AF Pharmacy Shield Scott Air Force Base USAF Medical Service Shield

PHARMACY FORMULARY

Printable Copy  (Revised: 14 Jan 10)

Letter to Health Care Providers  (14 Jan 10)                       Letter to Patients  (14 Jan 10)

Medical Group Fact Sheet  (Nov 2007)

Medications:   By Category    Alphabetically

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FORMULARY CATEGORIES

(Click on a Category name to see Formulary items in that category)
ALKALINIZING AGENTS ANTITUSSIVE, EXPECTORANT & MUCOLYTIC MIGRAINE AGENTS
ALLERGY / ANTIHIST / DECONGEST ANTIVIRALS MISCELLANEOUS AGENTS
AMMONIA DETOXICANTS AUTONOMIC / CHOLINERGIC DRUGS NASAL (LOCAL ACTING) AGENTS
ANALGESICS AND ANTIPYRETICS BLOOD FORMATION / COAGULATION PROGESTINS
ANDROGENS CARDIAC DRUGS PSYCHOTHERAPEUTICS
ANTI-ANDROGEN CONTRACEPTIVES RESPIRATORY AGENTS
ANTICONVULSANTS DENTAL AGENTS SCHEDULE II DRUGS (click for details)
ANTIDIABETIC AGENTS DEVICES SCHEDULE III, IV & V (click for details)
ANTI-INFECTIVE LIQUIDS DIURETICS SKELETAL MUSCLE RELAXANTS
ANTI-INFECTIVE TABLETS / CAPSULES EAR AGENTS SMOOTH MUSCLE RELAXANTS
ANTILIPEMIC AGENTS EYE AGENTS SUPPOSITORIES / ENEMAS
ANTIMALARIAL AGENTS ESTROGENS THYROID-RELATED AGENTS
ANTIMUSCARINICS / ANTISPASMODICS GASTROINTESTINAL DRUGS TOPICALS
ANTINEOPLASTIC AGENTS HORMONES / REPLACEMENT ADRENALS   URICOSURIC AGENTS
ANTIPARKINSONIAN AGENTS HYPOTENSIVE AGENTS VAGINAL PREPARATIONS
ANTITUBERCULARS ION REPLACEMENT THERAPY VASODILATING AGENTS
VITAMINS / MINERALS
ITEMS (recently) REMOVED

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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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