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					       436th Medical Group
       Pharmacy Formulary
            Dover AFB




             DOVER AFB, DE




EDITION: August 2008
Dear Pharmacy Patron:

The 436th Medical Group, Dover Air Force Base Pharmacy dispenses medications for DoD eligible patients. In order to
improve service to our patients and their practitioners, we have prepared this guide of the medications routinely stocked and
some of our important pharmacy dispensing policies. Section I of the drug list is organized alphabetically by generic name
and Section II is organized by medication category. Please note that medications are often added to and deleted from this list
so please call the Pharmacy at 302-677-2019 to ensure we stock the medications you are looking for.

1. Prescription Policies:

    a. All prescriptions are filled with a generic equivalent if available. If a generic product is stocked or available, the
       pharmacy will not honor prescriptions that are marked or signed “Dispense as Written” or “Do not substitute”.

    b. Prescriptions must be written legibly in ink or typewritten. The prescriber’s signature must be signed in ink.
       Stamped signature prescriptions for ANY controlled substances will not be honored. Any changes made on the
       prescription should be corrected by crossing out the error and re-writing the information. In all cases, the prescriber
       must initial changes made to the prescription.

    c. Controlled substances MUST be written on separate prescriptions from other medications. The physician’s DEA
       number must be on all prescriptions for controlled substances. Schedule II and III prescriptions must be filled within
       seven days of the date written per Delaware law. Quantities of controlled substances in Schedule III-V may not
       exceed a 60 day supply. Quantities for Schedule II’s may not exceed a 30 day supply (DE Law). Methylphenidate,
       Dextroamphetamine AND similar drugs may be dispensed in a 90 day supply when ADD or ADHD is specified.
       The pharmacy will not fill prescriptions for controlled substances written by prescriber’s for themselves or their
       family members.

    d. Prescriptions from civilian practitioners for eligible beneficiaries will be honored provided the prescribed medication
       is routinely stocked. We strongly suggest that all medications be written on separate prescriptions to prevent an
       inconvenience if a medication is not stocked or cannot be filled at our pharmacy.

    e. The Pharmacy cannot accept new prescriptions or refill authorization via telephone or fax.

    f.   Quantities of maintenance medications are limited to the quantity written on the prescription, up to a maximum of a
         90-day supply. Please limit “PRN” medications to a quantity sufficient for an episode of care and add refills as
         necessary. Pharmacists will adjust refills on maintenance medications to conform to the dispensing limitations.
         Refills will be honored for no longer than one year from the original date of the prescription for non-controlled
         medications and six months for refillable controlled drugs.

    g. An 100% Military ID check is in place when picking up prescriptions.

2. Hours of Operation: Mon-Fri 0730-1700 excluding federal holidays. Exception: The 2nd Tuesday of every month the
   clinic hours are from 0730-1200.

3. Telephone Numbers: (302) 677-2019 or (302) 677-2531

4. 24-hour Refill Line: (302) 677-2533 or (800) 831-7944




                                                                                                                            2
                                                SECTION I: Alphabetical Formulary Listing
                Listings are alphabetical by generic name. For combination products, the most common brand name is used.
                                                 “*” Denotes a Controlled Drug Substance

Acetaminophen (APAP) 325, 500mg tab;              Bimatoprost (Lumigan) 0.03% soln                Clopidogrel 75mg tab (Plavix)
160mg/5ml elixir; 10mg/0.1ml drops; 120,          Bisacodyl 5mg tab; 10mg supp (Dulcolax)         Clotrimazole 1% top cr (Lotrimin); vag cr
650mg supp (Tylenol)                              Brimonidine 0.1%, 0.15% ophthalmic soln         (Gyne-Lotrimin)
APAP/butalbital/caffeine (Fioricet)               (Alphagan P)                                    Clotrimazole 10mg (Mycelex Troche)
*APAP 300mg/codeine 30mg tab (Tylenol#3)          Bromocriptine 2.5mg tab (Parlodel)              *Codeine 30mg tab
*APAP 300mg/codeine 60mg tab (Tylenol #4)         Budesonide 0.5mg, 0.25mg ampule                 *Codeine/guaifenesin (Robitussin AC)
*APAP 120mg/codeine 12mg/5ml elixir               (Pulmicort Respules)                            syrup 120ml
Acetazolamide 250mg tab (Diamox)                  Bupropion SR Tab 100 &150mg (Wellbutrin         Colchicine 0.6mg tab
Acetylcysteine sol 20% 30ml (Mucomyst)            SR)                                             Colestipol 1gm tab (Colestid)
Actoplusmet 15/500, 15/850mg (pioglitzaone/       Buspirone 5, 10, 15mg tab (Buspar)              Coreg Tab (see carvedilol)
metformin)                                        Calcium carbonate 500mg w/Vit D 200 IU tab      Cortisporin otic susp
Acyclovir 200, 400mg cap; 800mg tab, 5% oint      Calcium citrate with Vitamin D tab 315/200      Cosopt (dorzolamide/timolol) ophth soln
15gm, (Zovirax)                                   Calcitonin 200U/actuation nasal spray           Cromolyn 20mg/2ml neb soln, 60
*Adderall 5, 10, 20mg tab                         (Miacalcin)                                     amps/bx; nasal spray (Nasalcrom); oral inh
*Adderall XR 5, 10, 20, 25, & 30mg cap            Calcitriol 0.25mcg, 0.5mcg                      (Intal)
Aerochamber w/ or without mask                    Capsaicin Cream 0.025% (Zostrix)                Crotamiton cream (Eurax)
Albuterol 4mg tab; MDI; 2mg/5ml syrup; 0.5%       Captopril 25mg, 50mg tab (Capoten)              Co-trimoxazole (trimethoprim
inh soln 20ml; 2.5mg/3ml neb soln, 60             Carbamazepine 100mg chew tab, 200mg tab         160mg/sulfamethoxazole 800mg) DS tab;
amps/bx (Proventil)                               (Tegretol)                                      40mg/200mg susp (Bactrim)
Albuterol/ipratropium MDI (Combivent) 14.7gm      Carbamide peroxide otic soln (Debrox) 6.5%      Cyanocobolamin (Vitamin B-12) 1mg/ml inj
Alendronate 5, 10, 35, 70mg (Fosamax)             Carvedilol 3.125, 6.25, 12.5, 25mg tab          1ml vial
Alendronate+Vit D (Fosamax+D 2800 units)          (Coreg)                                         Cyclobenzaprine 5, 10mg tab (Flexeril)
Alesse                                            Carvedilol CR 10, 20, 40, 80mg caps (Coreg      Cyclophentolate ophth sol 1% (Cyclogel)
Alfuzosin 10mg tab (Uroxatral)                    CR)                                             Cyproheptadine 4mg tab (Periactin)
Allopurinol 100, 300mg tabs (Zyloprim)            Cefdinir Suspension (Omnicef) 125 &             Deconamine SR cap (CTM 8mg/Sudafed
Aluminum acetate/acid otic soln (Domeboro)        250mg/5ml (100ml)                               120mg)
Aluminum chloride 20% top soln (Drysol)           Cefpodoxime proxetil (Vantin) 100, 200mg        Demulen 1/35 28/pk
Amantidine 100mg cap (Symmetrel)                  tab                                             Desipramine 10, 50mg tab (Norpramin)
Amcinonide 0.1% cr (Cyclocort)                    Cefuroxime 250, 500mg tab, 125/5ml,             Desoximetasone 0.25% cr (Topicort)
Amiodarone HCL 200mg tab (Cordarone)              250/5ml susp 100ml (Ceftin)                     Dexamethasone 0.5, 0.75, 4mg tab &
Amitriptyline 10, 25, 50mg tabs (Elavil)          Celecoxib 100, 200mg cap (Celebrex)             0.5mg/5ml elixir (Decadron)
Amlodipine 2.5, 5, 10mg tab (Norvasc)             Celluvisc ophth sol 1% 30/bx                    Dexamethasone 0.1% ophth sol (Decadron)
Amlodipine/Benazepril 2.5/10mg; 5/10mg;           Cepacol throat lozenges #9/pk                   *Dextroamphetamine 5mg tab (Dexedrine)
5/20mg; 5/40mg; 10/40mg (Lotrel)                  Cephalexin 250, 500mg cap; 125mg/5ml;           *Diazepam 5mg tab (Valium)
Ammonium Lactate 12% lot (Lac Hydrin/Am           250mg/5ml susp (Keflex)                         Dicloxacillin 250mg cap
Lactin)                                           Cetirizine 10mg tab (Zyrtec); 5mg/5ml syrup     Dicyclomine 10mg tab, 20mg cap (Bentyl)
Amoxicillin 250mg chew tab; 250, 500mg cap;       Chantix Starter & Maintenance Packs             Digoxin 0.125, 0.25mg tabs; 0.05mg/ml
125mg/5ml; 250mg/5ml; 400mg/5ml susp              Chloraseptic Throat Spray                       elixir 60ml (Lanoxin)
(Amoxil)                                          *Chlordiazepoxide HCl 10mg, 25mg cap            Diltiazem 60mg tab, diltiazem long acting
Amoxicillin/clavulanate 250, 500, 875mg tab;      (Librium)                                       caps 120, 180, 240, 300, 360mg (Tiazac)
125mg/5ml; 250mg/5ml; 400mg/5ml;                  *Chloral Hydrate 500mg/5ml susp (Noctec)        Diphenhydramine 25mg cap, 12.5mg/5ml
600mg/5ml susp (Augmentin)                        Chlorhexidine gluconate (Peridex, Perioguard)   elixir (Benadryl)
Artificial Tears lubricant eye drops 15ml         480ml                                           *Diphenoxylate/atropine sulfate 2.5mg tab
Aspirin 81mg chewable, 325mg EC tab (Ecotrin)     Chloroquine 500mg tab (Aralen)                  (Lomotil)
*Aspirin 325mg/butalbital 50mg/caffeine 40mg      Chlorpheniramine 4mg tab; 2mg/5ml syrup         Dipyridamole 25, 75mg tab (Persantin)
(Fiorinal)                                        (CTM)                                           Disopyramide 100, 150mg cap (Norpace)
Atenolol 25, 50, 100mg tab (Tenormin)             Chlorthalidone 25, 50mg tab (Hygroton)          Disulfiram 250mg tab (Antabuse)
Atomoxetine (Strattera) 10, 18, 25, 40 & 60mg     Chlorzoxazone 500mg tab (Parafon Forte          Divalproex 250 & 500mg tab (Depakote)
cap                                               DSC)                                            Divalproex Tab 250 & 500mg ER (Depakote
Atorvastatin 40, 80mg tablet only (Lipitor)       Cholestyramine light #60 pkt/bx (Prevalite)     ER)
Atropine sulfate 1% ophth soln; 1% ophth oint     Choline magnesium trisalicylate 750mg tab       Docusate 100mg cap (Colace)
Auralgan otic soln                                (Trilisate)                                     Donepezil 5, 10mg tab (Aricept)
Azathioprine 50mg tab (Imuran)                    Ciclopirox 8% soln (Penlac)                     Donnatal (belladona/phenobarbital) tab;
Azelastine Nasal Spray (Astelin)                  Ciprodex Otic Sol                               elixir
Azithromycin 250mg tab (Z-pak); 200mg/5ml         Ciprofloxicin 250, 500, 750mg tab (Cipro)       Dorsolamide 2% ophth soln 10ml (Trusopt)
susp 30ml; 1-gram pkt, 500mg Tri-pak              Citalopram 20, 40mg tab (Celexa)                Doxazosin 2, 4, 8mg tab (Cardura)
(Zithromax)                                       Clarithromycin 250, 500mg tab (Biaxin)          Doxepin 10mg, 25mg cap (Sinequan)
Bacitracin 500 U/gm ophth oint                    Clarithromycin 500mg (Biaxin XL) tab            Doxycycline 100mg tab
Bacitracin Zinc top oint                          Clindamycin 150mg, 300mg cap; 1% top soln;      EMLA cr (lidocaine 2.5%/prilocaine 2.5%)
Baclofen 10mg tab (Lioresel)                      2% vag cr (Cleocin)                             Enoxaparin sodium inj (Lovenox)
Bellergal-S extended tab                          Clobetasal Propionate 0.05% oint (Temovate)     Epipen and Epipen Jr
Benzonatate 100mg cap (Tessalon Perles)           Clomiphene 50mg tab (Clomid)                    Ergocalciferol 50,000 Unit (Drisdol)
Benzatropine 1, 2mg tab (Cogentin)                *Clonazepam 0.5, 1mg tab (Klonopin)             Erythromycin ethylsuccinate 200mg/5ml
Benzoyl Peroxide 5% gel, 10% Wash (Desquam-X)     Clonidine 0.1, 0.2, 0.3mg tab (Catapres)        susp; base 250mg tab delayed released;
Betamethasone valerate 0.1% top lot; 0.1% cr      Clonidine TTS 1 (0.1mg/24hr), TTS 2             5mg/gm ophth oint 3.5gm; 2% top sol (T-
45gm (Valisone)                                   (0.2mg/24hr), TTS 3 (0.3mg/24hr); 4             Stat)
Betaxolol 0.025% susp (Betoptic S)                patches/bx                                      Esomeprazole 20, 40mg cap (Nexium)

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Estradiol (Estrace) 0.5mg, 1mg tab                  Insulin Regular with NPH (Novolin 70/30)        Metoprolol/HCTZ (Lopressor HCT)
Estinyl 0.2mg tab                                   10ml                                            50/25mg; 100/25mg; 100/50mg
Estradiol transdermal patches (Climara)             Insulin Glargine (Lantus) 10ml, 3ml cartridge   Metolazone 2.5, 5mg tab (Zaroxolyn)
0.05mg/day: 0.1mg/day                               Ipecac syrup 30ml btl                           Metronidazole 250, 500mg tab (Flagyl)
Estrogen 0.3, 0.45, 0.625, 0.9, 1.25mg tab          Ipratropium (Atrovent) MDI; 0.02% neb soln      Metronidazole 1% top gel (Metrogel); 0.75%
(Premarin); Premarin Vag Cr; Prempro                60 amps/bx                                      vag cr (Metrogel Vag)
0.45mg/1.5mg, 0.625mg/2.5mg,                        Isoniazid 300mg tab (INH)                       Miconazole top cr 2%, vag cr 2% (Monistat)
0.625mg/5mg, Premphase 0.625mg/5mg                  Isopto Homatropine 5% ophth soln 15ml           *Midrin
Ethambutol 100, 400mg tabs (Myambutal)              Isosorbide dinitrate 5mg (SL); 10mg IR; 40mg    (isometheptene/dichloralphenazone/
Exenatide 5, 10mcg inj (Byetta)                     SR (Isordil)                                    acetaminophen) cap
Ezetimibe Tab 10mg (Zetia)                          Isosorbide mononitrate (Imdur) 20mg, 30mg,      Minocycline 50, 100mg cap (Minocin)
Felodipine 2.5, 5, 10mg tab (Plendil)               & 60mg                                          Minoxidil 10mg tab (Loniten)
Fenofibrate 50, 160mg tab (Triglide)                Isoxsuprine 10mg tab (Vasodilan)                Mirtazapine 15, 30, 45mg tabs and sol tab
Ferrous Sulfate 325mg tab; 125mg/ml pediatric       Ketoconazole 2% cream (Nizoral)                 (Remeron)
soln                                                Ketoconazole 2% shampoo (Nizoral)               Misoprostol 200mcg tab (Cytotec)
Finasteride 5mg tab (Proscar)                       Ketoconazole 200mg tab (Nizoral)                Mometasone nasal spray (Nasonex)
Fluconazole 100, 150, & 200mg tab (Diflucan)        Ketorolac ophth sol 0.5% 5ml (Acular)           *Morphine sulfate (IR) 30mg, MS Contin 15,
Fluconazole Oral Susp 40mg/ml                       Labetalol 100, 200mg tab                        30, & 60mg tab
Fluocinolone 0.1% soln, (Synalar);                  Lactulose syrup 473ml (Cephulac)                Moisturizing Cr 4oz jar (Eucerin)
Fluocinonide 0.05% oint 30gm, cream 15gm            Lancets 100 per bx                              Montelukast 4, 5mg chewable, 10mg tab
(Lidex)                                             Levlen-28                                       (Singulair)
Fluoride drops and 1mg tab                          Levofloxacin 250, 500, 750mg tab (Levaquin)     Moxifloxacin oph sol 5ml (Vigamox)
Fluorometholone 0.1% ophth soln (FML/Flarex)        Levobunolol 0.5% ophth sol 10ml (Betagan)       Moxifloxacin 400mg tab (Avelox)
Flunisolide nasal spray (Nasalide)                  Levonorgesterol 0.75mg (Plan B)                 Multivitamins, Pediatric (Vi-Daylin ADC),
Fluoxetine 10, 20mg cap (Prozac)                    Levothyroxine 25, 50, 75, 88, 100, 112, 125,    Poly-Vitamin drops with Fe
Folic Acid 1mg tab                                  137, 150, 175, 200mcg tab (Synthroid)           Mupirocin oint 2% 15gm (Bactroban)
Fluticosone Oral inh 44, 110, 220 mcg (Flovent)     Lidocaine 2% top gel, (Viscous) 2% oral soln    Naproxen 375, 500mg tab (Naprosyn)
Fluticasone nasal (Flonase)                         Liothyronine 25mcg tab (Cytomel)                Nexium 20, 40mg cap
Fluticasone/Salmeterol (Advair Diskus) 100/50;      Lipitor 40, 80mg tab only                       Niacin ER (Niaspan) 500, 750, 1000mg tab
250/50; 500/50                                      Lisinopril 5, 10, 20, 30, 40mg tab (Zestril)    Nicotine patch 7, 14, 21mg 14/box
Fosamax, Fosamax + D                                Lisinopril/HCTZ tab (Zestoretic)                Nicotine gum 2, 4mg, 96/box
Furosemide 20, 40mg tab (Lasix)                     Lithium Carbonate 300mg cap                     Nifedipine Cap 10mg (Procardia)
Gabapentin 100, 300, 400, caps, 600, 800mg          Lodoxamide 0.1% ophth soln (Alomide)            Nifedipine ER Tab 30, 60, 90mg (Adalat CC)
tabs (Neurontin)                                    Lo-Estrin FE 1/20; 1.5/30, 28/pk                Nitrofurantoin 25mg/5ml susp (Furadantin)
Gatifloxacin 0.3% opth soln (Zymar)                 Lo-Ovral 28/pk                                  Nitrofurantoin 50mg cap (Macrodantin)
Gaviscon 80mg tab                                   Loperamide HCl 2mg cap (Imodium)                Nitrofurantoin (Macrobid) 100mg cap
Gemfibrozil 600mg tab (Lopid)                       Loratadine 10mg tab (Claritin)                  Nitroglycerin 0.3, 0.4, 0.6mg SL tabs;
Gentamicin 0.3% ophth soln, 3.5gm oint              *Lorazepam 0.5, 1mg tab (Ativan)                2.5mg cap; Nitrolingual oral spray 0.4mg
(Garamycin)                                         Losartan 25, 50, 100mg tab (Cozaar)             Nitroglycerin patches 0.1mg/hr, 0.2mg/hr,
Glipizide 5, 10mg tab, (Glucotrol & Glucotrol XL)   Losartan/HCTZ 50/12.5, 100/25mg tab             0.4mg/hr patches bx/30’s (Nitro-Dur)
Glynase prestab 1.5, 3, 6mg tab                     (Hyzaar)                                        Nor-QD tab 28/pk
Glucagon Emergency Kit                              Loteprednol (Lotemax) ophth 0.5% soln           Norethindrone 5mg tab (Aygestin)
Glyburide 2.5, 5mg tab (Micronase)                  Loxapine succinate 25mg cap (Loxitane)          Norgesic Forte (orphenadrine 100mg/ASA
Golytely, 4000ml soln                               Magnesium Citrate Oral soln 10oz                77mg/caffeine 60mg) tab
Griseofulvin 125mg ultramicrosize tab (Gris-Peg)    Magnesium Oxide 400mg tab (MagOx)               Nortriptyline 25, 75mg cap (Pamelor)
125mg/5ml susp 120ml (Fulvicin)                     Malathion (Ovide) Lotion                        NuvaRing
Guaifenesin (Robitussin, Robitussin DM) 120ml       Maxzide (triamterene 75mg/hctz 50mg) tab        Nystatin 100,000 unit/ml oral susp; top
*Guaifenesin w/Codeine (Robitussin AC)              Mebendazole 100mg tab (Vermox)                  cream 15gm
Gyne-lotrimin vag cr (Mycelex)                      Meclizine 25mg tab (Antivert)                   Olopatadine 0.1% (Patanol)
Haloperidol 1, 5, 10mg tab (Haldol)                 Medroxyprogesterone (Provera) 2.5, 10mg         Omeprazole 10, 20mg cap (Prilosec)
Hemorrhoidal supp w/ hydrocortisone (Anusol         tab; (Depo-Provera) 150mg/1ml                   Omnicef Suspension 125 & 250mg/5ml
HC)                                                 Megestrol 20, 40mg tab, 40mg/ml susp            OptiPranolol 0.3% ophth sol (Metipranolol)
Hydralazine 10, 25, 100mg tab (Apresoline)          (Megace)                                        Ortho-Cept 28/pk
Hydrochlorothiazide 25, 50mg tab (Hydrodiuril)      Meloxicam 7.5, 15mg tab (Mobic)                 Ortho-Cyclen 28/pk
Hydrochlorothiazide 12.5mg cap (Microzide)          *Meperidine 50mg tab (Demerol)                  Ortho Evra patch
Hydrocortisone 20mg tab, 1% cr 30gm, 1% oint        Mesalamine Tab 400mg (Asacol)                   Ortho Novum 1/35, 7/7/7 28/pk
30gm                                                Metformin 500, 850, 1000mg tab                  Ortho Tri-Cyclen 28/pk
Hydrocortisone Valerate (Westcort) 0.2% cr          (Glucophage)                                    Ortho Tri-Cyclen Lo
15gm                                                Metformin ER 500mg tab (Glucophage XR)          Ofloxacin 0.3% ophth soln (Ocuflox)
*Hydromorphone 2mg tab (Dilaudid)                   Metformin/Glyburide (Glucovance)                Ofloxacin otic soln (Floxin)
Hydroxychloroquine sulfate 200mg tab                1.25/250mg; 2.5/500mg; 5/500mg                  Oxaprozin 600mg tab (Daypro)
(Plaquenil)                                         Methocarbamol 500, 750mg tab (Robaxin)          Oxybutynin Tab 5mg (Ditropan)
Hydroxyzine 10, 25mg tab, 10mg/5ml syrup            Methazolamide 50mg tab (Neptazane)              Oxymetazoline (Afrin) nasal spray
(Atarax)                                            Methotrexate 2.5mg tab                          Pancrelipase DR Cap 4,500 lipase/20,000
Hyzaar 50/12.5mg, 100/25mg tab                      Methylodopa 250, 500mg tab (Aldomet)            amylase/25,000 protease (Pancrease)
Ibuprofen 400, 600, 800mg tab; 100mg/5ml            Methylergonovine 200mcg tab (Methergine)        Paroxetine 10, 20, 30, 40mg tab (Paxil)
syrup (Motrin)                                      *Methylphenidate 5, 10mg tab (Ritalin)          Pediazole Susp
Imipramine 10, 25mg tab (Tofranil)                  *Methylphenidate ER 18, 27, 36, 54mg tab        (erythromycin200mg/sulfixsoxazole
Imiquimod Cr 5% 12’s (Aladara)                      (Concerta)                                      600mg)/5ml susp, 200ml
Indomethacin 25mg cap (Indocin)                     Methylprednisolone 4mg (Medrol Dose-pak)        Penicillamine 250mg cap (Cuprimine)
Insulin Aspart vial and Flexpen (Novolog)           Metoclopramide 10mg tab; 5mg/5ml syrup          Penicillin VK 250, 500mg tab; 250mg/5ml
Insulin NPH (Novolin N) 100u/ml 10ml                (Reglan)                                        susp 200ml
Insulin Regular (Novolin R) 100u/ml 10ml            Metoprolol 50, 100mg tab (Lopressor)            Pentoxifylline 400mg tab (Trental)
Insulin Lente (Novolin L) 10ml vial                 Metoprolol XL 25, 50, 100, 200mg (Toprol XL)

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*Percocet 5 (oxycodone 5mg/APAP 325mg) tab      Raloxifene 60mg tab (Evista)                      Tetracycline 250mg cap; (Achromycin)
Permethrin (Elimite) 5% top cr 60gm             Rantidine 150, 300mg tab, 15mg/ml syrup           Theophylline (TheoDur) 200mg, 300mg
Perphenazine 2mg tab (Trilafon)                 (Zantac)                                          tab; (SloBid) 200mg cap, oral liquid
Phenazopyridine 100mg tab (Pyridium)            Refresh ophth sol, Refresh Plus ophth sol,        Thiamine (B1) 50mg tab
*Phenobarbital 30mg tab                         Refresh PM ophth oint                             Thyroid dessicated 30, 60, 120mg tab
Phenylephrine Opht Soln 2.5% 15ml               Rifampin 300mg cap (Rifadin)                      Timolol 0.5% ophth soln; XE 0.25% & 0.5%
Phenytoin 50mg chewable tab, 100mg Cap;         Risperidone 0.25, 0.5, 1, 2, 3, & 4mg             gel (Timoptic)
125mg/5ml oral susp (Dilantin)                  (Risperdal)                                       Tiotropium (Spiriva)
Phytonadione 5mg tab (Mephyton)                 Rondec (carbinoxamine/pseudo) syrup &             Tobramycin 0.3%ophth soln; ophth oint
Pilocarpine Oph Sol                             pediatric drops                                   3.5gm (Tobrex)
Pimecrolimus (Elidel) 1%, 30 & 100gm            Rosiglitazone 2, 4, & 8mg (Avandia)               Tobramycin/dexamethasone (TobraDex)
Pioglitazone 15, 30, 45mg tab (Actos)           Salicylic acid 17% top soln wart remover          ophth susp 5ml, oph oint 3.5gm
Piroxicam 20mg cap (Feldene)                    Salmeterol (Serevent Diskus)                      Tolterodine (Detrol LA) 2, 4mg cap
Polyethylene Glycol Pwd 225gm (Miralax)         Salsalate (Disalcid) 500, 750mg tabs              Topiramate (Topamax) 25, 50, 100, 200mg
Polysporin ophth oint 3.5gm                     Selenium sulfate lot (Selsun) 2.5%                tab
Polytrim ophth soln 5ml                         Senna tab (Senokot)                               Tramadol 50mg tab (Ultram)
Potassium Chloride 8mEq (Slow-K)                Sertraline 25, 50, 100mg tab (Zoloft)             Trazodone 50, 100, 150mg tab (Desyrel)
Potassium Chloride 20 mEq (K-Dur) tab           Sharps container (for insulin syrs and needles)   Tretinoin (Retin A) 0.025%, 0.05% cr;
Potassium Chloride 20mEq/15ml 10% oral soln     Silvadene (silver sulfadiazine) 1% top cr         0.025% gel
Potassium Chloride 20mEq powder (Klorvess)      Simethicone 80mg tab; (Mylicon)                   Triamcinolone 0.1% cr 15gm, 80gm, 0.1%
Pramosone 1% rectal cr                          Simvastatin 5, 10, 20, 40, 80mg tab (Zocor)       oint; (Kenalog in Orabase) 0.1% dental
Pravastatin 10, 20, 40, 80mg tab (Pravachol)    Sinemet (levodopa/carbidopa) 25/100,              paste 5gm; top spray (Kenalog) 63gm/can
Prazosin 1, 2, 5mg cap (Minipress)              25/250 tab                                        Triamcinolone (Azmacort) oral inh
Precision Xtra test strip 100/bx                Sitagliptin 50, 100mg tab (Januvia)               Triglide 50, 160mg tab
Prednisolone 0.12% ophth susp (Pred Mild); 1%   Sodium Chloride 0.9% amps for neb 100/bx;         Trihexyphenidyl 2mg tab (Artane)
(Pred Forte); (0.25% prednisolone acetate/10%   nasal spray/drops 15ml                            Tri-Levlen/Triphasil 28/pk
sulfacetamide) (Pred-G) prednisolone acetate    Sodium Chloride (Muro-128) ophth sol 5% &         Trimethobenzamide 200mg supp (Tigan)
1%/gentamicin 0.3%)                             oint                                              Triple Paste
Prednisolone 15mg/5ml (Orapred) oral liq        Sodium Fluoride 0.5mg/ml oral drops 50ml          Tropicamide 0.5%, 1% ophth soln
Prednisone 1, 5, 10, 20, 50mg tab, 5mg/5ml      (Luride)                                          (Mydriacyl)
oral liq                                        Sodium Fluoride 1.1% gel (Prevident)              Valacyclovir 500mg 1gm tab (Valtrex)
Prenatal Vitamins (only for female age 45 or    Sodium phosphate enema (Fleets) 135ml;            Valproic Acid 250, 500mg tab (Depakote);
less)                                           Sodium phosphate Soda oral soln 60ml              250mg/5ml oral syrup (Depakene)
Primaquin 26.3mg (15mg base) tab                Spiriva HandiHaler 18mcg                          Varenicline Starting Mo. Pack 0.5mg/1mg
Primidone 50, 250mg tab (Mysoline)              Spironolactone 25, 100mg tab (Aldactone)          Varenicline Continuing Mo. Pack 1mg
Probenecid 500mg tab (Benemid)                  Spironolactone 25mg/hctz 25mg                     Venlafaxine 37.5, 75, 150mg ER caps
Procainamide 250mg tab, 500mg ER tab            (Aldactazide)                                     (Effexor XR)
(Procan)                                        Stannous fluoride 0.4% gel (Gel-Kam)              Verapamil 80mg; SR 240mg (Calan SR)
Prochlorperazine 5, 10mg tab (Compazine)        Sucralfate 1gm tab (Carafate)                     *Vicodin (hydrocodone
Proctofoam HC rectal foam                       Sulfasalazine 500mg tab (Azulfidine)              5mg/acetaminophen 500mg)
Promethazine 25mg tab, 6.25mg/5ml soln;         Sulfisoxazole 500mg/5ml susp (Gantrisin)          Vigamox Oph sol 5ml
25mg rectal supp (Phenergan)                    Sulindac 200mg tab (Clinoril)                     Viroptic 1% ophth sol 7.5ml
Proparacaine 0.5% ophth sol (Alcaine)           Sumatriptan 6mg inj 2/bx; (Imitrex); 25mg,        Vosol HC otic soln
Propranolol 10mg, 40mg tabs; 80mg LA, 120mg     50mg, 100mg tabs 9/pk                             Vytorin 10/10, 10/20, 10/40, 10/80
LA cap (Inderal)                                Symbicort MDI 80/4.5, 160/4.5                     Warfarin 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10mg tab
*Propoxyphene /APAP (Darvocet-N 100)            Syr Insulin 1ml 100’s; 0.5ml (LoDose) 100/bx      (Coumadin)
Propylthiouracil (PTU) 50mg tab                 Tamoxifen 10mg tab (Nolvadex)                     Yasmin
Pseudophedrine 30mg, 60mg tab; 6mg/ml           Telmisartan 40, 80mg tab (Micardis)               Yaz
syrup (Sudafed)                                 Telmisartan/HCTZ (Micardis HCT)                   Zolmitriptan 2.5, 5mg tab (Zomig)
Pyrazinamide 500mg tab                          *Temazepam 15, 30mg cap (Restoril)                *Zolpidem 5, 10mg tab (Ambien)
Pyridoxine 50mg (B6) tab                        Terazosin cap 1, 2, 5, 10mg cap (Hytrin)
Quetiapine 25, 100, 200, 300mg (Seroquel)       Terbinafine 250mg tab, 1% cr (Lamisil)            *Denotes a Controlled Drug Substance
Quinidine gluconate 324mg tab (Quinaglute)      Terconazol (Terazol 7) 0.4% vag cr; (Terazol
Quinidine sulfate tab 200mg                     3) 80mg vag supp




                                                                                                                                             5
                                  SECTION II: Formulary Listing by Medication Category
                    All items are listed alphabetically by generic name with most common trade name in (parenthesis).
                                                  (*) Denotes a Controlled Drug Substance

ANALGESICS                                      Anti-Virals                                     Sulfonamides
Anti-Rheumatics                                 Acyclovir 200, 400mg cap, 800mg tab             Sulfamethoxazole/trimethoprim
Azathioprine 50mg tab (Imuran)                  (Zovirax)                                       800/160mg DS tabs, 400mg/40mg susp
Hydroxychloroquine 200mg tab (Plaquenil)        Amantidine 100mg cap (Symmetrel)                (Bactrim/Septra)
Methotrexate 2.5mg tab                          Valacyclovir 500mg, 1gm tablet (Valtrex)        Sulfisoxazole 500mg/5ml susp (Gantrisin)
Sulfasalazine 500mg tab (Azulfidine)                                                            Erythromycin Ethyl Succinate/Sulfisoxazole
                                                Anti-Malarials                                  Susp 200mg/600mg/5ml (Pediazole)
Muscle Relaxants                                Chloroquine phosphate 500mg tab (Aralan)
Baclofen 10mg tab (Lioresal)                    Primaquine phosphate 26.3mg tab (15mg           Tetracyclines
Chlorzoxazone 500mg tab (Parafon Forte DSC)     primaquine base)                                Doxycycline 100mg cap (Vibramycin)
Cyclobenzaprine 5, 10mg tab (Flexeril)          Mefloquin 250mg tab (Lariam)                    Minocycline 50mg, 100mg cap (Minocin)
Methocarbamol 500, 750mg tab (Robaxin)                                                          Tetracycline 250mg cap (Achromycin)
Orphenadrine 50mg/aspirin 770mg/ caffeine       Anti-Fungals
60mg tab (Norgesic Forte)                       Clotrimazole (Mycelex Troche)                   Miscellaneous
                                                Fluconazole 100, 150, & 200mg tab (Diflucan)    Clindamycin 150 & 300mg cap (Cleocin)
Narcotic Analgesics                             Fluconazole Suspension 40mg/ml                  Malathion 0.5% Lotion (Ovide)
*APAP 300mg/codeine 30mg tab (Tylenol#3)        Griseofulvin 125mg ultramicrosized tab (Gris-   Nitrofurantoin 25mg/5ml susp (Furadantin)
*APAP 300mg/codeine 60mg tab (Tylenol #4)       Peg), 125mg/5mg susp (Fulvicin)                 Nitrofurantoin 50, 100mg cap
*APAP 120mg/codeine 12mg/5ml elixir             Ketoconazole Tab 200mg (Nizoral)                (Macrodantin)
APAP 325/butalbital 50/caffeine 40mg tab        Nystatin 100,000 U/ml oral susp (Mycostatin)    Nitrofurantoin SR Cap 100mg (Macrobid)
(Fioricet)                                      Terbinafine 250mg tab (Lamisil)
*Aspirin 325/butalbital 50/caffeine 40mg tab                                                    CARDIOVASCULAR
(Fiorinal)                                      Anti-Parasitics                                 ACE Inhibitors
*Codeine phosphate 30mg tabs                    Mebendazole 100mg tab (Vermox)                  Captopril 25, 50mg tab (Capoten)
*Hydromorphone 2mg tab (Dilaudid)               Metronidazole 250, 500mg tab (Flagyl)           Lisinopril 5, 10, 20, 40mg tab (Zestril)
*Meperidine 50mg tab (Demerol)
*Morphine sulfate 30mg tab (MSIR), 15, 30,      Cephalosporins                                  Angiotensin II Antagonist (ARB)
60mg CR tab (MS Contin)                         Cephalexin 250, 500mg cap, 125/5ml,             Losartan 25, 50, 100mg tab (Cozaar)
*Oxycodone 5mg/APAP 325mg tab (Percocet 5)      250/5ml susp 100ml (Keflex)                     Losartan/HCTZ 50/12.5, 100/25mg tab
*Propoxephene napsylate/APAP tab (Darvocet N-   Cefpodoxime 100, 200mg tab,                     (Hyzaar)
100)                                            Cefdinir Susp 125mg/5ml, 250mg/5ml susp         Telmisartan 40, 80mg tab (Micardis)
*Hydrocodone bitartrate tab 5mg/APAP 500mg      100ml (Omnicef)                                 Telmisartan/HCTZ (Micardis HCT)
(Vicodin)                                       Cefuroxime 250, 500mg tab, 125/5ml,
                                                250/5ml susp 100ml (Ceftin)                     Anti-Adrenergics
NSAID’s                                                                                         Clonidine 0.1, 0.2, 0.3mg tab (Catapres)
Celecoxib 100, 200mg cap (Celebrex)             Fluoroquinolones                                Clonidine Transdermal Patch 0.1mg (TTS
Choline magnesium trisalicylate 750mg tab       Ciprofloxicin 250, 500, 750mg tab (Cipro)       1), 0.2mg (TTS 2), 0.3mg (TTS 3) 4/bx
(Trilisate)                                     Levofloxacin 250, 500, 750mg tab (Levaquin)     Doxazosin 2, 4, 8mg tab (Cardura)
Ibuprofen 400mg, 600mg, 800mg tab,              Moxifloxacin 400mg tab (Avelox)                 Methyldopa 250, 500mg tab (Aldomet)
100mg/5ml syrup (Motrin)                                                                        Prazosin 1, 2, 5mg cap (Minipress)
Indomethacin 25mg cap (Indocin)                 Macrolides                                      Terazosin 1, 2, 5, 10mg cap (Hytrin)
Meloxicam 7.5, 15mg tab (Mobic)                 Azithromycin 250mg tabs (Z-Pak),
Naproxen 375, 500mg tab (Naprosyn)              200mg/5ml susp 30ml, 1 gram pkt, 500mg          Anti-Arrhythmics
Oxaprozin 600mg tab (Daypro)                    Tri-pak (Zithromax)                             Amiodarone 200mg (Cordarone)
Piroxicam 20mg cap (Feldene)                    Clarithromycin 250, 500mg tab (Biaxin)          Digoxin 0.125, 0.25mg tab, 0.05mg/ml
Salsalate 500mg, 750mg tab (Disalcid)           Clarithromycin 500mg (Biaxin XL) 7-Day Pack     elixir 60ml (Lanoxin)
Sulindac 200mg tab (Clinoril)                   Erythromycin base 250mg tab (Ery-Tab),          Disopyramide 100, 150mg cap (Norpace)
                                                Erythromycin ethyl succ. 200mg/5ml susp         Procainamide 250mg tab (Procan), 500mg
Other                                           (EES)                                           ER tab (Procan SR)
APAP 325, 500mg tab, 160/5ml elixir,            Erythromycin Ethyl Succinate/Sulfisoxazole      Quinidine gluconate 324mg tab
10mg/0.1ml drops, 120/325/650 mg supp           Susp 200mg/600mg/5ml (Pediazole)                (Quinaglute)
(Tylenol)                                                                                       Quinidine sulfate 200mg tab (Quinidex)
Mesalamine Tab 400mg (Asacol)                   Penicillins
Tramadol 50mg tab (Ultram)                      Amoxicillin 250mg chew tab, 250, 500mg          Anti-Hyperlipidemics
                                                caps; 125/5ml, 250/5ml; 400/5ml susp            Colestipol 1gm tab (Colestid)
ANTIMICROBIALS                                  (Amoxil)                                        Ezetimibe Tab 10mg (Zetia)
Anti-Mycobacterials                             Amoxicillin/clavulanic acid 250, 500, 875mg     Fenofibrate 50, 160mg (Triglide)
Ethambutol 100, 400mg tab (Myambutol)           tab; 125/5ml, 250/5ml, 400mg/5ml;               Gemfibrozil 600mg tab (Lopid)
Isoniazid 300mg tab (INH)                       600mg/5ml susp (Augmentin)                      Niacin ER (Niaspan) 500, 750, 1000mg tab
Pyrazinamide 500mg tab                          Penicillin V 250, 500mg tab (Pen-V K)           Cholestyramine 4gm/pkt 60 pkts/bx
Rifampin 300mg cap (Rifadin)                    Dicloxacillin 250mg cap, 62.5mg/5ml susp        (Prevalite)
                                                (Dynapen)


                                                                                                                                           6
HMG-COA Reductase Inhibitors
Atorvastatin 40, 80mg only (Lipitor)                DERMATOLOGY                                      Corticosteroids
Pravastatin 10, 20, 40, 80mg tab (Pravachol)        Acne                                             Dexamethasone 0.5, 0.75, 4mg tab &
Simvastatin 5, 10, 20, 40, 80mg tab (Zocor)         Benzoyl Peroxide 5, 10% Wash (Desquam-X)         0.5mg/5ml elixir (Decadron)
Vytorin 10/10, 10/20, 10/40, 10/80                  Clindamycin 1% top soln (Cleocin)                Hydrocortisone 20mg tab (Cortef)
                                                    Erythromycin 2.0% top soln (T-Stat)              Methylprednisolone 4mg (Medrol Dose-pak)
Anti-Platelet                                       Tretinoin 0.025%, 0.05% cr, 0.025% gel (Retin-   Prednisolone 15mg/5ml oral soln (Prelone)
Aspirin 81mg tab, 325mg EC tab                      A)                                               Prednisone 1, 5, 10, 20, 50mg tab,
Clopidogrel 75mg tab (Plavix)                                                                        5mg/5ml oral soln
Dipyridamole 25, 75mg tab (Persantine)              Anti-Bacterials
                                                    Bacitracin zinc oint 30gm                        Diabetes Related
Beta Blockers                                       Metronidazole 1% top gel (Metrogel)              Actoplusmet 15/500, 15/850 (pioglitzone/
Atenolol 25, 50, 100 mg tab (Tenormin)              Mupirocin 2% oint (Bactroban)                    metformin)
Carvedilol 3.125, 6.25, 12.5, 25mg tab (Coreg)                                                       Exenatide 5, 10mcg inj (Byetta)
Carvedilol CR 10, 20, 40, 80mg caps (Coreg CR)      Anti-Fungals                                     Glipizide 5, 10mg tab (Glucotrol)
Labetalol 100, 200mg tab                            Ciclopirox 8% soln (Penlac)                      Glipizide CR 5, 10mg tab (Glucotrol XL)
Metoprolol 50, 100mg tab (Lopressor)                Clotrimazole 1% cr (Lotrimin)                    Micronized glyburide 1.5, 3, 6mg tab
Metoprolol XL 25, 50, 100mg tab (Toprol XL)         Ketoconazole 2% cream (Nizoral)                  (Glynase PresTab)
Propranolol 10, 40mg tab (Inderal); 80mg,           Ketoconazole 2% shampoo (Nizoral)                Glucagon emergency kit
120mg (Inderal LA)                                  Miconazole 2% top cr (Monistat-Derm)             Glyburide 5mg tab (Micronase/DiaBeta)
                                                    Nystatin top cr (Mycostatin)                     Metformin ER 500mg tab (Glucophage XR)
Calcium Channel Blockers                            Terbinafine 1% top cr (Lamisil)                  Metformin 500, 850, 1000mg tab
Amlodipine 2.5, 5, 10mg tab (Norvasc)                                                                (Glucophage)
Diltiazem 60mg tab (Cardizem)                       Anti-Parasitics                                  Metformin/Glyburide (Glucovance)
Diltiazem 120, 180, 240, 300, 360mg caps CR         Crotamiton cr (Eurax)                            1.25/250mg; 2.5/500mg; 5/500mg
(Tiazac)                                            Malathion (Ovide) Shampoo                        Pioglitazone 15, 30, 45mg tab (Actos)
Felodipine 2.5, 5, 10mg tab (Plendil)               Permethrin 5% top cr (Elimite)                   Rosiglitazone 2, 4, 8mg tab (Avandia)
Nifedipine CR Tabs 30mg, 60mg, 90mg (Adalat                                                          Sitagliptin 50, 100mg tab (Januvia)
CC)                                                 Anti-Virals
Verapamil 80, 120mg tab (Calan), 180, 240mg         Acyclovir 5% oint (Zovirax)                      Lancets (generic) #100/bx
SR tab (Calan SR)                                                                                    Sharps container
                                                    Corticosteroid/Anti-microbial combination        Insulin syrs; ½ cc (Lo-Dose), 1cc #100/bx
Combination Products                                Nystatin/triamcinolone cr (Mycolog II)           Precision Xtra test strips 100/bx
Amlodipine/benazepril 2.5/10mg; 5/10mg,
5/20mg 5/40mg; 10/20mg; 10/40mg cap                 Corticosteroids                                  Insulin (Human)
(Lotrel)                                            Amcinonide 0.1% cr (Cyclocort)                   NPH, Regular, 70/30, Lente (Novolin Brand
Lisinopril/HCTZ (Zestoretic)                        Betamethasone valerate 0.1% lot, 1% cr           ONLY)
Losartan/HCTZ 50/12.5, 100/25mg (Hyzaar)            (Valisone)                                       Insulin Aspart (Novolog) 10ml vials &
Metoprolol/HCTZ (Lopressor HCT) 50/25mg;            Clobetasol propanate 0.05% oint (Temovate)       FlexPen
100/25mg; 100/50mg                                  Desoximetasone 0.25% cr (Topicort)               Insulin Glargine (Lantus) 10ml vial &
Triamterene 75mg/HCTZ 50mg tab (Maxzide)            Fluocinolone 0.1% soln (Synalar)                 cartridge (3ml) (w/OptiClik)
Spironolactone 25mg/HCTZ 25mg tab                   Fluocinonide 0.05% oint, cream (Lidex)
(Aldactazide)                                       Hydrocortisone 1% cr, oint (Cortizone)           Gout-Related
Telmisartan/HCTZ 40/12.5, 80/12.5, 80/25            Hydrocortisone valerate 0.2% cr (Westcort)       Allopurinol 100, 300mg tab (Zyloprim)
(Micardis HCT)                                      Triamcinolone 0.1% cr, oint, 0.1% dental         Colchicine 0.6mg tab
                                                    paste, top spray (Kenalog)                       Probenecid 500mg tab (Benemid)
Diuretics
Chlorthalidone 25, 50mg tab                         Hemorrhoid Care                                  Minerals
Furosemide 20, 40mg tab (Lasix)                     Hydrocortisone 25mg supp (Anusol HC)             Calcium carbonate 500mg tab w/Vit D
HCTZ 12.5mg cap, 25, 50mg tab (HydroDiuril)         Hydrocortisone 1%/pramoxine 1% rectal foam       Calcium citrate 315mg with Vitamin D
Metolazone 2.5, 5mg tab (Zaroxolyn)                 (ProctoFoam HC)                                  Ferrous sulfate 325mg tab, 75mg/0.6ml
Spironolactone 25, 100mg tab (Aldactone)            Pramoxine 1% rectal cr (ProctoCr)                pediatric soln
Spironolactone 25mg/hctz 25mg tab                                                                    Sodium Fluoride oral drops 0.5mg/ml, 1mg
(Aldactazide)                                       Miscellaneous                                    tab
Triamterine 75mg/hctz 50mg tab (Maxzide)            Ammonium lactate 12% lot (Lac Hydrin/Am          Magnesium oxide 400mg tab (Mag-Ox)
                                                    Lactin)                                          Potassium chloride 8mEq tab (Slow K)
Nitrates                                            Capsaicin 0.025% cr (Zostrix)                    Potassium chloride 20 mEq tab (K-Dur)
Isosorbide dinitrate 5mg SL tab, 10mg tab,          Imiquimod Cr 5% 12’s (Aldara)                    Potassium chloride 20mEq/15ml oral soln
40mg SR tab (Isordil)                               Lidocaine 2.5%/prilocaine 2.5% cr (EMLA)         (10%)
Isosorbide mononitrate (Imdur) 20mg, 30mg, &        Lidocaine 2% gel, 2% viscous soln (Xylocaine)    Potassium chloride 20 mEq powder pkt
60mg                                                Moisturizing Cr 1 lb jar (Eucerin)               (Klorvess)
Nitrogylcerin 0.3, 0.4, 0.6mg SL tabs (NitroStat)   Pimecrolimus (Elidel) 1% 30gm, 100gm
Nitroglycerin 0.4mg oral spray (NitroLingual)       Salicylic acid 17% top soln (Wart Remover)       Thyroid Agents
Nitroglycerin 2.5mg cap                             Selenium sulfate lot 2.5% (Selsun)               Levothyroxine 25, 50, 75, 88, 100, 112,
Nitroglycerin 0.1, 0.2, 0.4, 0.6 mg/hr              Silver sulfadiazine 1% top cr (Silvadene)        125, 137, 150, 175, 200mcg tab
transdermal patches (Nitro-Dur)                     Triple Paste                                     (Synthroid)
                                                                                                     Liothyronine 25mcg tab (Cytomel)
Miscellaneous                                       ENDOCRINE AND METABOLIC                          Propylthiouricil 50mg tab (PTU)
Aspirin low dose 81mg chew tab (Baby Aspirin)       Bisphosphonates                                  Thyroid, dessicated 30, 60, 120mg tab
Aspirin 325mg Enteric Coated tab (Ecotrin)          Alendronate 5, 10, 35, 70mg tab (Fosamax)        (Armour Thyroid)
Hydralazine 25mg tab (Apresoline)                   Alendronate 70mg + Vit D (Fosamax + D
Nicotine patch 7, 14, 21mg 14/box                   2800 IU)                                         Vitamins
Nicotine gum 2, 4mg 96/box                          Raloxifene 60mg tab (Evista)                     Cyanocobalamin 1mg/ml inj (Vit B12) 1ml
Varenicline Starter and Maintenance Pack                                                             SDV

                                                                                                                                                 7
Fluoride pediatric drops                           Anti-Emetics-Other                              Migraine
Folic acid 1mg tab                                 Metoclopramide 10mg tab, 5mg/5ml syrup          Acetaminophen/butalbital/caffeine tab
Multivitamins, Pediatric Poly-Vitamin drops        (Reglan)                                        (Fioricet)
Phytonadione 5mg tab (Mephyton/Vitamin K)          Prochlorperazine 5mg tab (Compazine)            Isometheptene/dichloralphenazone/acetam
Prenatal Vitamins (limited to females up to and    Promethazine 25mg tab, 6.25mg/5ml, 25mg         inophen cap (Midrin)
including age 45)                                  supp (Phenergan)                                Sumatriptan 6mg inj 2/bx, 25, 50, 100mg
Pyridoxine 50mg tab (Vitamin B-6)                  Trimethobenzamide 200mg supp (Tigan)            tabs 9/pk (Imitrex)
Thiamine 50mg tab (Vitamin B-1)                    Meclizine 25mg tab (Antivert)                   Zolmitriptan 2.5, 5mg tab plain and ZMT

Miscellaneous                                      Antacids                                        Parkinsonian Agents
Calcitonin nasal spray (Miacalcin)                 Aluminum hydroxide tab (Gaviscon)               Benztropine 1, 2mg tab (Cogentin)
Calcitriol 0.25, 0.5mcg                            Aluminum/Magnesium hydroxide liq                Bromocriptine 2.5mg tab (Parlodel)
Epipen and Epipen Jr                               (Mylanta)                                       Levodopa/carbidopa 10/100, 25/100,
Ergocalciferol 50,000 unit (Drisdol)               Sucralfate 1gm tab (Carafate)                   25mg/250mg tab (Sinemet)
                                                                                                   Trihexyphenidyl 2mg tab (Artane)
EAR, NOSE, & THROAT                                H2 Antagonists
Anti-Histamines                                    Ranitidine 150, 300mg tab, 75mg/5ml syrup       OBSTETRICS AND GYNECOLOGY
Azelastine Nasal Spray (Astelin)                   (Zantac)                                        Estrogens
Cetirizine 10mg tab, 5mg/5ml syrup (Zyrtec)                                                        Estradiol 0.5, 1mg tab (Estrace)
Chlorpheniramine 4mg tab, 2mg/5ml syrup            Proton Pump Inhibitor                           Estradiol transdermal patches 0.05, 0.1mg
(CTM)                                              Esomeprazole 20, 40mg cap (Nexium)              (Climara)
Cyproheptadine 4mg tab (Periactin)                 Omeprazole 10, 20mg cap (Prilosec)              Ethinyl estradiol 0.2mg tab (Estinyl)
Diphenhydramine 25mg cap, 12.5mg/5ml elixir                                                        Conjugated estrogens 0.3, 0.45, 0.625,
(Benadryl)                                         Laxatives                                       0.9, 1.25mg tab (Premarin)
Hydroxyzine 10, 25mg tab, 10mg/5ml syrup           Bisacodyl 5mg tab, 10mg supp (Dulcolax)
(Atarax)                                           Docusate 100mg cap (Colace)                     Hormone Replacement Combinations
Loratadine 10mg (Claritin)                         Lactulose syrup (Cephulac)                      Conjugated
                                                   Magnesium citrate oral soln                     estrogens/medroxyprogesterone
Antitussives/Expectorants/Decongestant             Polyethylene Glycol Pwd 255gm (Miralax)         0.45mg/1.5mg, 0.625mg/2.5mg,
Benzonatate caps 100mg (Tessalon Perles)           Polyethylene glycol with electrolytes 4L        0.625mg/5mg (PremPro)
Guaifenesin syrup (Robitussin),                    (GoLytely)                                      Conjugated
guaifenesin/dextromethrophan syrup                 Psyllium powder (Konsyl-D)                      estrogens/medroxyprogesterone
(Robitussin DM)                                    Senna tab (Senokot)                             0.625mg/5mg (Premphase)
*Guaifenesin with codeine elixir (Robitussin AC)   Sodium phosphate enema (Fleets)                 Esterified estrogens/methyltestosterone
Chlorpheniramine 8mg/pseudoephedrine               Sodium phosphate/sodium biphosphate oral        1.25mg/2.5mg (Estratest), 0.625/1.25
120mg SR cap (Deconamine SR)                       soln (Fleets Phospho-soda)                      (Estratest HS)
Pseudoephedrine 30mg, 60mg tab, 6mg/ml
syrup (Sudafed)                                    Anti-Ulcer & Miscellaneous                      Oral Contraceptives
Rondec (carbinoxamine/pseudoephedrine) syrup       Dicyclomine 10mg tab, 20mg cap (Bentyl)         Alesse
& drops                                            Phenobarbital/atropine/hyoscyamine/scopola      Demulen 1/35 (35mcg ethinyl estradiol,
                                                   mine tab, elixir (Donnatal)                     1mg ethynodiol)
Ear Preparations                                   Misoprostol 200mcg tab (Cytotec)                Levlen-28
Acetic acid otic soln (Domeboro)                   Pancrelipase 4500U lipase/20000U                Levonorgestrel 0.75mg (Plan B)
Antipyrine/benzocaine otic soln (Auralgan)         amylase/25000U protease caps (Pancrease)        Loestrin FE 1/20 (ethinyl estradiol,
Carbamide peroxide 6.5% otic soln (Debrox)         Simethicone 80mg tab (Mylicon)                  norethindrone, iron)
CiproDex Otic Sol                                                                                  Loestrin FE 1.5/30 (ethinyl estradiol,
Hydrocortisone/polymyxin/neomycin otic susp        HEMATOLOGY                                      norethindrone, iron)
(Cortisporin)                                      Anti-coagulant                                  Lo-Ovral (30mcg ethinyl estradiol, 0.3mg
Acetic acid/propylene glycol/hydrocortisone 1%     Enoxaparin inj (Lovenox)                        norgestrel)
otic soln (VoSol HC)                               Warfarin 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10mg tab   Norethindrone Tablets 0.35mg (Nor-QD)
Ofloxacin otic (Floxin)                            (Coumadin)                                      Ortho-Cept/Desogen (ethinyl estradiol,
                                                                                                   desogestrel)
Nasal Preparations                                 Other                                           Ortho-Cyclen (ethinyl estradiol,
Cromolyn sodium nasal spray (Nasalcrom)            Pentoxifylline 400mg tabs (Trental)             norgestimate)
Flunisolide nasal spray (Nasalide)                                                                 Ortho-Tri-Cyclen (ethinyl estradiol,
Fluticasone nasal spray (Flonase)                  NEUROLOGY                                       norgestimate)
Mometasone nasal inh (Nasonex)                     Anti-Convulsants                                Ortho Tri-Cyclen Lo
Oxymetazoine nasal spray (Afrin)                   Carbamazepine 100mg chew tab, 200mg tab         Ortho-Novum 1/35 (Necon) (ethinyl
Saline nasal spray 0.65% (Ocean)                   (Tegretol)                                      estradiol, norethindrone)
                                                   Gabapentin 100, 300, 400mg caps, 600,           Ortho-Novum 7/7/7 (ethinyl estradiol,
Throat/Mouth                                       800mg tabs (Neurontin)                          norethindrone)
Cepacol maximum strength lozenges 9/pk             *Phenobarbital 30mg tab                         Triphasil/Tri Levlen (ethinyl estradiol,
Chloraseptic throat spray                          Phenytoin 50mg chewable tabs, 100mg cap,        levonorgestrel)
Chlorhexidine gluconate (Peridex/Periogard)        125mg/5ml susp (Dilantin)                       Yasmin (drospirenone, ethinyl estradiol)
Sodium Fluoride 1.1% gel (PreviDent)               Primidone 50, 250mg tab (Mysoline)              Yaz
Stannous fluoride 0.4% gel (Gel-Kam)               Topiramate (Topamax) 25, 50, 100, & 200mg
                                                   tab                                             Other Contraceptives
GASTROENTEROLOGY                                   Valproic acid 250, 500mg tab (Depakote),        Ortho Evra patch
Anti-Diarrheals                                    250, 500mg ER tab (Depakote ER)                 Medroxyprogesterone 150mg/ml inj (Depo-
*Diphenoxylate 2.5mg/atropine sulfate tab          Valproic acid 250mg/5ml oral soln               Provera, IM Formulation only)
(Lomotil)                                          (Depakene)                                      NuvaRing
Loperamide 2mg cap (Imodium)




                                                                                                                                              8
Progestins                                       Phenylephrine 2.5% ophth soln (AK-             Anxiolytics/Hypnotics
Medroxyprogesterone acetate 2.5mg, 10mg tab      Dilate/Neo-Synephrine)                         Buspirone 5, 10, 15mg tab (Buspar)
(Provera)                                        Tropicamide 0.5%, 1% ophth soln (Mydriacyl)    *Chlordiazepoxide 10mg, 25mg cap
Megestrol acetate 20mg tab (Megace)                                                             (Librium)
Norethindrone 5mg tab (Aygestin)                 Nonsteroidal Anti-inflammatory                 *Clonazepam 0.5, 1mg tab (Klonopin)
                                                 Ketorolac 0.5% ophth soln (Acular)             *Diazepam 5mg tab (Valium)
Vaginal Preparations                                                                            *Lorazepam 0.5, 1mg (Ativan)
Clindamycin 2% vag cr (Cleocin Vag)              Ocular Decongestants & Anti-Allergy            *Chloral hydrate 500mg/5ml susp (Noctec)
Clotrimazole vag cr with applicator (Gyne-       Lodoxamide 0.1% ophth soln (Alomide)           *Temazepam 15, 30mg cap (Restoril)
Lotrimin)                                        Naphazoline 0.1% ophth soln (Vasocon A)        *Zolpidem 5, 10mg tab (Ambien)
Conjugated estrogen vag cr (Premarin Vag)        Olopatadine 0.1% ophth soln (Patanol)
Metronidazole 0.75% vag cr (Metrogel-Vag)                                                       Alcohol Dependence
Miconazole 2% vag cr (Monistat)                  Other                                          Disulfiram 250mg tab (Antabuse)
Terconazole 0.4% vag cr with applicators         Artificial tears ophth drops 15ml btl
(Terazol 7), 80 mg vag supp. (Terazol 3)         Celluvisc 1% ophth drops                       PULMONARY
                                                 Epinephrine 1%, 2% ophth soln                  Beta Agonists
Other                                            Hydroxypropyl methylcellulose 2.5% ophth       Albuterol 4mg tab, MDI, 2mg/5ml syrup,
Clomiphene citrate 50mg tab (Clomid)             soln (Goniosol)                                0.5% inh 20ml soln, 2.5mg/3ml premix neb
Methylergonovine 200mcg tab (Methergine)         Proparacaine 0.5% ophth soln (Alcaine)         vials #30/bx (Proventil/Ventolin)
Prenatal Vitamins (Female <45yo only)            Lubricating ophth drops preservative free      Albuterol/ipratropium MDI (Combivent)
Tamoxifen 10mg tab (Nolvadex)                    (Refresh, Refresh Plus), ophth oint (Refresh   14.7gm
                                                 PM)                                            Salmeterol (Serevent Diskus)
OPHTHALMOLOGY
Anti-Bacterials                                  PSYCHIATRY                                     Inhaled Steroids
Bacitracin 500 U/gm ophth oint                   ADHD                                           Budesonide 0.25mg/2ml, 0.5mg/2ml
Erythromycin ophth oint (Ilotycin)               Atomoxetine (Strattera) 10, 18, 25, 40 &       (Pulmicort Respules)
Gatifloxacin 0.3% opth soln (Zymar)              60mg cap                                       Budesonide/Formoterol MDI 80/4.5,
Gentamicin 0.3% ophth soln, oint (Garamycin)     *Dextroamphetamine & racemic amphetamine       160/4.5 (Symbicort)
Ofloxacin 0.3% ophth soln (Ocuflox)               5, 10, 20 mg tab (Adderall)                   Fluticasone MDI 44, 110, 220mcg (Flovent)
Moxifloxacin (Vigamox) Oph sol                   *Dextroamphetamine & racemic amphetamine       Fluticasone/Salmeterol (Advair Diskus)
Polymyxin B/bacitracin ophth oint (Polysporin)    5, 10, 20, 25, & 30mg cap (Adderall XR)       Triamcinolone MDI (Azmacort)
Polymixin B/trimethoprim ophth soln (Polytrim)   *Dextroamphetamine 5mg tab (Dexedrine)
Tobramycin 0.3% ophth soln, oint (Tobrex)        *Methylphenidate 5, 10 tab (Ritalin)           Leukotriene inhibitors
                                                 *Methylphenidate ER 18, 27, 36, 54mg           Montelukast 4, 5mg chewable, 10mg tab
Anti-Bacterial & Corticosteroid Combinations     (Concerta)                                     (Singulair)
Prednisolone acetate 1%/gentamicin 0.3% (Pred
G)                                               Alzheimer’s Dementia                           Methylxanthines
Sulfacetamide/prednisone ophth soln              Donepezil 5, 10mg tab (Aricept)                Theophylline 200, 300mg tab (Theo-Dur),
(Vasocidin)                                                                                     200mg cap (Slo-Bid), oral liquid
Tobramycin/dexamethasone ophth soln              Anti-Depressants
(Tobradex)                                       Amitriptyline 10, 25, 50 mg tab (Elavil)       Others
                                                 Bupropion SR tab 100, 150, 200mg               Acetylcysteine soln 20% 30cc vial
Anti-Viral                                       (Wellbutrin SR)                                (Mucomyst)
Trifluridine 1% ophth soln (Viroptic)            Citalopram 20, 40mg tab (Celexa)               Cromolyn 20mg/2ml soln, MDI (Intal)
                                                 Desipramine 10, 50mg tab (Norpramin)           Ipratropium MDI, 0.02% neb soln (Atrovent)
Corticosteroids                                  Doxepin 10, 25mg cap (Sinequan)                Sodium chloride 0.9% amps for neb
Dexamethasone 0.1% ophth soln (Decadron)         Fluoxetine 10, 20mg caps (Prozac)              Spacer one size (Aerochamber)
Fluorometholone 0.1% ophth soln (FML/Flarex)     Imipramine 10, 25mg tab (Tofranil)             Spacer with mask sm, med, lg
Loteprednol (Lotemax) ophth 0.5% soln            Mirtazapine 15, 30, 45mg tab and soltab        (Aerochamber)
Prednisolone acetate 0.12% ophth susp (Pred      (Remeron)                                      Tiotropium 18mcg (Spiriva)
Mild), 1% ophth soln (Pred Forte)                Nortriptyline 25, 75mg cap (Pamelor)
                                                 Paroxetine 10, 20, 30, 40mg tabs (Paxil)       TOXICOLOGY
Glaucoma Agents                                  Sertraline 25, 50, 100mg tab (Zoloft)          Acetylcysteine 20% soln (Mucomyst)
Betaxolol 0.25% susp (Betoptic S)                Trazadone 50, 100, 150mg tab (Desyrel)         Ipecac syrup 30ml/btl
Bimatoprost (Lumigan) ophth 0.03% soln           Venlafaxine 37.5, 75, 150mg XR caps (Effexor   Penicillamine 250mg cap (Cuprimine)
Brimonidine 0.1, 0.15% ophth soln (Alphagan P)   XR)
Cosopt (dorzolamide/timolol) ophth soln                                                         UROLOGY
Dorsolamide 2% ophth soln (Trusopt)              Anti-Manic                                     Benign Prostatic Hyperplasia
Lantanoprost 0.005% ophth soln (Xalatan)         Lithium carbonate 300mg cap                    Alfuzosin 10mg tab (Uroxatral)
Levobunolol 0.5% ophth soln (Betagan)                                                           Doxazosin 2, 4, 8mg tab (Cardura)
Metipranolol 0.3% ophth soln (OptiPranolol)      Anti-Psychotics                                Finasteride 5mg tab (Proscar)
Pilocarpine 1, 2% oph sol                        Haloperidol 1, 5, 10mg tab (Haldol)            Terazosin 1, 2, 5, 10mg cap (Hytrin)
Timolol 0.5% ophth soln (Timoptic), 0.25% &      Loxapine 25mg cap (Loxitane)
0.5% gel (Timoptic XE)                           Olanzapine 2.5, 5, 10mg tab (Zyprexa)          Neurogenic Bladder
                                                 Perphenazine 2mg tab (Trilafon)                Oxybutynin 5mg tab (Ditropan)
Mydriatics & Cycloplegics                        Quetiapine (Seroquel) 25, 50, 100, 200, &      Tolterodine (Detrol LA) 2, 4mg cap
Atropine sulfate 1% ophth soln, oint             300mg
Cyclophentolate 1% ophth soln (Cyclogel)         Risperidone (Risperdal) 0.25mg, 0.5mg, 1mg,    Other
Homatropine 5% ophth soln (Isopto                2mg, 3mg, & 4mg                                Phenazopyridine 100mg tab (Pyridium)
Homatropine)




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