78th MEDICAL GROUP FORMULARY - May 2013

78th MEDICAL GROUP FORMULARY - May 2013 

*Medications are listed alphabetically by generic name with the exception of combination products* 

Basic Core Formulary (BCF) items in bold are preferred and available at every military treatment facility (MTF) 

See last page for more information @ restriction information on last page 

Additions since Nov 2012 

Azithromycin (Zithromax) 1 g packet 

@ Clarithromycin (Biaxin) 500 mg tabletfor 

H. Pylori only 

Diclofenac patch (Flector) 

@ Eszopiclone (Lunesta) 2 mg & 3 mg 

tablet- must have failed Ambien IR 

and/or Sonata (off-base providers should 

state failure on Rx) 

Guanfacine (Tenex) 1 mg & 2 mg tablet 

Janumet XR [sitagliptan/metformin] 50 

mg/500 mg, 50 mg/1000mg, & 100 

mg/1000 mg tablet 

Memantine (Namenda) 5 mg & 10 mg 

tablet 

Methylphenidate extended release 

(Metadate CD) 10 mg, 20 mg, 30 mg, 

40 mg capsule 

Methylphenidate (Ritalin) 20 mg tablet 

Morphine sulfate extended release 

(Morphine ER) 100 mg & 200 mg 

tablet 

Symbicort [budesonide/formoterol] 80/4.5 

mcg & 160/4.5 mcg inhaler 

Testosterone transdermal 2% gel pump 

(Fortesta) 

Venlafaxine (Effexor/XR) 25 mg, 37.5 

mg, & 100 mg tablet; 225 mg ER 

tablet 

@ Zolpidem extended release (Ambien CR) 

6.25 mg & 12.5 mg tablet- must have 

failed Ambien IR and/or Sonata (offbase 

providers should state failure on 

Rx) 

Deletions since Nov 2012 

Testosterone transdermal 1% gel pump 

and gel packets (Androgel) 

Antirheumatic Agents 

Muscle Relaxants 

Non-Opioid Analgesic 

Combinations 

Non-Steroidal Antiinflammatories 

Opioid Agonists 

Opioid Analgesic 

Combinations 

Other Analgesics 

Antifungal Agents 

Azathioprine (Imuran) 

Hydroxychloroquine (Plaquenil) 

Methotrexate 

Baclofen (Lioresal) 

Carisoprodol (Soma) (C-IV) 

Cyclobenzaprine (Flexeril) 

@ Metaxalone (Skelaxin) 

Methocarbamol (Robaxin) 

Tizanidine (Zanaflex) 

Fioricet (C-III) 

[butalbital/acetaminophen/caffeine] 

Ultracet [tramadol/acetaminophen] 

Aspirin 

Celecoxib (Celebrex) 

Ibuprofen (Motrin) 

Indomethacin (Indocin) 

Meloxicam (Mobic) 

Nabumetone (Relafen) 

Naproxen (Naprosyn) 

Naproxen sodium (Anaprox DS) 

Salsalate (Disalcid) 

Codeine (C-II) 

Meperidine (Demerol) (C-II) 

Morphine sulfate (MS Contin) (C-II) 

Morphine (C-II) 

Hycet (C-III) [hydrocodone/acetaminophen] 

Lortab (C-IV) 

[hydrocodone/acetaminophen] 

Norco (C-V) [hydrocodone/acetaminophen] 

Percocet (C-II) [oxycodone/acetaminophen] 

Tylenol #3 (C-III) 

[acetaminophen/codeine] 

Tylenol w/codeine (C-V) 

[acetaminophen/codeine] 

Acetaminophen (Tylenol) 

Tramadol (Ultram) 

Fluconazole (Diflucan) 

Griseofulvin ultramicronized 

Ketoconazole (Nizoral) 

Metronidazole (Flagyl) 

Nystatin 

Terbinafine (Lamisil) 

ANALGESICS 

50 mg tablet 

200 mg tablet 

2.5 mg tablet 

10 mg tablet 

350 mg tablet 

5 mg & 10 mg tablet 

800 mg tablet 


4 mg tablet 

50 mg/325 mg/40 mg tablet 

ANTIMICROBIALS 

37.5 mg/325 mg tablet 

81 mg chewable tablet; 81 mg & 325 mg EC tablet; 325 mg tablet 

100 mg & 200 mg capsule 

400 mg, 600 mg, & 800 mg tablet; 100 mg/5 ml oral suspension 


7.5 mg & 15 mg tablet 


250 mg & 500 mg tablet; 125 mg/5 ml oral suspension 



30 mg tablet 

50 mg tablet 

15 mg, 30 mg, & 60 mg tablet 

15 mg tablet 

7.5 mg-325 mg/15 ml solution 

5 mg/500 mg tablet 

5 mg/325 mg, 7.5 mg/325 mg & 10 mg/325 mg tablet 

5 mg/325 mg & 10 mg/325 mg tablet 


120 mg-12 mg/5 ml oral solution 

80 mg/0.8 ml drop; 160 mg/5 ml elixir; 325 mg tablet; 120 mg 

pediatric suppository 

50 mg tablet 

100 mg, 150 mg & 200 mg tablet 

125 mg & 250 mg tablet; 125 mg/5 ml oral suspension 

200 mg tablet 


100,000 U/ml oral suspension 

250 mg tablet 

Access the formulary anytime at: http://www.robins.af.mil/library/factsheets/factsheet.asp?id=8025 

Like us on Facebook! Robins AFB Pharmacy 

Page 1 of 9

Antimalarials 

Antimycobacterial Agents 

Antiviral Agents 

Cephalosporins 

Macrolides 

Penicillins 


Chloroquine (Aralen) 

Malarone [atovaquone/proguanil] 

Mefloquine (Lariam) 

Primaquine 

Ethambutol (Myambutol) 

Isoniazid (INH) 

Pyrazinamide 

Rifampin (Rifadin) 

Acyclovir (Zovirax) 

Amantadine (Symmetrel) 

Valacyclovir (Valtrex) 

Cefdinir (Omnicef) 

Cefditoren (Spectracef) 

Cefprozil (Cefzil) 

Cephalexin (Keflex) 

Azithromycin (Zithromax) 

Erythromycin 

Amoxicillin 

Ampicillin 

Augmentin 

Dicloxacillin (Dynapen) 

Penicillin VK 

500 mg tablet 


250 mg tablet 

26.3 mg tablet 



500 mg tablet 

300 mg capsule 

200 mg capsule; 400 mg & 800 mg tablet; 200 mg/5 ml oral 

suspension 

100 mg tablet; 100 mg capsule; 50 mg/5 ml syrup 


125 mg/5 ml & 250 mg/5 ml oral suspension; 300 mg capsule 

200 mg tablet 

250 mg tablet; 250 mg/5 ml oral suspension 

250 mg & 500 mg capsule; 250 mg/5 ml oral suspension 

250 mg & 500 mg tablet & Z-Pak; 100 mg/5 ml, 200 mg/5 ml oral 

suspension; 1 gm packet 

250 mg tablet (base); 250 mg tablet (stearate); EES 200 mg/5 ml 

oral suspension 

250 mg & 500 mg capsule; 875 mg tablet; 250 mg/5 ml, & 400 

mg/5 ml oral suspension; 250 mg chewable tablet 


125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, & 400 mg/5 ml oral 

suspension; 600 mg/5 ml ES oral suspension; 250 mg, 500 mg, 

& 875 mg tablet 


250 mg & 500 mg tablet; 125 mg/5 ml & 250 mg/5 ml oral 

suspension 

Quinolones 

Ciprofloxacin (Cipro) 

Levofloxacin (Levaquin) 

100 mg, 250 mg, 500 mg, & 750 mg tablet; 5 g/100 ml oral 

suspension 

250 mg, 500 mg, & 750 mg tablet; 25 mg/ml oral solution 

Sulfonamides Bactrim (Septra) 400 mg/80 mg tablet; 800 mg/160 mg tablet; 200 mg/40 mg/5 ml 

& 800 mg/160 mg/5 ml oral suspension 

Tetracyclines 

Doxycycline 

Minocycline (Minocin) 

Tetracycline 

100 mg tablet; 100 mg capsule 



Other Antimicrobials 

ACE Inhibitors 

Clindamycin (Cleocin) 

Mebendazole (Vermox) 

Nitrofurantoin (Macrobid) 

Nitrofurantoin (Macrodantin) 

Captopril (Capoten) 

Lisinopril (Prinivil/Zestril) 

Ramipril (Altace) 

CARDIOVASCULAR 


100 mg chewable tablet 


50 mg capsule 

12.5 mg, 25 mg, 50 mg, & 100 mg tablet 

2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, & 40 mg tablet 

1.25 mg, 2.5 mg, 5 mg, & 10 mg capsule 

Aldosterone Antagonists Spironolactone (Aldactone) 25 mg, 50 mg and 100 mg tablet 

Angiotensin Receptor Losartan (Cozaar) 


Blockers (ARBs) 

Telmisartan (Micardis) 


Anti-Dysrhythmics/ Cardiac 

Arrest 

Anti-Hyperlipidemic 

Agents 

Antiadrenergic Agents 

Valsartan (Diovan) 

Amiodarone (Cordarone) 

Digoxin (Lanoxin) 

Atorvastatin (Lipitor) 

Colestipol (Colestid) 

Ezetimibe (Zetia) 

Fenofibrate (Tricor) 

Fenofibrate (Triglide) 

Gemfibrozil (Lopid) 

Niacin (Niaspan) 

Pravastatin (Pravachol) 

Simvastatin (Zocor) 

Vytorin [ezetimibe/simvastatin] 

Clonidine (Catapres) 

Methyldopa (Aldomet) 

40 mg, 80 mg, 160 mg, & 320 mg tablet 

200 mg tablet 

0.125 mg & 0.25 mg tablet 

10 mg, 20 mg, 40 mg & 80 mg tablet 

1 gm tablet 

10 mg tablet 



600 mg tablet 

500 mg, 750 mg, & 1000 mg ER tablet 


5 mg, 10 mg, 20 mg, 40 mg, & 80 mg tablet 

10 mg/20 mg, 10 mg/40 mg, 10 mg/80 mg tablet 

0.1 mg, 0.2 mg, & 0.3 mg tablet 




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Antihypertensive 

Combinations 


Prazosin (Minipress) 

Terazosin (Hytrin) 

Diovan HCT 

[valsartan/hydrochlorothiazide] 

Hyzaar [losartan/hydrochlorothiazide] 

Lotrel [amlodipine/benazepril] 

Maxzide 

[Triamterene/Hydrochlorothiazide] 

Micardis HCT 

[telmisartan/hydrochlorothiazide] 

Zestoretic 

[lisinopril/hydrochlorothiazide] 

1 mg, 2 mg & 5 mg capsule 

1 mg, 2 mg, 5 mg & 10 mg capsule 

80 mg/12.5 mg, 160 mg/12.5 mg, 160 mg/25 mg, 320 mg/12.5 mg, 

& 320 mg/25 mg tablet 

50 mg/12.5 mg, 100 mg/12.5 gm & 100 gm/25 mg tablet 

2.5 mg/10 mg, 5 mg/10 mg, 5 mg/20 mg, 5 mg/40 mg, 10 mg/20 

mg, & 10 mg/40 mg capsule 

37.5 mg/25 mg & 75 mg/50 mg tablet 

40 mg/12.5 mg, 80 mg/12.5 mg, & 80 mg/25 mg tablet 

10 mg/12.5 mg, 20 mg/12.5 mg, 20 mg/25 mg tablet 

Antihypertensives Hydralazine (Apresoline) 10 mg, 25 mg, 50 mg, & 100 mg tablet 

Antiplatelet Drugs Clopidogrel (Plavix) 75 mg & 300 mg tablet 

Beta-Blockers 

Atenolol (Tenormin) 

Carvedilol (Coreg/CR) 

Calcium Channel Blockers 

(CCBs) 

Diuretics 

Nitrates 

Metoprolol Succinate (Toprol XL) 

Metoprolol Tartrate (Lopressor) 

Nadolol (Corgard) 

Propranolol (Inderal) 

Amlodipine (Norvasc) 

Diltiazem (Cardizem/Tiazac) 

Nifedipine (Adalat CC) 

Nisoldipine (Sular) 

Verapamil (Calan) 

Acetazolamide (Diamox) 

Chlorthalidone (Hygroton) 

Furosemide (Lasix) 

Hydrochlorothiazide 

Indapamide (Lozol) 

Metolazone (Zaroxlyn) 

Isosorbide Dinitrate (Isordil) 

Isosorbide Mononitrate (Imdur) 

Nitroglycerin (NitroDur/Nitrostat) 

25 mg, 50 mg & 100 mg tablet 

3.125 mg, 6.25 mg, 12.5 mg, & 25 mg tablet; 10 mg, 20 mg, 40 mg, 

& 80 mg capsule 



40 mg tablet 

10 mg, 20 mg, & 40 mg tablet; 80 mg & 120 mg LA capsule 

2.5 mg, 5 mg, & 10 mg tablet 

60 mg tablet; 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, & 420 mg 

ER capsule 



80 mg & 120 mg tablet; 120 mg, 180 mg, & 240 mg ER tablet 

250 mg tablet 


20 mg & 40 mg tablet; 10 mg/ml oral solution 

12.5 mg capsule; 25 mg & 50 mg tablet 

2.5 mg tablet 


5 mg, 10 mg, 20 mg, & 30 mg tablet; 40 mg ER tablet; 2.5 mg SL 

tablet 


0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.6 mg, & 0.8 mg 24 hour patch; 

0.4 mg/spray SL spray; 0.4 mg SL tablet 

Pressors/Inotropes Epinephrine (Epipen/-Jr) 2-Pak 0.15 mg & 0.3 mg autoinjectors 

DERMATOLOGY 

Acne Preparations 

Adapalene (Differin) 

0.1% & 0.3% gel 

Benzaclin [clindamycin/benzoyl peroxide] 

Benzoyl Peroxide (Benzac AC) 

Clindamycin (Cleocin T) 

Erythromycin (Emgel/Ery Pad) 

Tretinoin (Retin A) 

1%/5% topical gel 

10% gel 

1% topical solution 

2% gel; 2% pads 

0.025% gel; 0.025% & 0.05% cream 

Actinic Keratosis 

Diclofenac (Voltaren) 

1% gel 

Preparations 

Antibacterials (Topical) 

Antifungals (Topical) 

Flourouracil (Efudex) 

Bacitracin 

Metronidazole (Noritate) 

@ Mupirocin (Bactroban) 

Silver Sulfadiazine (Silvadene) 

Clotrimazole (Lotrimin) 

Ketoconazole (Nizoral) 

Nystatin 

5% cream 

500 U/gm ointment 

1% cream 

2% ointment 

1% cream 

Antiparasitics (Topical) Permethrin (Elimite) 5% cream 

Antivirals (Topical) 

@ Acyclovir (Zovirax) 

Imiquimod (Aldara) 

5% ointment 

5% cream 

Atopic Dermatitis 

Pimecrolimus (Elidel) 

1% cream 

Preparations 

Corticosteroid/Antimicrobial 

Combinations 

Mycolog II [nystatin/triamcinolone] cream 

1% cream 

2% shampoo & cream 

100,000 U/gm cream & ointment 



Page 3 of 9

Corticosteroids (Topical) 


Betamethasone Dipropionate (Diprolene) 

Betamethasone Valerate (Valisone) 

Clobetasol (Temovate) 

Desonide (Tridesilon) 

Fluocinonide (Lidex) 

Hydrocortisone 

Hydrocortisone Valerate (Westcort) 

Triamcinolone (Kenalog) 

Hemorrhoid Care Hydrocortisone (Anusol-HC) 25 mg suppository 

Other Dermatologic Agents Aluminum Chloride (HyperCare) 

Ammonium Lactate (Lac-Hydrin) 

Dermacerin 

Lidocaine (Lidoderm/Xylocaine) 

Pramosone [pramoxine/hydrocortisone] 

Salicylic Acid (Compound W) 

Selenium Sulfide (Selsun) 

Androgens/Anabolic 

Steroids 

Bisphosphonates 

Corticosteroids 

Diabetes-Related 

ENDOCRINE AND METABOLIC 

Testosterone Cypionate (C-III) 

200 mg/ml 

Alendronate (Fosamax) 

Fosamax Plus D [alendronate/vitamin D] 

Ibandronate (Boniva) 

Cortisone 

Dexamethasone (Decadron) 

Fludrocortisone (Florinef) 

Hydrocortisone (Cortef) 

Methylprednisolone (Medrol) 

Prednisolone (Prelone) 

Prednisone (Deltasone) 

Alcohol Pads 

Glipizide (Glucotrol/XL) 

Glyburide (Diabeta/Glynase) 

Insulin, Aspart (Novolog 70/30 mix) 

Insulin, Aspart (Novolog) 

Insulin, Glargine (Lantus) 

Insulin, Human (Novolin) N, R, & 70/30 

Insulin, Detemir (Levemir) 

Janumet [sitagliptin/metformin] 

Lancets 

Metformin (Glucophage/XR) 

Pen Needles (NovoFine) 

Pioglitazone (Actos) 

Precision Xtra Glucose Monitor 

Precision Xtra Test Strips 

Sitagliptin (Januvia) 

Syringes, Insulin 

True-Result Blood Glucose Meter 

True-2-Go Blood Glucose Meter 

Truetest Blood Glucose Test Strips 

Allopurinol (Zyloprim) 

Colchicine (Colcrys) 

0.05% ointment 

0.1% cream & lotion 

0.05% cream & ointment 

0.05% cream 

0.05% ointment, gel, & cream 

1% & 2.5% cream 

0.2% cream 

0.1% & 0.5% cream; 0.1% ointment; 0.1% paste (in orabase) 

20% topical solution 

12% lotion 

moisturizing cream 

5% patch; 2% jelly; 5% ointment 

1% cream 

17% gel 

2.5% shampoo 


70 mg/2800 U & 70 mg/5600 U tablet 

150 mg tablet 

25 mg tablet 

0.75 mg & 4 mg tablet; 0.5 mg/5 ml elixir 

0.1 mg tablet 

20 mg tablet 

4 mg tablet & Dosepak 

15 mg/5 ml oral solution 

1 mg, 5 mg, 10 mg, 20 mg, & 50 mg tablet 

2.5 mg, 5 mg & 10 mg tablet; 5 mg & 10 mg XL tablet 

1.25 mg, 2.5 mg, & 5 mg tablet; 1.5 mg, 3 mg, & 6 mg micronized 

tablet 

100 U/ml vial; Flexpen 

100 U/ml vial, FlexPen, & Cartridge 

100 U/ml vial & Solostar pen 

100 U/ml vial 

100 U/ml vial 

50 mg/500 mg & 50 mg/1000 mg tablet 

500 mg, 850 mg, & 1000 mg tablet; 500 mg & 750 mg ER tablet 

30 G 


100 strips/box 


U 100, 0.5 ml & 1 ml 

50 strips/box & 100 strips/box 

Gout-Related 


0.6 mg tablet 

Probenecid (Benemid) 

500 mg tablet 

Minerals 

Ferrous Sulfate 

325 mg tablet; 15 mg/1 ml oral solution 

Fluoride 

0.5 mg/ml oral drops 

Potassium Chloride (Klor-Con/Micro-K) 8 mEq, 10 mEq, & 20 mEq ER tablet; 10 % oral solution; 10 

mEq ER capsule; 20 mEq packet 

Calcium with Vitamin D 

600 mg/400 IU tablet 

Nutritionals Omega-3 Acid (Lovaza) 1 gm capsule 

Thyroid Agents 

Levothyroxine (Synthroid) 

25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 

mcg, 150 mcg, 175 mcg, 200 mcg, & 300 mcg tablet 

Methimazole (Tapazole) 

10 mg tablet 

Propylthiouracil 

50 mg tablet 



Page 4 of 9


Vitamins 

Cyanocobalamin (B12) 

D-Vi-Sol 

Ergocalciferol (Vitamin D) 

Folic Acid 

Multivitamin 

Nicotinic Acid (Niacin) 

Poly-Vi-Sol 

Prenatal Vitamin 

Pyridoxine (B6) 

Syringes, B-12 

Thiamine (B1) 

Tocopherol (Vitamin E) 

1000 mcg/ml vial 

400 U/mL drops 

50,000 U capsule 

1 mg tablet 

500 mg tablet 

drops 

tablet 

50 mg tablet 

3 ml 25 G x 5/8” & 25 G x 1” 

50 mg tablet 

400 U 

Other Desmopressin (DDAVP) 0.1 mg & 0.2 mg tablet 

Antihistamines 

Antitussives/ Expectorants 

Combination Products 

ENT 

Cetirizine (Zyrtec) 

Chlorpheniramine (Chlor-Trimeton) 

Cyproheptadine (Periactin) 

Diphenhydramine (Benadryl) 

Fexofenadine (Allegra) 

Hydroxyzine (Atarax) 

Hydroxyzine Pamoate (Vistaril) 

Loratadine (Claritin) 

Meclizine (Antivert) 

Benzonatate (Tessalon) 

Guaifenesin (Mucinex/Robitussin) 

Dimaphen 

[brompheniramine/phenylephrine] 

Dimaphen DM 

[brompheniramine/phenylephrine/ 

dextromethorphan] 

Mucinex D [guaifenesin/sudafed] 

Mucinex DM 

[guaifenesin/dextromethorphan] 

Robitussin AC (C-III) [guaifenesin/codeine] 

Robitussin DM 

[guaifenesin/dextromethorphan] 

Tussionex (C-III) 

[chlorpheniramine/hydrocodone] 

10 mg tablet; 1 mg/1 ml syrup 

4 mg tablet 


25 mg & 50 mg capsule; 12.5 mg/5 ml syrup 


10 mg, 25 mg, & 50 mg tablet; 10 mg/5 ml oral solution/syrup 



25 mg chewable tablet 

100 mg & 200 mg perle 


1-2.5 mg/5 ml elixir 

1-2.5-5 mg/5 ml elixir 



100 mg-10 mg/5 ml syrup 

100 mg-10 mg/5 ml syrup 

8 mg-10 mg/5 ml Pennkinetic ER suspension 

Decongestants Pseudoephedrine (Sudafed) 30 mg tab; 30 mg/5 ml syrup 

Ear Preparations 

Auralgan [benzocaine/antipyrine] 

Carbamide peroxide (Debrox) 

Ciprodex [ciprofloxacin/dexamethasone] 

Cortisporin [hydrocortisone/polymyxin/ 

neomycin] 

Domeboro 

Ofloxacin (Floxin) 

Swim Ear [isopropyl alcohol/anhydrous 

glycerins] 

2% otic solution 

0.3% otic solution 

95%-5% otic drops 

Mouth and Lip Preparations 

Nasal Preparations 

Antidiarrheals 

Antiemetics 

Chlorhexidine (Peridex) 

Lidocaine viscous 

Magic Mouthwash 

Sodium Fluoride (Prevident 5000 Plus & 

Sensitive) 

Azelastine (Astelin) 

Fluticasone (Flonase) 

Mometasone (Nasonex) 

Oxymetazoline (Afrin) 

Sodium Chloride (Sea Soft) 

5.4-1.4% otic solution 

6.5% otic solution 

0.3-0.1% otic suspension 

3.5 mg/10,000 U/10 mg otic suspension 

0.12% rinse 

2% solution 

1:1:1 oral solution 

1.1%/5% paste 

137 mcg nasal spray 



0.05% nasal spray 

0.65% spray 

GASTROENTEROLOGY 

Lomotil (C-V) [diphenoxylate/atropine] 2.5 mg/0.025 mg tablet 

Loperamide (Imodium) 

2 mg capsule 

Metoclopramide (Reglan) 

Prochlorperazine (Compazine) 


10 mg tablet 



Page 5 of 9


Promethazine (Phenergan) 

25 mg tablet; 12.5 mg & 25 mg suppository; 6.25 mg/5 ml oral 

solution 

Scopolamine (Transderm Scop) 

1.5 mg patch 

Antiulcer 

Cimetidine (Tagamet) 

Dicyclomine (Bentyl) 

Esomeprazole (Nexium) 

Hyoscyamine (Levsin) 

Omeprazole (Priloec) 

Ranitidine (Zantac) 

Sucralfate (Carafate) 


10 mg capsule; 20 mg tablet; 10 mg/5 ml oral solution 


0.125 mg SL tablet 

10 mg, 20 mg, & 40 mg capsule 

150 mg tablet; 15 mg/ml syrup 

1 gm tablet 

Laxatives 

Bisacodyl (Dulcolax) 

Docusate Sodium (Colace) 

GO-Lytely PEG 3350 

Lactulose 

MoviPrep PEG 3350 

Polyethylene Glycol (Miralax) 

5 mg tablet; 10 mg suppository 


Powder for solution 

10 gm/15 ml syrup 

Powder for solution 

255 gm & 527 gm 

Ulcerative Colitis Sulfasalazine (Azulfidine) 500 mg tablet; 500 mg DR tablet 

Other GI Agents Neomycin (Mycifradin) 500 mg tablet 

HEMATOLOGY 

Anticoagulants 

Immunosuppression 

Dabigatran (Pradaxa) 

Enoxaparin (Lovenox) 

Warfarin (Coumadin) 

Melatonin/B6 

Cyclosporine (Sandimmune) 

Cyclosporine modified (Gengraf) 

Mycophenolate (Cellcept) 

HERBAL AND ALTERNATIVE THERAPIES 

3 mg/338 mcg tablet 

IMMUNOLOGY 


30 mg, 40 mg, 60 mg, 80 mg, 100 mg & 120 mg syringe 

1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, & 10 mg 

tablet 

25 mg capsule 

25 mg capsule 

250 mg capsule; 500 mg tablet 

MISCELLANEOUS 

Pill cutter 

NEUROLOGY 

Alzheimer’s Disease Donepezil (Aricept) 5 mg & 10 mg tablet 

Anticonvulsants 

Carbamazepine (Tegretol) 

Migraine Therapy 

Parkinsonian Agents 

Contraceptives 

EE = ethinyl estrogen 

Gabapentin (Neurontin) 

Phenobarbital (C-IV) 

Phenytoin (Dilantin) 

@ Rizatriptan (Maxalt/MLT) 

@ Sumatriptan (Imitrex) 

@ Zolmitriptan ZMT (Zomig) 

Benztropine (Cogentin) 

Ropinirole (Requip) 

Sinemet [carbidopa/levodopa] 

Trihexyphenidyl (Artane) 

Jolessa [EE/levonorgestrel] 

Levora [EE/levonorgestrel] 

Loestrin Fe [EE/norethindrone acetate] 

Low-Ogestrel [EE/norgestrel] 

Lutera [EE/levonorgestrel] 

Mononessa [EE/norgestimate] 

Necon 1/35 & 777 [EE/norethindrone] 

Nor-QD [norethindrone] 

Norinyl [EE/norethindrone] 

Nuvaring 

Ortho Tri-Cyclen Lo [EE/norgestimate] 

OrthoEvra 

Plan-B One Step 

Trinessa [EE/norgestimate] 

Trivora [EE/levonorgestrel] 

Yasmin [EE/drospirenone] 

OB/GYN 

100 mg chewable tablet; 100 mg/5 ml oral suspension; 200 mg 

tablet; 400 mg ER tablet 

100 mg, 300 mg, & 400 mg capsule; 600 mg & 800 mg tablet 

15 mg, 30 mg, 60 mg, & 100 mg tablet; 20 mg/5 ml oral solution 

50 mg chewable tablet; 100 mg capsule; 125 mg/5 ml oral 

suspension 

5 mg & 10 mg tablet; 5 mg & 10 mg ODT tablet 

25 mg, 50 mg, & 100 mg tablet; 6 mg/0.5 ml injection 



0.25 mg, 0.5 mg, 1 mg tablet 

10 mg/100 mg, 25 mg/100 mg & 25 mg/250 mg tablet 

2 mg tablet; 0.4 mg/ml elixir 

30 mcg/0.15 mg tablet 

30 mcg/ 0.15 mg tablet 

20 mcg/1 mg & 30 mcg/1.5 mg tablet 




35 mcg/1 mg & 35 mcg/0.5 mg, 0.75 mg, 1 mg tablet 

0/0.35 mg tablet 

0.035 mg/1 mg tablet 

0.015 mg/0.12 mg vaginal ring 

25 mcg/0.18 mg, 0.215 mg, 0.25 mg tablet 

20 mcg/150 mcg patch 

0/1.5 mg 

35 mcg/0.18 mg, 0.215 mg, 0.25 mg tablet 

30 mcg, 40 mcg, 30 mcg/0.05 mg, 0.075 mg, 0.125 mg tablet 

30 mcg/3 mg tablet 



Page 6 of 9


Yaz [EE/drospirenone] 

Zovia 1/35 [EE/ethynodiol diacetate] 



Estrogens 

Estradiol (Climara) 

Estradiol (Estrace) 

Estradiol (Estraderm) 

Estrogen, Conjugated (Premarin) 

0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 

0.075 mg/24 hr, & 0.1 mg/24 hr weekly patch 


0.05 mg & 0.1 mg bi-weekly patch 

0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, & 1.25 mg tablet; 0.625 mg/g 

vaginal cream 

Hormone Combinations Prem-Pro [estrogens, 

conjugated/medroxyprogesterone] 

0.3 mg/1.5 mg, 0.45 mg/1.5 mg, 0.625 mg/2.5 mg, & 0.625 mg/5 

mg tablet 

Ovulation Stimulants Clomiphene (Clomid) 50 mg tablet 

Progestins 

Medroxyprogesterone (Provera/Depo- 

Provera) 

Megesterol (Megace) 

Norethindrone (Aygestin) 

Progesterone (Prometrium) 

2.5 mg, 5 mg, & 10 mg tablet; 150 mg/ml syringe 

40 mg tablet 

5 mg tablet 


Selective Estrogen Receptor 

Modulators 

Raloxifene (Evista) 

Tamoxifen (Nolvadex) 

60 mg 


Uterotonics Methylergonovine (Methergine) 0.2 mg tablet 

Vaginitis Preparations Clindamycin (Clindesse) 

Metronidazole (Vandazol) 

Terconazole (Terazol 7) 

2% vaginal cream 

0.75% vaginal gel 

vaginal cream 

ONCOLOGY 

Hormones Goserelin acetate (Nolvadex) 3.6 mg & 10.8 mg implant 

Antiallergy Naphazoline (Naph-Con A) 

Olopatadine (Patanol) 

Olopatadine (Pataday) 

Antibacterials 

Cromolyn (Crolom) 

Erythromycin (Ilotycin) 

Gentamicin 

Moxifloxacin (Vigamox) 

Neosporin 

[neomycin/polymyxin/gramicidin] 

Polysporin [polymyxin/bacitracin] 

Polytrim [polymyxin/trimethoprim] 

Corticosteroid & 

Antibacterial Combinations 

Corticosteroids 

Sulfacetamide sodium (Bleph-10) 

Cortisporin 

[neomycin/polymyxin/hydrocortisone] 

Maxitrol 

[dexamethasone/neomycin/polymyxin] 

Tobradex [tobramycin/dexamethasone] 

Flourometholone (FML) 

Loteprednol (Alrex) 

Prednisolone 

OPHTHALMOLOGY 

Glaucoma Agents Betaxolol (Betoptic S) 

Brimonidine (Alphagan/P) 

Dorzolamide (Trusopt) 

Latanoprost (Xalatan) 

Pilocarpine (Pilopine HS/Isopto Carpine) 

Timolol (Timoptic/XE) 

Other Ophthalmologic 

Agents 

Antidepressants 

Artificial Tears 

Celluvisc 

@ Cyclosporine (Restasis) 

Lacrilube 

Amitriptyline (Elavil) 

Bupropion (Wellbutrin/SR/XL) 

Citalopram (Celexa) 

Desipramine (Norpramine) 

Doxepin (Sinequan) 

Fluoxetine (Prozac) 

0.1% ophthalmic solution 



4% ophthalmic solution 

5 mg/gm ophthalmic ointment 

0.3% ophthalmic solution; 0.3% ophthalmic ointment 


ophthalmic ointment & solution 

opthalmic ointment 

ophthalmic solution 

10% ophthalmic solution 

3.5 mg/10,000 U/10 mg ophthalmic suspension 

3.5 mg/10,000 U/0.1% ophthalmic ointment 

0.3-0.05% ophthalmic solution & ointment 

0.1% ophthalmic solution & ophthalmic ointment 

0.2% ophthalmic drops 

0.12% & 1% ophthalmic suspension 

0.25% drops 

0.15% & 0.2% ophthalmic solution 

2% drops 


1%, 2%, & 4% ophthalmic solution; 4% ophthalmic gel 

0.25% & 0.5% drops; 0.25% & 0.5% gel 

drops 


PSYCHIATRY 


75 mg & 100 mg tablet; 100 mg & 150 mg ER 12-hour tablet; 

150 mg & 300 mg ER 24-hour tablet 

10 mg, 20 mg, & 40 mg tablet; 10 mg/5 ml oral solution 

25 mg tablet 

10 mg, 25 mg, 50 mg, & 75 mg capsule; 10 mg/ml concentrate 

10 mg, 20 mg, & 40 mg capsule; 20 mg/5 ml oral solution 



Page 7 of 9

Antimanic (Bipolar) Agents 

Antipsychotics 

Anxiolytics/Hypnotics 

Drug Dependence Therapy 

Stimulants/ADHD/ 

Anorexiants 

Beta-Agonists 

Combinations 

Inhaled Steroids 

Leukotriene Inhibitors 

Other Pulmonary 

Medications 

Benign Prostatic 

Hyperplasia 

Bladder Agents 

Erectile Dysfunction 


Imipramine (Tofranil/PM) 

Mirtazapine (Remeron) 

Nortriptyline (Pamelor) 

Paroxetine (Paxil) 

@ Sertraline (Zoloft) 

Trazodone (Desyrel) 

Venlafaxine (Effexor/ XR) 

Divalproex (Depakote) 

Lithium Carbonate 

Lithium Citrate 

Topiramate (Topamax) 

Aripiprazole (Abilify) 

Quetiapine (Seroquel/XR) 

Risperidone (Risperdal) 

Thiothixene (Navane) 

Alprazolam (Xanax) (C-IV) 

Buspirone (Buspar) 

Clonazepam (Klonopin) (C-IV) 

Diazepam (Valium) (C-IV) 

Lorazepam (Ativan) (C-IV) 

Temazepam (Restoril) (C-IV) 

Zolpidem (Ambien) (C-IV) 

Bupropion (Zyban) 

Nicotine 

@ Varenicline (Chantix) 

Adderall/XR (C-II) 

[dextroamphetamine/amphetamine] 

Dextroamphetamine (Dexedrine) (C-II) 

Methylphenidate (Concerta) (C-II) 

Methylphenidate (Ritalin) (C-II) 

Albuterol (Ventolin) 

Levalbuterol (Xopenex) 

Salmeterol (Serevent) 

Advair [fluticasone/salmeterol] 

Combivent [albuterol/ipratropium] 

Dulera [mometason/formoterol] 

Budesonide (Pulmicort) 

Fluticasone (Flovent) 

Mometasone (Asmanex Twisthaler) 

@ Montelukast (Singulair) 

Ipratropium (Atrovent) 

Spacer (Easivent) 

Spacer/Mask (Opti-Chamber) 

Theophylline (Theocron/Theo-24) 

Tiotropium (Spiriva) 

Alfuzosin (Uroxatral) 

Finasteride (Proscar) 

Tamsulosin (Flomax) 

Oxybutynin (Ditropan/XL) 

Phenazopyridine (Pyridium) 

Tolterodine (Detrol LA) 

@ Sildenafil (Viagra) 

PULMONARY 

UROLOGY 

10 mg, 25 mg, & 50 mg tablet; 75 mg capsule 


10 mg, 25 mg, & 50 mg capsule 


25 mg, 50 mg, & 100 mg tablet; 20 mg/ml concentrate 


50 mg, & 75 mg tablet; 37.5 mg, 75 mg, & 150 mg capsule 

125 mg sprinkle capsule; 125 mg, 250 mg, & 500 mg DR tablet; 

250 mg & 500 mg ER tablet 


8 mEq/5 ml oral solution 



25 mg, 50 mg, 100 mg, 200 mg, 300 mg, & 400 mg tablet; 50 mg, 

150 mg, 200 mg, 300 mg & 400 mg XR tablet 

0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg & 4 mg tablet; 1 mg/ml oral 

solution 

5 mg capsule 

0.25 mg & 0.5 mg tablet 




1 mg tablet 



150 mg ER tablet 

7 mg, 14 mg & 21 mg patches; 2 mg & 4 mg gum 

starter & continuation pack 

10 mg tablet; 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, & 30 mg XR 

capsule 

15 SR capsule 

18 mg, 27 mg, 36 mg, & 54 mg SR tablet 


HFA MDI; 0.083% unit dose nebulizer solution; 2 mg/5 mL syrup 

HFA; 0.31 mg, 0.63 mg, 1.25 mg inhalation solution 

Diskus 

100 mcg/50 mcg, 250 mcg/50 mcg, & 500 mcg/50 mcg diskus; 45 

mcg/21 mcg, 115 mcg/21 mcg, & 230 mcg/21 mcg HFA MDI 

MDI 

100 mcg/5 mcg & 200 mcg/5 mcg inhaler 

0.25 mg & 0.5 mg respule 

44 mcg, 110 mcg, & 220 mcg HFA MDI; 50 mcg, 100 mcg, & 250 

mcg diskus 

110 mcg & 220 mcg 

4 mg packet; 4 mg & 5 mg chewable tablet; 10 mg tablet 

MDI; 0.02% unit dose nebulizer solution 

200 mg, 300 mg, & 400 mg ER tablet; 300 mg & 400 mg ER 

capsule; 80 mg/15 ml elixir 

INH capsule 

10 mg tablet 

5 mg tablet 

0.4 mg capsule 

5 mg tablet; 5 mg, 10 mg, & 15 mg ER tablet 


2 mg & 4 mg ER capsule 

25 mg, 50 mg, & 100 mg 



Page 8 of 9


FORMULARY RESTRICTIONS 

NON-CONTROLLED PRESCRIPTIONS 

@ Acyclovir Ointment: Limited to one tube per 30 days 

@ Bupropion (Zyban ONLY): available only for individuals who go 

through the HAWC 

@ Clarithromycin (Biaxin): for H. Pylori only 

@ Cyclosporine (Restasis): Must be prescribed by eye-care providers 

only 

@ Eszopiclone (Lunesta): must have failed Ambien IR and/or Sonata 

(off-base providers should state failure on Rx) 

@ Metaxalone: Use only after failed trial of cyclobenzaprine (Flexeril) 

@ Montelukast: Prior Authorization required 

@ Mupirocin Ointment: Limited to one tube per 30 days 

@ Omega-3 Acid (Lovaza): Prior Authorization required 

@ Rizatriptan: Max of 12 tabs/30 days; up to 36 tabs/90 days 

@ Sertraline: Doses > 200 mg daily must be from psychiatric only 

@ Sildenafil: Must be male and 40 years of age or older (Prior 

Authorization required for all others). For erectile dysfunction: 

max of 6 tabs/30 days; up to 18 tabs/90 days 

@ Sumatriptan: Max of 18 tabs/30 days; up to 54 tabs/90 days 

@ Tretinoin (Retin A): Age maximum = 35 

@ Varenicline: available only for individuals who go through the 

HAWC 

@ Vitamin E: Primary dysmenorrheal treatment only 

@ Zolmitriptan: Max of 12 tabs/30 days; up to 36/90 days 

@ Zolpidem extended release (Ambien CR): must have failed Ambien 

IR and/or Sonata (off-base providers should state failure on Rx) 

Underlined items are available within 3 duty days of receipt of valid 

prescription. 

Dashed-underlined items are available within 5 duty days of receipt 

of valid prescription. 

ALL PRESCRIPTIONS 

Must contain the provider’s original or electronic signature; stamps 

must be accompanied by the provider’s signature. 

Must be brought in to the pharmacy; faxes are not accepted at this 

time. 

Will be filled generically when available. 

Indications for use are highly encouraged to prevent prescription 

errors. 

Medication availability may be subject to change due to wholesaler 

or manufacturer availability. 

CONTROLLED PRESCRIPTIONS 

C-III, C-IV, & C-V medications are honored up to 180 days from 

the date the prescription was written. 

C-II medications will be filled at the discretion of the pharmacy 

and may not be refilled. 

Maintenance medications may be written for up to a 90 day supply 

with a maximum of 1 refill when requested by the prescriber. 

o C-II mediations may not be refilled. 

o C-III, C-IV, & C-V medications with “prn” in the sig are not 

considered maintenance. 

All other medications may be written for up to a 30 day supply 

with a maximum of 5 refills. 

Providers are reminded to include their DEA number on all 

controlled prescriptions. 

Honored up to 365 days from the date the prescription was written. 

Antibiotic prescriptions over 10 days old will be filled at the 

discretion of the pharmacy. 

May be written for up to a 90 day supply with a maximum of 3 

refills. 

We reserve the right to adjust quantities and refills to benefit the 

patient. 

o Example: 30 day supply with 11 refills may be changed to 90 

day supply with 3 refills 

HOURS OF OPERATION 

Monday - Friday 0730-1630 

Filling of prescriptions written by civilian providers ends daily at 

1615 

Closed weekends, Federal holidays, Family days, and for 

mandatory training (2 nd and 4 th Thursday of the month 1100-1630) 

OPERATIONS 

To avoid extended wait times, check in to drop off/activate your 

prescription and then come back. Filled prescriptions are held for 

up to 5 duty days. 

To transfer medications in, please bring all bottles with refills and 

allow at least 48 hours. 

Prescriptions may be filled after 75% of the previous days’ supply 

for the same drug/dose has elapsed. 

Wait time is directly correlated to prescription volume. 

HOW TO REFILL YOUR PRESCRIPTION 

Call in your refill to 1-478-327-8150 or 1-800-537-2137. 

o Call in before 1400 and it will be available for pick-up after 

1500 the next duty day (excluding federal holidays, family 

days, and mandatory training). 

o For example, if the prescription is called in on Saturday and 

Monday is a holiday, the prescription will be ready 

Wednesday after 1500. 

Use TRICARE Online at www.tricareonline.com. 

Wait until the time you are told your medication will be ready to 

come pick up it. 

If used correctly, these policies will result in limited wait time 

when picking up your prescription at the pharmacy. 

Walk-up refills are done on an emergency basis only at the 

discretion of the pharmacy and will be treated as all others (i.e. 

turn-around time is the same as above). Please plan accordingly!!! 

ITEMS NEEDED TO PICK UP OR DROP OFF A PRESCRIPTION 

ALL beneficiaries over the age of 18 

o Patient’s military ID (or front and back copy) 

Non-Active Duty members 

o Third Party Collections- electronic update must occur at least 

annually 

Although medications are provided at no cost to our patients, this 

service is not free – their service to our country and the American 

taxpayer pay the bill. 

Please consider less expensive alternatives whenever possible when 

prescribing. 



Page 9 of 9

78th MEDICAL GROUP FORMULARY - May 2013

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