TG 200 ATTACHMENT A

DRUG FORMULARY

MEDICATIONS CATEGORY
ALLERGY, COUGH and COLD
Cetirizine HCL 10 mg TAB (Zyrtec) ANTIHISTAMINE
Diphenhydramine HCL 25mg CAP (Benadryl) ANTIHISTAMINE
Fexofenadine 60 mg, 180 mg TAB (Allegra) ANTIHISTAMINE
Fluticasone propionate nasal spray (Flonase) ANTIHISTAMINE
Loratadine 10 mg TAB (Claritin) ANTIHISTAMINE
Pseudoephedrine HCL 120 mg/Fexofenadine 60 ANTIHISTAMINE SD
mg TAB (Allegra-D 12 hour)
Pseudoephedrine 30 mg TAB DECONGESTANT SD
Phenylephedrine 5 mg TAB DECONGESTANT
Guaifenesin 100mg and dextromethorphan ANTITUSSIVE
15mg/5ml, (Robitussin DM) or Sucrets Cough Drops
Benzocaine Sore Throat Lozenges (Cepacol) ANALGESIC-THROAT

ANALGESIC
Acetaminophen 325 mg TAB (Tylenol) ANALGESIC
Acetaminophen 650 mg SUPP (Tylenol ANALGESIC
suppository)
Aspirin Tabs 81mg, 325 mg TAB ANALGESIC/SALICYLATES
Ibuprofen Tabs 200 mg, 400mg TAB (Motrin, ANALGESIC
Advil)
Naproxen sodium, 220 mg TAB (Aleve) ANALGESIC

ANTIMICROBIAL
Amoxicillin 500 mg CAP PENICILLIN
Amoxicillin 875 mg/Clav 125mg TAB (Augmentin) PENICILLIN
Azithromycin 250 mg TAB (Zithromax) MACROLIDE
Cephalexin Caps 500 mg CAP (Keflex) CEPHALOSPORIN
Ceftriaxone Sodium 250 mg INJ (Rocephin) CEPHALOSPORIN
Ciprofloxacin HCL 500 mg TAB FLUOROQUINOLONE
Clarithromycin 500mg TAB MACROLIDE
Clindamycin 300 mg (Cleocin) MACROLIDE
Doxycycline 100mg CAP TETRACYC/P-MALARIAL
Erythromycin Stearate 250 mg TAB MACROLIDE
Levofloxacin 500 mg TAB (Levaquin) FLUOROQUINOLONE
Nitrofurantoin 100 mg CAP ( Macrodantin) URINARY
March 2016
 TG 200 ATTACHMENT A

Penicillin VK 500 mg TAB PENICILLIN

Penicillin G Benzathine & Procaine 1,200,000 units PENICILLIN
INJ (Bicillin)
Sulfamethoxazole/Trimethoprim 800/160 mg, TAB SULFA
(Bactrim DS)

ANTIFUNGAL
Fluconazole 150mg TAB (Diflucan) ANTIFUNGAL

ANTIHELMITES
Albendazole 200mg TAB (Albenza) ANTHELMINTIC
Praziquantel 600 mg TAB (Biltricide) ANTHELMINTIC
Mebendazole 100 mg TAB (Vermox) ANTHELMINTIC

ANTIPROTOZOAL
Metronidazole 500mg TAB (Flagyl) AMEBICIDE
Paromomycin Sulphate 250 mg CAP (Humatin) AMEBICIDE
Tinidazole 500 mg TAB (Tindamax) AMEBICIDE

ANTIMALARIAS
Atovaquone/Proguanil 250/100mg TAB (Malarone) MALARIAL SD
Chloroquine Phosphate 250 mg TAB (Aralen) MALARIAL SD
Mefloquine HCL 250 mg TAB (Lariam) MALARIAL SD
Primaquine Phosphate 15 mg base TAB MALARIAL SD
(Primaquine)
Artemether 20 mg/lumefantrine 120 mg TAB MALARIAL SD
(Coartem)
Artemether 80 mg/lumefantrine 480 mg TAB MALARIAL SD
(Coartem)
Artesunate INJ MALARIAL INJ SD

ANTITUBERCULOSIS
Isoniazid 300 mg TAB (INH) ANTI-TUBERUCLOSIS SD
Rifampin 300 mg TAB (Rifadin) ANTI-TUBERCULOSIS SD
Vitamin B6 50mg TAB (Pyriodoxine) VITAMIN

ANTIVIRAL
Emtricitabine 200 mg and Tenofovir 300 mg TAB ANTIRETROVIRAL SD
(Truvada)
 TG 200 ATTACHMENT A

Raltegravir 400mg TAB (Isentress) ANTIRETROVIRAL SD

Acyclovir 200mg CAP ANTIVIRAL

Oseltamivir phosphate (Tamiflu) 75 mg CAP ANTIVIRAL SD

Zanamivir (Relenza) 5mg DISC INH ANTIVIRAL SD

ASTHMA
Albuterol Inhaler, 17gm, (Proventil) (HAZ) BETA2AGONIST
Albuterol Sol. 0.5%, 5 mg/ml (Nebulizer) BETA2AGONIST
Fluticasone 110mcg (HAZ) (Flovent) INHALED CORTICOSTEROID
Fluticasone/Salmeterol 250/50 MCG (Advair BETA2AGONIST/CORTICOSTEROID
Diskus)
Montelukast Sodium 10 mg (Singulair) LEUKOTRIENE ANTAGONIST

CARDIOVASCULAR
Amlodipine 5mg TAB (Norvasc)
Lisinopril 10 mg TAB
Hydrochlorothiazide 25mg TAB
Metoprolol tartrate 50 mg TAB (Lopressor)
Valsartan 80 mg TAB (Diovan)
Atorvastatin Calcium 20 mg (Lipitor)
Furosemide Tabs, 20mg, (Lasix)
Potassium Chloride Tabs, (8 or 10 mEq)
ANTI-HYPERTENS-CA CHANNEL BLOCKER
ANTI-HYPERTENSIVE- ACE INHIBITOR
ANTI-HYPERTENSIVE-DIURETIC
ANTI-HYPERTENSIVE-BETA BLOCKER
ANTI-HYPERTENSIVE-ARB
CHOLESTEROL-STATIN
DIURETIC
ELECTROLYTE

CENTRAL NERVOUS SYSTEM

Bupropion HCL 150 mg TAB (Wellbutrin XL) ANTI- DEPRESSANT
Escitalopram Oxalate 10 mg TAB (Lexapro) ANTI-DEPRESSANT- SSRI
Fluoxetine 20mg TAB (Prozac) ANTI- DEPRESSANT-SSRI
Sertraline HCL 50 mg TAB (Zoloft) ANTI- DEPRESSANT- SSRI
Haloperidol 5 mg TAB (Haldol) ANTIPSYCHOTIC 1st generation
Haloperidol 5 mg/ml INJ (Haldol) ANTIPSYCHOTIC INJ 1st generation
Risperidone 1mg TAB ATYPICAL ANTIPSYCHOTIC
Lorazepam 1mg, TAB(Ativan) CS- BENZODIAZEPINES
Lorazepam 2mg/ml INJ(Ativan) CS - BENZODIAZEPINES - INJ
Zolpidem tartrate 5 mg TAB (Ambien) HYPNOTIC
Sumatriptan 25 or 50 mg TAB(Imitrex) MISC-MIGRAINE
 TG 200 ATTACHMENT A

CONTRACEPTION
Condoms
Ethinyl estradiol 20 mcg/1 mg norethindrone ESTROGEN/PROGESTIN COMBO
acetate TAB (Microgestin) 1/20)
Ethinyl estradiol 30mg/ Norgestrel 0.3 mg TAB ESTROGEN/PROGESTIN COMBO
(Low-Ogestrel 28)
Ethinyl estradiol 35 mcg/Norgestimate 0.18 ESTROGEN/PROGESTIN COMBO
mg/0.215mg / 0.25 mg TAB (TriNessa)
Ethinyl estradiol 20 mcg/ Drospirenone 3 mg/ TAB ESTROGEN/PROGESTIN COMBO
(Yaz)
Ethinyl estradiol 30 mcg/ Drospirenone 3 mg/ TAB ESTROGEN/PROGESTIN COMBO
(Yasmin)
Levonorgestrel 0.75 mg TAB (Plan B) PROGESTIN
Medroxyprogesterone 150mg/1ml INJ (Depo- PROGESTIN
Provera)

CONTROLLED SUBSTANCE ANALGESIC

Acetaminophen 300mg/Codeine phosphate 30mg CS OPIATE AGONIST
TAB
Morphine Sulphate INJ, 10 mg/ml CS - OPIATE AGONIST
Guaifenesin 100 mg/codeine phosphate 10 mg per CS ANTITUSSIVE
5 ml SYRUP (Robafen AC)

DENTAL
Sensodyne toothpaste DENTAL
Dental Floss DENTAL

EAR PREPARATIONS
Polymyxin, Neomycin, HCL Solution, OTIC DROP ANTIMICROBIAL
(Cortisporin)
Carbamide peroxide 6.5% OTIC DROP (Debrox) CERUMINOLYTIC

EMERGENCY KIT
Epinephrine 0.3 mg/0.3ml INJ (EPI PEN) ADRENERGIC
Epinephrine, 1:1000(1mg/ml) INJ (EPI Vial) ADRENERGIC - INJ
Diphenhydramine HCL 50 mg/ml INJ (Benadryl) ANTIHISTAMINE
Nitroglycerine Sublingual 0.3 mg, TABs (Nitrostat) CARDIOVASCULAR
Glucagon, 5mg, 10 mg INJ CARDIOVASCULAR
Methyprednisone succinate 125 mg Inj. (Solu- CORTICOSTEROID - INJ
Medrol)
Charcoal, Act Pwd, 12.5 gm MISCELLANEOUS
 TG 200 ATTACHMENT A

Ammonia Inhalant 10/pkg. (HAZ) MISCELLANEOUS

ENDOCRINE
Levothyroxine sodium 25-100 mcg TAB (Synthroid) THYROID AGENT
Metformin 500mg TAB (Glucophage) ANTIDIABETIC

EYE PREPARTIONS
Ciprofloxacin 0.3% OPHTH SOL (Ciloxan) ANTIMICROBIAL
Trimethoprim-polymyxin B 0.1%-10,000 units/mL ANTIMICROBIAL
OPHTH DROP
Artificial Tears OPHTH SOL MISCELLANEOUS
Naphazoline 0.25 percent and pheniramine 0.3 VASOCONSTRICTOR/ANTIHISTAMINE
percent (Naphcon-A)

GASTROINTESTINAL
Omeprazole 20 mg TAB/CAP (Prilosec) ACID REDUCERS- PPI
Ranitidine Tabs150 mg TAB (Zantac) ACID REDUCERS- H2
Calcium Carbonate 420 mg or 500mg TAB (TUMS) ANTACIDS
Bismuth subsalicylate TAB (Pepto-Bismol) ANTIDIARRHEAL
Loperamide 2mg TAB (Imodium) ANTIDIARRHEAL
Psyllium (Metamucil) ANTIDIARRHEAL/LAXATIVE
Promethazine HCL 25 mg SUPP (Phenergan) ANTIHISTIMINE / ANTIEMTIC
Promethazine HCL 25 mg TAB (Phenergan) ANTIHISTIMINE / ANTIEMTIC
Docusate Sodium 100 mg CAP (Colace) LAXATIVE/STOOL SOFTENER
Oral Rehydration Salts REHYDRATION

GENITOURINARY
Phenazopyridine 100 mg TAB (Pyridium) URINARY ANALGESIC

GYNECOLOGY
Medroxyprogesterone Acetate 5 mg (Provera) PROGESTIN

INJECTION ADJUNCTS
Sodium Chlorine 20 ml for INJ INJECTION
Sterile Water 5 ml for INJ INJECTION
Lidocaine, HCL 1% 10mg/ml, INJ INJECTION
Lidocaine, HCL 1%/Epi, Inj, 10mg/ml, INJ INJECTION
 TG 200 ATTACHMENT A

SKIN AND MUCCOUS MEMBRANE AGENTS

Diphenhydramine/Calamine LOTION/CREAM ANESTHETIC
(Caladryl)
Hydrocortisone 1% CREAM STEROID
Triamcinolone acetonide 0.1 CREAM/OINT STEROID
Miconazole 4% CREAM (Monostat 3) ANTIFUNGAL
Clotrimazole1% CREAM (Lotrimin) ANTIFUNGAL
Selenium Sulfide 2.5% LOTION (Selsun) ANTIFUNGAL
Selenium Sulfate 1% SHAMPOO (Selsun) ANTIFUNGAL
Mupirocin 2% OINT(Bactroban) ANTIMICROBIAL
Neomycin, Polymy & Baci Oint, OINT (Neosporin) ANTIMICROBIAL
Sulfadiazine Silver, 1%, 20 gm CREAM (Silvadene) ANTIMICROBIAL
Permethrin 1% CREAM RINSE (NIX 1 %) ANTIPARASITIC
Permethrin 5% CREAM (ELIMITE 5%) ANTIPARASITIC
Salicylic Acid, 40% ( plaster paper) wart tx KERATOLYTIC
Podofilox 0.5% (Condylox) genital wart tx KERATOLYTIC

STEROIDS
Prednisone 5 mg, 10 mg TAB STEROID

VACCINES Check for country specific recommendations

PPD (Mantoux) 5 TU Dose VACCINES - All Regions
Hepatitis A VACCINES
Hepatitis B VACCINES
Tetanus/TDap VACCINES
Influenza VACCINES
MMR VACCINES
Rabies VACCINES
Rabies Immune Globulin VACCINES
Typhoid (ViCPS) VACCINES
Meningococcal A/C/Y/W-135, (Menomun) VACCINES
Tick-borne Encephalitis VACCINES
Japanese Encephalitis VACCINES
Polio VACCINES
Pneumococcal VACCINES
 TG 200 ATTACHMENT A

VITAMINS
Multivitamin & Mineral TAB VIT / MIN
Ferrous Sulfate 324 mg, TAB (Iron) VIT / MIN
Prenatal TAB VIT / MIN