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This formulary is a closed, non-tiered formulary. It is a supplement to the alphabetic listing.
(C) means that the drug is only available for administration at the clinic.
(B) means the drug is available through BuyRite Pharmacy for contract eligible patients only.
(S) means that the drug is not stocked, but wil be ordered if requested.
(R) means that there is one or more restrictions on the drug.
GENERIC NAME
BRAND NAME
GENERIC NAME
BRAND NAME
Acetaminophen 100mg/1mL drops Tylenol drops Acetaminophen 160mg/5mL susp Tylenol susp Budesonide 0.25mg/2mL ampule Pulmicort 0.25mg Nebule Carbamide Peroxide 6.5% Drops Debrox drops Page 1 of 7
This formulary is a closed, non-tiered formulary. It is a supplement to the alphabetic listing.
(C) means that the drug is only available for administration at the clinic.
(B) means the drug is available through BuyRite Pharmacy for contract eligible patients only.
(S) means that the drug is not stocked, but wil be ordered if requested.
(R) means that there is one or more restrictions on the drug.
GENERIC NAME
BRAND NAME
GENERIC NAME
BRAND NAME
Dexmethylphenidate XR10mg (R)B Focalin XR 10mg cap (R)B Dexmethylphenidate XR15mg (R)B Focalin XR 15mg cap (R)B Dexmethylphenidate XR 20mg (R)B Focalin XR 20mg cap (R)B Dexmethylphenidate XR 25mg (R)B Focalin XR 25mg cap (R)B Dexmethylphenidate XR 30mg (R)B Focalin XR 30mg cap (R)B Dexmethylphenidate XR 35mg (R)B Focalin XR 35mg cap (R)B Dexmethylphenidate XR 40mg (R)B Focalin XR 40mg cap (R)B Diazepam10mg/2ml(Abboject ® )(c)Valium 10mg/2ml inj (C ) Diphenhydramine 12.5mg/5mL syr Benadryl syr Diphenhydramine 50mg/ml inj (C ) Benadryl inj (C ) Cyclosporine 0.05% ophth emulsion Restasis 0.05% Desmopressin 0.01% nasal spray DDAVP nasal spray Dexmethylphenidate 2.5mgtab (R)B Focalin 2.5mg tab (R)B Dexmethylphenidate 5mgtab (R)B Focalin 5mg tab (R)B Dexmethylphenidate 10mgtab(R)B Focalin 10mg tab (R)B Dexmethylphenidate XR5mg (R)B Focalin XR 5mg cap (R)B Page 2 of 7
This formulary is a closed, non-tiered formulary. It is a supplement to the alphabetic listing.
(C) means that the drug is only available for administration at the clinic.
(B) means the drug is available through BuyRite Pharmacy for contract eligible patients only.
(S) means that the drug is not stocked, but wil be ordered if requested.
(R) means that there is one or more restrictions on the drug.
GENERIC NAME
BRAND NAME
GENERIC NAME
BRAND NAME
Estradiol cypionate 5mg/mL inj (C ) Depo-Estradiol inj (C ) Estradiol valerate 40mg/ml inj (C ) Delestrogen inj (C ) Hydrocortisone 2.5% rectal cream Proctosol HC Page 3 of 7
This formulary is a closed, non-tiered formulary. It is a supplement to the alphabetic listing.
(C) means that the drug is only available for administration at the clinic.
(B) means the drug is available through BuyRite Pharmacy for contract eligible patients only.
(S) means that the drug is not stocked, but wil be ordered if requested.
(R) means that there is one or more restrictions on the drug.
GENERIC NAME
BRAND NAME
GENERIC NAME
BRAND NAME
Lidocaine/epinephrine 1%/1:100,000 inj (C ) Lignospan Forte inj Lisdexamfetamine 20mgcap (B)(R )Vyvanse 20mg (B)(R ) Lisdexamfetamine 30mgcap (B)(R ) Vyvanse 30mg (B)(R ) Lisdexamfetamine 40mgcap (B)(R ) Vyvanse 40mg (B)(R ) Insulin Detemir (Levemir) FlexPen Levemir FlexPen Lisdexamfetamine 50mgcap (B)(R ) Vyvanse 50mg (B)(R ) Lisdexamfetamine 60mgcap (B)(R ) Vyvanse 60 mg(B)(R ) Lisdexamfetamine 70mgcap (B)(R ) Vyvanse 70 mg(B)(R ) Isosorbide Dinitrate 40mg ER tab Isordil 40mg ER tab Megestrol Acetate 40mg/mL Susp Megace 40mg/mL susp Page 4 of 7
This formulary is a closed, non-tiered formulary. It is a supplement to the alphabetic listing.
(C) means that the drug is only available for administration at the clinic.
(B) means the drug is available through BuyRite Pharmacy for contract eligible patients only.
(S) means that the drug is not stocked, but wil be ordered if requested.
(R) means that there is one or more restrictions on the drug.
GENERIC NAME
BRAND NAME
GENERIC NAME
BRAND NAME
Morphine sulfate 15mg IR tab (B,R) MSIR 15mg tab (B,R) MS Contin 30mg ER Oxycodone/acetaminophen 10/325 tab (B,R) Percocet 10/325 tab Morphine sulfate 30mg IR tab (B,R) MSIR 30mg tab (B,R) Oxycodone/acetaminophen 10/650 tab (B,R) Percocet 10/650 tab Oxycodone/acetaminophen 5/325 tab (B,R) Percocet 5/325 tab Oxycodone/acetaminophen 5/500 tab (B,R) Percocet 5/500 tab Oxycodone/acetaminophen 7.5/325 tab (B,R) Naloxone hydrochloride 0.4mg/mL inj (C ) Narcan 0.4mg/mL inj Oxycodone/acetaminophen 7.5/500 tab (B,R) Neomycin/Polymyxin B/Dexameth ophth oint Maxitrol ophth oint Neomycin/Polymyxin B/Dexameth ophth soln Maxitrol ophth soln Norethindrone and ethinyl estradiol Tri-nessa tab Page 5 of 7
This formulary is a closed, non-tiered formulary. It is a supplement to the alphabetic listing.
(C) means that the drug is only available for administration at the clinic.
(B) means the drug is available through BuyRite Pharmacy for contract eligible patients only.
(S) means that the drug is not stocked, but wil be ordered if requested.
(R) means that there is one or more restrictions on the drug.
GENERIC NAME
BRAND NAME
GENERIC NAME
BRAND NAME
PolymyxinB/Bacitracin/Neomycin topical oint Triple Antibiotic Polyvinyl Alcohol 1.4% ophth soln Refresh Tears ophth Sertraline 50mg tab (Restricted to 25mg dose) Sevelamer Carbonate 800mg tab Renvela 800mg tab Sodium Bicarbonate 8.4% inj (Abboject ® )(C ) Promethazine 25mg/1ml amp (C ) Phenergan 25mg/mL amp (C ) Bicarbonate 8.4% inj (Abboject®)(C ) Sodium chloride 0.65% nasal soln Ocean 0.65% nasal soln Sulfameth/Trimethoprim 200mg/40mg/5mL susp Sulfameth/Trimethoprim DS 800mg/160mg/tab Page 6 of 7
This formulary is a closed, non-tiered formulary. It is a supplement to the alphabetic listing.
(C) means that the drug is only available for administration at the clinic.
(B) means the drug is available through BuyRite Pharmacy for contract eligible patients only.
(S) means that the drug is not stocked, but wil be ordered if requested.
(R) means that there is one or more restrictions on the drug.
GENERIC NAME
BRAND NAME
GENERIC NAME
BRAND NAME
Testosterone cypionate 200mg/mL inj (C ) Triamcinolone 0.1% cream 15gm Kenalog 0.1% cream Triamcinolone 0.1% Dental Paste Kenalog 0.1% dental paste Page 7 of 7

Source: http://www.poarchcreekindians.org/wmlib/pdf/12/1010_generic_formulary.pdf