Scott Air Force Base
Scott Air Force Base
PHARMACY FORMULARY
Printable Copy (Revised: 26 Mar 08)
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ALLERGY/ ANTIHIST/ DECONGEST
| ACTIFED TAB |
| ALLEGRA 30mg, 60mg & 180mg TAB |
| ALLEGRA-D 12hr & 24hr SR TAB |
| ATARAX 10mg & 25mg TAB ** |
| ATARAX 10mg/5mL SYRUP ** |
| BENADRYL 12.5mg/5mL ELIXIR |
| BENADRYL 25mg & 50mg CAP |
| CHLOR-TRIMETON 2mg/5mL SYRUP |
| CHLOR-TRIMETON 4mg TAB |
| CHLOR-TRIMETON 8mg SR CAP |
| CLARITIN 10mg TAB & 1mg/mL SYRUP |
| DECONAMINE SR CAP ** |
| PERIACTIN 4mg TAB ** |
| SUDAFED 30mg/5mL SYRUP |
| TWINJECT 0.15mg & 0.3mg AUTO-INJECTOR |
| ZYRTEC 10mg TAB & 1mg/mL SYRUP |
| ZYRTEC-D 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 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) ** |
| VISCOUS LIDOCAINE 2% SOLUTION |
(* indicates quantity restrictions)
(** indicates Basic Core Formulary -
available at all military treatment centers)
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ANTIPARKINSONIAN AGENTS
| ARTANE 2mg TAB** |
| COGENTIN 2mg TAB** |
| ELDEPRYL 5mg TAB |
| SINEMET TABS & CR TABS (all strengths) ** |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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ANTIMUSCARINICS / ANTISPASMODICS
| BELLERGAL-S TAB |
| BENTYL 10mg CAP & 20mg TAB ** |
| DONNATAL ELIXIR & TAB |
| LEVBID 0.375mg SR TAB |
| LEVSIN 0.125mg TAB |
| PRO-BANTHINE 15mg TAB |
| ZELNORM 2mg & 6mg 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 TABS & CAPS (all strengths)** |
| TEGRETOL 100mg CHEWABLE & 200mg TAB ** |
| TEGRETOL 100mg/5mL SUSPENSION ** |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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ANTIDIABETIC AGENTS
| AMARYL 2mg & 4mg TAB |
| AVANDAMET TAB (all strengths)** |
| AVANDIA 2mg, 4mg & 8mg TAB ** |
| GLYBURIDE 2.5 & 5mg TAB ** |
| GLYNASE 3mg PRESTAB ** |
| GLIPIZIDE 2.5mg, 5mg & 10mg TAB ** |
| GLUCAGON 1mg INJECTION KIT |
| GLUCOTROL XL 2.5mg, 5mg & 10mg TAB |
| GLUCOPHAGE 500mg, 850mg, & 1000mg TAB ** |
| GLUCOVANCE TAB (all strengths) |
| 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 SUSPENSION ** | GANTRISIN 500mg/5mL SUSPENSION |
| AUGMENTIN 200mg/mL, 250mg/mL & 400mg/5mL** | GRIFULVIN 125mg/5mL SUSPENSION ** |
| AUGMENTIN ES 600mg/5mL SUSPENSION ** | KEFLEX 250mg/5mL SUSPENSION ** |
| BACTRIM SUSPENSION ** | NYSTATIN SUSPENSION ** |
| CEFZIL 250mg/5mL SUSPENSION | OMNICEF 125mg/5mL & 250mg/5mL SUSPENSION |
| CLEOCIN 75mg/5mL SUPPENSION | PEDIAZOLE 200mg/600mg/5mL SUSPENSION ** |
| *DIFLUCAN 10mg/mL & 40mg/mL (children only) | PENICILLIN VK 250mg/5mL SUSPENSION ** |
| DURICEF 250mg/5mL & 500mg/5mL SUSPENSION | ZITHROMAX 100mg/5mL & 200mg/5mL SUSPENSION |
| E.E.S. 200mg/5mL SUSPENSION ** | ZITHROMAX 1g PACKET SUSPENSION |
| FURADANTIN 25mg/5mL 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** | GRIS-PEG 125mg TAB ** |
| AUGMENTIN 250mg, 500mg & 875mg TAB ** | KEFLEX 250mg & 500mg CAP ** |
| BACTRIM & BACTRIM DS TAB ** | LEVAQUIN 250mg & 500mg TAB ** |
| BIAXIN 250mg & 500mg TAB | MACROBID 100mg CAP |
| CEFZIL 250mg & 500mg TAB | MACRODANTIN 50mg & 100mg CAP ** |
| CLEOCIN 150mg CAP ** | MINOCIN 50mg & 100mg CAP |
| CIPRO 250mg, 500mg & 750mg TAB** | MYCELEX 10mg TROCHES |
| DAPSONE 25mg TAB | NYSTATIN TABS 500,000 UNITS ** |
| DECLOMYCIN 150mg TAB | 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-MYCIN 250mg TAB ** | VIBRAMYCIN 100mg TAB ** |
| E.E.S. 400mg TAB ** | ZITHROMAX 250mg TAB ** (10 tabs/30 days) |
| FLAGYL 250mg & 500mg TAB ** | ZITHROMAX 500mg TAB TRI-PAK |
| GANTRISIN 500mg TAB |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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ANTILIPEMIC AGENTS
| COLESTID GRANULES & 1g TAB ** |
| LIPITOR 10mg, 20mg, 40mg & 80mg TAB |
| LOPID 600mg TAB ** |
| NIASPAN 500mg, 750mg & 1000mg TAB ** |
| PRAVACHOL 10mg, 20mg, 40mg & 80mg TAB ** |
| QUESTRAN LIGHT 4g/scoop POWDER |
| TRIGLIDE 50mg & 160mg TAB ** |
| VYTORIN (all strengths) TAB ** |
| ZETIA 10mg TAB |
| ZOCOR 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 & 10.6mg 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
| ENTEX PSE 400mg/120mg CAP ** |
| ROBITUSSIN PLAIN or DM SYRUP |
| MUCINEX TABLETS |
| 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 |
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BLOOD FORMATION / COAGULATION
| COUMADIN TAB (all strengths) ** |
| FER-IN-SOL SOLUTION |
| FERROUS SULFATE 325mg TAB ** |
| LOVENOX INJ (all strengths) ** |
| PLAVIX 75mg TAB ** |
| TRENTAL 400mg TAB |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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CALCIUM CHANNEL BLOCKERS
| ADALAT CC 30mg, 60mg & 90mg TAB ** |
| DILTIAZEM 60mg TAB |
| PLENDIL 2.5mg, 5mg & 10mg TAB |
| TIAZAC 120mg, 180mg, 240mg, 300mg & 360mg CAP ** |
| VERAPAMIL 80mg & 120mg TAB |
| VERAPAMIL SR 120mg, 180mg & 240mg TAB ** |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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CARDIAC DRUGS
| CORDARONE 200mg TAB ** |
| INDERAL 10mg, 40mg & 80mg TAB |
| INDERAL LA 60mg, 80mg, 120mg & 160mg CAP |
| LANOXIN 0.125mg & 0.25mg TAB ** |
| LANOXIN 0.25mg/ml SOLUTION |
| PROCAINAMIDE 250mg CAP |
| PROCAN SR 500mg & 750mg TAB |
| TAMBOCOR 100mg TAB |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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CONTRACEPTIVES
| ALESSE TAB ** | ORTHO-CYLEN 28 TAB ** |
| DEMULEN 1-35 TAB | 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 | PLAN B (LEVONORGESTREL 0.75MG) TAB |
| NORDETTE 28 TAB ** | TRI-LEVLEN TAB |
| NORINYL 1-35 TAB ** | YASMIN TAB ** |
| NUVARING | 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 |
| 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 SUSP |
| CORTISPORIN OTIC SOLUTION & SUSP ** |
| CYCLOGYL 0.5% & 1% OPH SOLUTION |
| 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 | ISOPTO HOMATROPINE 1% & 2% OPH SOL | POLYSPORIN OPH OINTMENT |
| ALPHAGAN-P 0.1%, 0.15% & 0.2% OPH SOL ** | LOTEMAX 0.5% OPH SUSPENSION | POLYTRIM OPH SOLUTION ** |
| ATROPINE 1% OPH SOLUTION | MAXITROL OPH OINTMENT | PRED FORTE 1% OPH SUSPENSION ** |
| BACITRACIN OPH OINTMENT | MURO-128 5% OPH SOLUTION & OINT | PRED MILD 0.12% OPH SOLUTION |
| BLEPHAMIDE OPH SUSPENSION | MYDRIACYL 1% OPH SOLUTION | SULAMYD 10% OPH OINT & SUSP ** |
| CILOXAN OPH 0.3% SOLUTION | NAPHCON A OPH SOLUTION | TIMOPTIC 0.25% & 0.5% OPH SOL ** |
| CORTISPORIN OPH SUSPENSION | NEOSPORIN OPH OINTMENT & SOL ** | TIMOPTIC-XE 0.25 & 0.5% OPH SOL ** |
| COSOPT 2%/0.5% OPH SOLUTION | NEOSYNEPHRINE 2.5% & 10% OPH SOL | TRUSOPT OPH SOLUTION |
| DIAMOX 250mg TAB & 500mg SR CAP | PATADAY 0.2% OPH SOLUTION | VIGAMOX OPH SOLUTION |
| FLAREX 0.1% OPH SOLUTION | PATANOL 0.1% OPH SOLUTION | VIROPTIC 1% OPH SOLUTION |
| GARAMYCIN OPH SOL & OINT ** | PILOCARPINE 1% & 2% OPH SOL ** | XALATAN 0.005% OPH SOLUTION ** |
| ILOTYCIN OPH OINTMENT | PILOCARPINE 4% OPH GEL ** | ZYLET 0.5%/0.3% OPH SUSPENSION |
| PILOPINE HS 4% OPH GEL ** |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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NASAL AGENTS
| AFRIN NASAL SPRAY |
| *ASTELIN NASAL SPRAY (4 inhalers/90 days) |
| DDAVP 0.1mg/mL NASAL SPRAY |
| *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 |
| POTASSIUM CHLORIDE 10 mEq TAB ** |
| PHOSLO 667mg TAB |
| POTASSIUM CHLORIDE 10% ELIXIR ** |
(** 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 TAB ** |
| BUMEX 0.5mg, 1mg & 2mg TAB |
| HYDROCHLOROTHIAZIDE 25mg & 50mg TAB ** |
| HYGROTON 25mg, 50mg & 100mg 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 | NEXIUM 20mg & 40mg SR CAP ** |
| AZULFIDINE 500mg TAB ** | NULYTELY & GOLYTELY SOLUTION |
| CARAFATE 1gm TAB | PANCREASE (LIPRAM) CAP ** |
| CIMETIDINE 300mg, 400mg TAB & 300mg/5mL SYR | PEPTO-BISMOL TAB |
| COLACE 100mg CAPSULE | PHENERGAN 25mg TAB ** |
| COMPAZINE 5mg 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 ** | *ZOFRAN 4mg & 8mg TAB (45 tabs/90days) |
| MIRALAX 119g & 238g POWDER |
(* 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 |
| PREMPRO TAB (all strengths) ** |
| PREMARIN TAB (all strengths) ** |
| PREMARIN VAGINAL CREAM ** |
(** 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 TAB |
| PROPYLTHIOURACIL 50mg TAB ** |
| SYNTHROID TABS (all strengths) ** |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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HYPOTENSIVE AGENTS
| ALDOMET 250mg TAB | LOPRESSOR 50mg & 100mg TAB ** |
| APRESOLINE 10mg & 25mg TAB ** | LOTREL CAPS (all strengths) ** |
| BETAPACE 80mg 120mg & 160mg | MICARDIS 20mg, 40mg & 80mg TAB ** |
| CAPOTEN 25mg & 100mg TAB ** | MICARDIS HCT (all strengths) TAB ** |
| CARDURA 2mg, 4mg & 8mg TAB ** | MONOPRIL 10mg, 20mg & 40mg TAB |
| CATAPRES 0.1mg & 0.2mg TAB ** | NORVASC 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 | TENORMIN 25mg, 50mg & 100mg TAB ** |
| COZAAR 25mg, 50mg & 100mg TAB | TOPROL-XL 25mg, 50mg, 100mg & 200mg TAB |
| HYTRIN 1mg, 2mg, 5mg & 10mg CAP ** | TRANDATE 200mg TAB |
| HYZAAR TAB (all strengths) | UROXATRAL 10mg TAB** |
| LONITEN 2.5mg & 10mg TAB | ZESTRIL/PRINIVIL (all strengths) TAB ** |
| ZESTORETIC/PRINZIDE (all strengths) TAB ** |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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MIGRAINE AGENTS
| CAFERGOT TAB |
| FIORICET TAB ** |
| HYDERGINE 1mg SL TAB |
| *MAXALT MLT 5mg & 10mg (36 tabs/90 days) |
| *MAXALT 5mg & 10mg TAB (36 tabs/90 days) |
| MIDRIN CAP ** |
| *IMITREX 6mg INJ (2 syr/box-max 12 boxes/90 days) ** |
| *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 TAB | LUPRON DEPOT 3.75mg, 7.5mg, 11.25mg INJ KIT |
| CLOMID 50mg TAB | MIACALCIN NASAL SPRAY |
| CUPRIMINE 250mg TAB | NEORAL (GENERIC) 25mg & 100mg CAP |
| DIDRONEL 200mg TAB | NEORAL 100mg/mL SOLUTION |
| EDEX 20mcg & 40mcg INJECTION KIT | OXSORALEN 10mg CAP |
| FOSAMAX 10mg, 35mg, & 70mg TAB ** | PARLODEL 2.5mg TAB |
| FOSAMAX PLUS D 70mg/5600IU TAB ** | PROSCAR 5mg TAB ** |
| KAYEXALATE 15gm/60mL SUSPENSION | STRATTERA 10mg, 18mg, 25mg, 40mg, 60mg CAP |
| *LEVITRA (all strengths) TAB (18 tabs/90 days) (over age 50 requires Prior Authorization Form) |
ZYLOPRIM 100 & 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, 100mg, 200mg & 300mg TAB ** |
| BUSPAR 5mg, 10mg & 15mg TAB ** | SEROQUEL XR 200mg, 300mg, 400mg TAB ** |
| CELEXA 10mg, 20mg & 40mg TAB** | SERZONE 100mg, 150mg, 200mg & 250mg TAB |
| EFFEXOR 25mg, 37.5mg, 50mg & 75 mg 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 50mg TAB | TRAZODONE 50mg, 100mg & 150mg TAB ** |
| PAMELOR 10mg & 25mg CAP ** | WELLBUTRIN SR TABS (all strengths) ** |
| 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 TAB (all strengths) & 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 DISKUS (all strengths) (3 disk/90 days) ** | PROVENTIL 2mg TAB |
| AEROBID INHALER | *PROVENTIL INHALER (6 inhalers/90 days) ** |
| (CURRENTLY UNAVAILABLE) | |
| *ATROVENT HFA INHALER (6 inhalers/90 days) ** | *PROVENTIL HFA INHALER (6 inhalers/90 days) |
| *ATROVENT INH SOL 0.02% (540 amps/90 days)** | PROVENTIL 2mg/5mL SYRUP |
| *AZMACORT INHALER (6 inhalers/90 days) ** | *PULMICORT RESPULES 0.25mg & 0.5mg |
| BRETHINE 5mg TAB | (360 amps or 720 amps/90 days) ** |
| COMBIVENT INHALER ** | *SEREVENT DISKUS (3 disk/90 days) ** |
| *FLOVENT HFA INH 44mcg, 110mcg & 220mcg | SINGULAIR 5mg & 10mg TABS ** |
| (6 inhalers/90 days) ** | SINGULAIR 4mg CHEW TABS & GRANULES ** |
| *INTAL INHALER (6 inhalers/90 days) | SLO-BID 200mg & 300mg CAP ** |
| *INTAL SOL FOR NEBULIZER (540 amps/90 days) | *SPIRIVA 18mcg HANDIHALER (90 caps/90 days) |
| NORMAL SALINE 5mL BULLETS | THEOPHYLLINE 80mg/5mL LIQUID ** |
| *PROVENTIL 0.083% NEB SOL (500 amps/90 days) ** | *TILADE INHALER (9 inhalers/90 days) |
| *PROVENTIL 0.5% NEB SOL (9 boxes/90 days) ** | VOLMAX ER 4MG |
(* 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, 20mg & 30mg TAB | METHYLIN ER 10mg & 20mg TAB |
| ADDERALL XR CAP (all strengths) ** | METHYLPHENIDATE 5mg, 10mg TAB & 20mg SR TAB ** |
| CONCERTA 18mg, 27mg, 36mg & 54mg TAB ** | MORPHINE SULF (MSIR) 15mg & 30mg TAB ** |
| CODEINE SULFATE 15mg, 30mg & 60mg TAB | MS CONTIN TAB (all strengths) ** |
| DEMEROL 50mg & 100mg TAB | OXYCONTIN 10mg, 20mg, 40mg & 80mg TAB |
| DEXEDRINE 5mg TAB | PERCOCET 5/325mg TAB ** |
| DILAUDID 2mg & 4mg TAB | ROXICODONE 5mg TAB |
| METHADONE 5mg & 10mg TAB | ROXANOL 20mg/mL SOLUTION |
(** 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 SYRUP (120mL bottles) |
| HALCION 0.125mg & 0.25mg TAB | SERAX 10mg, 15mg, & 30mg CAP |
| KLONOPIN 0.5mg, 1mg & 2mg TAB ** | TESTOSTERONE TRANSDERMAL SYSTEM |
| LIBRIUM 5mg, 10mg, & 25mg CAP | 2.5mg/day & 5mg/day |
| LOMOTIL TAB | TYLENOL #3 TABS & 12/120mg/5mL ELIXIR ** |
| METHYLTESTOSTERONE 10mg CAP | VALIUM 2mg, 5mg & 10mg TAB ** |
| MIDRIN CAP ** | VICODIN 5/500mg ** & 7.5/750mg TAB |
| NOVAHISTINE EXPECORANT | XANAX 0.25mg, 0.5mg, 1mg & 2mg TAB |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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SKELETAL MUSCLE RELAXANTS
| FLEXERIL 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 ** |
| 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 | EFUDEX 2% SOL & 5% CREAM | METROCREAM 0.75% CREAM |
| BACITRACIN OINTMENT | ELDOPAQUE FORTE 4% CREAM | METROGEL 1% GEL (replaces 0.75%) |
| BACTROBAN OINTMENT ** | ELDOQUIN 2% CREAM | MYCOLOG II CREAM |
| BENZOYL PEROXIDE 10% GEL | ELIDEL 1% CREAM | NITROBID 2% OINTMENT |
| BENZACLIN 1%/5% GEL | ELIMITE 5% CREAM ** | NIZORAL 2% CREAM & SHAMPOO |
| CAPITROL SHAMPOO | ELOCON 0.1% CREAM | NYSTATIN CREAM, OINTMENT & POWDER |
| CARAC 0.5% CREAM | ERYTHROMYCIN TOPICAL SOLUTION 2% ** | PRAMOSONE CREAM |
| CARMOL 20% & 40% CREAM | HYDROCORTISONE 1% CREAM & OINTMENT | PROTOPIC 0.1% & 0.03% OINTMENT |
| CLEOCIN 1% TOPICAL SOLUTION ** | KENALOG 0.1% CREAM ** & OINTMENT | RETIN-A CREAM **, GEL & MICRO GEL |
| CORDRAN TAPE | KENALOG SPRAY | (Limited to patients up to and including age 35) |
| DERMA-SMOOTHE/FS | KLARON 10% LOTION | SELSUN SHAMPOO ** |
| DESONIDE 0.05% CREAM & OINTMENT | LAC-HYDRIN 12% LOTION | SILVADENE 1% CREAM ** |
| DIFFERIN 0.1% GEL | LIDEX 0.05% CREAM, GEL & OINTMENT ** | SYNALAR 0.01% SOLUTION |
| *DOVONEX OINTMENT (900gm/90 days) | LOTRIMIN 1% CREAM & SOLUTION | *TAZORAC 0.1% & 0.5% GEL (300gm/90 days) |
| *DOVONEX SOLUTION (900mL/90 days) | LUXIQ FOAM 0.12% | *TAZORAC 0.1% & 0.5% CREAM (180gm/90 days) |
| DRYSOL 20% SOLUTION | MEDIPLAST 40% | TEMOVATE 0.05% CRM, OINTMENT, & SOL |
| DUAC GEL | 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 ** |
| NITROGYLCERIN 0.1mg, 0.2mg & 0.4mg/h 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 AND WITHOUT IRON |
| MULTIVITAMIN SOL WITH FLUOR & IRON |
| MULTIVITAMIN DROP |
| PRENATAL VIT W/FOLIC ACID 1mg TAB ** (limited to women up to and including age 45) |
| NIACIN 50mg & 500mg TAB |
| NIASPAN 500mg, 750mg & 1000mg TAB |
| PYRIDOXINE 50mg TAB |
| ROCALTROL 0.25mg CAP |
| THIAMINE 50mg TAB |
| VITAMIN B-12 1000mcg/ml INJ |
| 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
(26 March 2008)
| ANTURANE |
| CALGLUCON |
| DANAZOL |
| DANOCRINE 50mg CAP |
| DEXTROSTAT |
| IPECAC SYRUP |
| METHERGINE |
| MUCOMYST |
| RIDURA |
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ITEMS RECENTLY ADDED
(1 December 2007)
| ACTONEL 75mg TAB |
| ALPHAGAN 0.1% & 0.2% OPH Solution ** |
| FOSAMAX PLUS D 70mg/5600IU TAB ** |
| NEXIUM 20mg & 40mg SR CAP ** |
| SEROQUEL XR 200mg, 300mg, 400mg TAB ** |
| TRIGLIDE 50mg & 160mg TAB ** |
| CELEBREX 100mg & 200mg CAP |
| PATADAY 0.2% OPH SOLUTION |
| TEXTURNA 150mg TAB |
| MIRALAX 119g & 238g POWDER (new size) |
(** indicates Basic Core Formulary -
available at all military treatment centers)
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