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1-800-227-0848 www.hospiscript.com 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 Vaselineā¢ Balls if high or hard impaction present. Saline Laxative Give in 4-8 ounces of liquid. Vaselineā¢ 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