidepressant
Infection-Bacterial
Vasodilators
BASE
BASE
BASE
BASE
BASE
LIVER
BASE
BASE
BASE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
BASE
BASE
NEUROMUSCULAR
BASE
BASE
CARDIAC/LIVER
Pain, Dyspnea-Opioid
BASE
Pain, Dyspnea-Opioid
BASE
Pain, Dyspnea-Opioid
Fever, Pain-Nonsteroidal AntiInflammatory Drug
Cough-Expectorant
Topical-Antifungal/Corticosteroid
Topical Antifungal
Infection-Fungal
Gastrointestinal-Antacid
Gastrointestinal-Gas
Beta Adrenergic Blockers
Pain-Nonsteroidal AntiInflammatory Drug
Pain-Nonsteroidal AntiInflammatory Drug
Topical-Anti-infective
Topical-Anti-infective
Neuropathic Pain-Antiepileptic
Calcium Channel Blockers
Calcium Channel Blockers
Infection-Bacterial
BASE
BASE
BASE
BASE
CARDIAC/STROKE
STROKE
BASE
Antianginal Agents
CARDIAC
BASE
BASE
BASE
BASE
BASE
BASE
BASE
LIVER
BASE
BASE
Generic/Brand Drug Name
Generic/Brand Drug Name
NitroMist, Nitro-Bid, NitroDur,
Nitrostat
Nitroglycerin
Norco
Hydrocodone/Acetaminophen
Normodyne
Labetalol
Norpramin
Desipramine
Nortriptyline
Pamelor
Norvasc
Nystatin
Nystatin Oral Suspension
Nystatin/Triamcinolone Cream
Olmesartan
Olmesartan/Hctz
Amlodipine
Mycostatin/Nystop
Nystatin
Mycolog
Benicar
Benicar HCT
Omeprazole OTC
Prilosec OTC
Ophthalmic Lubricant
Oretic
Oxazepam
Lacrilube
Hydrochlorothiazide
Serax
Oxybutynin
Ditropan (IR ONLY)
Oxycodone IR
Roxicodone (NO SUSTAINED
RELEASE)
Oxycodone Soln (NO SUSTAINED
RELEASE)
Oxyfast
Oxycodone/Acetaminophen
Percocet
Pacerone
Amiodarone
Pamelor
Nortriptyline
Pancrease
Pancrelipase
Pepcid
Pancrelipase
Pancrease, Creon
Famotidine (NO ORAL LIQ)
Percocet
Oxycodone/Acetaminophen
Petroleum Jelly
Phenazopyridine
Vaseline
Pyridium
Phenergan
Promethazine
Phenobarbital
Phenytoin
Plendil
Polyethylene Glycol
Potassium Chloride
Pramipexole
Luminal
Dilantin
Felodipine
Miralax OTC
Klor-Con, K-Dur
Mirapex (NO ER)
Prednisone
Deltasone
Pregabalin
Lyrica
Prilosec OTC
Omeprazole OTC
Prinivil
Prinzide
Procardia
Lisinopril
Lisinopril/Hctz
Nifedipine
Prochlorperazine
Compazine
HSDBF V1
Indication/Drug Class
Formulary
Antianginal Agents
CARDIAC
Nociceptive Pain-Combination
Opioid/Nonopioid
Beta Adrenergic Blockers
Neuropathic Pain-Tricyclic
Antidepressant
Neuropathic Pain-Tricyclic
Antidepressant
Calcium Channel Blockers
Topical Antifungal
Infection-Fungal
Topical-Antifungal/Corticosteroid
Angiotensin Receptor Blockers
Angiotensin Receptor Blockers
Gastrointestinal-Proton Pump
Inhibitor
Dry Eyes-Lubricant
Thiazide Diuretics
Benzodiazepine
Genitourinary-Bladder SpasmsAnticholinergic
CARDIAC/STROKE
BASE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
Dyspnea, Pain-Opioid
BASE
Dyspnea, Pain-Opioid
BASE
Nociceptive Pain-Combination
Opioid/Nonopioid
Antiarrhythmic Agent
Neuropathic Pain-Tricyclic
Antidepressant
Pancreatic Enzymes
Pancreatic Enzymes
Gastrointestinal-H2 Antagonist
Nociceptive Pain-Combination
Opioid/Nonopioid
Constipation-Lubricant
Genitourinary-Urinary Analgesic
Nausea & VomitingChemoreceptor Trigger ZonePhenothiazine
Agitation, Seizures-Barbiturate
Seizures-Maintenance
Calcium Channel Blockers
Osmotic Laxative
Cardiac-Potassium Supplement
Parkinson's Disease Agents
Anorexia, Fatigue, Pain, Pruritus,
Respiratory Anti-InflammatoryCorticosteroid
Neuropathic Pain-Antiepileptic
Gastrointestinal-Proton Pump
Inhibitor
ACE Inhibitors
ACE Inhibitors
Calcium Channel Blockers
Nausea & Vomiting:
Chemoreceptor Trigger ZonePhenothiazine
BASE
CARDIAC/STROKE
BASE
BASE
BASE
BASE
CARDIAC/STROKE
LIVER
BASE
BASE
CARDIAC
BASE
CANCER
CANCER
BASE
BASE
BASE
BASE
BASE
BASE
BASE
CARDIAC/STROKE
BASE
BASE
NEUROMUSCULAR
BASE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
Generic/Brand Drug Name
Generic/Brand Drug Name
Promethazine
Phenergan
Propranolol
Proventil
Inderal
Albuterol
Prozac
Fluoxetine (NO WEEKLY)
Psyllium
Pyridium
Qvar
Quetiapine
Quinapril
Quinapril/Hctz
Ramipril
Ranitidine
Reglan
Metamucil
Phenazopyridine
Beclomethasone
Seroquel (NO XR)
Accupril
Accuretic
Altace
Zantac (NO ORAL LIQ)
Metoclopramide
Remeron
Mirtazapine
Requip
Restoril
Risperidone
Risperdal
Ropinirole (NO XL)
Temazepam (NO 7.5 OR 22.5 MG)
Risperdal
Risperidone
Ritalin
Methylphenidate (NO CR)
Robinul
Glycopyrrolate
Robitussin
Robitussin AC
Robitussin DM
Ropinirole
Roxanol
Saline-Nebulized
Salmeterol Xinafoate
Guaifenesin
Guaifenesin/Codeine
Guaifenesin/Dextromethorphan
Requip (NO XL)
Morphine IR
Oxycodone IR (NO SUSTAINED
RELEASE)
Saline-Nebulized
Serevent Diskus
Salmeterol-Fluticasone
Advair
Sarna Lotion
Camphor/Menthol Lotion
Scopolamine Patch
Transderm Scop
Selegiline
Eldepryl (NO EMSAM OR ZELAPAR)
Senna
Senokot
Senna/Docusate Sodium
Senokot S
Senokot
Senna
Senokot S
Senna/Docusate Sodium
Serax
Serevent Diskus
Seroquel
Oxazepam
Salmeterol Xinafoate
Quetiapine (NO XR)
Sertraline
Zoloft
Silvadene
Silver Sulfadiazine Cream
Simethicone
Sinemet
Silver Sulfadiazine Cream
Silvadene
Mylicon
Levodopa/Carbidopa
Sinequan
Doxepin (NO SILENOR)
Roxicodone
HSDBF V1
Indication/Drug Class
Formulary
Nausea & VomitingChemoreceptor Trigger ZoneBASE
Phenothiazine
Beta Adrenergic Blockers
CARDIAC/STROKE/LIVER
Beta Agonist Bronchodilator
BASE
Depression-Selective Serotonin
BASE
Reuptake Inhibitor
Diarrhea-Absorbent-Bulk Laxative
BASE
Genitourinary-Urinary Analgesic
BASE
Corticosteroids - Inhaled
PULMONARY
Atypical Antipsychotics
NEUROMUSCULAR/ DEMENTIA
ACE Inhibitors
CARDIAC/STROKE
ACE Inhibitors
CARDIAC/STROKE
ACE Inhibitors
CARDIAC/STROKE
Gastrointestinal-H2 Antagonist
BASE
Hiccups, Nausea & Vomiting
BASE
Anorexia, Depression, InsomniaBASE
Atypical Antidepressant
Parkinson's Disease Agents
NEUROMUSCULAR
Insomnia-Benzodiazepine
BASE
Atypical Antipsychotics
DEMENTIA
Atypical Antipsychotics
DEMENTIA
Depression, FatigueBASE
Psychostimulant
Nausea & Vomiting, SecretionsBASE
Anticholinergic
Cough-Expectorant
BASE
Cough-Expectorant/Suppressant
BASE
Cough-Expectorant/Suppressant
BASE
Parkinson's Disease Agents
NEUROMUSCULAR
Pain, Dyspnea-Opioid
BASE
Pain, Dyspnea-Opioid
BASE
Respiratory-Humidifier
Beta Adrenergic Agonists
Beta Adrenergic
Agonist/Corticosteroid
Topical-Antipruritic
Nausea & Vomiting, SecretionsAnticholinergic
BASE
PULMONARY
Parkinson's Disease Agents
NEUROMUSCULAR
Constipation-Stimulant Laxative
Constipation-Stimulant and
Softener Combination
Constipation-Stimulant Laxative
Constipation-Stimulant and
Softener Combination
Benzodiazepine
Beta Adrenergic Agonists
Atypical Antipsychotics
Depression-Selective Serotonin
Reuptake Inhibitor
Topical-Burn & Antibacterial
Topical-Burn & Antibacterial
Gastrointestinal-Gas
Parkinson's Disease Agents
Neuropathic Pain, PruritusTricyclic Antidepressant
BASE
PULMONARY
BASE
BASE
BASE
BASE
BASE
LIVER
PULMONARY
NEUROMUSCULAR/ DEMENTIA
BASE
BASE
BASE
BASE
NEUROMUSCULAR
BASE
Generic/Brand Drug Name
Generic/Brand Drug Name
Sodium Chloride 0.9%
Sodium Phosphate Enema
Sorbitol 70% Soln
Spiriva
Ocean Spray, Saline
Fleet Enema
Sorbitol
Tiotropium
Spironolactone
Aldactone
Stalevo
Sucralfate
Sular
Sulfamethoxazole/Trimethoprim
Sween
Symmetrel
Levodopa/Carbidopa/Entacapone
Carafate
Nisoldipine
Bactrim
Vitamin A & D Cream
Amantadine
Tegretol
Carbamazepine
Temazepam
Tenormin
Tenoretic
Terazosin
Tessalon Perles
Thickening Agent
Thick-It
Restoril (NO 7.5 OR 22.5 MG)
Atenolol
Atenolol/Chlorthalidone
Hytrin
Benzonatate
Theophylline (SINGLE AGENT
PRODUCTS ONLY)
Theo-Dur (SINGLE AGENT
PRODUCTS ONLY)
Thick-It
Thickening Agent
Thorazine
Chlorpromazine
Thymol/Menthol Ointment
Tigan
Tiotropium
Tizanidine
Toprol XL
Tramadol
Calmoseptine
Trimethobenzamide
Spiriva
Zanaflex
Metoprolol Succinate
Ultram (REGULAR RELEASE ONLY)
Transderm Scop
Scopolamine Patch
Trazodone
Tribenzor
Trihexyphenidyl
Trilisate
Trimethobenzamide
Tylenol
Urecholine
Desyrel (NO XR)
Amlodipine/Olmesartan/Hctz
Artane
Choline Magnesium Trisalicylate
Tigan
Acetaminophen
Tramadol (REGULAR RELEASE
ONLY)
Bethanechol
Valium
Diazepam (NO DIASTAT)
Valproic Acid/Divalproex
Depakene/Depakote (NO STAVZOR)
Valsartan
Valsartan/Hctz
Vaseline
Vasotec
Vasoretic
Verapamil
Vibramycin
Diovan
Diovan HCT
Petroleum Jelly
Enalapril, Enalaprit
Enalapril/Hctz
Calan
Doxycycline
Vicodin, Vicodin ES
Hydrocodone/Acetaminophen
Vistaril
Hydroxyzine Pamoate
Theo-Dur
Theophylline
Ultram
HSDBF V1
Indication/Drug Class
Formulary
Injection, Irrigation, Nasal Spray
Constipation-Osmotic Laxative
Constipation-Osmotic Laxative
Pulmonary-Anticholinergic
Fluid Retention-Potassium
Sparing Diuretic
Parkinson's Disease Agents
Gastrointestinal-Protectant
Calcium Channel Blockers
Infection-Bacterial
Topical-Emollient
Parkinson's Disease Agents
Neuropathic Pain, SeizuresAntiepileptic
Insomnia-Benzodiazepine
Beta Adrenergic Blockers
Beta Adrenergic Blockers
Alpha Adrenergic Blockers
Cough-Antitussive
BASE
BASE
BASE
PULMONARY
BASE
NEUROMUSCULAR
BASE
STROKE
BASE
BASE
NEUROMUSCULAR
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
Pulmonary-Xanthines
PULMONARY
Pulmonary-Xanthines
PULMONARY
Dysphagia
Dysphagia
Agitation, Hiccups, Nausea &
Vomiting-Phenothiazine
Topical-Protectant
Antiemetics-Antihistamine
Pulmonary-Anticholinergics
Antispasmodics
Beta Adrenergic Blockers
Pain-Opioid
Nausea & Vomiting, SecretionsAnticholinergic
Insomnia-Antidepressant
Calcium Channel Blockers
Parkinson's Disease Agents
Pain-Salicylate Anti-Inflammatory
Antiemetics-Antihistamine
Fever, Pain-Nonopioid
BASE
BASE
BASE
BASE
NEUROMUSCULAR
PULMONARY
NEUROMUSCULAR
CARDIAC/STROKE
BASE
BASE
BASE
CARDIAC/STROKE
NEUROMUSCULAR
BASE
NEUROMUSCULAR
BASE
Pain-Opioid
BASE
Genitourinary-Cholinergic
Anxiety, Dyspnea, Muscle
Spasms, Nausea & Vomiting,
Seizures-Benzodiazepine
Seizures-MaintenanceAntiepileptic
Angiotensin Receptor Blockers
Angiotensin Receptor Blockers
Constipation-Lubricant
ACE Inhibitors
ACE Inhibitors
Calcium Channel Blockers
Infection-Bacterial
Nociceptive Pain-Combination
Opioid/Nonopioid
Anxiety, Pruritus-Antihistamine
BASE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
BASE
Generic/Brand Drug Name
Generic/Brand Drug Name
Vitamin A & D Cream
Vitamin K
Warfarin
Sween
Mephyton, AquaMephyton
Coumadin
Xanax
Alprazolam (NO XR OR ODT)
Xylocaine
Xylocaine Viscous
Zanaflex
Zantac
Zaroxolyn
Zeasorb AF
Zebeta
Ziac
Zestril
Zestoretic
Zinc Oxide + Dimethicone
Zinc Oxide Ointment
Zithromax
Lidocaine Inj for Nebulization
Lidocaine
Tizanidine
Ranitidine (NO ORAL LIQ)
Metolazone
Myconazole Cream, Powder
Bisoprolol
Bisoprolol/Hctz
Lisinopril
Lisinopril/Hctz
Baza Protect
Desitin
Azithromycin
Zoloft
Sertraline
Zovirax
Acyclovir (ORAL ONLY)
Indication/Drug Class
Formulary
Topical-Emollient
Coagulants
Anticoagulants
Anxiety, Dyspnea, Insomnia,
Nausea & VomitingBenzodiazepine
Cough-Suppressant
Pain-Pharyngeal
Antispasmodics
Gastrointestinal-H2 Antagonist
Fluid Retention-Thiazide Diuretic
Topical Antifungal
Beta Adrenergic Blockers
Beta Adrenergic Blockers
ACE Inhibitors
ACE Inhibitors
Topical-Protectant
Topical-Protectant
Infection-Bacterial
Depression-Selective Serotonin
Reuptake Inhibitor
Infection-Antiviral
BASE
LIVER
CANCER/CARDIAC/STROKE
BASE
BASE
BASE
NEUROMUSCULAR
BASE
BASE
BASE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
BASE
BASE
BASE
BASE
Please Note: Unless otherwise noted, all strengths and dosage forms of listed medications are covered on both the Base List and
Diagnosis Specific Categories.
HSDBF V1