KENNER ARMY HEALTH CLINIC FORMULARY 10 May 2012
KENNER ARMY HEALTH CLINIC FORMULARY 10 May 2012
KENNER ARMY HEALTH CLINIC FORMULARY 10 May 2012
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<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong><br />
(*Supersedes 21 December 2011 Formulary)<br />
This Formulary is a list of medications available at the Kenner Army Health Clinic<br />
(KAHC) Pharmacy.<br />
PRODUCT TRADE NAMES ARE LISTED FOR CONVENIENCE ONLY.<br />
ALL MEDICATIONS ARE DISPENSED IN GENERIC FORM WHEN AVAILABLE.<br />
Providers are strongly encouraged to authorize Voluntary Formulary Substitution on<br />
their prescriptions. If you have questions, please call the Pharmacy at 734 – 9137.<br />
This formulary is subject to change without notice.<br />
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *<br />
You can get a copy of this formulary from the clinic’s web site.<br />
http://kenner.narmc.amedd.army.mil/Pages/Pharmacy.aspx<br />
Click on Kenner’s Formulary<br />
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *<br />
“DO NOT USE” DOSE DESIGNATIONS AND ABBREVIATIONS<br />
KAHC approved the following list of “Do Not Use” dose designations and abbreviations<br />
based on the National Patient Safety Goal 2b from the Joint Commission on<br />
Accreditation of Healthcare Organizations. To improve patient safety and avoid<br />
future errors and potential patient harm, please avoid using these dangerous<br />
abbreviations and dose designations when writing prescriptions for your patients.<br />
(1) Trailing Zeros (1.0mg) –- use 1mg<br />
(2) Naked Decimals or Lack of Leading Zero (.5mg) –- use 0.5mg<br />
(3) U or u -- use Unit<br />
(4) I.U. or IU -- use International Unit<br />
(5) Q.D. or Q/D –- use every day or daily<br />
(6) Q.O.D. –- use every other day<br />
(7) MgSO4 –- use magnesium sulfate<br />
(8) MS or MSO4 –- use morphine sulfate
2<br />
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Actos 15mg Tablet<br />
Actos 30mg Tablet<br />
Actos 45mg Tablet<br />
Acular 0.5% Ophth Soln, 5ml<br />
Adalat CC 30mg Tablet<br />
Adalat CC 60mg Tablet<br />
Adalat CC 90mg Tablet<br />
Adderall 5mg Tablet (C-II)<br />
Adderall <strong>10</strong>mg Tablet (C-II)<br />
Adderall 20mg Tablet (C-II)<br />
Adderall XR <strong>10</strong>mg Capsule (C-II)<br />
Adderall XR 15mg Capsule (C-II)<br />
Adderall XR 20mg Capsule (C-II)<br />
Adderall XR 25mg Capsule (C-II)<br />
Adderall XR 30mg Capsule (C-II)<br />
Advair Diskus <strong>10</strong>0/50 Inhaler<br />
Advair Diskus 250/50 Inhaler<br />
Advair Diskus 500/50 Inhaler<br />
Advair HFA 45/21 Inhaler, 12g<br />
(120 doses)<br />
Advair HFA 115/21 Inhaler, 12g<br />
(120 doses)<br />
Advair HFA 230/21 Inhaler, 12g<br />
(120 doses)<br />
Albuterol 0.083% Inhalation<br />
Soln, 2.5mg/3ml Vial (60s)<br />
Albuterol Inhalation Solution,<br />
0.5%, 20ml<br />
Albuterol HFA Oral Inhaler,<br />
18g (200 doses)<br />
Albuterol 2mg/5ml Syrup<br />
Albuterol 4mg Extended Release<br />
Tablet<br />
Alesse/Levlite, 28 Tablets<br />
Allopurinol <strong>10</strong>0mg Tablet<br />
Allopurinol 300mg Tablet<br />
Alphagan-P 0.15% Ophth Soln,<br />
<strong>10</strong>ml<br />
Alrex 0.2% Ophth Susp, 5ml<br />
Aluminum Acetate Astringent<br />
Powder Packets<br />
Amantadine <strong>10</strong>0mg Capsule<br />
Amaryl 1mg Tablet<br />
Amaryl 2mg Tablet<br />
Amaryl 4mg Tablet<br />
Ambien 5mg Tablet (C-IV)<br />
Ambien <strong>10</strong>mg Tablet (C-IV)<br />
Amiodarone 200mg Tablet<br />
Amitriptyline <strong>10</strong>mg Tablet<br />
Amitriptyline 25mg Tablet<br />
Amlodipine 2.5mg Tablet<br />
Amlodipine 5mg Tablet<br />
Amlodipine <strong>10</strong>mg Tablet<br />
Amoxicillin 250mg Capsule<br />
Amoxicillin 500mg Capsule<br />
Amoxicillin 250mg/5ml Susp,<br />
80ml & 150ml<br />
Amoxicillin 400mg/5ml Susp,<br />
<strong>10</strong>0ml<br />
Antipyrine 5.4% & Benzocaine<br />
1.4% Otic Soln, <strong>10</strong>ml<br />
Aricept 5mg Tablet<br />
Aricept <strong>10</strong>mg Tablet<br />
Artificial Tears, 15ml<br />
Asacol 400mg Delayed-Release<br />
Tablet<br />
Asmanex 1<strong>10</strong>mcg Twisthaler<br />
(30 doses)<br />
Asmanex 220mcg Twisthaler<br />
(30, 60 & 120 doses)<br />
Aspirin 81mg Tablet<br />
(Enteric Coated)<br />
Astelin Nasal Inhaler, 30ml<br />
(200 doses)<br />
Atacand 8mg Tablet<br />
Atacand 16mg Tablet<br />
Atacand 32mg Tablet<br />
Atacand HCT 16mg-12.5mg Tablet<br />
Atacand HCT 32mg-12.5mg Tablet<br />
Atarax <strong>10</strong>mg/5ml Syrup, 4oz<br />
Atarax <strong>10</strong>mg Tablet<br />
Atarax 25mg Tablet<br />
Ativan 0.5mg Tablet (C-IV)<br />
Ativan 1mg Tablet (C-IV)<br />
Atropine 1% Ophth Soln, 5ml<br />
Atrovent 0.02% Inhalation<br />
Soln, 0.5mg/2.5ml Vial (60s)<br />
Atrovent Oral Inhaler, 14g<br />
(200 doses)<br />
Augmentin 200mg/5ml Susp,<br />
<strong>10</strong>0ml<br />
Augmentin 250mg/5ml Susp,<br />
150ml<br />
Augmentin 400mg/5ml Susp,<br />
<strong>10</strong>0ml<br />
Augmentin ES-600 Susp, <strong>10</strong>0ml
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Augmentin 250mg Tablet<br />
Augmentin 500mg Tablet<br />
Augmentin 875mg Tablet<br />
Bacitracin Ointment, 30g<br />
Bacitracin Ophth Oint, 3.5g<br />
Baclofen <strong>10</strong>mg Tablet<br />
Bactrim DS Tablet<br />
Bactrim Suspension<br />
Bactroban 2% Ointment<br />
Benadryl 12.5mg/5ml Elixir 4oz<br />
Benadryl 25mg Capsule<br />
Bentyl <strong>10</strong>mg Capsule<br />
Bentyl 20mg Tablet<br />
Betoptic S 0.25% Ophth Susp,<br />
<strong>10</strong>ml<br />
Boniva 150mg Tablet<br />
(For Osteoporosis ONLY)<br />
(Once MONTHLY dose ONLY)<br />
Bromocriptine 2.5mg Tablet<br />
Buspar <strong>10</strong>mg Tablet<br />
Calan SR 180mg Tablet<br />
Calan SR 240mg Tablet<br />
Calcium 500mg & Vitamin D<br />
200 units/tablet, 60s<br />
Capoten 25mg Tablet<br />
Carafate 1gm Tablet<br />
Carbamazepine <strong>10</strong>0mg Chewable<br />
Tablet<br />
Carbamazepine <strong>10</strong>0mg/5ml Susp<br />
Carbamazepine 200mg Tablet<br />
Carbamazepine XR 400mg Tablet<br />
Cardizem 60mg Tablet<br />
Cardura 2mg Tablet<br />
Cardura 4mg Tablet<br />
Cardura 8mg Tablet<br />
Cefdinir 125mg/5ml Susp, <strong>10</strong>0ml<br />
Cefdinir 300mg Capsules<br />
Cefzil 250mg Tablet<br />
Cefzil 500mg Tablet<br />
Celexa <strong>10</strong>mg Tablet<br />
Celexa 20mg Tablet<br />
Celexa 40mg Tablet<br />
Cepacol Lozenges<br />
Chloroquine 500mg Tablet<br />
Chlorthalidone 25mg Tablet<br />
Chlorthalidone 50mg Tablet<br />
Cipro 250mg Tablet<br />
Cipro 500mg Tablet<br />
Cipro 750mg Tablet<br />
Claritin 5mg/5ml Syrup, 120ml<br />
Claritin <strong>10</strong>mg Tablet<br />
Cleocin 150mg Capsule<br />
Cleocin 300mg Capsule<br />
Cleocin 2% Vaginal Cream, 40g<br />
Cleocin-T 1% Topical Soln,<br />
60ml<br />
Climara, Specify Dose,<br />
4 Patches/Package<br />
(ordered when RX presented)<br />
Clonidine 0.1mg Tablet<br />
Clotrimazole 1% Topical Soln,<br />
30ml<br />
Clotrimazole 1% Vaginal Cream,<br />
45g (7-Day Treatment)<br />
Codeine 30mg Tablet (C-II)<br />
Cogentin 2mg Tablet<br />
Colcrys (Colchicine) 0.6mg<br />
Tablet<br />
Colestid Powder, 300g<br />
Combipatch (0.05mg estradiol/<br />
0.14mg norethindrone)<br />
Combivent Oral Inhaler, 14.7g<br />
(200 doses)<br />
Compazine <strong>10</strong>mg Tablet<br />
Compazine 25mg Suppository<br />
Concerta 18mg Extended Release<br />
Tablet (C-II)<br />
(Once daily dosing ONLY)<br />
Concerta 27mg Extended Release<br />
Tablet (C-II)<br />
(Once daily dosing ONLY)<br />
Concerta 36mg Extended Release<br />
Tablet (C-II)<br />
(Once daily dosing ONLY)<br />
Concerta 54mg Extended Release<br />
Tablet (C-II)<br />
(Once daily dosing ONLY)<br />
Condylox 5% Topical Soln,<br />
3.5ml<br />
Coreg 3.125mg Tablet<br />
Coreg 6.25mg Tablet<br />
Coreg 12.5mg Tablet<br />
Coreg 25mg Tablet<br />
Cortifoam Rectal Foam, 15g<br />
Cortisporin Otic Susp, <strong>10</strong>ml<br />
Cosopt Ophth Soln, <strong>10</strong>ml<br />
3
4<br />
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Coumadin 1mg Tablet<br />
Coumadin 2mg Tablet<br />
Coumadin 2.5mg Tablet<br />
Coumadin 3mg Tablet<br />
Coumadin 5mg Tablet<br />
Cozaar 25mg Tablet<br />
Cozaar 50mg Tablet<br />
Cozaar <strong>10</strong>0mg Tablet<br />
CTM 4mg Tablet<br />
Cyclogyl 1% Ophth Soln, 5ml<br />
Debrox Ear Drops, 15ml<br />
Decadron 4mg Tablet<br />
Demerol 50mg Tablet (C-II)<br />
Demulen 1/35, 28 Tablets<br />
Depakene 250mg Capsule<br />
Depakene 250mg/5ml Syrup<br />
Depakote ER 250mg Tablet<br />
Depakote ER 500mg Tablet<br />
Depakote 250mg Enteric Coated<br />
Tablet<br />
Depakote Sprinkles 125mg<br />
Capsule<br />
Desogen, 28 Tablets<br />
Desquam-X 5% Gel, 42.5g<br />
Desquam-X 5% Wash, 5oz<br />
Desyrel 50mg Tablet<br />
Detrol LA 2mg Capsule<br />
Detrol LA 4mg Capsule<br />
Dicloxacillin 250mg Capsule<br />
Diflucan <strong>10</strong>0mg Tablet<br />
Diflucan 150mg Tablet<br />
(1-Tablet Dose for Vaginal<br />
Candidiasis ONLY)<br />
Dilantin <strong>10</strong>0mg Capsule<br />
Dilantin 125mg/5ml Suspension<br />
Dilantin Infatabs 50mg<br />
Chewable Tablet<br />
Diovan 40mg Tablet<br />
Diovan 80mg Tablet<br />
Diovan 160mg Tablet<br />
Diovan 320mg Tablet<br />
Diovan HCT 80/12.5mg Tablet<br />
Diovan HCT 160/12.5mg Tablet<br />
Diovan HCT 160/25mg Tablet<br />
Diovan HCT 320/12.5mg Tablet<br />
Diovan HCT 320/25mg Tablet<br />
Ditropan 5mg Tablet<br />
Ditropan XL 5mg Tablet<br />
Ditropan XL <strong>10</strong>mg Tablet<br />
Ditropan XL 15mg Tablet<br />
Domeboro Otic Soln, 60ml<br />
Donnatal Elixir<br />
Donnatal Tablet<br />
Dovonex 0.005% Cream, 60g<br />
Doxepin <strong>10</strong>mg Capsule<br />
Doxepin 25mg Capsule<br />
Doxycycline <strong>10</strong>0mg Tablet<br />
Drysol Topical Soln, 37.5ml<br />
Dulcolax 5mg Tablet<br />
Dulera <strong>10</strong>0/5 Oral Inhaler, 13g<br />
(120 doses)<br />
Dulera 200/5 Oral Inhaler, 13g<br />
(120 doses)<br />
Effexor 50mg Tablet<br />
Effexor XR 37.5mg Capsule<br />
Effexor XR 75mg Capsule<br />
Effexor XR 150mg Capsule<br />
Efudex 5% Cream, 40g<br />
Elidil 1% Cream, 30g<br />
Elimite 5% Cream, 60g<br />
EpiPen 2-Pak<br />
EpiPen Jr 2-Pak<br />
Erythromycin Ophth Oint, 3.5g<br />
E-Mycin 25Omg Tablet<br />
E-Mycin 333mg Tablet<br />
Estrace 1mg Tablet<br />
Estratest H.S. Tablet<br />
Estratest Tablet<br />
Ethambutol 400mg Tablet<br />
Evista 60mg Tablet<br />
Feldene 20mg Capsule<br />
Femhrt 1mg/5mcg, 28 Tablets<br />
Feosol 220mg/5ml Elixir<br />
Ferrous Sulfate Drops, 50ml<br />
(15mg iron/ml)<br />
Ferrous Sulfate 325mg Tablet<br />
Fexofenadine 60mg Tablet<br />
Fexofenadine 180mg Tablet<br />
Fioricet Tablet<br />
Flagyl 250mg Tablet<br />
Flagyl 500mg Tablet<br />
Fleet Enema, 133ml<br />
Flexeril 5mg Tablet<br />
Flexeril <strong>10</strong>mg Tablet<br />
Florinef 0.1mg Tablet
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Flovent HFA 44mcg Oral Inhaler,<br />
12g (120 doses)<br />
Flovent HFA 1<strong>10</strong>mcg Oral<br />
Inhaler, 12g (120 doses)<br />
Flovent HFA 220mcg Oral<br />
Inhaler, 12g (120 doses)<br />
Floxin 0.3% Otic Soln, 5ml<br />
Fluorometholone 0.1% Ophth<br />
Susp (FML), 5ml<br />
Fluvoxamine 50mg Tablet<br />
Fluvoxamine <strong>10</strong>0mg Tablet<br />
Folic Acid 1mg Tablet<br />
Fosamax 35mg Tablet<br />
(For Osteoporosis ONLY)<br />
(Once WEEKLY dose ONLY)<br />
Fosamax 70mg Tablet<br />
(For Osteoporosis ONLY)<br />
(Once WEEKLY dose ONLY)<br />
Fosamax PlusD (70mg/2800 Vit D)<br />
(For Osteoporosis ONLY)<br />
(Once WEEKLY dose ONLY)<br />
Fosamax PlusD (70mg/5600 Vit D)<br />
(For Osteoporosis ONLY)<br />
(Once WEEKLY dose ONLY)<br />
Gentamicin 0.3% Ophth Soln, 5ml<br />
Gentamicin 0.3% Ophth Oint,<br />
3.5g<br />
GenTeal Night-time PM Ophth<br />
Oint, 3.5g<br />
Glucophage 500mg Tablet<br />
Glucophage 850mg Tablet<br />
Glucophage <strong>10</strong>00mg Tablet<br />
Glucophage ER 500mg Tablet<br />
Glucophage ER 750mg Tablet<br />
Glucotrol 5mg Tablet<br />
Glucotrol <strong>10</strong>mg Tablet<br />
Glyburide 2.5mg Tablet<br />
Glyburide 5mg Tablet<br />
Glycerin Suppositories, Child<br />
Glynase 3mg Tablet<br />
GoLYTELY, 4 Liters (1 gallon)<br />
Gris-Peg 250mg Tablet<br />
Griseofulvin 125mg/5ml Susp,<br />
4oz<br />
HCTZ 25mg Tablet<br />
Hemorrhoidal HC Supp, 12s<br />
Homatropine 5% Ophth Soln, 5ml<br />
Hydralazine 25mg Tablet<br />
Hydrocortisone 1% Cream, 1oz<br />
Hydrocortisone 20mg Tablet<br />
Hytrin 1mg Capsule<br />
Hytrin 2mg Capsule<br />
Hytrin 5mg Capsule<br />
Hytrin <strong>10</strong>mg Capsule<br />
Hyzaar 50/12.5mg Tablet<br />
Hyzaar <strong>10</strong>0/12.5mg Tablet<br />
Hyzaar <strong>10</strong>0/25mg Tablet<br />
Ibuprofen 400mg Tablet<br />
Ibuprofen 600mg Tablet<br />
Ibuprofen 800mg Tablet<br />
Imdur ER 30mg Tablet<br />
Imdur ER 60mg Tablet<br />
Imipramine <strong>10</strong>mg Tablet<br />
Imipramine 25mg Tablet<br />
Imitrex STATdose System<br />
(Kit contains 2 x 6mg doses)<br />
(Quantity limited to 4 kits<br />
per 30 days)<br />
Imitrex 25mg Tablet<br />
(9 tablets per package)<br />
(Quantity limited to 18<br />
tablets per 30 days)<br />
Imitrex 50mg Tablet<br />
(9 tablets per package)<br />
(Quantity limited to 18<br />
tablets per 30 days)<br />
Imitrex <strong>10</strong>0mg Tablet<br />
(9 tablets per package)<br />
(Quantity limited to 9<br />
tablets per 30 days)<br />
Imodium 2mg Capsule<br />
Imuran 50mg Tablet<br />
Inderal <strong>10</strong>mg Tablet<br />
Inderal 20mg Tablet<br />
Inderal 40mg Tablet<br />
Inderal LA 80mg Capsule<br />
Inderal LA 120mg Capsule<br />
Indocin 25mg Capsule<br />
Isoniazid (INH) 300mg Tablet<br />
Isordil <strong>10</strong>mg Tablet<br />
Isordil 40mg Sustained Release<br />
Tablet<br />
Januvia 50mg Tablet<br />
Januvia <strong>10</strong>0mg Tablet<br />
5
6<br />
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
INSULIN & DIABETIC SUPPLIES<br />
BD Ultra-Fine Pen Needles,<br />
Short, 8mm 31G (<strong>10</strong>0s)<br />
Lancets<br />
Lantus, <strong>10</strong>0 units/ml, <strong>10</strong>ml<br />
Lantus SoloStar, <strong>10</strong>0 units/ml,<br />
5 X 3ml Prefilled Pens<br />
Novolin N, <strong>10</strong>0 units/ml, <strong>10</strong>ml<br />
Novolin R, <strong>10</strong>0 units/ml, <strong>10</strong>ml<br />
Novolin 70/30, <strong>10</strong>0 units/ml,<br />
<strong>10</strong>ml<br />
NovoLog <strong>10</strong>0 units/ml, <strong>10</strong>ml<br />
NovoLog FlexPen, <strong>10</strong>0 units/ml,<br />
5 X 3ml Prefilled Syringes<br />
NovoLog Mix 70/30 FlexPen,<br />
<strong>10</strong>0 units/ml,<br />
5 X 3ml Prefilled Syringes<br />
Precision Xtra Blood Glucose<br />
Test Strips (<strong>10</strong>0s)<br />
(For use with the Precision<br />
Xtra Meter Only.)<br />
U-<strong>10</strong>0 Insulin Syringes, 1ml<br />
(Quantity limited to a<br />
maximum of 300 syringes per<br />
90 days.)<br />
U-<strong>10</strong>0 Lo-Dose Insulin Syringes<br />
(Quantity limited to a<br />
maximum of 300 syringes per<br />
90 days.)<br />
Janumet 50mg/500mg Tablet<br />
Janumet 50mg/1,000mg<br />
Keflex 250mg Capsule<br />
Keflex 500mg Capsule<br />
Keflex 125mg/5ml Susp, 200ml<br />
Keflex 250mg/5ml Susp, 200ml<br />
Kenalog in Orabase, 5g<br />
Klonopin 0.5mg Tablet (C-IV)<br />
Klonopin 1mg Tablet (C-IV)<br />
Klonopin 2mg Tablet (C-IV)<br />
Lactulose <strong>10</strong>g/15ml Syrup<br />
Lanoxin 0.125mg Tablet<br />
Lanoxin 0.25mg Tablet<br />
Lariam 250mg Tablet<br />
Lasix 20mg Tablet<br />
Lasix 40mg Tablet<br />
Levaquin 250mg Tablet<br />
Levaquin 500mg Tablet<br />
Levaquin 750mg Tablet<br />
Lidex 0.05% Cream, 30g & 60g<br />
Lidex 0.05% Ointment,<br />
30g & 60g<br />
Lidoderm 5% Patch, 30s<br />
(Limited to 3 Boxes per<br />
RX fill)<br />
Lipitor <strong>10</strong>mg Tablet<br />
Lipitor 20mg Tablet<br />
Lipitor 40mg Tablet<br />
Lipitor 80mg Tablet<br />
Lisinopril 5mg Tablet<br />
Lisinopril <strong>10</strong>mg Tablet<br />
Lisinopril 20mg Tablet<br />
Lisinopril 40mg Tablet<br />
Lisinopril/HCT <strong>10</strong>mg/12.5mg<br />
Tablet<br />
Lisinopril/HCT 20mg/12.5mg<br />
Tablet<br />
Lisinopril/HCT 20mg/25mg<br />
Tablet<br />
Lithium Carbonate 300mg Capsule<br />
Lo/Ovral, 28 Tablets<br />
Loestrin Fe 1/20, 28 Tablets<br />
Loestrin Fe 1.5/30, 28 Tablets<br />
Lopid 600mg Tablet<br />
Lortab 7.5mg/500mg Tablet<br />
(7.5mg hydrocodone + 500mg<br />
acetaminophen) (C-III)<br />
Lotemax 0.5% Ophth Susp, 5ml<br />
Lotrel 2.5mg/<strong>10</strong>mg Capsule<br />
Lotrel 5mg/<strong>10</strong>mg Capsule<br />
Lotrel 5mg/20mg Capsule<br />
Lotrel 5mg/40mg Capsule<br />
Lotrel <strong>10</strong>mg/20mg Capsule<br />
Lotrel <strong>10</strong>mg/40mg Capsule<br />
Lotrisone Cream, 45g<br />
Lovenox Injection, Specify Dose<br />
(ordered when RX presented)<br />
Macrobid <strong>10</strong>0mg Capsule<br />
Macrodantin 50mg Capsule<br />
Magnesium Oxide 400mg Tablet<br />
Maxalt 5mg Tablet<br />
(Quantity limited to 12<br />
tablets per 30 days)
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Maxalt <strong>10</strong>mg Tablet<br />
(Quantity limited to 12<br />
tablets per 30 days)<br />
Maxalt-MLT 5mg Oral Disinte-<br />
grating Tablet<br />
(Quantity limited to 12<br />
tablets per 30 days)<br />
Maxalt-MLT <strong>10</strong>mg Oral Disinte-<br />
grating Tablet<br />
(Quantity limited to 12<br />
tablets per 30 days)<br />
Maxzide 37.5/25 Tablet<br />
Maxzide 75/50 Tablet<br />
Meclizine 25mg Tablet<br />
Mediplast 40% Plaster<br />
Medrol Dosepak<br />
Methazolamide 50mg Tablet<br />
Methotrexate 2.5mg tablet<br />
Methyldopa 250mg Tablet<br />
Metoprolol 25mg Tablet<br />
Metoprolol 50mg Tablet<br />
Metoprolol <strong>10</strong>0mg Tablet<br />
Metoprolol Extended Release<br />
25mg Tablet<br />
Metoprolol Extended Release<br />
50mg Tablet<br />
Metoprolol Extended Release<br />
<strong>10</strong>0mg Tablet<br />
Metoprolol Extended Release<br />
200mg Tablet<br />
Metrocream 0.75%, 45g<br />
Metronidazole 0.75% Gel, 45g<br />
MetroGel-Vaginal 0.75%, 70g<br />
Micardis 20mg Tablet<br />
(30 tablets per package)<br />
Micardis 40mg Tablet<br />
(30 tablets per package)<br />
Micardis 80mg Tablet<br />
(30 tablets per package)<br />
Micardis HCT 40mg/12.5mg Tablet<br />
(30 tablets per package)<br />
Micardis HCT 80mg/12.5mg Tablet<br />
(30 tablets per package)<br />
Micardis HCT 80mg/25mg Tablet<br />
(30 tablets per package)<br />
Miconazole 2% Cream, 1oz<br />
Minipress 1mg Capsule<br />
Minipress 2mg Capsule<br />
Minipress 5mg Capsule<br />
Minocin 50mg Capsule<br />
Miralax Powder, 527g<br />
Mobic 7.5mg Tablet<br />
Mobic 15mg Tablet<br />
Monopril <strong>10</strong>mg Tablet<br />
Monopril 20mg Tablet<br />
Morphine 15mg Immediate Release<br />
Tablet (C-II)<br />
Morphine 30mg Immediate Release<br />
Tablet (C-II)<br />
Motrin Susp. <strong>10</strong>0mg/5ml, 120ml<br />
MS Contin 15mg SR Tablet<br />
(C-II)<br />
MS Contin 30mg SR Tablet<br />
(C-II)<br />
MS Contin 60mg SR Tablet<br />
(C-II)<br />
MucinexD 600mg/60mg, 18s<br />
(Limited to 18 tablets and<br />
NO REFILLS)<br />
Muro 128 (5% NaCl) Ophth Oint,<br />
3.5g<br />
Muro 128 (5% NaCl) Ophth Soln,<br />
15ml<br />
Mycolog II Cream, 15g<br />
Mylicon 40mg/0.6ml Drops, 30ml<br />
Mysoline 50mg Tablet<br />
Mysoline 250mg Tablet<br />
Naphcon-A Ophth Soln, 15ml<br />
Naprosyn 250mg Tablet<br />
Naprosyn 375mg Tablet<br />
Naprosyn 500mg Tablet<br />
Nasonex Nasal Inhaler, 17g<br />
(120 doses)<br />
Neomycin 500mg Tablet<br />
Neosporin Ophth Ointment, 3.5g<br />
Neosporin Ophth Solution, <strong>10</strong>ml<br />
Neurontin <strong>10</strong>0mg Capsule<br />
Neurontin 300mg Capsule<br />
Neurontin 400mg Capsule<br />
Neurontin 600mg Tablet<br />
Nexium 20mg Capsule<br />
Nexium 40mg Capsule<br />
Niaspan 500mg Extended Release<br />
Tablet<br />
7
8<br />
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Niaspan 750mg Extended Release<br />
Tablet<br />
Niaspan <strong>10</strong>00mg Extended<br />
Release Tablet<br />
Nitro-Dur 0.2mg/hr Patch, 30’s<br />
Nitro-Dur 0.4mg/hr Patch, 30’s<br />
Nitrolingual Pumpspray, 12g<br />
(200 doses)<br />
Nitrostat 0.4mg SL Tablet, 25s<br />
Nix 1% Creme Rinse Kit, 60ml<br />
Nizoral 2% Cream, 15g & 60g<br />
Nizoral 2% Shampoo, 4oz<br />
Nizoral 200mg Tablet<br />
Nor-QD, 28 Tablets<br />
Nordette/Levlen, 28 Tablets<br />
Norinyl 1+35, 28 Tablets<br />
Nortriptyline <strong>10</strong>mg Capsule<br />
Nortriptyline 25mg Capsule<br />
NuLytely, 4 Liters (1 gallon)<br />
NuvaRing Vaginal Ring<br />
Nystatin <strong>10</strong>0,000 Units/g<br />
Cream, 30g<br />
Nystatin <strong>10</strong>0,000 Units/g<br />
Ointment, 30g<br />
Nystatin Oral Suspension,<br />
<strong>10</strong>0,000 Units/ml<br />
Nystatin 500,000 Units Oral<br />
Tablet<br />
Ocuflox 0.3% Ophth Soln, 5ml<br />
OptiChamber for Metered Dose<br />
Inhalers<br />
OptiChamber Face Mask, Small<br />
OptiChamber Face Mask, Medium<br />
OptiChamber Face Mask, Large<br />
Optive Lubricant Eye Drops,<br />
15ml<br />
Oral Electrolyte Soln, 1 Liter<br />
Ortho-Cyclen, 28 Tablets<br />
Ortho Evra Transdermal System,<br />
3 Systems/Package<br />
Ortho-Novum 7/7/7, 28 Tablets<br />
Ortho-Tri-Cyclen, 28 Tablets<br />
Ortho-Tri-Cyclen Lo, 28 Tablets<br />
Pancrelipase Delayed-Release<br />
Capsule<br />
(Each capsule contains<br />
Lipase 5,000 units<br />
Amylase 27,000 units<br />
Protease 17,000 units)<br />
Patanol 0.1% Ophth Soln, 5ml<br />
Paxil 20mg Tablet<br />
Paxil 30mg Tablet<br />
Paxil 40mg Tablet<br />
Penicillin VK 250mg/5ml<br />
Solution, 200ml<br />
Penicillin VK 250mg Tablet<br />
Penicillin VK 500mg Tablet<br />
Percocet-5/325 Tablet (C-II)<br />
(5mg oxycodone + 325mg<br />
acetaminophen)<br />
Periactin 2mg/5ml Syrup<br />
Periactin 4mg Tablet<br />
Peridex 0.12% Oral Rinse,<br />
473ml<br />
Phenergan 12.5mg Suppository<br />
Phenergan 25mg Suppository<br />
Phenergan 25mg Tablet<br />
Phenobarbital 30mg Tablet<br />
(C-IV)<br />
Pilocarpine 1% Ophth Soln,<br />
15ml<br />
Pilocarpine 2% Ophth Soln,<br />
15ml<br />
Pilocarpine 4% Ophth Soln,<br />
15ml<br />
Plaquenil 200mg Tablet<br />
Plavix 75mg Tablet<br />
Plendil 2.5mg tablet<br />
Plendil 5mg Tablet<br />
Plendil <strong>10</strong>mg Tablet<br />
Polytrim Ophth Soln, <strong>10</strong>ml<br />
Polyvitamin Infant Drops, 50ml<br />
Potassium Chloride 20mEq/15ml<br />
Soln<br />
Potassium Chloride Controlled<br />
Release <strong>10</strong>mEq Tablet<br />
(Klor-Con)
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Potassium Chloride Controlled<br />
Release 20mEq Tablet<br />
(Klor-Con M20)<br />
Prandin 0.5mg Tablet<br />
Prandin 1mg Tablet<br />
Prandin 2mg Tablet<br />
Pravachol <strong>10</strong>mg Tablet<br />
Pravachol 20mg Tablet<br />
Pravachol 40mg Tablet<br />
Pravachol 80mg Tablet<br />
Pred Forte 1% Ophth Susp, 5ml<br />
Prednisolone 5mg/5ml Oral<br />
Soln (Pediapred)<br />
Prednisolone 15mg/5ml Syrup<br />
(Prelone)<br />
Prednisone 1mg Tablet<br />
Prednisone 5mg Tablet<br />
Prednisone <strong>10</strong>mg Tablet<br />
Prednisone 20mg Tablet<br />
Premarin 0.3mg Tablet<br />
Premarin 0.45mg Tablet<br />
Premarin 0.625mg Tablet<br />
Premarin 0.9mg Tablet<br />
Premarin 1.25mg Tablet<br />
Premarin Vaginal Cream, 42.5g<br />
Prempro 0.3mg/1.5mg, 28 Tablets<br />
Prempro 0.45mg/1.5mg,<br />
28 Tablets<br />
Prempro 0.625mg/2.5mg,<br />
28 Tablets<br />
Prempro 0.625mg/5mg,<br />
28 Tablets<br />
Prenatal Vitamins with 1mg<br />
Folic Acid<br />
(Limited to women up to and<br />
including age 45)<br />
PreviDent 5000 Plus Dental<br />
Paste, 51g<br />
Prilosec 20mg Capsule<br />
Primaquine 26.3mg Tablet<br />
Probenecid 500mg Tablet<br />
Prometrium <strong>10</strong>0mg Capsule<br />
Proscar 5mg Tablet<br />
Protopic 0.03% Oint, 60g<br />
Protopic 0.1% Oint, 60g<br />
(Adult Strength for patients<br />
16 years old & older)<br />
Provera 2.5mg Tablet<br />
Provera 5mg Tablet<br />
Provera <strong>10</strong>mg Tablet<br />
Provigil <strong>10</strong>0mg Tablet (C-IV)<br />
Provigil 200mg Tablet (C-IV)<br />
Prozac <strong>10</strong>mg Capsule<br />
Prozac 20mg Capsule<br />
Pulmicort Respules 0.25mg/2ml,<br />
30 per Carton<br />
Pulmicort Respules 0.5mg/2ml,<br />
30 per Carton<br />
Pyrazinamide 500mg Tablet<br />
Pyridium <strong>10</strong>0mg Tablet<br />
Refresh Celluvisc Lubricant Eye<br />
Drops, 0.4ml (30s)<br />
Refresh Plus Lubricant Eye<br />
Drops, 0.4ml (30s)<br />
Reglan <strong>10</strong>mg Tablet<br />
Remeron 15mg Tablet<br />
Remeron 30mg Tablet<br />
Remeron 45mg Tablet<br />
Retin-A 0.01% Gel, 45g<br />
Retin-A 0.025% Cream, 45g<br />
Retin-A 0.05% Cream 20g<br />
Rifadin 300mg Capsule<br />
Risperdal 1mg Tablet<br />
Risperdal 2mg Tablet<br />
Risperdal 3mg Tablet<br />
Ritalin 5mg Tablet (C-II)<br />
Ritalin <strong>10</strong>mg Tablet (C-II)<br />
Ritalin SR 20mg Tablet (C-II)<br />
Robaxin 500mg Tablet<br />
Robitussin <strong>10</strong>0mg/5ml Syrup,<br />
4oz<br />
Robitussin AC Syrup, 4oz<br />
(C-IV)<br />
Robitussin DM Syrup, 4oz<br />
Saline Nasal Mist, 50ml<br />
Salsalate 750mg Tablet<br />
Selsun 2.5% Lotion, 4oz<br />
Serevent Diskus Inhaler<br />
Seroquel 25mg Tablet<br />
Seroquel 50mg Tablet<br />
Seroquel <strong>10</strong>0mg Tablet<br />
Seroquel XR 200mg Tablet<br />
Seroquel XR 300mg Tablet<br />
Seroquel XR 400mg Tablet<br />
Silvadene 1% Cream, 20g<br />
Sinemet <strong>10</strong>/<strong>10</strong>0 Tablet<br />
9
<strong>10</strong><br />
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Sinemet 25/<strong>10</strong>0 Tablet<br />
Sinemet 25/250 Tablet<br />
Singulair 4mg Chewable Tablet<br />
Singulair 4mg Granules<br />
Singulair 5mg Chewable Tablet<br />
Singulair <strong>10</strong>mg Tablet<br />
Sodium Chloride 0.9% Inh Soln,<br />
3ml Vial (<strong>10</strong>0s)<br />
Sodium Fluoride Drops, 50ml,<br />
(0.5mg fluoride ion/ml)<br />
Solaquin Forte 4% Cream, 1oz<br />
Spiriva Handihaler, 30 capsules<br />
Spironolactone 25mg Tablet<br />
Strattera <strong>10</strong>mg Capsule<br />
Strattera 18mg Capsule<br />
Strattera 25mg Capsule<br />
Strattera 40mg Capsule<br />
Strattera 60mg Capsule<br />
Sudafed 30mg Tablet<br />
Sudafed 30mg/5ml Syrup, 120ml<br />
Sulfacetamide <strong>10</strong>% Ophth Soln,<br />
15ml<br />
Sulfasalazine 500mg Tablet<br />
Symbicort 80/4.5, <strong>10</strong>.2g<br />
(120 Doses)<br />
Symbicort 160/4.5, <strong>10</strong>.2g<br />
(120 Doses)<br />
Synalar 0.01% Solution, 60ml<br />
Synthroid 0.025mg Tablet<br />
Synthroid 0.05mg Tablet<br />
Synthroid 0.075mg Tablet<br />
Synthroid 0.088mg Tablet<br />
Synthroid 0.1mg Tablet<br />
Synthroid 0.112mg Tablet<br />
Synthroid 0.125mg Tablet<br />
Synthroid 0.137mg Tablet<br />
Synthroid 0.15mg Tablet<br />
Synthroid 0.175mg Tablet<br />
Synthroid 0.2mg Tablet<br />
Systane Balance Ophth Soln,<br />
<strong>10</strong>ml<br />
Tagamet 400mg Tablet<br />
Tamoxifen <strong>10</strong>mg Tablet<br />
Tamoxifen 20mg Tablet<br />
Tamsulosin 0.4mg Capsule<br />
Tarsum Shampoo/Gel, 4oz<br />
Temazepam 15mg Capsule (C-IV)<br />
Temazepam 30mg Capsule (C-IV)<br />
Temovate 0.05% Cream, 30g<br />
Temovate 0.05% Gel, 30g & 60g<br />
Temovate 0.05% Ointment,<br />
30g & 60g<br />
Tenormin 25mg Tablet<br />
Tenormin 50mg Tablet<br />
Terbinafine 250mg Tablet<br />
Tessalon <strong>10</strong>0mg Perles<br />
Theo-Dur 200mg Tablet<br />
Theo-Dur 300mg Tablet<br />
Tiazac 120mg Capsule<br />
Tiazac 180mg Capsule<br />
Tiazac 240mg Capsule<br />
Tiazac 300mg Capsule<br />
Tiazac 360mg Capsule<br />
Timoptic 0.5% Ophth Soln, 5ml<br />
Timoptic-XE 0.25% Ophth Soln,<br />
5ml<br />
Timoptic-XE 0.5% Ophth Soln,<br />
5ml<br />
TobraDex Ophth Oint, 3.5g<br />
Topamax 25mg Tablet<br />
Topamax 50mg Tablet<br />
Topamax <strong>10</strong>0mg Tablet<br />
Topamax 200mg Tablet<br />
Treximet<br />
(9 tablets per package)<br />
(Quantity limited to 9<br />
tablets per 30 days)<br />
Tri-Levlen, 28 Tablets<br />
Triamcinolone 0.1% Cream,<br />
15g & 80g<br />
Triamcinolone 0.1% Oint<br />
15g & 80g<br />
Triglide 50mg Tablet<br />
Triglide 160mg Tablet<br />
Trihexyphenidyl 2mg Tablet<br />
Trusopt 2% Ophth Soln, <strong>10</strong>ml<br />
Tylenol Drops 80mg/0.8ml, 15ml<br />
Tylenol Elixir 160mg/5ml,<br />
120ml<br />
Tylenol Suppository 120mg<br />
Tylenol 325mg Tablet<br />
Tylenol w/codeine Elixir,<br />
4oz (C-V)<br />
Tylenol #3 Tablet (C-III)
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Tylox Capsule (C-II)<br />
(5mg oxycodone + 500mg<br />
acetaminophen)<br />
Ultram 50mg Tablet<br />
Uroxatral <strong>10</strong>mg Extended<br />
Release Tablet<br />
Valium 5mg Tablet (C-IV)<br />
Valtrex 500mg Tablet<br />
Vermox <strong>10</strong>0mg Chewable Tablet<br />
Viagra 25mg tablet<br />
(For Erectile Dysfunction<br />
Only)<br />
(Quantity limited to 6<br />
tablets per 30 days)<br />
Viagra 50mg tablet<br />
(For Erectile Dysfunction<br />
Only)<br />
(Quantity limited to 6<br />
tablets per 30 days)<br />
Viagra <strong>10</strong>0mg tablet<br />
(For Erectile Dysfunction<br />
Only)<br />
(Quantity limited to 6<br />
tablets per 30 days)<br />
Vicodin Tablet (C-III)<br />
(5mg hydrocodone + 500mg<br />
acetaminophen)<br />
Vicodin ES Tablet (C-III)<br />
(7.5mg hydrocodone + 750mg<br />
acetaminophen)<br />
Viscous Lidocaine 2%, <strong>10</strong>0ml<br />
Vitamin B-6 50mg Tablet<br />
Vitamin B-12 Injection, 1ml<br />
(1,000mcg/ml)<br />
Vitamin D2 (Ergocalciferol)<br />
50,000 units/capsule<br />
Vitamin D3 (Cholecalciferol),<br />
1,000 units/capsule<br />
Vivelle dot 0.05mg/24 hr Patch<br />
Vivelle dot 0.1mg/24 hr Patch<br />
Vytorin <strong>10</strong>mg/<strong>10</strong>mg Tablet<br />
Vytorin <strong>10</strong>mg/20mg Tablet<br />
Vytorin <strong>10</strong>mg/40mg Tablet<br />
Vytorin <strong>10</strong>mg/80mg Tablet<br />
Wellbutrin 75mg Tablet<br />
Wellbutrin <strong>10</strong>0mg Tablet<br />
Wellbutrin SR <strong>10</strong>0mg Tablet<br />
Wellbutrin SR 150mg Tablet<br />
Wellbutrin XL 150mg Tablet<br />
(Once DAILY dose ONLY)<br />
Wellbutrin XL 300mg Tablet<br />
(Once DAILY dose ONLY)<br />
Westcort 0.2% Cream, 15g & 60g<br />
Westcort 0.2% Oint, 15g & 60g<br />
Xalatan 0.005% Ophth Soln,<br />
2.5ml<br />
Xanax 0.25mg Tablet (C-IV)<br />
Xanax 0.5mg Tablet (C-IV)<br />
Xanax 1mg Tablet (C-IV)<br />
Xopenex 0.63mg/3ml Inh Soln,<br />
3ml Vial (24s)<br />
Xopenex 1.25mg/3ml Inh Soln,<br />
3ml Vial (24s)<br />
Yasmin, 28 Tablets<br />
YAZ, 28 Tablets<br />
Zaditor 0.025% Ophth Soln, 5ml<br />
Zantac 150mg Tablet<br />
Zantac 15mg/ml Syrup<br />
Zetia <strong>10</strong>mg Tablet<br />
Zithromax <strong>10</strong>0mg/5ml Susp, 15ml<br />
Zithromax 200mg/5ml Susp, 15ml<br />
Zithromax 200mg/5ml Susp,<br />
22.5ml & 30ml<br />
Zithromax 250mg Tablet<br />
Zithromax Tri-Pak, 3 Tablets<br />
Zithromax Z-PAK, 6 Tablets<br />
Zocor 5mg Tablet<br />
Zocor <strong>10</strong>mg Tablet<br />
Zocor 20mg Tablet<br />
Zocor 40mg Tablet<br />
Zocor 80mg Tablet<br />
Zoloft 25mg Tablet<br />
Zoloft 50mg Tablet<br />
Zoloft <strong>10</strong>0mg Tablet<br />
Zomig 2.5mg Tablet<br />
(6 tablets per package)<br />
(Quantity limited to 12<br />
tablets per 30 days)<br />
Zomig 5mg Tablet,<br />
(3 tablets per package)<br />
(Quantity limited to 12<br />
tablets per 30 days)<br />
Zovirax 200mg Capsule<br />
Zovirax 800mg Tablet<br />
11
12<br />
<strong>KENNER</strong> <strong>ARMY</strong> <strong>HEALTH</strong> <strong>CLINIC</strong> <strong>FORMULARY</strong><br />
<strong>10</strong> <strong>May</strong> <strong>2012</strong>*<br />
(*Supersedes 21 December 2011 Formulary)<br />
Zylet Ophth Susp, 5ml<br />
Zymar 0.3% Ophth Soln, 5ml<br />
Zyprexa 5mg Tablet<br />
Zyprexa <strong>10</strong>mg Tablet<br />
Zyrtec 1mg/ml Syrup, 120ml<br />
Zyrtec 5mg Tablet<br />
Zyrtec <strong>10</strong>mg Tablet
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