Formulary Listings - Jul 2011 Subject to Change Without...

**Adderal (Amphetamine -mixed salts) 5, 10 & 20, 30mg Tab - C-II/90 day supply/No refills

**Adderal XR (Amphetamine -mixed salts) 5, 10, 15, 20, 25, 30mg Cap - C-II/90 day supply/No refills

Advair Diskus (Fluticasone/Salmeterol) 100/50mcg, 250/50mcg, 500/50mcg

Advair HFA 45-21mcg, 115/21mcg, 230/21mcg

Aerochamber (Small, Medium, and Large) w/ Mask

Aerochamber Plus

Afrin nasal spr

Aggrenox (ASA/Dipyrimamole (25/200mg Cap)

Albuterol 4mg Tab

Albuterol 2mg/5ml Syrup

Albuterol 0.5% Inhalant Soln 20ml Bottle

Albuterol 0.083mg Premixed Nebulizer Soln

Albuterol HFA 90mcg Inhaler

Alcohol Swabs (Isopropyl alcohol) 200 per box

Aldactone (Spironolactone) 25mg Tab

Aldara (Imiquimod) 5% crm

Aldomet (Methyldopa) 250mg Tab

Alesse-28/Lutera (Ethinyl Estradiol/Levonorg)

Alfuzosin (Uroxatral) 10mg Tab

Allegra (Fexofenadine) 60mg, 180mg Tab

Allegra D-12 (Fexo/Pseudo) 60mg/120mg – 20/pck

Alkeran (Melphalan) 2mg Tab

Alocril (Nedocromil) 2% Ophthalmic Sol 5ml

Alomide (Lodoxamide) 0.1% Opth Drops

Alphagan P (Brimonidine) 0.15% Opht Sol 10ml

Altace (Ramipril) 1.25, 2.5, 5, 10mg Cap

Apresoline (Hydralazine ) 25mg Tab

Alupent (Metaproterenol Sulfate) 10mg Tab

Formulary Listings - Jul 2011 Subject to Change Without Notice Substitution: Brand names are listed for reference only. We stock many generics. Generic equivalents will be dispensed whenever possible. Providers are encouraged to authorize generic substitution. Legend Medications – Maintenance medications may be filled up to a 90-day supply with refills up to 1 year as authorized by the prescriber. Medications for acute conditions or medications normally taken on an as needed basis will be limited to a 30 day supply or less with refills as medically appropriate. CII Medications - 30-day supply/no refills ADHD Medications - up to 90 day supply CIII-V Medications - 30 day supply/up to 5 refills as authorized by the prescriber. ** Indicates a controlled substance * Indicates quantity limit Bold/underline indicates Basic Core Formulary (BCF). BCF is a medication list required to be on formulary at all full-service Military Treatment Facilities.

Amaryl (Glimepiride) 1mg, 2mg & 4mg Tab

** Ambien (Zolpidem) 5 & 10mg Tab

C-IV/ 30 day supply/ 5 refills max

Amicar (AminoCaproic Acid) 500mg Tab

Amitiza (Lubiprostone) 8mcg gel Cap

Amrix SR (Cyclobenzaprine) 15, 30mg Cap

Amoxil (Amoxicillin) 250, 500mg Cap, 250mg tbch

Amoxil (Amoxicillin) 875mg Tab

Amoxil (Amoxicillin) 125mg/5ml, 250mg/5ml, 400mg/5ml Susp

Amitiza (Lubiprostone) 24mcg GCP

Anaprox (Naproxen Sod) 275mg Tab

Anaprox DS (Naproxen Sod) 550mg Tab

** Androderm (Testosterone) 2.5mg, 5mg patches

**Androgel (Testosterone) 1% Pump

AnTabuse (Disulfiram) 250mg Tab

Antivert (Meclizine) 25mg Chewable Tab

Anusol-HC (Hemorrhoidal Sup/w hydrocortisone) Supp

Aphthasol (Amlexanox) 5% oral paste

Apresoline (Hydralazine) 10, 25 & 50mg Tab

Apriso (Mesalamine) 0.375mg Tablet

Aralen (Chloroquine phosphate) 500mg Tab

Aricept (Donepezil hydrochloride) 5mg & 10mg Tab

Aristocort Triamcinolone 0.1% Oint 15gm Tube

Aristocort A (Triamcinolone Acetonide) 0.1% Cr 15gm, 60gm

Artane (Trihexyphenidyl HCL) 2mg Tab, 0.4mg/ml sol

Artificial Tears ophthalmic soln

Asacol 400mg (Mesalamine EC) Tab

Asmanex twst (Mometasone) 110mcg, 220 mcg inh

Aspercreme (Trolamide salicylate) 10% Cr

Aspirin (Acetylsalicylic Acid) 81mg Tab

Aspirin (Acetylsalicylic Acid) 81mg chewable Tab

Aspirin EC (Acetylsalicylic Acid EC) 325mg Tab

Astelin (Azelastine) 137 mcg nasal spr

Atacand (Candesartan) 4, 8, 16, 32mg Tab

Atacand HCT (Candesartan HCT) 16/12.5, 32/12.5mg

Atarax (Hydroxyzine HCl) 10mg & 25mg, 50mg Tab

Atarax (Hydroxyzine HCl) 10mg/5ml Syrup

**Ativan (Lorazepam) 0.5mg & 1mg Tab

C-IV/30 day supply/5 refills max

Atropine Sulfate 1% Ophthalmic Sol 15ml

Atropine Sulfate 1% Ophthalmic Oint

Atrovent (Ipratropium Bromide) 0.02% Inhalant Sol

Atrovent (Ipratropium Bromide) 0.03%, 0.06% Nas Spr

Atrovent HFA (Ipratropium BR) 17gm Inhaler

Augmentin (Amox/Clavulanate) 500 & 875mg Tab

Augmentin (Amox/Clavulanate) 125/5 & 250/5 Susp

Augmentin (Amox/Clavulanate) 200/5 & 400/5 Susp

Augmentin Chew Tab (200mg amoxil/28.5mg clavulanate)

Augmentin Chew Tab (400mg amoxil/57mg clavulanate)

Augmentin ES (Amoxicillin/Clavulanic) 600mg Susp

Augmentin XR (Amox tr/pot clavul) 1,000mg Tab

Auralgan (Antipyrine/Benzocaine) 1.4/5.4% Otic Sol

Avelox (Moxifloxacin) 400mg Tab

Aygestin (Norethindrone acetate) 5mg Tab

Azasite (Azithromycin) 1% sol, 2.5ml

Azulfidine (Sulfasalazine) 500mg Tab

Bacitracin 500 U/gm Topical Ointment

Bacitracin 500 U/gm Ophthalmic Ointment

Baclofen 10mg Tab

Bactrim DS (Sulfamethoxazole/Trimethoprim) 160/800, 80/400 Tab

Bactrim (Sulfamethoxazole/Trimethoprim) 200/40 per 5ml Susp

Bactroban (mupirocin) 2% Oint, 22gm/Cr 30gm Tube

Bellergal-S (Belladonna/Phenobarb/Ergotamine) 0.2/40/0.6 Tab

Benadryl (Diphenydramine) 12.5mg/5ml Elixir

120ml,bottle (Pediatric Only), 25mg and 50mg Cap

Bentyl (Dicyclomine) 10mg Cap, 20mg Tab

Bentyl (Dicyclomine) 10mg/5ml Syrup

Benzoyl Peroxide 10% Topical Gel

Besivance 0.6% Opht drops

Betadine 10% Top Sol, 7.5% Top Soap

Betapace (Sotalol) 80mg, 120mg, 160mg & 240mg Tab

Beta-Val (Betamethasone) 0.1% Topical Cr/Lotion

Betoptic S (Betaxolol HCI) 0.25% Ophthalmic Sol 10ml

Biaxin (Clarithromycin) 125mg/5ml Susp

Biaxin (Clarithromycin) 250mg, 500mg Tab

Biaxin XL PAC (Clarithromycin) 500mg Tab

Blephamide (Sulfacetamide/prednisolone) 10%/0.2% Oint

Blephamide (Sulfacetamide/Prednisolone) 10%/0.2% Soln

Boniva (Ibandronate) 150mg

Brethine (Terbutaline Sulfate) 5mg Tab

Brevicon (Norethindrone/Ethinyl Estradiol) 0.5mg/35mcg 28 day

Buspar (Buspirone) 5mg, 10mg & 15mg Tab

Byetta (Exenatide) 5mcg/0.02ml, 10mcg/0.04ml pen injctr

Cafergot (Ergotamine tartrate) Tab

Calan (Verapamil) 80mg Tab

Calan SR (Verapamil) 120mg, 180mg & 240mg Tab

Calcium w/Vit D chewable

Capoten (Captopril) 12.5mg, 25mg, & 50mg Tab

Capozide (Hydrochlorothizide/Captopril) All strengths

Capaicin (Trixaicin) 0.025% Top Cr

Captopril 50mg, 100mg Tab

Carafate (Sucralfate) 1gm Tab

Carbachol (Isoptocarbachol) 3% Ophthalmic Sol 15ml

Carbamazepine 100mg/5ml Suspension

Cardizem (Diltiazem) 60mg Tab

Cardura (Doxazocin) 1, 2, 3, 4, 8mg Tab

Carmol-10 (Urea) 10% Lotion, 40% Cr

Casodex (Bicalutamide) 50mg Tab

*Castellani Paint (Sol 30) ml Bt – max qty 1 btl w/refills

Cataflam (Diclofenac Potassium) 50mg Tab

Catapres (Clonidine) 0.1, 0.2, & 0.3mg Tab

Catapres TTS (Clonidine) TTS-1, TTS-2, TTS-3 patches

Cefzil (Cefprozil) 250mg and 500mg Tab

Cefzil (Cefprozil) 250/5 Susp

Celebrex (Celecoxib) 100mg, 200mg Cap

Celexa (Citalopram) 10, 20, & 40mg Tab; 10mg/ml soln

Cellcept (Mycophenolate) 250mg

Cerave (Ceramides) top cr

*Cepacol lozenges Extra strength (18/box)

Cetamide (Sulfacetamide Sodium) 10% Ophth Oint/Sol

Chlorphen Maleate 4 mg Tab

Chlorhexidine 0.12% liq

Ciloxan (Ciprofloxacin) 0.3% Ophthlamic Oint & Soln

Ciprodex (Ciprofloxacin/Dexamethasone) Otic Drops

Cipro (Ciprofloxacin) 100mg, 250mg, 500mg, 750mg

Claritin (Loratadine) 10mg Tab

Claritin (Loratadine) 5mg/5ml Syrup

Claritin-D-24 HR (P-ephed/loratidine SR) Tab

Cleocin (Clindamycin) 300mg

Cleocin (Clindamycin) 150mg Cap

Cleocin (Clindamycin phosphate) Vag Cr 2%

Cleocin T (Clindamycin) 1% Top Sol

Climara Patches (Estradiol) 0.025, 0.05, 0.06, 0.075, .0375, 0.1mg/24 hr

Clinoril (Sulindac) 200mg Tab

*Clomid (Clomiphene Citrate) 50mg Tab (10 Tab/30 days)

Clobex (Clobetasol) 0.05% Shampoo- Restricted to Derm

**Codeine Sulfate 30mg Tab /C-II/30 day supply/No refills

CO-Enzyme Q10 (Ubidecarerone) 200mg Cap

Cogentin (Benztropine Mesylate) 0.5, 1, & 2mg Tab

Colace (Docusate Sodium) 100mg Cap

Colchicine 0.6mg Tab

Colestid (Colestipol) 1 gram Tab

Colocort (Hydrocortisone) 100mg/60ml Rectal Enema

Coly-Mycin S (1% Hydrocortisone/3.3mg Neomycin) Otic Susp

Colyte Powder for Reconstitution (PEG electrolyte sol)

Combigan (Brimonidine) 0.2%-0.5% opt drops

Combipatch (Estradiol/norethindrone) 0.05/0.14 & 0.05/0.25mg

Combivent (Albuterol/Ipratropium) Inhaler

Compazine (Prochlorperazine) 25mg Suppository

Compazine (Prochlorperazine) 5mg Tab

**Concerta (Methylphenidate) 18, 27, 36,

54mg ER Tab - C-II/90 days/no refills

Cordarone (Amiodarone) 200mg Tab

Cordran (Flurandrenoline) Tape (large) 4 mcg/sq

Coreg (Carvedilol) 3.125mg & 6.25mg Tab

Coreg (Carvedilol) 12.5mg & 25mg Tab

Coreg CR (Carvedilol 24hr) 10, 20, 40, 80mg Cap

Coricidin HBP (Dextrom/Chlor) 30mg/4mg tab

Cortef (Hydrocortisone) 20mg Tab

Cort-Enema (Hydrocortisone) 100mg/60ml Enema

Cortisone Acetate 25mg Tab

Cortisporin 1% top Ointment

Cortisporin (neomycin/polymyxin/hydrocortisone)

Opht SuspCortisporin (neomycin/polymyxin/hydrocortisone) Otic Susp

Cortisporin (neomycin/polymyxin/hydrocortisone) Otic Sol

Condylox (Podofilox) 0.5% Sol 60ml Bottle

Cosopt (timolol/dorzolamide) Ophthalmic Solution

Coumadin (Warfarin) 1mg & 2mg Tab

Coumadin (Warfarin) 2.5mg & 3mg Tab

Coumadin (Warfarin) 4mg & 5mg Tab

Coumadin (Warfarin) 6, 7.5, 10mg Tab

Cozaar (Losartan) 25mg, 50mg, 100mg Tab

Crestor (Rosuvastatin) 5, 10, 20, 40mg Tab

Cresylate (Cresyl/Ben/Buta/Ipa) 25% Otic Drops

Cyanobalamin (B-12) 1mg/ml Injection

Cyclogyl (Cyclopentolate) 1%, 2% Opt Soln

Cyclomydril (Cyclo/Phenyl) 0.2%/1% Opt Sol

Cytomel (Liothyronine sodium) 5, 25mcg Tab

Cytoxan (Cyclophosphamide) 50mg Tab

Dapsone 25mg Tab

**Darvocet N 100 (100 mg Propoxyphene/650 mg APAP)

Tab / C-IV/30 days/6 month max

Daypro (Oxaprosin) 600mg Tab

DDAVP (Desmopressin acetate) 0.1mg/ml Nasal Spr

Debrox (Carbamide Peroxide) ear drop 15 ml

Decadron (Dexamethasone) 0.75mg & 4mg Tab

Decadron (Dexamethasone) 0.5mg/5ml Elixir

Delsym (Dextromethorphan) 30mg/5ml susp

Deltasone (prednisone) 1mg, 5mg, 10mg & 20mg Tab

5mg/5ml sol

**Demerol (Meperidine) 50mg Tab C-II/30 days/no refills

Demulen 1/35 (thynodiol diacetate/ethinyl estradiol) 28 day pk

Depakene (Valproic acid) 250mg/5ml Syrup

Depakote ER (Divalproex) 250, 500mg Ext Rel Tab

Depakote (Divalproex Sodium DR) 125, 250 & 500mg

Depakote (Divallproex Sodium) 125mg sprinkles Cap

Depo-Provera Vial (Medroxyprogesterone Acetate) 150mg/dose - C-V/30 days or 1 vial/5 refills max

**Depo-Testosterone Inj 200mg/ml 1ml multidose vial

Derma-Smooth/FS (Fluocinolone Acetonide) 0.01% Top Oil

Desowen (Desonide) .05% Cr 15gm Tube

Desowen (Desonide) .05% Lotion 120ml Bottle

Desquam (Benzoyl Peroxide) 5%, 10% topical soap

Desyrel (Trazodone) 50mg, 100mg, 150, 300mg Tab

Detrol LA (Tolterodine Tartrate) 2mg & 4mg Cap

**Dexedrine Spansule (Dextroamphetamine) 5mg Tab, 10mg &15mg CPSR, C-II/90 day supply/no refills

Diamox (Acetozolamide) 250mg Tab

Diamox SR (Acetozolamide) 500mg Sequels

Diaphragm Kit 60, 65, 70, 75, 80, 85, 90

Diflucan (Fluconazole) 100mg, 200mg Tab

Diflucan (Fluconazole) 150mg Tab (Vag Candidiasis Only)

Dilantin (Phenytoin) 100mg Cap “Parke Davis Brand”

Dilantin (Phenytoin) 125mg/5ml Susp “Parke Davis Brand”

Dilantin (Phenytoin) 50mg Chew Tab “Parke Davis Brand”

**Dilaudid (hydromorphone) 2mg Tab

C-II/30 day supply/no refills

Diovan (Valsartan) 40mg, 80mg, 160mg, 320mg Tab

Diovan HCT (Valsartan HCTZ) 80-12.5mg, 160-25mg ,

320-12.5mg, 320-25mg Tab

Disalcid (Salsalate) 500mg, 750mg Tab

Ditropan (Oxybutynin) 5mg Tab

Ditropan (Oxybutynin) 5mg/5ml Elixir

Ditropan XL (Oxybutynin chloride) 5, 10, 15mg tab

**Dolophine (Methadone HCL) 5mg, & 10mg Tab


Domeboro (Aluminum acetate) Otic Sol

Domeboro Pkt Powder (Calcium Acet/Alum Sulf)

Donnatal (Belladonna alkaloids/phenobarbital) Tab

Donnatal (Belladonna alkaloids/Phenobarbital) Elixir 120ml Bt

Doryx (Doxycycline Hyclate) 100mg,150mg delayed release Tab

Dovonex (Calcipotriene) .005% Cr and Solution

Doxepin HCL 10, 25, 50, 75mg Tab, 10mg/ml Suspension

Drysol (Aluminum chloride) 20% Sol 30ml Bt

Duac Top (Clindamycin/Benzoyl perox) Gel

Dulcolax (Bisacodyl) 5mg Tab, 10ng suppositories

Dulera (Mometasone/Fomoterol) 100mcg/5mcg and

200mcg/5mcg inhaler

Duoneb (Ipratropium/Albuterol) 0.5-3mg/3 inh sol

Duricef (Cefadroxil) 125mg/5ml & 250mg/5ml Susp

Dynapen (Dicloxacillin sodium) 250mg & 500mg Cap

EES (Erythromycin ethylsuccinate) 200mg/5ml Susp

Effexor XR (Venlafaxine) 37.5mg, 75mg & 150mg Cap

Effexor 100mg (Venlafaxine) Tab

Efudex (Fluorouracil) 5% Cr 40gm Tube

Elavil (Amitriptyline) 10mg, 25mg, 50mg & 75mg Tab

Eldepryl (Selegiline) 5mg Tab

Eldoquin Forte (Hydroquinone) 4% Cr 30gm Tube

Elestat 0.05% opth sol (Elesol Epinastine HCL)

Elidel (Pimecrolimus) Cr 30gm Tubes

Elmiron (Pentosan polysulfate) 100mg Cap

Elimite (Permethrin) 5% Cr

Enablex (Darifenacin hydrobromide) 7.5 and 15mg Tab

Enema Disp Liq (SOD phosphate/SOD/Biphos) 4.5 oz

Epifrin (Epinephrine HCL) 1% Ophthalmic Sol

Epi-Pen (Epinephrine) .3 mg Auto Injector Pen

Epi-Pen Jr. (Epinephrine) .15mg Auto Injector Pen

Epinephrine (Twinjet)

Eryderm (Erythromycin) 2% Solution 60ml Bt

Erygel (Erythromycin) 2% topical gel

Erythromycin BASE (Erythromycin) 250mg Tab

Erythromycin Ophthalmic Ointment

Eskalith (Lithium Carbonate) 300mg Cap

Eskalith CR (Lithium Carbonate) 450mg TB

Estradiol 0.25, 0.75, 1mg/24hr, 37.5mcg/24hr

0.025, 0.05, 0.06, 0.075, 0.1, 0.0375mg

Estratest (1.25mg esterified estrogen /2.5mg

methyltestosterone) Tab

Estratest HS (0.625mg estrogen /1.25mg methyltestosterone) Tab

Estring (Estradiol) 2mg Vaginal Ring

Evista (Raloxiphene) 60mg Tab

Exelon (Rivastigmine) 4.6mg/24 hr, 9.5mg/24hr Patch

E-Z Spacer

Feldene (Piroxicam) 20mg Cap

Fenofibrate 54mg, 160mg Tab

Ferrex 150 Plus (Iron, Vit C, Succinic Acid) Capule

Ferrous Sulfate 325mg Tab

Ferrous Sulfate 220mg/5ml Liquid

Ferrous Sulfate (Fer-Iron) 15mg/ml Oral Drop

Finacea (Azelaic acid) gel top 15%

Restricted to Dermatologist (Mil & Civ)

Fioricet (Butalbital/caffeine/APAP) 50/40/325 Tab

**Fiorinal (Butalbital/caffeine/aspirin) 50/40/325 Tab

C-IV/30 days/6 month max

First-Mouthwash Blm 25-200/30 - Soln

Fish Oil 1000mg Cap

Fibercon (Polycarbophil) 625mg Tab

Flagyl (Metronidazole) 250mg & 500mg Tab

Flagyl (Metronidazole) 0.75% vaginal gel

Flector Patch (Diclofenac) 1.3%

Fleet Enema (Sodium phosphate) 133ml

Fleet Enema (Sodium phosphate) pediatric 65/ml

Fleet Phospo-Soda oral sol/bt unflavor 36 x 1.5 oz

Flexeril (Cyclobenzaprine) 5, 10mg Tab

Flomax (Tamsulosin) 0.4mg Cap

Flonase (Fluticasone) 0.05% Nasal Inhaler

Florinef (Fludrocortisone acetate) 0.1mg Tab

Flovent (Fluticasone) Diskus 50, 100 & 250mcg/blister

Flovent (Fluticasone) HFA44mcg, 110mcg & 220mcg Inhaler

Floxin (Ofloxacin) Otic Drops 0.3% 5ml

Fluoride Sodium 1mg Tbch

FML (Fluorometholone) 0.1% Ophthalmic Susp & Oint

Folic Acid 1mg Tab

Foradil (Formoterol) 12mcg inhaler Cap/dev

Fosamax (Alendronate) 5mg, 10mg, 35mg & 70mg Tab

Fosamax (Alendronate) 70mg/75ml soln

Fosamax PlusD (Alendronate/cholecalciferol)

70mg/2,800 units, 70mg/5600mg units

Fungoid Tincture top 2% soln

Furadantin (Nitrofurantoin) 25mg/5ml Susp

Garamycin (Gentamicin) 0.1% Topical Cr and ointment

Garamycin (Gentamicin sulfate) 3mg/ml Opht Sol

Garamycin (Gentamicin sulfate) 3mg/gm Opht Oint

Geodon (Ziprasidone HCl) 20mg, 40mg, 60mg & 80mg Cap

Glucagon Inj 1mg kit

Glucophage (Metformin) 500mg, 850mg, & 1000mg

Glucophage (Metformin) XR 500mg, 750mg Tab

Glucose dextrose 40% oral gel (Glutose) 37.5gm tube

Glucotrol (Glipizide) 5mg 10mg Tab Immediate Release

Glucotrol XL (Glipizide) 2.5mg, 5mg & 10mg Tab

Glucovance (Glyburide/metformin) 1.25/250mg, 2.5/500mg & 5/500mg Tab

Glynase PresTab (Micronized glyburide) 1.5, 3 & 6mg Tab

Gris-Peg (Ultramicrosized griseofulvin) 125mg, 250mg Tab

Gris-Peg (Griseofulvin) 125/5 Susp

Guaifenesin 400 mg Tab

Half-lytely powder + bisacodyl Tab

Hibiclens (Chlorhexidine Gluc) 4% Top Liquid

Homatropine 5% Ophthalmic Sol 15ml

*Humira Pen/Syr (Adalimumab) 40mg/0.8ml inj

30 day supply with refills

Hydrea (Hydroxyurea) 500mg Cap

Hydrochlorothiazide 12.5mg, 25mg & 50mg Tab

Hydrocortisone 1% Cr / 2% Lotion

Hygroton (Chlorthalidone) 50mg Tab

Hytrin (terazosin) 1mg, 2mg, 5mg & 10mg Cap

Hyzaar HCTZ (Losartan/HCTZ) 50-12.5mg,

100-12.5mg, 100-25mg Tab

Icy Hot (Methyl Salicylate/menthol) Top Cr

Ilotycin (erythromycin) 5% Ophthalmic Oint

Imdur (Isosorbide mononitrate) 30mg, 60mg, 120mg Tab

*Imitrex (Sumatriptan) Stat dose kit

*Imitrex (Sumatriptan) 6mg/0.5ml Syringe 4 units p/30 days

*Imitrex (Ssumatriptan) 20mg, 5mg Nasal Spr 6 p/30 day

* Imitrex (Sumatriptan) 25, 50, 100mg Tab

Imodium (Loperamide) 2mg Cap

Imuran (Azathioprine) 50mg Tab

Inderal LA (Propranolol) 60mg, 80mg, 120mg & 160mg Cap

Indocin (Indomethacin) 25mg & 50mg Cap

Inspirease Replacement Bags 3 bags/Box

Inspirease Kit with 3 bags

Iopidine (Apraclonidine) 1% Opth Soln

Ismo 20mg (Isosorbide Mononitrate Tab

Isoniazid (INH) 100mg & 300mg Tab

Isoniazid (INH) 50mg/5ml Syrup

Isopto-Cetapred (Sulfacetamide) 10% Ophthalmic Sol

Isopto-Cetapred (Sulfacetamide) 10% Ophthalmic Oint

Isopto-Hyoscine (Scopolamine hydrobromide) 0.25% Sol

Isordil (Isosorbide dinitrate) 5, 10, 20 & 30mg Tab

Isordil (Isosorbide dinitrate) 40mg ER Tab

Janumet (Sitagliptin phos/metform) 50/500mg, 50/1000mg

Januvia (Sitagliptin phos) 25, 50, 100mg Tab

Kayexlate (Sodium polystyrene) 15gm/60ml Susp

K-Dur (Potassium chloride) 10meq & 20mEq Tab

Keflex (Cephalexin) 250 & 500mg Cap; 250mg/5ml susp

Kenalog (Triamcinolone acetonide) 0.1% Top Spr 63gm

Kenalog (Triamcinolone) 0.1% Cr 15gm Tube

Kenalog (Triamcinolone) 0.1% Oint 15gm Tube

Kenalog in Orabase (Triamcinolone acetonide) Oral Paste

Keppra (Levetiracetam) 250, 500, 750mg Tab, 100mg/ml sol

Ketoconazole 2% crm 30gm

**Klonopin (Clonazepam) 0.5mg, 1mg Tab

C-III/30 day supply/6 month max

Klor-Con (Potassium CHL) 8Meq TBSR

Lac-Hydrin (Ammonium Lactate) 12% Lotion /Cr

Lactulose 10mg/15ml Syrup

Lamictal (Lamotrigene) 25, 100, 150, 200mg Tab

Lamictal ODT (Lamotrigine ODT) 100, 200mg Tab

Lamisil (Terbinafine) 250mg Tab and 1% Cr

Lancets 100 per box

Lanoxin (Digoxin) 0.125 & 0.25mg Tab

Lanoxin (Digoxin).05mg/1ml Sol Brand Name Only 60ml

Lantus (Insulin glargine) 10ml Bottle

Lantus Solo (Insulin glargine) 100u/ml PFS 5x3 ml

Lariam (Mefloquine) 250mg Tab

*Lasix (Furosemide) 10mg/ml Sol, 60 ml bottle

Lasix (Furosemide) 20mg & 40mg Tab

Leukeran (Chlorambucil) 2mg Tab

Leuprolide kit (Lupron depot) 11.25mg SolR

*Levaquin (Levofloxacin) 250mg, 500mg & 750mg Tab

Levaquin (Levofloxacin) 25mg/ml soln

Levemir (Detemir) insulin Flexpen

Levemir vials (Detemir) 100 units /10ml vials

*Levitra (Vardinifil) 5, 10, 20mg Tab - 6 Tab per month

Note: Only for pts 40 yrs of age and over

Levsin SL (Hyoscyamine) 0.125mg Tab

Librax (Chlordiazepoxide) 5/2.5mg Cap

**Librium (Chlordiazepoxide) 5, 10mg Cap - C-IV/30 day

Lidex E (Fluocinonide) 0.05% Cr 15gm Tube

Lidex (Fluocinonide) 0.05% Oint 15gm tube; 0.05% Cr

Lithium Citrate 8meq/5ml soln

Lidex (Fluocinonide) 0.05% Gel 15gm Tube

Lidex (Fluocinonide) 0.05% Top Sol – 60ml/bt

**Lidocaine (Lidoderm) 5% , 700mg, Top Ptch - 5 refills

Lipitor (Atorvastatin) 10mg, 20mg, 40mg, 80mg Tab

Loestrin Fe 1.5/30 (norethindrone/ethinyl estradiol) 28 days

Loestrin Fe 1/20 (norethindrone/ethinyl estradiol) 28/ds

**Lomotil (Dphenoxylate)/ 2.5mg Tab

C-IV/30days supply/5 refills max

Loniten (Minoxidil) 2.5mg, 10mg Tab

Lo/Ovral (0.3mg norgesterol/30mcg Ethinyl Estradiol)/28/ds

Lopid (Gemfibrozil) 600mg Tab

Lopressor (Metoprolol) 25mg 50mg 100mg Tab

**LorTab (Hydrocodone/APAP)2.5mg-167mg/5ml elixir

C-III/30 day supply/5 refills max

Lotemax 0.5% Opht susp

Lotensin (Benazepril) 5mg, 10mg, 20mg & 40mg Tab

Lotensin HCT (Benazepril/HCTZ) 5mg/6.25mg Tab



Lotensin HCT (Benazepril/HCTZ) 20mg/25mg Tab

Lotrel (Amlodipine/benazepril) 2.5/10, 5/10, 5/20, 5/40,

10/20, 10/40mg Cap

Lotrimin (Clotrimazole) 1% Cr, soln

Lotrisone (Clotrim/Beta) 1/0.05% Cr

Lovenox (Enoxaparin Sodium) 30, 40, 60, 80, 100mg

No refills

Lovaza (Omega-3) 1gm Cap

Lozol (Indapamide) 1.25mg & 2.5mg Tab

Lumigan (Bimatoprost) 0.03% Ophthalmic drops

**Lunesta (Eszopiclone) 1, 2, 3 mg Tab C-IV/30 day

supply/5 refills max

Lupron Depot (Leuprolide acetate) 3.75mg & 7.5mg Inj

Lupron Depot (Leuprolide acetate) 22.5mg Injection

Luride (Sodium fluoride) 2.2mg Tab

Luvox (Fluvoxamine) 50mg & 100mg Tab

Macrobid (Nitrofurantoin macrocrystals) 100mg Cap

Macrodantin (Nitrofurantoin macrocrystals) 50mg & 100mg

Magnesium Citrate – regular liq 10oz

Magnesium Oxide (Magox) 400mg Tab

Matulane (Procarbazine) 50mg Cap

*Maxalt (Rizatriptan) 5mg, 10mg Tab- 18 Tab per 30 ds

*Maxalt MLT (Rizatriptan) 5, 10mg Tab – 18 Tab per 30 ds

Maxzide (HCTZ/Triamterene) 50/75mg Tab

Maxzide-25 (HCTZ/Triamterene) 25/37.5mg Tab

Mediplast 40%/salisylic acid

Medrol (Methylprednisolone) 4mg Tab & Dosepak

Megace (Megestrol acetate) 40mg Tab

Mephyton Pytonadione (Vitamin K) 5mg Tab

Mestinon (Pyridaostigmine bromide) 60mg Tab

Metamucil (Psyllium/sucrose)

Methadone 5mg, 10mg Tab

Methergine (Methylergonovine maleate) 200mcg Tab

Methotrexate 2.5mg Tab

MetroCr (Metronidazole 0.75%, 45g)

Metrogel (Metronidazole) 1% top; vag Gel 45gm Tube

Mexitil (Mexilitine) 150mg

Micardis (Telmisartan/) 20mg, 40mg, 80mg

Micardis HCT (Telmisartan hydrochlorothiazide)

40/12.5mg, 80/12.5mg, 80/25mg

Miochol E (Acetylcholine Chloride) 20mg Opth Sol

Mircette 28 days Tab

Micronase (Glyburide) 1.25mg, 2.5mg and 5mg Tab

Minocin (Minocycline) HCL 50mg & 100mg Cap

Miralax Pwd (Polyethylene glycol) 255gm, 527 gm

Mirapex (Pramipexole) .125, .25, .0.5, 1.5, 1mg Tab

Mircette 28 days (birth control)

Micronor (norethindrone) 0.35mcg 28 day cycle

Minipress (Prazosin) 1mg, 2mg & 5mg Cap

Mobic (Meloxicam) 7.5mg & 15mg Tab

Monistat 3 Combo Pck (supp/Cr)

Monoket (Isosorbide Mononitrate) 10mg Tab

Monopril (Fosinopril) 10mg & 20mg Tab

**Morphine Sulfate10mg/5ml Sol


*Motrin (Ibuprofen) 100mg/5ml Susp (Pediatric Only)

Motrin (Ibuprofen) 400mg, 600mg & 800mg Tab

**MS Contin (morphine sulfate) 15mg, 30mg, 60mg, & 100mg - C-II/30 day supply/no refills

** MSIR (Morphine sulfate) 15mg & 30mg (immediate rel) Tab - C-II/30 day supply/no refills

Mucinex (Guaifenecin SA) 600mg Tab

Mucinex DM (Guafenesin DM) 600/30 Tab - 40/Box

Mucinex D(Guai/Pseu) 600/60 TBSR - 18/Box

Mucinex MM Child (Guaifenesin) 50mg - 12/Box

Mucus Relief (Guafenesin) 400mg Tab

Mucomyst (Acetylcysteine) 20% Inhalant Soln

Multaq (Dronedarone) 400mg

Multivitamins Tab and chewables

Muro-128 (Sodium Chl) 5% Opth Oint, Sol

Myambutol (Ethambutol) 100 & 400mg Tab

Mycelex (clotrimazole) 10mg Troches, 1% Cr/15gm

Mycifradin (neomycin sulfate) 500mg Tab

Mycolog II (nystatin/triamcinolone) Cr

Myleran (busulfan) 2mg Tab

Mysoline (primidone) 50mg & 250mg Tab

Naftin (naftifine) 1% Cr/Gel

Naprosyn (Naproxen) 250 & 500mg Tab; 125mg/5ml susp

Nasonex 50mcg nasal spr 17gm (mometasone)

Neomycin/polymyxin/gramicidin opth soln

Neomycin/ploymyxin/hydrocortisone

Neosporin (neomy/polymyx/bacitracin) Opth Sol/top oint

Neptazane (methazolamide) 50mg Tab

Neurontin (gabapentin) 100mg, 300mg & 400 Cap

Neurontin (gabapentin) 600mg & 800mg Tab

Nevanac (Nepafenac opth) susp 0.1%

Nexium (Esomeprazole) 20, 40mg Cap

Nexium (Esomeprazole) 10, 20, 40 Suspension - 30/pck

Niaspan (Niacin) 500mg, 750mg & 1000mg Tab SR

Nilandron (nilutamide) 150mg Tab

Nitro-BID (nitroglycerin) 6.5mg & 9mg Cap SR

Nitro-Dur (Nitroglycerin) 0.2, 0.4, 0.6mg patch

Nitrol (Nitroglycerin) 2% Oint 60 gram tube

Nitrospr (Nitroglycerin) 400mcg/spr Spr

Nitrostat SL (Nitroglycerin) 0.4mg Sublingual Tab

Nizoral (Ketoconazole) 200mg Tab

Nizoral (Ketoconazole) 2% Shampoo

Nix Crm Rinse (Permethrin) 1% - 2oz

Nolvadex (Tamoxifen citrate) 10mg, 20mg Tab

Nonoxynol 9 (Shur-Seal) Vag 2% gel

Nordette 28 – 0.15/0.03 (levonorgestrel/ethin)

Norflex (Orphenadrine) 100mg Tab

Norgesic Forte (Orphenadrine/ASA/Caffeine) 50/770/60 Tab

Norlutate (Norethindrone acetate) 5mg Tab

Normodyne (Labetolol) 100mg & 200mg Tab

Norpace (Disopyramide) 100mg & 150mg Cap Reg Rel only

Norvasc (Amlodipine) 2.5mg, 5mg, 10mg Tab

Novofine 30 (Needles, ins) 100/box

Novolin 70/30 (Insulin NPH/Reg HM) Vial

(NOTE: not the same as NovoLog 70/30)

Novolin R (Insulin R) 100/ml vial

Novolin N (Insulin N NPH) 100ml/vial

Novolog Flx Pen (insulin aspart) 10ml Bottle

Novolog Mix Flex Pen 70/30 vial

Novolog (insulin Aspart) 10ml Bottle

NovoLog Mix (Aspart/Human) 70/30 10ml Bottle

(NOTE: not the same as Novolin 70/30)

Nuvaring vag ring (Etonogestrel ethinyl estradiol)

**Nuvigil (Armodafinil) 50, 150, 250mg Tab

Nystatin (Mycostatin) 500,000units Tab

Nystatin (Mycostatin) 100,000units/gm Susp and Cr

Nystatin (Mycostatin) 100,000units/gm Powder 60ml Bottle

Ocufen (Flurbiprofen) 0.03% Ophthalmic Sol 2.5ml

Ocuflox (Ofloxacin) 3mg/ml Ophthalmic Sol 5ml

Ocupress (Carteolol) 1% Ophthalmic Sol 10ml

Ocusoft Lid top kit

Ocean (Sodium Chloride) 0.65% NAS Spr

Ogen (Estropipate) 0.75mg &1.5mg Tab

Olux (Clobetasol) 0.05% foam

Olux E (Clobetasol prop/emoll 0.05% foam

Omnicef (Cefdinir) 125mg/5ml, 250mg/5ml suspension

Omnicef (Cefdinir) 300mg Cap

OptiPranolol (Metipranolol) 0.30% Ophthalmic Sol

Oracea (Dosycline monohydrate) 40mg Cap

Orapred ODT (Orapred Prednisolone) 10, 15, 30mg TBSL

Orapred (Prednisolone/So/Phos) 15mg/5ml solution

Ortho-Cept (desogestrel/ethinyl estradiol) 0.15mg/30mcg

Ortho-Cyclen (ethinyl estradiol/norgestimate) 35mg/0.25mg Tab

Ortho-Evra (norelgestromin/Ethinyl Estradiol) Weekly Patch

Ortho-Gynol (nonoxyl-9) Contraceptive Gel

Ortho-Novum 1/35 (1mg norethindrone/35 mcg ethinyl estradiol)

Ortho-Novum 1/50 (1mg norethindrone/50 mcg ethinyl estradiol)

Ortho-Novum 777 (norethindrone/ ethinyl estradiol)

Ortho Tri-Cyclen (norgestimate/ethinyl estradiol) 28 day pck

Ortho Tri-Cyclen Lo (norgestimate/ethinyl estradiol) 28 day pck

Orudis (Ketoprofen) 75mg Cap

Oscal 500 plus D (Caldium & vitamin D) 500mg Tab

Osmoprep Tablets

Osteobiflex (Glucosamine/Chondroitin) 500mg/400mg Cap

**Oxycodone HCL 5mg Tab – limit of 60 Tab

** Oxycontin (Oxycodone ER) 10, 20mg Tab – limit/20 Tab

Pamelor (Nortriptyline HCL) 10mg & 25mg, 50mg Cap

10mg/5ml sol

Pancreaze DR 4.2k-10k, 10.5k-25k, 16.8-40-70k, 21-37-61k Cap

Panoxyl (Benzoyl peroxide) Top 10% gel, 1.5oz

Paraguard T-380-A intra uterine device (IUD)

Parlodel (Bromocriptine mesylate) 2.5mg Tab

*Patanol (Olopatadine) 0.10% Opht Sol /2 units per month

Paxil (Paroxetine) 10mg, 20mg Tab

Penlac (Ciclopirox) 8% Top Soln

Pen VK (Penicillin V – Potassium) 250mg & 500mg Tab

Pen VK (Penicillin V – Potassium) 125mg/5ml, 250/5 Susp

Pepcid (Famotidine) 20mg, 40mg Tab

Pepcid (Famotidine) 40mg/5ml Suspension

Pepto Bismol (Pink Bismuth) Tab

**Percocet (Oxycodone/APAP) 5mg/325mg Tab


Periactin (Cyproheptadine) 4mg Tab; 2mg/5ml syr

Peridex (Chlorhexidine gluconate) 0.12% Mouth Rinse

Persantine (Dipyridamole) 25mg & 75mg Tab

Petrolatum (Vaseline) 30gm tube

Phenergan (Promethazine) 25mg Tab

Phenergan (Promethazine) 12.5mg and 25mg Supp

Phenergan (Promethazine) 6.25mg/5ml Syrup

**Phenobarbital 15, 30, 60, 100mg Tab -C-IV /30 days / 6

month max

**Phenobarbital 20mg/5ml Elixir -C-IV/90days/6mth max

Phospholine Iodine 0.06% Sol

Pilocarpine 1%, 2% and 4% Sol 15ml

Pilocarpine 4% Ophthalmic Gel

Pill Cutters

Pill Planner weekly

Plaquenil (Hydroxychloroquine) 200mg

Plan B (Levonorgestrel) 0.75mg

Plavix (Clopidogrel) 75mg Tab

Plendil (Felopidine) 2.5mg, 5mg & 10mg Tab

Plexion cloths (Sulfur/sulfacetamide) limited/1 month

Polycitra-K Crystals powder

Polysporin (Polymixin B/bacitracin) 10000u/500u Opht Oint

Polytrim (PpolymixinB/trimethoprim) 10000u/1mg Opht Sol

Poly-vi-sol (Multivitamin) Soln

Ponstel (mefenamic acid) 250mg Cap

Pradaxa (dabigatran) 150mg Cap

Pravachol (pravastatin) 10mg, 20mg, 40mg, & 80mg Tab

Precision Extra Monitor Blood Glucose Monitor

*Precision Extra Test Strips - Max of 400 strips for 90 days

Pred Forte (Prednisolone acetate) 1% Ophthalmic Susp 10ml

Pred Mild (Prednisolone acetate) 0.12% Susp

Prelone (Prednisolone acetate) 15mg/5ml Syrup

Premarin (Conjugated estrogens) 0.45, 0.625, 0.3, 0.9, 1.25mg Tab

Premarin (conjugated estrogens) 0.625mg/gm Vaginal Cr

Prempro (Estrogen/Medroxyprogeterone) 0.3/1.5mg, 0.45/1.5mg, 0.625/2.5mg, 0.625/5mg Tab

Prenatal Vits (pregnant, lactating women or

45 years or younger)

Prenatal Vits with DHA

Prevident 5000 PLUS (Sodium Flouride) Dental Paste

Prilosec (Omeprazole) 10mg, 20mg

Primaquine Phosphate 26.3mg Tab

Prinivil (Lisinopril) 2.5gm, 5mg, 10mg, 20mg & 40mg Tab

Probenecid 500mg Tab

Procan SR (Procainamide) 500mg Tab

Proctofoam-HC (Pramoxine/hydrocortisone) Rectal Foam

Procto-zone (Hydrocortisone) 2.5% Rectal Cr

Prometrium (Progesterone) 100, 200mg Cap

Propylthiouracil (PTU) 50mg Tab

Proscar (Finasteride) 5mg Tab

Protopic (Tacrolimus) .03%, 30gm, 0.1%, 30 & 60gm oint

Provera (Medroxyprogesterone) 2.5mg, 5mg & 10mg Tab

** Provigil (modafinil) 100 & 200mg Tab C-IV/30

day supply/5 refills max

Prozac (Fluoxetine) 10, 20, & 40mg Cap; 20mg/5ml soln

Pulmicort Respules (Budesonide) 0.25mg/2ml & 0.5mg/2ml Inh Susp

Pulmicort respules (Budesonide) 1mg/2ml

Purinethol (MerCaptopurine) 50mg Tab

Pyrazinamide 500mg Tab

Pyridium (Phenazopyridine) 100mg, 200mg Tab

Pyridoxine (B-6) 50mg Tab

Questran Light (Cholestyramine) 4gm/scoop powder

Refresh opt drp (Polyvinyl alc/povidone) tears

Refresh Celluvisc opth drops

Refresh PM opt oint (Lubrifresh) 3.75 gms

Reglan (Metoclopramide) 10mg Tab

Reglan (Metoclopramide) 5mg/5ml Syrup

Relafen (Nabumetone) 500mg, 750mg Tab

Remeron (Mirtazapine) 15mg, 30mg, & 45mg Tab

Restasis (Cyclosporine) 0.05% Opt Sol

**Restoril (Temazepam) 15mg & 30mg Cap

C-IV/30 day supply/5 refills max

Requip (Ropinirole) 0.25, 0.5, 1, 2, 3, 4mg Tab

Requip XL (Ropinirole) 2, 4, 6, 8, 12mg Tab

Retin A: Limited to beneficiaries age 35 or younger

*Retin-A (Tretinoin) 0.025% Cr 45gram Tube

*Retin-A (Tretinoin) 0.05% Cr 20gram tube

*Retin-A Micro (Tretinoin) 0.04% and 0.1% gel

Ridaura (Auranofin) 2mg Cap

Rifadin (Rifampin) 300mg Cap

Risperdal (Risperidone) 0.25, 0.5, 1, 2, 3, 4mg Tab, 1mg/ml syr

Risperdal (Risperidone) 1mg/1ml solution

**Ritalin (Methylphenidate) 5mg, 10mg, & 20mg Tab

CII/90 day supply/no refills

**Ritalin-SR (Methylphenidate) 20mg Sustained Release Tab - CII/90 day supply/no refills

Robaxin (Methocarbamol) 500mg Tab

Robitussin (Guaifenisen) Syrup 100mg/5ml

**Robitussin AC (Guaifensin/codeine)l Syrup Bts of 120ml

CV/30 day supply/5 refills max

Robitussin DM (Guaifensin/DM) 100mg/10mg in 5mlr

Rocaltrol (Calcitrol) 0.25mcg Cap

Rowasa (Mesalamine) Enema

**Roxicet (Oxycodone) Elixir 5-325/5ml

Rythmol (Propafenone) 150mg & 300mg Tab

Santyl (Collangenase) Oint

Scopolamine Hbr (Hyoscine HBr) 15ml Oph Sol

Selsun Shampoo (Selenium sulfide) 2.5%

Senokot S (DOK Plus ) 8.6/50mg Tab

**Serax (oxazepam) 15mg Cap\

CIV/30 day supply/5 refills max

Serevent Diskus (Salmetrol) 50mcg Inhaler

Serophene (Clomiphene citrate) 50mg Tab

Seroquel (Quetiapine) 25, 50, 100, 200, 300, 400mg, Tab

Seroquel XR (Quetiapine) 50, 150, 200, 300, 400mg Tab

Silvadene (Silver sulfadiazine) Cr 20gm, 85gm &400gm Tab

Simethicone 40mg/0.6ml Suspension

Sinemet (Carbidopa/levodopa) 10/100mg & 25mg/100mg Tab

Sinemet (Carbidopa/levodopa) 25mg/250mg Tab

Sinemet CR (Carbidopa/levodopa) 50mg/200mg & 25mg/100 Tab

Singulair (Montelukast) 10mg Tab

Singulair (Montelukast) 4mg & 5mg Chewable

Singulair (Montelukast) 4mg Oral Granules

Slow-K (Potassium chloride) 8mEq Tab SR

Skelaxin (Metaxalone) 400mg & 800mg Tab

Sodium Chloride 0.9% Inhalation Sol 5ml Amp

Solodyn ER (Minocycline HCL) 65mg Tab

Spiriva 18mcg (Tiotropium bromide Cap w/dev)

Strattera (Atomoxetine) 10mg, 18mg, 25mg, 40mg & 60mg Cap

*Sudafed (Psuedoephedrine) 30mg Tab (1 box per month)

Sudafed (Psuedoephedrine) 30mg/5ml Liq (Pediatric Only)

Sulfacetamide Sodium 10% Sol

Suprax (Cefixine) 400mg Tab

Symbicort (Budesonide/Formoterol) 80/4.5mcg, 160/4.5mcg Inh

Symmetrel (Amantadine) 100mg Cap

Synalar (Fluocinolone acetonide) 0.01% Sol 60ml Bt

Synalar (Fluocinolone acetonide) 0.025% Cr 15gm Tube

Synthroid Brand Only

Synthroid+ (Levothyroxine) 0.025mg & 0.05mg Tab




Synthroid+ (levothyroxine) 0.15mg & 0.137mg Tab

Synthroid+(Levothyroxine) 0.2mg & 0.3mg Tab

*Syringes (Insulin) 0.5cc, 0.3cc & 1cc Max 600- 90 days

Syringes: TB for B-12 shots

Taclonex (betamet diprop/calcipotriene) oint 60gms/.005%

Restricted to DERMATOLOGIST (MIL or CIV)

Tagamet (Cimetidine) 400mg Tab

Tambocor (Flecainide) 100mg Tab

Tamiflu (Oseltamivir) 75mg Cap, 12mg/ml suspension

Tapazole (Methimazole) 5mg Tab

Tazorac (Tazarotene) top crm 0.1%, 30gms tube

Tegretol (Carbamazepine) 200mg Tab; 100mg/5ml susp

Tegretol (Carbamazepine) 100mg Chewable Tab

Tekturna (Aliskiren) 150mg, 300mg Tab

Tekturna HCT (aliskiren/HCTZ) 150/12.5mg, 150/25mg

Tekturna HCT (aliskiren/HCTZ) 300/12.5mg, 300/25mg

Temovate (Clobestasole) 0.05% Oint 60gm, 0.05% gel 60gm, 0.05% soln 60gm

Temovate-E (Clobestasole) 0.05% Emollient base Cr 60gm

Tenormin (Atenolol) 25mg, 50mg & 100mg Tab

Tenoretic (Chlorthalidone/atenolol) All strengths Tab

Terazol-3 (Terconazole) Vaginal Cr 0.8%, 20gms

Terazol-7 (Terconazole) Vaginal Cr 0.4%, 45gms

Tessalon (Benzonatate) 100mg Cap

Tetracycline 250mg Cap

Thalitone (Chlorthalidone) 25 & 50mg Tab

TRUERESULT blood glucose monitor

TRUE2GO blood glucose meter

Trusopt (Dorzolamide) 2% Sol 10ml

T-Stat (Erythromycin) 2% Sol 60ml Bottle

Twinject (Epinephrine) 0.15mg/0.15ml, 0.3mg/0.3ml

*Tylenol (Acetaminophen) 80mg/0.8ml Drops (Peds Only)

*Tylenol (Acetaminophen) 160mg/5ml Sol (Peds Only)

Tylenol (Acetaminophen) 325mg Tab

*Tylenol (Acetaminophen) 325mg/650mg Rectal Supp (Peds Only)

**Tylenol No.3 (acetaminophen/codeine) 325mg/30mg Tab - CIV/ 30 day supply/5 refills max

**Tylenol w/ Codeine** (APAP/codeine) 120mg/12mg Elixir - CIV/30 day supply/5 refills max

**Tylox (acetaminophen/oxycodone) 500mg/5mg Cap

CII/30 day supply/no refills

*Ultram (Tramadol) 50mg Tab (Only a 30 day supply)

Urecholine (Bethanechol) 25mg Tab

Urocit-K (Potassium citrate) 10mg Tab

Vagifem (Estradiol) 10mcg Tab

Valisone (Betamethasone valerate) 0.1% Cr

Valisone (Betamethasone valerate) 0.1% Sol 60ml Bt

**Valium (diazepam) 5mg Tab

CIV/30 day supply/5 refills max

Valtrex (Valacyclovir HCL) 500mg , 1000mg Tab

Vasodilan (Isoxsuprine) 10mg Tab

Vectical (Calcitriol) 3mcg top oint

Vermox (Mebendazole) 100mg Chewable Tab

Vexol (Rimexolone) 1% Sol 5ml

Vibramycin (Doxycycline) 50mg, 100mg Cap

**Vicodin (APAP/hydrocodone) 500mg/5mg & 750/7.5 Tab –

CIII/30 day supply/ 5 refills max

**Vicoprofen (hydrocodone/ibuprofen) 7.5mg/200mg Tab

Victoza (Liraglutide) 6mg/ml inj pen

Vigamox (Moxifloxacin) Ophthalmic Drops

*Viroptic (Trifluridine) 1% Ophthalmic Sol 10ml

Visquen (Pindolol) 5, 10 mg Tab

Vistaril (Hydroxyzine Pamoate) 25mg, 50mg Cap

Vitamin B Complex with Vit C

Vitamin B-1 100mg (Thiamine) Tab

Vitamin B-6 (Pyridoxine) Tab

Vitamin B-6 – 50mg Tab

Vitamin B-12 (Cyanocobalamin) 1000mcg Tab

Vitamin B-12 (Cyanocobalamin) 1000mcg /ml

Vitamin D (calciferol) 1.25mg Cap

Vitamin D (Cholecalciferol) 400 units

Vitamin K (Phytonadione) 5mg Tab

Voltaren (Diclofenac sodium) 75mg Tab

Voltaren gel 1% (Diclofenac sodium)

VoSol (Acetic acid) 2% Otic Sol 10ml

VoSol HC (Acetic acid/hydrocortisone) Otic Sol 10ml

Vytorin (Ezetimibe/simvastatin) 10/10mg, 10/20mg,

10/40mg.10/80mg Tab

Wellbutrin (Bupropion) 75mg, 100mg Tab

Wellbutrin SR (Bupropion) 100mg, 150mg, 200mg Tab

Wellbutrin XL (Bupropion XL) 150mg, 300mg Tab

Wellcovorin (Leucovorin) 5mg Tab

Westcort (Hydrocortisone valerate) 0.2% Cr / oint 45gm

Xalatan (Latanoprost) 0.005% Ophthalmic Sol 2.5ml Bt

**Xanax (Alprazolam) 0.25mg, 0.5mg & 1mg Tab

CIV/30 day supply/ 5 refiil max

Xopenex HFA Inh (Levalbuterol) 15 gm

Xopenex (Levalbuterol) 0.31mg/3ml inh sol 28/box

Xopenex (Levalbuterol) 1.25mg/3ml inh sol 28 box

Xopenex (Levalbuterol) 0.63mg/3ml inh sol 28 box

Xylocaine (Llidocaine) 2% Jelly 30gm Tube, 5% Oint 30gm

Xylocaine (Viscous lidocaine) 2% Liquid

Yasmin (Drospirenone/ethinyl estradiol) 3mg/30mcg Tab 28 ds

Yaz (Drospirenone/ethinyl estradiol) 3mg/20mcg Tab 28 ds

Zanaflex (Tizanidine) 2mg, 4mg tab

Zantac (Ranitidine) 150mg Tab, 15mg/ml Syrup

Zarontin (Ethosuximide) 250mg Cap, 250 mg/5ml Syrup

Zaroxolyn (Metolazone) 2.5mg & 5mg Tab

Zestril (Lisinopril) 2.5, 5, 10, 20, 30mg & 40mg Tab

Zestoretic (Hydrochlorothiazide/lisinopril) All strengths

Zetia (Ezetimibe) 10mg Tab

Zirgan (Ganciclovir) ( 0.15% opth gel

Zithromax (Azithromycin) 200mg/5ml & 1gm Susp,

250mg , 500mg Tab, Z-Pak

Zithromax (Azithromycin) 100mg/5ml Susp 15ml syrup

Zocor (Simvastatin) 5mg, 10mg, 20mg, 40mg, 80mg

*Zofran (Ondansetron) 4, 8mg Tab

*Zofran ODT 4mg, 8mg - 60 Tabs/30 ds/180 Tabs/ 90 ds

Zoladex (Goserelin) 3.6mg & 10.8mg Inj

Zoloft (Sertraline) 25mg, 50mg & 100mg Tab; 20mg/ml conc

Zomig (Zolmitriptan) 2.5, 5mg Tab – limit 12 boxes/90ds

Zomig ODT (Zolmitriptan odt) 2.5, 5mg Tab

limit 12 boxes/90ds

Zostrix (Capaicin) crm 2oz

Zovirax (Acyclovir) 200mg Cap and /400mg, 800mg Tab

Zovirax (Acyclovir) 5% oint, cream

Zovirax (Acyclovir) 200mg/5ml Suspension

Zyloprim (Allopurinol) 100mg & 300mg Tab

Zylet 0.3%-0.5% opht drops susp

Zyrtec (Cetirizine) 5 mg, 10mg Tab ,5mg tbch, 5mg/5ml syrup

Zyprexa (Olanzapine) 2.5, 5, 10, 15mg Tab

Formulary Listings - Jul 2011 Subject to Change Without...

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