Fillable Printable Formulary For Non-Ihsc Staffed Detention Facilities
Fillable Printable Formulary For Non-Ihsc Staffed Detention Facilities
Formulary For Non-Ihsc Staffed Detention Facilities
ICE HEALTH SERVICE CORPS
Formulary for NON-IHSC Staffed Detention Facilities
The formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs. Brand name drugs
with generic equivalents are considered non-formulary. Last Revised: 09 November 2017.
Page 1 of 4
Drug Category
Formulary Agents: generics, BRANDS
ANTI-INFECTIVES
Penicillins
amoxicillin, amoxicillin/clavulanate, ampicillin, BICILLIN-LA, dicloxacillin, penicillin-VK
Cephalosporins
cefaclor, cefadroxil, cefprozil, cefuroxime axetil, cephalexin, ceftriaxone
Ketolides
Requires approval
Macrolides
azithromycin, clarithromycin, clindamycin, ery-tab, erythromycin base, erythromycin ES
Quinolones
ciprofloxacin, moxifloxacin, ofloxacin
Tetracyclines
doxycycline, minocycline, tetracycline
Anthelmintic
albendazole, mebendazole
Anti-herpetic
acyclovir, acyclovir cream, famciclovir
Anti-influenza
amantadine, RELENZA, rimantadine, TAMIFLU
Antifungals
clotrimazole, fluconazole, griseofulvin, ketoconazole, terbinafine
Antimycobaterial
ethambutol, isoniazid, pyrazinamide, rifampin, streptomycin
Antiretrovirals
ALL AGENTS ARE ON FORMULARY
Misc. Anti-infectives
metronidazole, sulfamethoxazole/trimethoprim,
Urinary Anti-infective
nitrofurantoin
CARDIOVASCULAR
ACE Inhibitors
benazepril, captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril
Angiotensin Receptor Blockers (ARBs)
losartan, valsartan
Anti-hypertensive Combos
Requires Approval
Beta Blockers
acebutolol, atenolol, betaxolol, bisoprolol, metoprolol, nadolol, pindolol, propranolol, sotalol/-AF, timolol
Alpha-Beta Blockers
carvedilol, labetalol
Calcium Channel Blockers
--Dihydropyridines
felodipine, nicardipine, nifedipine, nifedipine XL, amlodipine
--Non-dihydropyridines
cartia XT, diltia XT, diltiazem HCl, diltiazem ER, diltiazem XR, verapamil-SR
Misc. Anti-hypertensives
clonidine, methyldopa
Diuretics
bumetanide, chlorthalidone, furosemide, hydrochlorothiazide, metolazone, spironolactone,
triamterene/hydrochlorothiazide
HMG-CoA
atorvastatin, lovastatin, pravastatin, simvastatin
Cholesterol, other
cholestyramine, fenofibrate, gemfibrozil
Nitrates
isosorbide dinitrate, isosorbide mononitrate, nitroglycerin SL
Cardiotonics
digoxin
Anti-arrhythmics
amiodarone
ANTICOAGULANTS
enoxaparin, warfarin, apixaban, rivaroxaban
Platelet Aggregation Inhibitors
clopidogrel
CENTRAL NERVOUS SYSTEM
Agents for Alzheimer’s dementia
donepezil
Antianxiety
alprazolam, buspirone, chlordiazepoxide, clorazepate, diazepam, lorazepam, oxazepam
Anticholinergic
benztropine
Anticonvulsants
carbamazepine, clonazepam, divalproex, gabapentin, levetiracetam, phenytoin, topiramate, valproic acid
Antidepressants— SSRIs
citalopram, escitalopram, fluoxetine, paroxetine, sertraline
Antidepressants – Tricylics
amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline
Antidepressants— other
bupropion HCl, bupropion SR, duloxetine, mirtazapine, nefazodone, trazodone, venlafaxine
Antiemetics
dimenhydrinate, meclizine, ondansetron, promethazine
Antimigraine
sumatriptan
Antipsychotics
aripiprazole, chlorpromazine, clozapine, fluphenazine, haloperidol (including injection), haloperidol decanoate,
lithium,
loxapine, lurasidone, perphenazine, quetiapine, risperidone, thioridazine, thiothixene, trifluoperazine, olanzapine,
ziprasidone
Sedative Hypnotics
estazolam, hydroxyzine pamoate, phenobarbital, temazepam, triazolam
Stimulants/ADHD
atomoxetine, dextroamphetamine, dexmethylphenidate ER, methylphenidate (all oral forms)
DERMATOLOGIC
Acne Products
benzoyl peroxide, clindamycin lotion, erythromycin gel, tretinoin
Agents for Eczema
clobetasol, fluocinonide, hydrocortisone, betamethasone valerate, triamcinolone
Anti-infectives
gentamicin, metronidazole cream, mupirocin
Anti-fungals
clotrimazole, nystatin, terbinafine
PEDICULICIDES
permethrin cream
ICE HEALTH SERVICE CORPS
Formulary for NON-IHSC Staffed Detention Facilities
The formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs. Brand name drugs
with generic equivalents are considered non-formulary. Last Revised: 09 November 2017.
Page 2 of 4
Drug Category
Formulary Agents generics, BRANDS
ENDOCRINE/ HORMONE
Contraceptives
levonorgestrel/ethinyl estradiol, medroxyprogesterone injection, norethindrone/ethinyl estradiol,
norethindrone, norgestrel/ethinyl estradiol, norgestimate/ethinyl estradiol
Emergency Contraceptive, Oral
levonorgestrel Emergency Contraceptive 0.75mg, ELLA, MY WAY, PLAN B, PLAN B ONE-STEP, OPCICON
ONE-STEP
Osteoporosis Agents
alendronate
Estrogens
Depo-Estradiol, estradiol, PREMARIN
Estrogen combo
Requires Approval
Estrogen, topical
Requires Approval
Pituitary Disorders
cabergoline, bromocriptine
Insulins
HUMULIN, HUMALOG, LANTUS, NOVOLOG, NOVOLIN
Progesterones
medroxyprogesterone, medroxyprogesterone injectable suspension
Oral Antidiabetic Agents
Sulfonylureas
glimepiride, glipizide, glipizide ER, glyburide, glyburide micronized, tolazamide
Biguanides
metformin, metformin ER
Glitazones
AVANDIA (access restricted), pioglitazone
Meglitinides
Requires Approval
Alpha-glucosidase inhibitors
Requires Approval
Corticosteroids
dexamethasone, methylprednisolone, hydrocortisone, prednisone, triamcinolone intramuscular injection
Thyroid
levothyroxine, thyroid
Testosterones
testosterone cypionate injectable
GASTROINTESTINAL
Antidiarrheal
diphenoxylate/atropine, loperamide
Antispasmodics
dicyclomine, hyoscyamine
Digestants
pancrelipase
GI Stimulants
metoclopramide
H2 Antagonists
cimetidine, famotidine, ranitidine
IBS Agents
Requires Approval
Misc. Anti-ulcer
sucralfate
Proton Pump Inhibitors
omeprazole, omeprazole OTC
Ulcerative Colitis
sulfasalazine, mesalamine (ASACOL, CANASA, DELZICOL, LIALDA, PENTASA)
MUSCULOSKELETAL, ANALGESICS
Opioids, long-acting
Opioids, short-acting
codeine/acetaminophen, hydrocodone/acetaminophen, oxycodone/acetaminophen, tramadol
NSAIDs
diclofenac, etodolac, ibuprofen, indomethacin, indomethacin/SR, ketoprofen, ketorolac, meloxicam,
nabumetone, naproxen, naproxen sodium, oxaprozin, piroxicam, salsalate, sulindac, tolmetin
COX-2
Requires Approval
Skeletal Muscle Relaxants
baclofen, carisoprodol, cyclobenzaprine, methocarbamol
OPHTHALMICS
Anti-infectives
ciprofloxacin, erythromycin ointment, gentamicin, sulfacetamide, tobramycin
Agents for allergic conjunctivitis
ketotifen
Agents for glaucoma
brimonidine, carteolol, dorzolamide, dorzolamide/timolol, latanoprost, timolol
Ophthalmic Steroids
prednisolone acetate
Combination Products
neomycin/polymyxin/dexamethasone
ICE HEALTH SERVICE CORPS
Formulary for NON-IHSC Staffed Detention Facilities
The formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs. Brand name drugs
with generic equivalents are considered non-formulary. Last Revised: 09 November 2017.
Page 3 of 4
OTICS
Anti-infectives
neomycin/polymyxin/hydrocortisone, ofloxacin
RESPIRATORY, ALLERGY
Beta-Agonists
albuterol, metaproterenol solution, PROAIR HFA, PROVENTIL HFA, SEREVENT, VENTOLIN HFA
Inhaled Steroids
Budesonide, FLOVENT HFA, QVAR
Inhaled Steroid/Beta-Agonist Combination
ADVAIR, SYMBICORT
Leukotriene Modifiers
montelukast
Nasal Steroids
flunisolide, fluticasone
Antihistamine (& Decongestant Combo)
chlorpheneramine CR, clemastine, cyproheptadine, diphenhydramine, loratadine OTC
Antitussive
benzonatate
Xanthine Derivatives
theophylline
UROLOGIC AGENTS
Agents for BPH
doxazosin, finasteride, prazosin, tamsulosin, terazosin
Agents for erectile dysfunction
Requires Approval
Agents for overactive bladder
oxybutynin
Agents for urinary analgesic
phenazopyridine
Alkalizing agents
potassium citrate
VITAMINS
Vitamins
cyanocobalamin, leucovorin, nephro-vite, prenatal vitamin, pyridoxine, vitamin D, calcitriol
MISCELLANEOUS
Agents for gout
allopurinol, colchicine
Agents for potassium removal
sodium polystyrene (SPS)
Agents for myasthenia gravis
pyridostigmine
Agents for phosphate removing
RENAGEL, RENVELA, calcium acetate, lanthanum
DMARDs
hydroxychloroquine, hydroxyurea, methotrexate
Dental paste
triamcinolone
Laxative
lactulose, polyethylene glycol/ electrolytes
Minerals and electrolytes
potassium chloride, sodium chloride, sodium bicarbonate
Mouthwashes and gargles
chlorhexidine gluconate (alcohol free product)
VACCINES
Hepatitis
Hepatitis A Vaccine
Hepatitis B Vaccine
Measles
Measles Virus Vaccine
Poliovirus Vaccine, IPV
Poliovirus Vaccine, IPV
Human Papillomavirus (HPV)
Human Papillomavirus (HPV) Quadrivalent Recombinant Vaccine
Influenza
Influenza vaccine
Rabies
Rabies Virus Vaccine, HDC
Rotavirus
Rotavirus Vaccine, Live Oral
Rubella
Rubella Virus Vaccine
Varicella
Varicella Virus Vaccine Live Oral
Yellow Fever
Yellow Fever Vaccine
Measles, Mumps & Rubella
Measles, Mumps & Rubella Virus Vaccines
Measles, Mumps, Rubella, Influenza
Measles-Mumps-Rubella-Varicella Virus Vaccines
Haemophilus B
Haemophilus B Polysac Vaccine
Meningococcal
Meningococcal Vaccine-A
ICE HEALTH SERVICE CORPS
Formulary for NON-IHSC Staffed Detention Facilities
The formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs. Brand name drugs
with generic equivalents are considered non-formulary. Last Revised: 09 November 2017.
Page 4 of 4
Meningococcal (con’t)
Meningococcal Group B Vaccine
Meningococcal Vaccine Group C Oligosaccharide Conjugated
Meningococcal Vaccine Group C Polysaccharide Conjugated
Pneumococcal
Pneumococcal Vac Polyvalent
Pneumococcal Vac Conjugate (PCV13)
Tetanus/Diptheria
TD (Tetanus/Diphtheria)
Tetansu/Diptheria/Pertussis
Tdap (Tetanus/Diptheria/Pertussis)
Typhoid Vaccine
Typhoid Vaccine
