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Healthez.com

AH Self-funded Pharmacy Formulary* (updated 1/2011)
*maximum allowed towards deductible or paid by AH. Other medications will not be paid. Requests for additions to formulary can be made to Dr. Johnston.
**Please note: prices are subject to change for any medication.
Level 1 Generic
Level 2 Generic & Name Brand
Level 1 Generic
Level 2 Generic & Name Brand
Allergies & Cold and Flu
Quantity
Arthritis & Pain
Quantity
(Allegies/Cold/Flu) Benzonatate 200mg
(Allegies/Cold/Flu) Cetirizine 1mg/mL
DILAUDID (Generic) 4mg
Fluticasone (Generic for Flonase) 16 grams DILAUDID (Generic) 4mg
DILAUDID (Generic) 8mg
DILAUDID (Generic) 8mg
Level 1 Generic
Level 2 Generic & Name Brand
Antibiotic Treatments
Quantity
Hydrocodone- Acetaminophen (Gen) 5-500mg Amoxicillin 125mg/5ml susp (100ml bottle) Amoxicillin 125mg/5ml susp (150ml bottle) Hydromorphone HCI (Generic for DILAUDID) 4mg Amoxicillin 200mg/5ml susp (100ml bottle) Amoxicillin 250mg/5ml susp (100ml bottle) Amoxicillin 250mg/5ml susp (150ml bottle) Amoxicillin 400mg/5ml susp (100ml bottle) Amox/Clav ( Generice for AUGMENTIN) 500mg Amox/Clav ( Generice for AUGMENTIN) 875mg Level 1 Generic
Level 2 Generic & Name Brand
Quantity
Albuterol 0.5% nebulizer soln (20ml bottle) Albuterol 0.083% nebulizer soln (25x3ml vials) Ipratropium 0.02% nebulizer soln (25x2.5ml vials) Nitrofurantion (Generic for MACROBID) 100 mg Level 1 Generic
Level 2 Generic & Name Brand
Level 1 Generic
Level 2 Generic & Name Brand
Diabetes
Quantity
Cholesterol
Quantity
Level 1 Generic
Level 2 Generic & Name Brand
Gastrointestinal Health (cont.)
Quantity
Level 1 Generic
Level 2 Generic & Name Brand
Glaucoma & Eye Care
Quantity
Atropine sulfate 1% op. soln (5ml bottle) Level 1 Generic
Level 2 Generic & Name Brand
Ear Health
Quantity
Neomycin/Polymyxin/Dexamethasone 0.1% op. oint. (3.5gm tube) Neomycin/Polymyxin/Dexamethasone 0.1% op. susp (5ml bottle) Antipyrine/Benzocainne otic (10ml bottle) Sulfacet Sodium 10% op. soln (15ml bottle) Level 1 Generic
Level 2 Generic & Name Brand
Fungal Infections
Quantity
Timolol Maleate 0.25% op. soln (5ml bottle) Timolol Maleate 0.5% op. soln (5ml bottle) Level 1 Generic
Level 2 Generic & Name Brand
Heart Health & Blood Pressure
Quantity
Level 1 Generic
Level 2 Generic & Name Brand
Gastrointestinal Health
Quantity
Level 1 Generic
Level 2 Generic & Name Brand
Level 1 Generic
Level 2 Generic & Name Brand
Heart Health & Blood (cont.)
Quantity
Mental Health
Quantity
Amlodipine (Generic for NORVASC) 5mg
Venlafaxine ER (Generice for EFFEXOR) 150mg Level 1 Generic
Level 2 Generic & Name Brand
Level 1 Generic
Level 2 Generic & Name Brand
Thyroid Conditions
Quantity
Skin Conditions
Quantity
Benzoyl Peroxide 4% creamy wash (170.1ml bottle) Betamethasone Dipropionate 0.05% crm (15gm tube) Betamethasone Dipropionate 0.05% crm (45gm tube) Betamethasone Val. 0.1% cream (45gm tube) Betamethasone Val. 0.1% ointment (15gm tube) Betamethasone Val. 0.1% ointment (45gm tube) Betamethasone Valerate 0.1% cream (15gm tube) Clindamycin (Generic for CLEOCIN T SOLN) 30ml Fluocinolone Acet. 0.01% soln (60ml bottle) Levothyroxine ( Generic for SYNTHRIOD) 25 mcg Mupirocin Oint (Generic for BACTROBAN) 22mg Levothyroxine ( Generic for SYNTHRIOD) 50 mcg Selenium Sulifide 2.5% lotion (120ml bottle) Levothyroxine ( Generic for SYNTHRIOD) 75 mcg Levothyroxine ( Generic for SYNTHRIOD) 88 mcg Levothyroxine ( Generic for SYNTHRIOD) 100 mcg Levothyroxine ( Generic for SYNTHRIOD) 112 mcg Levothyroxine ( Generic for SYNTHRIOD) 125 mcg Levothyroxine ( Generic for SYNTHRIOD) 137 mcg Levothyroxine ( Generic for SYNTHRIOD) 150 mcg Levothyroxine ( Generic for SYNTHRIOD) 175 mcg Levothyroxine ( Generic for SYNTHRIOD) 200 mcg Level 1 Generic
Level 2 Generic & Name Brand
Other Medical Conditions
Quantity
(GI) PROMETHAZINE 25mg
Level 1 Generic
Level 2 Generic & Name Brand
(Pinworms) Mebendazole 100mg
Quantity
(Sleep) Hydroxyzine HCL 25 mg
Chlorhexidine Gluconate 0.12% soln (473ml bottle) Level 1 Generic
Level 2 Generic & Name Brand
Lidocaine 2% viscous solution (100ml bottle) Vitamins & Nutritional Health
Quantity
Sodium Fluoride .25mg chewable (120ct bottle) Level 1 Generic
Level 2 Generic & Name Brand
Women's Health
Quantity

Source: https://www.healthez.com/Forms/AHH_Medication_formulary.pdf

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