Naval Hospital Jacksonville Formulary Alphabetical Listing ...

Naval Hospital Jacksonville Formulary Alphabetical Listing by Name

Updated Sept. 27, 2021 The availability of formulary items is subject to change

1

ACAMPROSATE

Acamprosate Outpatient Dosage Forms

Tablet Delayed Release, Oral, as calcium: Generic: 333 mg

Acarbose Outpatient Dosage Forms

Tablet, Oral: Generic: 25 mg, 50 mg, 100 mg

Acetaminophen Outpatient Dosage Forms

Suppository, Rectal: Generic: 120 mg, 650 mg

Suspension, Oral: Generic: 160 mg/5 mL

Tablet, Oral: Generic: 325 mg

Acetaminophen and Codeine Outpatient Dosage Forms

Solution, Oral [C-V]: Generic: Acetaminophen 120 mg and codeine phosphate 12 mg per 5 mL

Tablet, Oral [C-III]: Generic: Acetaminophen 300 mg and codeine phosphate 30 mg

Acetaminophen and Tramadol Outpatient Dosage Forms

Tablet, Oral: Generic: Acetaminophen 325 mg and tramadol hydrochloride 37.5 mg

Quantity Limits Ultracet: Maximum: 30 tablets in 22 days or 90 tablets in 68 days

AcetaZOLAMIDE Outpatient Dosage Forms

Capsule Extended Release 12 Hour, Oral: Generic: 500 mg

Tablet, Oral: Generic: 125 mg, 250 mg

Acetic Acid (Otic) Outpatient Dosage Forms

Solution, Otic: Generic: 2%

Acitretin Outpatient Dosage Forms

Capsule, Oral: Generic: 10 mg, 25 mg

Acyclovir (Systemic) Outpatient Dosage Forms

Capsule, Oral: Generic: 200 mg

Suspension, Oral: Generic: 200 mg/5 mL

Tablet, Oral: Generic: 400 mg, 800 mg

Acyclovir (Topical) Outpatient Dosage Forms

Ointment, External: Generic: 5%

Quantity Limits -

Adalimumab Outpatient Dosage Forms

Pen-injector Kit, Subcutaneous [preservative free]: Humira Pen: 40 mg/0.8 mL; 40 mg/0.4 mL [contains polysorbate 80] Humira Pen: 80 mg/0.8 mL (1 ea) [citrate free] Humira Pen-CD/UC/HS Starter: 40 mg/0.8 mL; 80 mg/0.8 mL [contains polysorbate 80] Humira Pen-Ps/UV/Adol HS Start: 40 mg/0.8 mL; 80 mg/0.8 mL & 40 mg/0.4 mL [contains polysorbate 80]

Prefilled Syringe Kit, Subcutaneous [preservative free]: Humira: 10 mg/0.2 mL; 20 mg/0.4 mL; 40 mg/0.8 mL; 10 mg/0.1 mL; 20 mg/ 0.2 mL; 40 mg/0.4 mL [contains polysorbate 80] Humira Pediatric Crohns Start: 40 mg/0.8 mL; 80 mg/0.8 mL; 80 mg/0.8 mL & 40 mg0.4 mL[contains polysorbate 80]

Formulary Comments Humira: Prior Authorization Required

Albendazole Outpatient Dosage Forms

Tablet, Oral: Albenza: 200 mg [contains saccharin sodium]

Albuterol Outpatient Dosage Forms

Aerosol Solution, Inhalation [CFC free]: ProAir HFA: 90 mcg/actuation

Nebulization Solution, Inhalation [preservative free]: Generic: 0.083% [2.5 mg/3 mL] Generic: 0.63 mg/3 mL; 1.25 mg/3 mL

Quantity Limits -

Alcohol (Isopropyl) Outpatient Dosage Forms

Pad, External: Generic: 70%

Alendronate Outpatient Dosage Forms

Solution, Oral: Generic: 70 mg/75 mL

Tablet, Oral: Generic: 5 mg, 10 mg, 35 mg, 70 mg

Alfuzosin Outpatient Dosage Forms

Tablet Extended Release 24 Hour, Oral, as hydrochloride: Generic: 10 mg

Allopurinol Outpatient Dosage Forms

Tablet, Oral, as sodium: Generic: 100 mg, 300 mg

ALPRAZolam Outpatient Dosage Forms

Tablet, Oral: Generic: 0.25 mg, 0.5 mg, 1 mg

Alprostadil Outpatient Dosage Forms

Kit, Intracavernosal: Edex: 10 mcg, 20 mcg, 40 mcg

Formulary Comments Muse: Limited to NH Jax Enrollees only

Quantity Limits Edex Kit (PS 2): Maximum: 3 units in 23 days or 9 units in 68 days; (PS 6) Maximum: 1 unit in 23 days or 3 units in 68 days

Aluminum Acetate Outpatient Dosage Forms

Powder, for Solution, External: Generic: Aluminum sulfate 1191 mg and calcium acetate 839 mg per packet Generic: Aluminum sulfate tetradecahydrate 1347 mg and calcium acetate monohydrate 952 mg per packet

Aluminum Chloride Hexahydrate Outpatient Dosage Forms

Solution, External: Drysol: 20%

Aluminum Hydroxide Outpatient Dosage Forms

Suspension, Oral: Generic: 320 mg/5 mL

Aluminum Hydroxide and Magnesium Trisilicate Outpatient Dosage Forms

Tablet, Chewable, Oral: Aluminum hydroxide 80 mg and magnesium trisilicate 20 mg

Amantadine Outpatient Dosage Forms

Capsule, Oral, as hydrochloride: Generic: 100 mg

Syrup, Oral, as hydrochloride: Generic: 50 mg/5 mL

Aminocaproic Acid Outpatient Dosage Forms

Tablet, Oral: Generic: 500 mg

Amiodarone Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 200 mg

Amitriptyline Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 10 mg, 25 mg, 50 mg, 75 mg

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BENZONATATE

Amitriptyline and Perphenazine Outpatient Dosage Forms

Tablet, Oral: Generic: Amitriptyline hydrochloride 25 mg and perphenazine 2 mg Generic: Amitriptyline hydrochloride 25 mg and perphenazine 4 mg

AmLODIPine Outpatient Dosage Forms

Tablet, Oral: Generic: 2.5 mg, 5 mg, 10 mg

Amlodipine and Benazepril Outpatient Dosage Forms

Capsule, Oral: Generic: 2.5/10: Amlodipine 2.5 mg and benazepril hydrochloride 10 mg Generic: 5/10: Amlodipine 5 mg and benazepril hydrochloride 10 mg Generic: 5/20: Amlodipine 5 mg and benazepril hydrochloride 20 mg Generic: 5/40: Amlodipine 5 mg and benazepril hydrochloride 40 mg Generic: 10/20: Amlodipine 10 mg and benazepril hydrochloride 20 mg Generic: 10/40: Amlodipine 10 mg and benazepril hydrochloride 40 mg

Amoxapine Outpatient Dosage Forms

Tablet, Oral: Generic: 50 mg

Amoxicillin Outpatient Dosage Forms

Capsule, Oral: Generic: 250 mg, 500 mg

Suspension Reconstituted, Oral: Generic: 125 mg/5 mL; 250 mg/5 mL; 400 mg/5 mL

Tablet Chewable, Oral: Generic: 125 mg, 250 mg

Amoxicillin and Clavulanate Outpatient Dosage Forms

Powder for Suspension, Oral: Augmentin: 125: Amoxicillin 125 mg and clavulanate potassium 31.25 mg per 5 mL [contains potassium 0.16 mEq/5 mL; banana flavor] Generic: 200: Amoxicillin 200 mg and clavulanate potassium 28.5 mg per 5 mL Generic: 250: Amoxicillin 250 mg and clavulanate potassium 62.5 mg per 5 mL Generic: 400: Amoxicillin 400 mg and clavulanate potassium 57 mg per 5 mL Generic: 600: Amoxicillin 600 mg and clavulanate potassium 42.9 mg per 5 mL

Tablet, Oral: Generic: 250: Amoxicillin 250 mg and clavulanate potassium 125 mg Generic: 500: Amoxicillin 500 mg and clavulanate potassium 125 mg Generic: 875: Amoxicillin 875 mg and clavulanate potassium 125 mg

Tablet, Extended Release, Oral: Generic: Amoxicillin 1000 mg and clavulanate acid 62.5 mg

Ampicillin Outpatient Dosage Forms

Capsule, Oral: Generic: 250 mg, 500 mg

Anastrozole Outpatient Dosage Forms

Tablet, Oral: Generic: 1 mg

Apixaban Outpatient Dosage Forms

Tablet, Oral: Eliquis: 2.5 mg, 5 mg Eliquis Starter Pack: 5 mg

Quantity Limits Eliquis dose pack: Maximum: 74 tablets (1 pack) per dispensing at retail or mail

ARIPiprazole Outpatient Dosage Forms

Tablet, Oral: Generic: 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg

Artificial Tears Outpatient Dosage Forms

Ointment, Ophthalmic: LubriFresh P.M Generic

Solution, Ophthalmic: Liquifilm Tears

Aspirin Outpatient Dosage Forms

Tablet, Oral: Generic: 325 mg

Tablet, Delayed Release, Oral: Generic: 81 mg, 325 mg

Atenolol Outpatient Dosage Forms

Tablet, Oral: Generic: 25 mg, 50 mg, 100 mg

AtoMOXetine Outpatient Dosage Forms

Capsule, Oral: Strattera: 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg

AtorvaSTATin Outpatient Dosage Forms

Tablet, Oral: Generic: 10 mg, 20 mg, 40 mg, 80 mg

Atropine (Ophthalmic) Outpatient Dosage Forms

Ointment, Ophthalmic, as sulfate: Generic: 1%

Solution, Ophthalmic, as sulfate: Generic: 1%

AzaTHIOprine Outpatient Dosage Forms

Tablet, Oral: Generic: 50 mg

Azelaic Acid Outpatient Dosage Forms

Gel, External: Finacea: 15% [contains benzoic acid, disodium edta, polysorbate 80, propylene glycol]

Azelastine (Nasal) Outpatient Dosage Forms

Solution, Nasal, as hydrochloride: Generic: 137 mcg/spray

Quantity Limits -

Azithromycin (Systemic) Outpatient Dosage Forms

Packet, Oral, as dihydrate [strength expressed as base]: Generic: 1 g

Suspension Reconstituted, Oral [strength expressed as base]: Generic: 100 mg/5 mL; 200 mg/5 mL

Tablet, Oral: Generic: 250 mg, 500 mg

Bacitracin, Neomycin, and Polymyxin B (Ophthalmic) Outpatient Dosage Forms

Ointment, Ophthalmic: Generic: Bacitracin 400 units, neomycin 3.5 mg, and polymyxin B 10,000 units per g

Bacitracin (Topical) Outpatient Dosage Forms

Ointment, External, as zinc [strength expressed as base]: Generic: 500 units/g (14 g)

Baclofen Outpatient Dosage Forms

Tablet, Oral: Generic: 10 mg, 20 mg

Belladonna and Opium Outpatient Dosage Forms

Suppository, Rectal: Generic: Belladonna extract 16.2 mg and opium 30 mg

Benazepril Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg, 20 mg, 40 mg

Benzocaine and Menthol Outpatient Dosage Forms

Lozenge, Mouth/Throat: Cepacol Sore Throat: Benzocaine 15 mg and Menthol 3.6 mg

Benzonatate Outpatient Dosage Forms

Capsule, Oral: Generic: 100 mg

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BENZOYL PEROXIDE

Benzoyl Peroxide Outpatient Dosage Forms

Gel, External: Generic: 5%; 10%

Liquid, External [wash]: Generic: 5%, 10%

Benztropine Outpatient Dosage Forms

Tablet, Oral, as mesylate: Generic: 0.5 mg, 1 mg, 2 mg

Betamethasone (Topical) Outpatient Dosage Forms

Cream, External, as dipropionate [strength expressed as base]: Generic: 0.05%

Lotion, External, as dipropionate [strength expressed as base]: Generic: 0.05%

Ointment, External, as dipropionate [strength expressed as base]: Generic: 0.05%

Ointment, External, as dipropionate augmented [strength expressed as base]: Generic: 0.05%

Betaxolol (Ophthalmic) Outpatient Dosage Forms

Suspension, Ophthalmic: Betoptic-S: 0.25%

Bethanechol Outpatient Dosage Forms

Tablet, Oral, as chloride: Generic: 10 mg, 25 mg

Bicalutamide Outpatient Dosage Forms

Tablet, Oral: Casodex: 50 mg Generic: 50 mg

Bimatoprost Outpatient Dosage Forms

Solution, Ophthalmic: Generic: 0.01%

Bisacodyl Outpatient Dosage Forms

Suppository, Rectal: Generic: 10 mg

Tablet Delayed Release, Oral: Generic: 5 mg

Bismuth Subcitrate, Metronidazole, and Tetracycline Outpatient Dosage Forms

Capsule, Oral: Pylera: Bismuth subcitrate potassium 140 mg, metronidazole 125 mg, and tetracycline hydrochloride 125 mg

Bismuth Subsalicylate Outpatient Dosage Forms

Tablet, Chewable, Oral: Generic: 262 mg

Brimonidine and Timolol Outpatient Dosage Forms

Solution, Ophthalmic: Combigan: Brimonidine tartrate 0.2% and timolol 0.5% [contains benzalkonium chloride]

Brimonidine (Ophthalmic) Outpatient Dosage Forms

Solution, Ophthalmic, as tartrate: Alphagan P: 0.1% Generic: 0.15%; 0.2%

Bromocriptine Outpatient Dosage Forms

Tablet, Oral: Generic: 2.5 mg

Budesonide (Oral Inhalation) Outpatient Dosage Forms

Suspension, Inhalation: Generic: 0.25 mg/2 mL; 0.5 mg/2 mL; 1 mg/2 mL

Quantity Limits -

Budesonide (Systemic) Outpatient Dosage Forms

Capsule Delayed Release Particles, Oral: Generic: 3 mg

Bumetanide Outpatient Dosage Forms

Tablet, Oral: Generic: 1 mg, 2 mg

BuPROPion Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 75 mg, 100 mg

Tablet Extended Release 12 Hour, Oral, as hydrochloride: Generic: 100 mg, 150 mg, 200 mg

Tablet Extended Release 24 Hour, Oral, as hydrochloride: Generic: 150 mg, 300 mg

BusPIRone Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg, 15 mg

Busulfan Outpatient Dosage Forms

Tablet, Oral: Myleran: 2 mg

Butalbital, Acetaminophen, and Caffeine Outpatient Dosage Forms

Tablet, Oral: Generic: Butalbital 50 mg, acetaminophen 325 mg, and caffeine 40 mg

Cabergoline Outpatient Dosage Forms

Tablet, Oral: Generic: 0.5 mg

Calcipotriene Outpatient Dosage Forms

Cream, External: Generic: 0.005%

Ointment, External: Generic: 0.005%

Solution, External: Generic: 0.005%

Quantity Limits -

Calcitonin Outpatient Dosage Forms

Solution, Nasal: Fortical: 200 units/actuation

Calcitriol (Systemic) Outpatient Dosage Forms

Capsule, Oral: Generic: 0.25 mcg, 0.5 mcg

Solution, Oral: Generic: 1 mcg/mL

Calcium Acetate Outpatient Dosage Forms

Capsule, Oral: Generic: 667 mg

Calcium and Vitamin D Outpatient Dosage Forms

Tablet, Oral: Generic: Calcium 500 mg and vitamin D 200 units

Calcium Carbonate Outpatient Dosage Forms

Tablet, Oral: Generic: 500 mg

Candesartan Outpatient Dosage Forms

Tablet, Oral, as cilexetil: Generic: 4 mg, 8 mg, 16 mg, 32 mg

Capsaicin Outpatient Dosage Forms

Cream, External: Generic: 0.025%

Captopril Outpatient Dosage Forms

Tablet, Oral: Generic: 12.5 mg, 25 mg, 50 mg, 100 mg

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CarBAMazepine Outpatient Dosage Forms

Capsule Extended Release 12 Hour, Oral: Generic: 100 mg, 300 mg

Suspension, Oral: Generic: 100 mg/5 mL

Tablet, Oral: Generic: 200 mg

Tablet, Chewable, Oral: Generic: 100 mg

Tablet Extended Release 12 Hour, Oral: Generic: 100 mg, 200 mg, 400 mg

Carbidopa and Levodopa Outpatient Dosage Forms

Tablet, Oral: Generic: 10/100: Carbidopa 10 mg and levodopa 100 mg [scored] Generic: 25/100: Carbidopa 25 mg and levodopa 100 mg [scored] Generic: 25/250: Carbidopa 25 mg and levodopa 250 mg [scored]

Tablet Extended Release, Oral: Generic: Carbidopa 25 mg and levodopa 100 mg Generic: Carbidopa 50 mg and levodopa 200 mg

Carboxymethylcellulose Outpatient Dosage Forms

Solution, Ophthalmic, as sodium: Refresh Plus: 0.5% Refresh Tears: 0.5% Generic: 1%

Carisoprodol Outpatient Dosage Forms

Tablet, Oral: Generic: 350 mg

Carvedilol Outpatient Dosage Forms

Capsule Extended Release 24 Hour, Oral, as phosphate: Generic: 10 mg, 20 mg, 40 mg, 80 mg

Tablet, Oral: Generic: 3.125 mg, 6.25 mg, 12.5 mg, 25 mg

Cefdinir Outpatient Dosage Forms

Capsule, Oral: Generic: 300 mg

Suspension Reconstituted, Oral: Generic: 125 mg/5 mL, 250 mg/5 mL

Cefixime Outpatient Dosage Forms

Suspension Reconstituted, Oral: Generic: 100 mg/5 mL (50 mL); 200 mg/5 mL (50 mL, 75 mL)

Tablet Chewable, Oral: Suprax: 200 mg

Cefpodoxime Outpatient Dosage Forms

Suspension Reconstituted, Oral: Generic: 100 mg/5 mL (50 mL, 100 mL)

Tablet, Oral: Generic: 100 mg, 200 mg

Cefprozil Outpatient Dosage Forms

Suspension Reconstituted, Oral: Generic: 125 mg/5 mL; 250 mg/5 mL

Cefuroxime Outpatient Dosage Forms

Tablet, Oral, as axetil [strength expressed as base]: Generic: 250 mg, 500 mg

Celecoxib Outpatient Dosage Forms

Capsule, Oral: CeleBREX: 100 mg, 200 mg Generic: 50 mg

Cephalexin Outpatient Dosage Forms

Capsule, Oral: Generic: 250 mg, 500 mg

Suspension Reconstituted, Oral: Generic: 125 mg/5 mL, 250 mg/5 mL

Cetirizine (Systemic) Outpatient Dosage Forms

Syrup, Oral, as hydrochloride: Generic: 1 mg/mL

CIPROFLOXACIN (OPHTHALMIC)

Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg

Chlorambucil Outpatient Dosage Forms

Tablet, Oral: Leukeran: 2 mg

ChlordiazePOXIDE Outpatient Dosage Forms

Capsule, Oral, as hydrochloride: Generic: 5 mg, 10 mg, 25 mg

Chlorhexidine Gluconate (Oral) Outpatient Dosage Forms

Solution, Mouth/Throat: Generic: 0.12%

Chloroquine Outpatient Dosage Forms

Tablet, Oral, as phosphate: Generic: 250 mg [equivalent to chloroquine base 150 mg], 500 mg [equivalent to chloroquine base 300 mg]

Chlorpheniramine Outpatient Dosage Forms

Tablet, Oral, as maleate: Generic: 4 mg

ChlorproMAZINE Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 25 mg, 50 mg, 100 mg

Chlorthalidone Outpatient Dosage Forms

Tablet, Oral: Generic: 25 mg, 50 mg

Chlorzoxazone Outpatient Dosage Forms

Tablet, Oral: Generic: 500 mg

Cholecalciferol Outpatient Dosage Forms

Liquid, Oral: Generic: 400 units/mL

Tablet, Oral: Generic: 400 units, 1000 units

Cholestyramine Resin Outpatient Dosage Forms

Powder, Oral: Generic: 4 g/dose

Chorionic Gonadotropin (Human) Outpatient Dosage Forms

Solution Reconstituted, Intramuscular: Generic: 10,000 units

Ciclopirox Outpatient Dosage Forms

Solution, External: Generic: 8%

Cilostazol Outpatient Dosage Forms

Tablet, Oral: Generic: 50 mg, 100 mg

Cimetidine Outpatient Dosage Forms

Solution, Oral, as hydrochloride [strength expressed as base]: Generic: 300 mg/5 mL

Tablet, Oral: Generic: 400 mg

Ciprofloxacin and Dexamethasone Outpatient Dosage Forms

Suspension, Otic: Ciprodex: Ciprofloxacin 0.3% and dexamethasone 0.1% [contains benzalkonium chloride, edetate disodium, tyloxapol]

Ciprofloxacin (Ophthalmic) Outpatient Dosage Forms

Solution, Ophthalmic, as hydrochloride: Generic: 0.3% (2.5 mL, 5 mL, 10 mL)

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CIPROFLOXACIN (SYSTEMIC)

Ciprofloxacin (Systemic) Outpatient Dosage Forms

Tablet, Oral, as hydrochloride [strength expressed as base]: Generic: 100 mg, 250 mg, 500 mg, 750 mg

Citalopram Outpatient Dosage Forms

Solution, Oral: Generic: 10 mg/5 mL

Tablet, Oral: Generic: 10 mg, 20 mg, 40 mg

Clarithromycin Outpatient Dosage Forms

Tablet, Oral: Generic: 250 mg, 500 mg

Tablet Extended Release 24 Hour, Oral: Generic: 500 mg

Clindamycin and Benzoyl Peroxide Outpatient Dosage Forms

Gel, External: Duac: Clindamycin phosphate 1.2% and benzoyl peroxide 5%

Clindamycin (Systemic) Outpatient Dosage Forms

Capsule, Oral, as hydrochloride [strength expressed as base]: Generic: 150 mg, 300 mg

Solution Reconstituted, Oral, as palmitate hydrochloride [strength expressed as base]:

Generic: 75 mg/5 mL

Clindamycin (Topical) Outpatient Dosage Forms

Cream, Vaginal, as phosphate [strength expressed as base]: Generic: 2%

Gel, External, as phosphate [strength expressed as base]: Generic: 1%

Lotion, External, as phosphate [strength expressed as base]: Generic: 1%

Solution, External, as phosphate [strength expressed as base]: Generic: 1%

Swab, External, as phosphate [strength expressed as base]: Generic: 1%

Clobetasol Outpatient Dosage Forms

Cream, External, as propionate: Generic: 0.05% [BCF]

Foam, External, as propionate: Generic: 0.05%

Lotion, External, as propionate: Generic: 0.05% (59 mL, 118 mL)

Ointment, External, as propionate: Generic: 0.05% [BCF]

Quantity Limits -

ClomiPHENE Outpatient Dosage Forms

Tablet, Oral, as citrate: Generic: 50 mg

ClomiPRAMINE Outpatient Dosage Forms

Capsule, Oral, as hydrochloride: Generic: 25 g, 50 mg

ClonazePAM Outpatient Dosage Forms

Tablet, Oral: Generic: 0.5 mg, 1 mg

CloNIDine Outpatient Dosage Forms

Patch Weekly, Transdermal: Generic: 0.1 mg/24 hr; 0.2 mg/24 hr; 0.3 mg/24 hr

Tablet, Oral, as hydrochloride: Generic: 0.1 mg, 0.2 mg, 0.3 mg

Tablet Extended Release 12 Hour, Oral, as hydrochloride: Generic: 0.1 mg

Clopidogrel Outpatient Dosage Forms

Tablet, Oral: Generic: 75 mg

Clorazepate Outpatient Dosage Forms

Tablet, Oral, as dipotassium: Generic: 7.5 mg

Clotrimazole (Oral) Outpatient Dosage Forms

Lozenge, Mouth/Throat: Generic: 10 mg

Clotrimazole (Topical) Outpatient Dosage Forms

Cream, External: Generic: 1%

Cream, Vaginal: Generic: 1%

Solution, External: Generic: 1%

Colchicine Outpatient Dosage Forms

Tablet, Oral: Colcrys: 0.6 mg [scored]

Colestipol Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 1 g

Contraceptive Devices Outpatient Dosage Forms

Diaphragm, Vaginal: Generic: Various sizes

Quantity Limits DoD single dose Meds >30 days

Cortisone Outpatient Dosage Forms

Tablet, Oral, as acetate: Generic: 25 mg

Cromolyn (Nasal) Outpatient Dosage Forms

Aerosol Solution, Nasal, as sodium: Generic: 5.2 mg/actuation

Cromolyn (Oral Inhalation) Outpatient Dosage Forms

Nebulization Solution, Inhalation, as sodium: Generic: 20 mg/2 mL

Quantity Limits -

Cyanocobalamin Outpatient Dosage Forms

Solution, Injection: Generic: 1000 mcg/mL

Cyclobenzaprine Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg

Quantity Limits -

Cyclopentolate Outpatient Dosage Forms

Solution, Ophthalmic, as hydrochloride: Generic: 1%, 2%

Cyclophosphamide Outpatient Dosage Forms

Tablet, Oral: Generic: 25 mg, 50 mg

CycloSPORINE (Ophthalmic) Outpatient Dosage Forms

Emulsion, Ophthalmic [preservative free]: Restasis: 0.05% [contains polysorbate 80]

Formulary Restrictions Restricted to Ophthalmology and Optometry only

Quantity Limits -

CycloSPORINE (Systemic) Outpatient Dosage Forms

Capsule, Oral: Generic: 25 mg, 50 mg, 100 mg

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DICYCLOMINE

Cyproheptadine Outpatient Dosage Forms

Syrup, Oral, as hydrochloride: Generic: 2 mg/5 mL

Tablet, Oral, as hydrochloride: Generic: 4 mg

Dabigatran Etexilate Outpatient Dosage Forms

Capsule, Oral: Pradaxa: 75 mg Pradaxa: 75 mg [contains fd&c yellow #6 (sunset yellow)] Pradaxa: 110 mg, 150 mg [contains fd&c blue #2 (indigotine)] Pradaxa: 150 mg [contains fd&c blue #2 (indigotine), fd&c yellow #6 (sunset yellow)]

Danazol Outpatient Dosage Forms

Capsule, Oral: Generic: 200 mg

Dantrolene Outpatient Dosage Forms

Capsule, Oral, as sodium: Generic: 25 mg, 100 mg

Dapsone (Systemic) Outpatient Dosage Forms

Tablet, Oral: Generic: 25 mg, 100 mg

Desipramine Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 10 mg, 25 mg, 50 mg

Desmopressin Outpatient Dosage Forms

Tablet, Oral, as acetate: Generic: 0.1 mg, 0.2 mg

Desonide Outpatient Dosage Forms

Cream, External: Generic: 0.05%

Ointment, External: Generic: 0.05%

Desoximetasone Outpatient Dosage Forms

Cream, External: Generic: 0.25%

Desvenlafaxine Outpatient Dosage Forms

Tablet Extended Release 24 Hour, Oral, as succinate [strength expressed as base]: Generic: 25 mg, 50 mg, 100 mg

DexAMETHasone (Systemic) Outpatient Dosage Forms

Solution, Oral: Generic: 0.5 mg/5 mL

Tablet, Oral: Generic: 0.5 mg, 0.75 mg, 4 mg

Dexmethylphenidate Outpatient Dosage Forms

Capsule Extended Release 24 Hour, Oral, as hydrochloride: Generic: 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg

Tablet, Oral, as hydrochloride: Generic: 2.5 mg, 5 mg, 10 mg

Dextroamphetamine Outpatient Dosage Forms

Tablet, Oral, as sulfate: Generic: 5 mg

Dextroamphetamine and Amphetamine Outpatient Dosage Forms

Capsule, Extended release, Oral: Generic: 5 mg [dextroamphetamine sulfate 1.25 mg, dextroamphetamine saccharate 1.25 mg, amphetamine aspartate monohydrate 1.25 mg, amphetamine sulfate 1.25 mg (equivalent to amphetamine base 3.1 mg)] Generic: 10 mg [dextroamphetamine sulfate 2.5 mg, dextroamphetamine saccharate 2.5 mg, amphetamine aspartate monohydrate 2.5 mg, amphetamine sulfate 2.5 mg (equivalent to amphetamine base 6.3 mg)] Generic: 15 mg [dextroamphetamine sulfate 3.75 mg, dextroamphetamine saccharate 3.75 mg, amphetamine aspartate monohydrate 3.75 mg, amphetamine sulfate 3.75 mg (equivalent to amphetamine base 9.4 mg)]

Generic: 20 mg [dextroamphetamine sulfate 5 mg, dextroamphetamine saccharate 5 mg, amphetamine aspartate monohydrate 5 mg, amphetamine sulfate 5 mg (equivalent to amphetamine base 12.5 mg)]

Generic: 25 mg [dextroamphetamine sulfate 6.25 mg, dextroamphetamine saccharate 6.25 mg, amphetamine aspartate monohydrate 6.25 mg, amphetamine sulfate 6.25 mg (equivalent to amphetamine base 15.6 mg)]

Generic: 30 mg [dextroamphetamine sulfate 7.5 mg, dextroamphetamine saccharate 7.5 mg, amphetamine aspartate monohydrate 7.5 mg, amphetamine sulfate 7.5 mg (equivalent to amphetamine base 18.8 mg)]

Tablet, Oral: Generic: 5 mg [dextroamphetamine sulfate 1.25 mg, dextroamphetamine saccharate 1.25 mg, amphetamine aspartate monohydrate 1.25 mg, amphetamine sulfate 1.25 mg (equivalent to amphetamine base 3.13 mg)] Generic: 10 mg [dextroamphetamine sulfate 2.5 mg, dextroamphetamine saccharate 2.5 mg, amphetamine aspartate monohydrate 2.5 mg, amphetamine sulfate 2.5 mg (equivalent to amphetamine base 6.3 mg)] Generic: 20 mg [dextroamphetamine sulfate 5 mg, dextroamphetamine saccharate 5 mg, amphetamine aspartate monohydrate 5 mg, amphetamine sulfate 5 mg (equivalent to amphetamine base 12.6 mg)] Generic: 30 mg [dextroamphetamine sulfate 7.5 mg, dextroamphetamine saccharate 7.5 mg, amphetamine aspartate monohydrate 7.5 mg, amphetamine sulfate 7.5 mg (equivalent to amphetamine base 18.8 mg)]

Diabetic Supplies Outpatient Dosage Forms

Lancets Syringe:

Generic: 0.5 mL [Lo-Dose] Generic: 1 mL Test Strips: FreeStyle Lite Test Strips Precision Xtra Blood Glucose Test Strips Quantity Limits Select Glucose Test Strips: Maximum: 100 units in 22 days or 300 units in 68 days Select Lancets: Maximum: 204 units in 22 days or 612 units in 68 days Select Syringes; Needles; Supplies: Maximum: 200 units in 22 days or 600 units in 68 days V-Go 20, V-Go 30, V-Go 40: Maximuim: 30 units in 23 days or 90 units in 68 days

DiazePAM Outpatient Dosage Forms

Gel, Rectal: Generic: 10 mg (1 ea); 20 mg (1 ea)

Solution, Oral: Generic: 1 mg/mL (5 mL)

Tablet, Oral: Generic: 2 mg, 5 mg

Dibucaine Outpatient Dosage Forms

Ointment, External: Generic: 1%

Diclofenac (Ophthalmic) Outpatient Dosage Forms

Solution, Ophthalmic, as sodium: Generic: 0.1%

Diclofenac (Systemic) Outpatient Dosage Forms

Tablet, Oral, as potassium: Generic: 50 mg

Tablet Delayed Release, Oral, as sodium: Generic: 25 mg, 50 mg, 75 mg

Tablet Extended Release 24 Hour, Oral, as sodium: Generic: 100 mg

Quantity Limits Cambia 50 mg Oral Packet: Maximum: 18 packets per 30 days at retail or 54 packets per 90 days at mail.

Diclofenac (Topical) Outpatient Dosage Forms

Gel, Transdermal, as sodium: Voltaren: 1% [contains isopropyl alcohol, propylene glycol]

Dicloxacillin Outpatient Dosage Forms

Capsule, Oral: Generic: 250 mg, 500 mg

Dicyclomine Outpatient Dosage Forms

Capsule, Oral, as hydrochloride: Generic: 10 mg

Solution, Oral, as hydrochloride: Generic: 10 mg/5 mL

Tablet, Oral, as hydrochloride: Generic: 20 mg

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DIGOXIN

Digoxin Outpatient Dosage Forms

Solution, Oral: Generic: 0.05 mg/mL

Tablet, Oral: Generic: 0.125 mg, 0.25 mg

DilTIAZem Outpatient Dosage Forms

Capsule Extended Release 24 Hour, Oral, as hydrochloride: Generic: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

Tablet, Oral, as hydrochloride: Generic: 60 mg

DimenhyDRINATE Outpatient Dosage Forms

Tablet, Oral: Generic: 50 mg

DiphenhydrAMINE (Systemic) Outpatient Dosage Forms

Capsule, Oral, as hydrochloride: Generic: 25 mg, 50 mg

Liquid, Oral, as hydrochloride: Generic: 12.5 mg/5 mL

Diphenoxylate and Atropine Outpatient Dosage Forms

Tablet, Oral: Generic: Diphenoxylate hydrochloride 2.5 mg and atropine sulfate 0.025 mg

Dipyridamole Outpatient Dosage Forms

Tablet, Oral: Generic: 25 mg, 50 mg

Disopyramide Outpatient Dosage Forms

Capsule, Oral: Generic: 100 mg, 150 mg

Disulfiram Outpatient Dosage Forms

Tablet, Oral: Generic: 250 mg

Docusate Outpatient Dosage Forms

Capsule, Oral, as calcium: Generic: 240 mg

Capsule, Oral, as sodium: Generic: 100 mg

Liquid, Oral, as sodium: Generic: 50 mg/5 mL

Syrup, Oral, as sodium: Generic: 60 mg/15 mL

Donepezil Outpatient Dosage Forms

Tablet, Oral, as hydrochloride: Generic: 5 mg, 10 mg

Dorzolamide Outpatient Dosage Forms

Solution, Ophthalmic: Generic: 2%

Dorzolamide and Timolol Outpatient Dosage Forms

Solution, Ophthalmic [drops]: Generic: Dorzolamide 2% [20 mg/mL] and timolol 0.5% [5 mg/mL]

Doxazosin Outpatient Dosage Forms

Tablet, Oral: Generic: 1 mg, 2 mg, 4 mg, 8 mg

Doxepin (Systemic) Outpatient Dosage Forms

Capsule, Oral: Generic: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg

Concentrate, Oral: Generic: 10 mg/mL

Doxycycline Outpatient Dosage Forms

Capsule, Oral, as hyclate [strength expressed as base]: Generic: 100 mg

Tablet, Oral, as hyclate [strength expressed as base]: Generic: 20 mg, 100 mg

Doxylamine Outpatient Dosage Forms

Tablet, Oral, as succinate: Sleep Aid: 25 mg [scored; contains fd&c blue #1 aluminum lake]

Dulaglutide Outpatient Dosage Forms

Solution Pen-injector, Subcutaneous [preservative free]: Trulicity: 0.75 mg/0.5 mL (0.5 mL); 1.5 mg/0.5 mL (0.5 mL); 3 mg/0.5 mL (0.5 mL); 4.5 mg/0.5 mL (0.5 mL) [contains polysorbate 80]

Formulary Comments Prior Authorization Required

DULoxetine Outpatient Dosage Forms

Capsule Delayed Release Particles, Oral: Generic: 20 mg, 30 mg, 40 mg, 60 mg

Eletriptan Outpatient Dosage Forms

Tablet, Oral: Relpax: 20 mg, 40 mg Generic: 20 mg, 40 mg

Quantity Limits Relpax: Maximum: 13 tablets in 30 days or 36 tablets in 90 days

Empagliflozin Outpatient Dosage Forms

Tablet, Oral: Jardiance: 10 mg, 25 mg

Empagliflozin and Metformin Outpatient Dosage Forms

Tablet, Oral: Synjardy: Empagliflozin 5 mg and metformin hydrochloride 500 mg Synjardy: Empagliflozin 5 mg and metformin hydrochloride 1000 mg Synjardy: Empagliflozin 12.5 mg and metformin hydrochloride 500 mg Synjardy: Empagliflozin 12.5 mg and metformin hydrochloride 1000 mg

Tablet Extended Release 24 Hour, Oral: Synjardy XR: Empagliflozin 5 mg and metformin hydrochloride 1000 mg Synjardy XR: Empagliflozin 10 mg and metformin hydrochloride 1000 mg Synjardy XR: Empagliflozin 12.5 mg and metformin hydrochloride 1000 mg Synjardy XR: Empagliflozin 25 mg and metformin hydrochloride 1000 mg

Enalapril Outpatient Dosage Forms

Tablet, Oral, as maleate: Generic: 2.5 mg, 5 mg, 10 mg, 20 mg

Formulary Comments Oral solution limited to NH Jax Enrollees only

Enoxaparin Outpatient Dosage Forms

Solution, Subcutaneous, as sodium [preservative free]: Lovenox: 120 mg/0.8 mL; 150 mg/mL [prefilled syringe] Generic: 30 mg/0.3 mL; 40 mg/0.4 mL; 60 mg/0.6 mL; 80 mg/0.8 mL; 100 mg/mL

Entacapone Outpatient Dosage Forms

Tablet, Oral: Generic: 200 mg

EPINEPHrine (Systemic) Outpatient Dosage Forms

Device, Injection: EpiPen 2-Pak: 0.3 mg/0.3 mL [latex free; contains sodium metabisulfite] EpiPen Jr 2-Pak: 0.15 mg/0.3 mL [contains sodium metabisulfite]

Ergocalciferol Outpatient Dosage Forms

Capsule, Oral: Generic: 50,000 units

Ergoloid Mesylates Outpatient Dosage Forms

Tablet, Oral: Generic: 1 mg

Erythromycin (Ophthalmic) Outpatient Dosage Forms

Ointment, Ophthalmic: Generic: 5 mg/g

Erythromycin (Systemic) Outpatient Dosage Forms

Suspension Reconstituted, Oral, as ethylsuccinate: E.E.S. Granules: 200 mg/5 mL [cherry flavor]

Tablet, Oral: Generic: 250 mg, 500 mg

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