Scott Air Force Base
Scott Air Force Base
PHARMACY FORMULARY
Printable Copy (Revised: 14 Jan 10)
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ALLERGY/ ANTIHIST/ DECONGEST
| ACTIFED - TAB |
CHLOR-TRIMETON - 8mg SR CAP |
| ALLEGRA - 30mg, 60mg & 180mg TAB | CLARITIN - 10mg TAB & 1mg/mL SYRUP |
| ALLEGRA-D - 12HR & 24HR SR TAB | DECONAMINE - SR CAP |
| ATARAX - 10mg & 25mg TAB ** | PERIACTIN - 4mg TAB ** |
| ATARAX - 10mg/5mL SYRUP ** | SUDAFED - 30mg/5mL SYRUP |
| BENADRYL - 12.5mg/5mL ELIXIR | TWINJECT - 0.15mg & 0.3mg AUTO-INJECTOR ** |
| BENADRYL - 25mg & 50mg CAP | ZYRTEC - 10mg TAB & 1mg/mL SYRUP |
| CHLOR-TRIMETON - 2mg/5mL SYRUP | ZYRTEC-D - TAB |
| CHLOR-TRIMETON - 4mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANALGESICS & ANTIPYRETICS
| ASPIRIN - 325mg TAB |
| ASPIRIN EC - 81mg & 325mg TAB |
| CELEBREX - 100mg, 200mg & 400mg CAP |
| DISALCID - 500mg & 750mg TAB ** |
| FELDENE - 20mg CAP |
| FIORICET - TAB ** |
| INDOCIN - 25mg & 50mg CAP ** |
| MOBIC - 7.5mg & 15mg TAB ** |
| MOTRIN - 100mg/5mL SUSPENSION ** |
| MOTRIN - 400mg, 600mg & 800mg TAB ** |
| NAPROSYN - 250mg, 375mg & 500mg TAB ** |
| PYRIDIUM - 100mg TAB ** |
| TYLENOL - 325mg & 500mg TAB |
| TYLENOL - 160mg/5mL ELIXIR |
| TYLENOL - INFANT DROPS |
| *ULTRAM - 50mg TAB (720 tabs/90days) ** |
(* indicates Quantity Restrictions)
(** indicates Basic Core Formulary -
available at all Military Treatment Centers)
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ANTIPARKINSONIAN AGENTS
| ARTANE - 2mg TAB ** |
| COGENTIN - 0.5mg, 1mg & 2mg TAB ** |
| ELDEPRYL - 5mg TAB |
| REQUIP - 0.25mg, 0.5mg, 0.75mg, 1mg, 2mg, 4mg & 5mg TAB |
| SINEMET - (all strengths) TAB & CR TAB ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANTIMUSCARINICS / ANTISPASMODICS
| BENTYL - 10mg CAP & 20mg TAB ** |
| DONNATAL - ELIXIR & TAB |
| LEVBID - 0.375mg SR TAB |
| LEVSIN - 0.125mg TAB |
| PRO-BANTHINE - 15mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANTICONVULSANTS
| CARBATROL - 100mg, 200mg & 300mg CAP |
| DEPAKENE - 250mg CAP & 250mg/5mL SYRUP |
| DEPAKOTE - 125mg SPRINKLE CAP |
| DEPAKOTE - 125mg, 250mg & 500mg TAB ** |
| DEPAKOTE ER - 250mg & 500mg TAB ** |
| DILANTIN - 125mg/5mL SUSPENSION ** |
| DILANTIN - 30mg & 100mg CAP ** |
| DILANTIN - 50mg CHEWABLE TAB ** |
| FELBATOL - 400mg & 600mg TAB |
| FELBATOL - 600mg/5mL SUSPENSION |
| MYSOLINE - 50mg & 250mg TAB |
| NEURONTIN - (all strengths) TABS & CAPS ** |
| TEGRETOL - 100mg CHEWABLE & 200mg TAB ** |
| TEGRETOL - 100mg/5mL SUSPENSION ** |
| TOPAMAX - 25mg, 50mg, 100mg & 200mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANTIDIABETIC AGENTS
| ACTOS - 15mg, 30mg & 45mg TAB |
| ALCOHOL PADS FOR DIABETICS |
| AMARYL - 2mg & 4mg TAB |
| AVANDAMET - (all strengths) TAB ** |
| AVANDIA - 2mg, 4mg & 8mg TAB ** |
| GLIPIZIDE - 5mg & 10mg TAB ** |
| GLUCAGON - 1mg INJECTION KIT |
| GLUCOPHAGE - 500mg, 850mg, & 1000mg TAB ** |
| GLUCOTROL XL - 2.5mg, 5mg & 10mg TAB |
| GLUCOVANCE - (all strengths) TAB |
| GLYBURIDE - 1.25mg, 2.5mg & 5mg TAB ** |
| GLYNASE - 1.5mg, 3mg & 6mg PRESTAB ** |
| JANUMET - 500mg/50mg, & 1000mg/50mg TAB |
| JANUVIA - 25mg, 50mg, & 100mg TAB |
| LANCETS FOR DIABETIC TESTING |
| LANTUS (GLARGINE) INSULIN ** |
| NOVOLIN INSULIN - (all types-vials only) ** |
| NOVOLOG & NOVOLOG MIX 70/30 INSULIN ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANTI-INFECTIVE LIQUIDS
| AMOXIL - 125mg/5mL, 250mg/5mL & 400mg/5mL ** | FURADANTIN - 25mg/5mL SUSPENSION |
| AUGMENTIN - 200mg/mL, 250mg/mL & 400mg/5mL ** | GANTRISIN - 500mg/5mL SUSPENSION |
| AUGMENTIN ES - 600mg/5mL SUSPENSION ** | GRIFULVIN - 125mg/5mL SUSPENSION ** |
| BACTRIM - SUSPENSION ** | KEFLEX - 250mg/5mL SUSPENSION ** |
| CEFZIL - 250mg/5mL SUSPENSION | NYSTATIN - SUSPENSION ** |
| CLEOCIN - 75mg/5mL SUPPENSION | OMNICEF - 125mg/5mL & 250mg/5mL SUSPENSION |
| * DIFLUCAN - 10mg/mL & 40mg/mL (children only) | PEDIAZOLE - 200mg/600mg/5mL SUSPENSION ** |
| DURICEF - 250mg/5mL & 500mg/5mL SUSPENSION | PENICILLIN VK - 125mg/5mL & 250mg/5mL SUSPENSION ** |
| E.E.S. - 200mg/5mL SUSPENSION ** | ZITHROMAX - 100mg/5mL & 200mg/5mL SUSPENSION |
| ZITHROMAX - 1g PACKET SUSPENSION ** |
(* indicates Quantity Restrictions)
(** indicates Basic Core Formulary -
available at all Military Treatment Centers)
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ANTI-INFECTIVE TABLETS / CAPSULES
| AMOXIL - 250mg & 500mg CAP ** & 875mg TAB | GANTRISIN - 500mg TAB |
| AUGMENTIN - 250mg, 500mg & 875mg TAB ** | GRIS-PEG - 125mg TAB ** |
| BACTRIM & BACTRIM DS - TAB ** | KEFLEX - 250mg & 500mg CAP ** |
| BIAXIN - 250mg & 500mg TAB | LEVAQUIN - 250mg, 500mg & 750mg TAB ** |
| CEFZIL - 250mg & 500mg TAB | MACROBID - 100mg CAP |
| CIPRO - 250mg, 500mg & 750mg TAB ** | MACRODANTIN - 25mg, 50mg & 100mg CAP ** |
| CLEOCIN - 150mg CAP ** | MINOCIN - 50mg & 100mg CAP |
| DAPSONE - 25mg TAB | MYCELEX - 10mg TROCHES |
| DECLOMYCIN - 150mg TAB | NYSTATIN - TABS 500,000 UNITS ** |
| DICLOXACILLIN - 250mg & 500mg CAP ** | PENICILLIN VK - 250mg & 500mg TAB ** |
| DIFLUCAN - 100mg & 200mg TAB | TETRACYCLINE - 250mg & 500mg CAP ** |
| DIFLUCAN - 150mg TAB ** | VANTIN - 100mg & 200mg TAB |
| DYNAPEN - 250mg CAP ** | VERMOX - 100mg TAB ** |
| E.E.S. - 400mg TAB ** | VIBRAMYCIN - 100mg TAB & CAP ** |
| E-MYCIN - 250mg TAB ** | ZITHROMAX - 250mg TAB ** (10 tabs/30 days) |
| FLAGYL - 250mg & 500mg TAB ** | ZITHROMAX - 500mg TAB TRI-PAK |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANTILIPEMIC AGENTS
| COLESTID - GRANULES & 1g TAB ** |
| FENOGLIDE - 40mg & 120mg TAB ** |
| LIPITOR - 10mg, 20mg, 40mg & 80mg TAB |
| LOPID - 600mg TAB ** |
| NIACIN - 50mg & 500mg TAB |
| NIASPAN - 500mg, 750mg & 1000mg TAB ** |
| PRAVACHOL - 10mg, 20mg, 40mg & 80mg TAB ** |
| QUESTRAN LIGHT - 4g/scoop POWDER |
| VYTORIN - (all strengths) TAB ** |
| ZETIA - 10mg TAB |
| ZOCOR - 5mg, 10mg, 20mg, 40mg & 80mg TAB ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANTIMALARIAL AGENTS
| ARALEN - 500mg TAB |
| LARIAM - 250mg TAB |
| PLAQUENIL - 200mg TAB |
| PRIMAQUINE - 26.3mg TAB |
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ANTINEOPLASTIC AGENTS
| HYDREA - 500mg CAP |
| IMURAN - 50mg TAB |
| MEGACE - 40mg TAB & 40mg/mL SUSPENSION |
| METHOTREXATE - 2.5mg TAB ** |
| TAMOXIFEN - 10mg TAB ** |
| ZOLADEX - 3.6mg & 10.8mg IMPLANTS ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANTITUBERCULARS
| ETHAMBUTOL - 400mg TAB ** |
| ISONIAZID - 50mg/5mL SYRUP ** |
| ISONIAZID - 100mg & 300mg TAB ** |
| PYRAZINAMIDE - 500mg TAB ** |
| RIFAMPIN - 150mg & 300mg CAP ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANTITUSSIVE, EXPECTORANT & MUCOLYTIC
| MUCINEX - TABLETS |
| ROBITUSSIN - PLAIN or DM SYRUP |
| TESSALON PERLES - 100mg |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANTIVIRALS
| SYMMETREL - 100mg CAP ** |
| VALTREX - 500mg & 1g TAB |
| ZOVIRAX - 200mg CAP & 400mg, 800mg TAB ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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AUTONOMIC / CHOLINERGIC DRUGS
| ARICEPT - 5mg & 10mg TABS |
| MESTINON - 60mg TAB & 180mg SR TAB |
| URECHOLINE - 10mg & 25mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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BLOOD FORMATION / COAGULATION
| COUMADIN - (all strengths) TAB ** |
| FER-IN-SOL - SOLUTION |
| FERROUS SULFATE - 325mg TAB ** |
| LOVENOX - (all strengths) INJ ** |
| PLAVIX - 75mg TAB ** |
| TRENTAL - 400mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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CARDIAC DRUGS
| CORDARONE - 200mg TAB ** |
| LANOXIN - 0.125mg & 0.25mg TAB ** |
| LANOXIN - 0.25mg/ml SOLUTION |
| TAMBOCOR - 100mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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CONTRACEPTIVES
| ALESSE - TAB ** | NUVARING |
| DEMULEN - 1-35 TAB | ORTHO-CYLEN - 28 TAB ** |
| IMPLANON SYSTEM | ORTHO-EVRA - PATCH |
| LEVLEN - 28 TAB | ORTHO-NOVUM - 7/7/7 TAB |
| LO-ESTRIN FE - 1.5/30 & 1/20 | ORTHO-TRI-CYLEN - 28 TAB ** |
| LO/OVRAL - 28 TAB | ORTHO-TRI-CYLEN - LO 28 TAB ** |
| MICRONOR - 28 TAB ** | OVRAL - TAB |
| MIRENA - IUD | TRI-LEVLEN - TAB |
| NORDETTE - 28 TAB ** | YASMIN - TAB ** |
| NORINYL - 1-35 TAB ** | YAZ - TAB ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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DENTAL AGENTS
| PERIDEX - 0.12% ORAL RINSE ** |
| PERIOSTAT - 20mg TAB |
| PREVIDENT - 5000 PLUS & BRUSH-ON GEL |
| SODIUM FLUORIDE - 1.1mg/mL DROPS, 1.1mg TAB |
| TRIAMCINOLONE - DENTAL PASTE |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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DEVICES
| EASIVENT - HOLDING CHAMBER ** |
| EASIVENT - MASK (SM, MED, LG) ** |
| * INSULIN SYRINGE - LO or HIGH DOSE (600 syringes / 90 days) ** |
| OPTIHALER - INHALER SPACER ** |
| PEAK FLOW - METERS (LOW & HIGH RANGE) |
| PRECISION XTRA - GLUCOSE MONITOR ** |
| * PRECISION XTRA - GLUCOSE TEST STRIPS (612 strips / 90 days) ** |
| PRECISION XTRA - BLOOD ß-KETONE STRIPS |
| TABLET SPLITTER |
(* indicates Quantity Restrictions)
(** indicates Basic Core Formulary -
available at all Military Treatment Centers)
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EAR AGENTS
| AURALGAN - OTIC SOLUTION ** |
| COLYMCIN-S - OTIC SUSPENSION |
| CORTISPORIN - OTIC SOLUTION & SUSP ** |
| DOMEBORO - OTIC SOLUTION |
| FLOXIN - OTIC 0.3% SOLUTION |
| VOSOL & VOSOL HC - OTIC DROPS |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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EYE AGENTS
| ACULAR - 0.5% OPH SOLUTION | ILOTYCIN - OPH OINTMENT ** | PILOPINE HS - 4% OPH GEL ** |
| ALPHAGAN-P - 0.1%, 0.15% OPH SOL ** | ISOPTO HOMATROPINE - 2% & 5% OPH SOL | POLYSPORIN - OPH OINTMENT |
| ATROPINE - 1% OPH SOLUTION | LOTEMAX - 0.5% OPH SUSPENSION | POLYTRIM - OPH SOLUTION ** |
| BACITRACIN - OPH OINTMENT | LUMIGAN - OPH SOLUTION | PRED FORTE - 1% OPH SUSPENSION ** |
| BLEPHAMIDE - OPH SUSPENSION | MAXITROL - OPH OINTMENT | PRED MILD - 0.12% OPH SOLUTION |
| CILOXAN - OPH 0.3% SOLUTION | MURO-128 - 5% OPH SOLUTION & OINT | SULAMYD - 10% OPH OINT & SUSP ** |
| COMBIGAN - OPH SOLUTION | MYDRIACYL - 1% OPH SOLUTION | TIMOPTIC - 0.25% & 0.5% OPH SOL ** |
| CORTISPORIN - OPH SUSPENSION | NAPHCON A - OPH SOLUTION | TIMOPTIC-XE - 0.25 & 0.5% OPH SOL ** |
| COSOPT - 2%/0.5% OPH SOLUTION | NEOSPORIN - OPH OINTMENT & SOL ** | TRUSOPT - OPH SOLUTION |
| CYCLOGYL - 0.5% & 1% OPH SOLUTION | NEOSYNEPHRINE - 2.5% & 10% OPH SOL | VIGAMOX - OPH SOLUTION |
| DIAMOX - 250mg TAB & 500mg SR CAP | PATADAY - 0.2% OPH SOLUTION | VIROPTIC - 1% OPH SOLUTION |
| FLAREX - 0.1% OPH SOLUTION | PATANOL - 0.1% OPH SOLUTION | XALATAN - 0.005% OPH SOLUTION ** |
| GARAMYCIN - OPH SOLUTION & OINT ** | PILOCARPINE - 1%, 2% & 4% OPH SOL ** | ZYLET - 0.5%/0.3% OPH SUSPENSION |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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NASAL (LOCAL ACTING) AGENTS
| AFRIN - NASAL SPRAY |
| *ASTELIN - NASAL SPRAY (4 inhalers/90 days) ** |
| *FLONASE - NASAL SPRAY (3 inhalers/90 days) ** |
| NASALCROM - NASAL SPRAY |
| *NASONEX - NASAL SPRAY (6 inhalers/90 days) |
(* indicates Quantity Restrictions)
(** indicates Basic Core Formulary -
available at all Military Treatment Centers)
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ELECTRO/ CALORIC/ WATER BALANCE
ALKALINIZING AGENTS
| BICITRA |
| UROCIT-K - (all strengths) |
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REPLACEMENT ION THERAPY
| K-PHOS NEUTRAL - TAB |
| PHOSLO - 667mg TAB |
| POTASSIUM CHLORIDE - 10% ELIXIR ** |
| POTASSIUM CHLORIDE - 10 mEq TAB ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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AMMONIA DETOXICANTS
| CEPHULAC - 10gm/15mL SYRUP ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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DIURETICS
| ALDACTAZIDE - 25mg/25mg TAB |
| ALDACTONE - 25mg & 100mg TAB ** |
| BUMEX - 0.5mg, 1mg & 2mg TAB |
| HYDROCHLOROTHIAZIDE - 25mg & 50mg TAB ** |
| HYGROTON - 25mg & 50mg TAB ** |
| LASIX - 20mg, 40mg & 80mg TAB ** |
| MAXZIDE - 37.5/25mg & 75/50mg TAB ** |
| ZAROXOLYN - 2.5mg & 5mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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GASTROINTESTINAL DRUGS
| ASACOL - 400mg TAB | MIRALAX - 119g & 238g POWDER |
| AZULFIDINE - 500mg TAB ** | NEXIUM - 20mg & 40mg SR CAP ** |
| CARAFATE - 1gm TAB | NULYTELY - SOLN |
| CIMETIDINE - 300mg, 400mg TAB & 300mg/5mL SYR | PANCREASE (CREON) - CAP |
| COLACE - 100mg CAPSULE | PEPTO-BISMOL - TAB |
| COLYTE - SOLUTION | PHENERGAN - 25mg TAB ** |
| COMPAZINE - 5mg & 10mg TAB & 25mg SUPP | PHENERGAN - 12.5mg & 25mg SUPP ** |
| CYTOTEC - 200mg TAB | PRILOSEC - 10mg & 20mg CAP ** |
| DULCOLAX - 5mg TABS & 10mg SUPP | RANITIDINE - 150mg TAB & 15mg/mL LIQ ** |
| FLEETS - ENEMA & PEDIATRIC ENEMA | TIGAN - 300mg CAP |
| FLEETS - PHOSPHO-SODA | TORECAN - 10mg TAB |
| IMODIUM - 2mg CAP ** | TRANSDERM SCOP - 1.5mg TDRM |
| METOCLOPRAMIDE - 10mg TB & 5mg/5mL SYR ** | TRILYTE - SOLUTION |
| *ZOFRAN - 4mg & 8mg TAB (45 tabs/90days) |
(* indicates Quantity Restrictions)
(** indicates Basic Core Formulary -
available at all Military Treatment Centers)
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HORMONES / REPLACEMENT ADRENALS
| CORTEF - 5mg & 10mg TAB |
| CORTONE ACETATE - 25mg TAB |
| DECADRON - 0.5mg, 0.75mg & 4mg TAB |
| FLORINEF - 0.1mg TAB |
| MEDROL DOSEPAK - 4mg TAB |
| ORAPRED - 15mg/5mL ** |
| PREDNISONE - 1mg, 5mg, 10mg & 20mg TAB ** |
| PREDNISONE - 5mg/5mL SOLUTION |
| PRELONE - 15mg/5mL SYRUP |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ANDROGENS
| METHYLTESTOSTERONE - 10mg CAP |
| TESTOSTERONE TRANSDERM - 2.5mg/d & 5mg/d |
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ANTI-ANDROGEN
| EULEXIN - 125mg CAP |
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ESTROGENS
| ESTRACE - 1mg & 2mg TAB |
| ESTRADERM - 0.05mg & 0.1mg TDRM |
| ESTRATEST & ESTRATEST HS - TAB |
| EVISTA - 60mg TAB |
| FEMHRT - 0.5/2.5mg & 1/5mg TAB |
| PREMARIN - (all strengths) TAB ** |
| PREMARIN - VAGINAL CREAM ** |
| PREMPRO - (all strengths) TAB ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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PROGESTINS
| AYGESTIN - 5mg TAB |
| DEPO PROVERA - 150mg/mL INJ |
| PROVERA - 2.5mg, 5mg, & 10mg TAB ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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THYROID-RELATED AGENTS
| CYTOMEL - 5mcg, 25mcg & 50mcg TAB |
| PROPYLTHIOURACIL - 50mg TAB ** |
| SYNTHROID - (all strengths) TABS ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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HYPOTENSIVE AGENTS
| ADALAT CC - 30mg, 60mg & 90mg TAB ** | LOTREL - (all strengths) CAPS ** |
| ALDOMET - 250mg TAB | MICARDIS - 20mg, 40mg & 80mg TAB ** |
| APRESOLINE - 10mg, 25mg & 50mg TAB ** | MICARDIS HCT - (all strengths) TAB ** |
| BETAPACE - 80mg 120mg & 160mg | MONOPRIL - 10mg, 20mg & 40mg TAB |
| CAPOTEN - 25mg, 50mg & 100mg TAB ** | NIFEDIPINE - 10mg CAP |
| CARDURA - 2mg, 4mg & 8mg TAB ** | NORVASC - 2.5mg, 5mg & 10mg TAB ** |
| CATAPRES - 0.1mg & 0.2mg TAB ** | PLENDIL - 2.5mg, 5mg & 10mg TAB |
| CATAPRES - TTS-1, TTS-2 & TTS-3 TDRM | TEKTURNA - 150mg TAB |
| COREG - 3.125mg, 6.25mg, 12.5mg & 25mg TAB | TEKTURNA HTZ - 150/12.5, 150/25, 300/12.5 & 300/25mg TAB |
| COZAAR - 25mg, 50mg & 100mg TAB | TENORETIC - 50/25mg, 100/25 mg TAB |
| DILTIAZEM - 60mg TAB | TENORMIN - 25mg, 50mg & 100mg TAB ** |
| HYTRIN - 1mg, 2mg, 5mg & 10mg CAP ** | TIAZAC - 120mg, 180mg, 240mg, 300mg & 360mg CAP ** |
| HYZAAR - (all strengths) TAB | TOPROL-XL - 25mg, 50mg, 100mg & 200mg TAB |
| INDERAL - 10mg, 40mg & 80mg TAB | TRANDATE - 200mg TAB |
| INDERAL LA - 60mg, 80mg, 120mg & 160mg CAP | VERAPAMIL - 80mg & 120mg TAB |
| LONITEN - 2.5mg & 10mg TAB | VERAPAMIL SR - 120mg, 180mg & 240mg TAB ** |
| LOPRESSOR - 25mg, 50mg & 100mg TAB ** | ZESTORETIC/PRINZIDE - (all strengths) TAB ** |
| ZESTRIL/PRINIVIL - (all strengths) TAB ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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MIGRAINE AGENTS
| CAFERGOT - TAB |
| FIORICET - TAB ** |
| *IMITREX - 6mg INJ (2 syr/box-max 12 boxes/90 days) ** |
| *MAXALT MLT - 5mg & 10mg (36 tabs/90 days) |
| *MAXALT - 5mg & 10mg TAB (36 tabs/90 days) |
| MIDRIN - CAP |
| *ZOMIG - 2.5mg & 5mg TAB (36 tabs/90 days) ** |
| *ZOMIG ZMT - 2.5mg & 5mg TAB (36 tabs/90 days) |
(* indicates Quantity Restrictions)
(** indicates Basic Core Formulary -
available at all Military Treatment Centers)
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MISCELLANEOUS AGENTS
| ACTONEL - 75mg & 150mg TAB | *LEVITRA - (all strengths) TAB (18 tabs/90 days) |
| BONIVA - 150mg TAB ** | (> age 50 requires Prior Authorization Form) |
| CLOMID - 50mg TAB | LUPRON DEPOT - 3.75mg, 7.5mg, 11.25mg INJ KIT |
| CUPRIMINE - 250mg TAB | NEORAL (GENERIC) - 25mg & 100mg CAP |
| DIDRONEL - 200mg TAB | NEORAL - 100mg/mL SOLUTION |
| DDAVP - 0.1mg/mL NASAL SPRAY | OXSORALEN - 10mg CAP |
| EDEX - 20mcg & 40mcg INJECTION KIT | PARLODEL - 2.5mg TAB |
| FORTICAL - NASAL SOLUTION | PROSCAR - 5mg TAB ** |
| FOSAMAX - 10mg, 35mg, & 70mg TAB ** | STRATTERA - 10mg, 18mg, 25mg, 40mg, 60mg CAP |
| KAYEXALATE - 15gm/60mL SUSPENSION | UROXATRAL - 10mg TAB |
| ZYLOPRIM - 100mg & 300mg TAB ** |
(* indicates Quantity Restrictions)
(** indicates Basic Core Formulary -
available at all Military Treatment Centers)
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PIGMENTING AGENTS
| OXSORALEN 10mg CAP |
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PSYCHOTHERAPEUTICS
| AMITRIPTYLINE - 10mg, 25mg & 50mg TAB ** | SEROQUEL - 25mg, 50mg, 100mg, 200mg & 300mg TAB |
| BUSPAR - 5mg, 10mg & 15mg TAB ** | SEROQUEL XR - 50mg, 150mg, 200mg, 300mg, 400mg TAB |
| CELEXA - 10mg, 20mg & 40mg TAB ** | SERZONE - 100mg, 150mg, 200mg & 250mg TAB |
| EFFEXOR - 25mg, 37.5mg, 50mg, 75mg & 100mg TAB | SINEQUAN - 10mg & 25mg CAP ** |
| EFFEXOR XR - 37.5mg, 75mg & 150mg CAP | THORAZINE - 25mg, 50mg & 100mg TAB |
| HALDOL - 1mg & 5mg TAB | TOFRANIL - 10mg & 25mg TAB ** |
| LITHIUM CARBONATE - 150mg & 300mg CAP ** | TOFRANIL PM - 75mg CAP ** |
| NORPRAMIN - 25mg & 50mg TAB | TRAZODONE - 50mg, 100mg & 150mg TAB ** |
| PAMELOR - 10mg & 25mg CAP ** | WELLBUTRIN SR - (all strengths) TABS ** |
| PAXIL - 10mg, 20mg, 30mg & 40mg TAB | ZOLOFT - 50mg & 100mg TABS ** |
| PROZAC - 10mg & 20mg CAP ** (Preferred SSRI) | ZYPREXA - 2.5mg, 5mg, 7.5mg, 10mg & 15mg TAB |
| RISPERDAL - (all strengths) TAB & 1mg/mL SOL ** | ZYPREXA ZYDIS - 5mg, 10mg, 15mg & 20mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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RESPIRATORY AGENTS
| *ADVAIR - (all strengths) DISKUS (3 disk/90 days) ** | PROVENTIL - 2mg TAB |
| *ADVAIR - HFA (6 inhalers/90 days) ** | *PROVENTIL - HFA INHALER (6 inhalers/90 days) |
| *ASMANEX - TWISTHALER (6 inhalers/90 days) ** | PROVENTIL - 2mg/5mL SYRUP |
| *ATROVENT - HFA INHALER (6 inhalers/90 days) ** | *PULMICORT - 0.25mg & 0.5mg RESPULES |
| *ATROVENT - 0.02% INH SOL (540 amps/90 days) ** | (360 amps or 720 amps/90 days) ** |
| BRETHINE - 5mg TAB | *SEREVENT - DISKUS (3 diskus/90 days) ** |
| COMBIVENT - INHALER ** | SINGULAIR - 5mg & 10mg TABS ** |
| *FLOVENT HFA INH - 44mcg, 110mcg & 220mcg (6 inhalers/90 days) ** | SINGULAIR - 4mg CHEW TABS & GRANULES ** |
| FLOVENT - DISKUS (6 inhalers/90 days) ** | *SPIRIVA - 18mcg HANDIHALER (90 caps/90 days) |
| *INTAL - INHALER (6 inhalers/90 days) | SYMBICORT - 80/45 mcg, 160/4.5 mcg INHALER |
| *INTAL SOL FOR NEBULIZER (540 amps/90 days) | THEOPHYLLINE - 80mg/5mL LIQUID ** |
| NORMAL SALINE - 5mL BULLETS | *TILADE - INHALER (9 inhalers/90 days) |
| *PROVENTIL - 0.083% NEB SOL (500 amps/90 days) ** | *VENTOLIN - HFA INHALER (6inhalers/90days) ** |
| *PROVENTIL - 0.5% NEB SOL (9 boxes/90 days) ** |
(* indicates Quantity Restrictions)
(** indicates Basic Core Formulary -
available at all Military Treatment Centers)
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SCHEDULE II DRUGS (no refills allowed)
| ADDERALL - 5mg, 10mg, 15mg, 20mg & 30mg TAB | METHYLIN ER - 10mg & 20mg TAB |
| ADDERALL XR - (all strengths) CAP ** | METHYLPHENIDATE - 5mg, 10mg TAB & 20mg SR ** |
| CODEINE SULFATE - 30mg TAB | MORPHINE SULF (MSIR) - 15mg & 30mg TAB ** |
| CONCERTA - 18mg, 27mg, 36mg & 54mg TAB ** | MS CONTIN - (all strengths) TAB ** |
| DEMEROL - 50mg & 100mg TAB | OXYCONTIN - 10mg, 20mg, 40mg & 80mg TAB |
| DEXEDRINE - 5mg TAB | PERCOCET - 5/325mg TAB ** |
| DILAUDID - 2mg & 4mg TAB | ROXANOL - 20mg/mL SOLUTION |
| METHADONE - 5mg & 10mg TAB | ROXICODONE - 5mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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SCHEDULE III, IV & V
(Up to a 90 day supply and refills for a total of 6 months from the date written)
| AMBIEN - 5mg & 10mg TAB ** | PHENOBARBITAL - 15mg, 30mg & 100mg TAB ** |
| ATIVAN - 0.5mg, 1mg & 2mg TAB | PHENOBARBITAL - 20mg/15ml ELIXIR ** |
| DARVOCET-N-100 - TAB | RESTORIL - 7.5mg, 15mg & 30mg CAP ** |
| DARVON-N-100 - TAB | ROBITUSSIN AC - (120mL bottles) SYRUP |
| HALCION - 0.125mg & 0.25mg TAB | SERAX - 10mg, 15mg, & 30mg CAP |
| KLONOPIN - 0.5mg **, 1mg & 2mg TAB | TESTOSTERONE TRANSDERMAL SYSTEM - 2.5mg/day & 5mg/day |
| LIBRIUM - 5mg, 10mg, & 25mg CAP | TYLENOL - #3 TABS & 12/120mg/5mL ELIXIR ** |
| LOMOTIL - TAB | VALIUM - 2mg, 5mg & 10mg TAB ** |
| METHYLTESTOSTERONE - 10mg CAP | VICODIN - 5/500mg ** & 7.5/750mg TAB |
| MIDRIN - CAP ** | XANAX - 0.25mg, 0.5mg, 1mg & 2mg TAB |
| NOVAHISTINE - EXPECORANT |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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SKELETAL MUSCLE RELAXANTS
| FLEXERIL - 5mg & 10mg TAB ** |
| LIORESAL - 10mg & 20mg TAB |
| NORFLEX - 100mg TAB |
| ROBAXIN - 500mg & 750mg TAB ** |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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SMOOTH MUSCLE RELAXANTS
| DETROL LA - 2mg & 4mg CAP ** |
| DITROPAN - 5mg TAB |
| DITROPAN XL - 5mg, 10mg, 15mg TAB ** |
| URISPAS - 100mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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SUPPOSITORIES / ENEMAS
| ANUSOL HC - 25mg SUPP & 2.5% CREAM ** |
| COMPAZINE - 25mg SUPP |
| CORTENEMA |
| PHENERGAN - 12.5mg & 25mg SUPP ** |
| PRAMOSONE - CREAM |
| PROCTOFOAM HC - FOAM |
| ROWASA - ENEMA |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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TOPICALS
| ALDARA - 5% CREAM | ELDOPAQUE FORTE - 4% CREAM | METROCREAM - 0.75% CREAM |
| AQUAPHOR - OINTMENT | ELDOQUIN - 2% CREAM | METROGEL - 1% GEL (replaces 0.75%) |
| BACITRACIN - OINTMENT | ELIDEL - 1% CREAM | MYCOLOG II - CREAM |
| BACTROBAN - OINTMENT ** | ELIMITE - 5% CREAM ** | NIX - 1% SOLUTION |
| BENZACLIN - 1%/5% GEL | ELOCON - 0.1% CREAM | NITROBID - 2% OINTMENT |
| BENZOYL PEROXIDE - 10% GEL | ERYTHROMYCIN - 2% SOL & GEL ** | NIZORAL - 2% CREAM & SHAMPOO |
| CAPITROL - SHAMPOO | HYDROCORTISONE - 1% CR & OINT | NYSTATIN - CREAM, OINT & POWDER |
| CARAC - 0.5% CREAM | KENALOG - 0.1% CREAM ** & OINT | PRAMOSONE - CREAM |
| CARMOL - 20% & 40% CREAM | KENALOG - SPRAY | PROTOPIC - 0.1% & 0.03% OINTMENT |
| CLEOCIN - 1% TOPICAL SOL ** | KLARON - 10% LOTION | RETIN-A - CREAM **, GEL & MICRO GEL |
| CORDRAN - TAPE | LAC-HYDRIN - 12% LOTION | (Limited to patients up to and including age 35) |
| DERMA-SMOOTHE/FS | LIDEX - 0.05% CR, GEL & OINT ** | SELSUN - SHAMPOO ** |
| DESONIDE - 0.05% CREAM & OINT | LIDOCAINE VISCOUS - 2% SOL | SILVADENE - 1% CREAM ** |
| DIFFERIN - 0.1%, 0.3% GEL | LIDOCAINE - 2% JEL, 5% OINT & 4% SOL | SYNALAR - 0.01% SOLUTION |
| *DOVONEX - CR & SOL (900gm/90 days) | LOTRIMIN - 1% CREAM & SOLUTION | *TAZORAC - 0.1% & 0.5% GEL (300gm/90 days) |
| DRYSOL - 20% SOLUTION | LOTRISONE - CREAM & LOTION | *TAZORAC - 0.1% & 0.5% CREAM (180gm/90 days) |
| DUAC - GEL | LUXIQ - 0.12% FOAM | TEMOVATE - 0.05% CRM, OINT, SOLN & GEL |
| EFUDEX - 2% SOL & 5% CREAM | MEDIPLAST - 40% | WESTCORT - 0.2% CREAM |
(* indicates Quantity Restrictions)
(** indicates Basic Core Formulary -
available at all Military Treatment Centers)
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URICOSURIC AGENTS
| BENEMID - 500mg TAB ** |
| COLCHICINE - 0.6mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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VAGINAL PREPARATIONS
| CLEOCIN - VAGINAL CREAM ** |
| CLOTRIMAZOLE - VAGINAL CREAM |
| METROGEL - 0.75% VAGINAL GEL ** |
| PREMARIN - VAGINAL CREAM ** |
| TERAZOL-7 - VAGINAL CREAM |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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VASODILATING AGENTS
| IMDUR - 30mg, 60mg & 120mg TAB ** |
| ISORDIL - 10mg & 20mg TAB & 40mg SR TAB ** |
| NITROBID - 6.5mg CAP |
| NITRO-DUR - 0.1mg, 0.2mg, 0.3mg & 0.4mg TDRM ** |
| NITROGLYCERIN - 0.3mg & 0.4mg SL TAB ** |
| NITROLINGUAL - SPRAY ** |
| PERSANTINE - 25mg, 50mg & 75mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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VITAMINS / MINERALS
| CYANOCOBALAMIN - 1mg/mL INJ VIAL |
| FOLIC ACID - 1mg TAB ** |
| LURIDE - 2.2mg TAB |
| MEPHYTON - 5mg TAB |
| MULTIVITAMIN - WITH & WITHOUT IRON |
| MULTIVITAMIN - DROP WITH & WITHOUT IRON |
| MULTIVITAMIN - SOL WITH FLUOR & IRON |
| NIACIN - 50mg & 500mg TAB |
| NIASPAN - 500mg, 750mg & 1000mg TAB ** |
| PRENATAL VITAMIN - W/FOLIC ACID 1mg TAB
** (limited to women up to and including age 45) |
| PYRIDOXINE - 50mg TAB |
| ROCALTROL - 0.25mg, 0.5mg CAP |
| THIAMINE - 50mg TAB |
| VITAMIN B-12 - 1000mcg/ml INJ |
| VITAMIN D - 1,000 IU CAP |
| VITAMIN D - 50,000 UNIT CAP |
| WELLCOVORIN - 5mg TAB |
(** indicates Basic Core Formulary - available at all Military Treatment Centers)
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ITEMS RECENTLY REMOVED
(January 2010)
| AXMACORT INHALER |
| AEROBID INHALER |
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