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Formulary Listing

Jan. 17, 2007 PRINT | E-MAIL
Accutane 20, 40mg caps
Acetaminophen w/Cod Elixir-@
Acetaminophen w/Cod Tabs #3-@
Acetic Acid/HC Otic Soln
Acetic Acid/Alum Acetate Otic Soln
Aciphex 20mg tab
Actonel 5, 35mg tabs
Actos 30 & 45mg tabs
Acyclovir 200 cap, 800 tab
Acyclovir 5% Ointment 3gm
Accuhist Drops
Adalat CC 30, 60, 90mg tab
Adderall XR 5, 10, 20, 30mg
Advair 100, 250, 500 oral inh
AeroChamber
AeroChamber w/mask (s, m, l)
Afrin 0.05% 12-H Nasal Spray
Albuterol 0.083% Unit dose
Albuterol MDI; Inh Sol
Albuterol 4mg tabs; PO syrup
Albuterol/Ipratropium MDI
Aldactone 25mg tab
Alendronate 5, 10, 35, 70mg tabs
Alendronate Plus D 70mg/2800 IU
Alesse
Alfuzosin 10 mg ER tablet
Allopurinol 100, 300mg tab
Alphagan-P 0.15% Opth Sol 5ml
Amantadine 100mg cap
Amaryl 1, 2, 4mg tabs
Ambien 10mg tabs-@
Amiodarone 200 mg tab
Amitriptyline 25mg tab
Amlodipine/Benazepril 5/10, 5/20, 10/20 mg capsule
Amoxil 125/5, 250/5, 400/5 susp
Amoxil cap 250, 500; 875 mg tab
Amox/Clav 500, 875 mg tab
Amox/Clav susp 250/5, 400/5mL
Amox/Clav ES susp 600/mL
Antivert 25mg tab
Anusol-HC 25mg Suppos
Anusol-HC 2.5% rectal CR
Apresoline 25mg tab
Aricept tablets 5, 10 mg
Artane 2mg tab
Asacol 400mg tab
Atacand 16 & 32mg tab
Atacand HCT 16/12.5, 32/12.5mg
Atarax 10 & 25mg tab & syrup
Atenolol 25 & 50mg tab
Ativan tab 1mg-@
Atrovent HFA Oral Inh
Atrovent UD Oral neb sol 0.02%
Augmentin susp 250/5, 400/5mL
Augmentin ES susp 600/5ml
Augmentin tablets 500, 875mg
Auralgan otic soln 10ml
Avandia 2, 4, 8mg tab
Avandamet 1/500, 2/500, 4/500
Avelox 400mg tablets
Avita Cream 0.025%, 0.05%
Azathioprine tab 50 mg
Azithromycin 250mg tab
Azithromycin Susp 100/5, 200/5
Azmacort Oral Inh (200 puffs)
Azulfadine 500mg tab
B-12 inj 1000 mcg/ml; 500mg tab
Bacitracin Ophth Oint 3.5gm
Bacitracin Top Oint 15gm
Bactrim Susp; Bactrim DS Tab
Bactroban 2% Top oint 15gm
Bellergal-S tab
Benemid 500mg tab
Bentyl 20mg tab
Benztropine 2mg
Benzonatate 100mg Perles
Benzoyl peroxide gel 5 & 10%
Betaxolol 0.25% Opth Susp 5ml
Betoptic-S 0.25% Susp 5ml
Biaxin susp 125 & 250mg/5ml
Bisacodyl 5mg tab
Boniva tab 150mg
Brimonidine 0.15% Opth Sol 5ml
Budesonide Resp 0.25/2, 0.5/2ml
# Bupropion SR 100, 150 mg tab
Buspar 5mg, 10mg tab
Buspirone 5, 10mg tab
Calan SR 180 & 240mg tab
Candesartan 16, 32mg tab
Candesartan/HCTZ 16-; 32/12.5
Capoten 25mg tab
Captopril 25mg tab
Carbamazepine 200mg tab
Carbidopa/levodopa
Carbinoxamine 1mg/pseudoephed 15mg/ml drops
Cardura 2, 4 & 8mg tab
Carisoprodal tab 350 mg
Catapres 0.1 & 0.2mg tab
Cefdinir 125/5; 250/5 susp
Cefprozil 125/5, 250/5 susp
Cefprozil tablets 250, 500mg
Cefzil susp 125 & 250mg/5ml
Cefzil tab 250 & 500mg
Celexa 20, 40 mg tab
Cephalexin 125/5, 250/5 susp
Cephalexin capsule 250, 500mg
Cetirizine 1mg/ml syrup (for peds)
Cetirizine-D 12-Hour Tabs
Chlorhexidine 0.12% oral rinse
Chlorthalidone 25mg tabs
Chloroquine Phosphate tab 500mg
Ciloxan Opth Sol 5ml
Cipro tab 500mg
Ciprofloxacin 500 mg tabs
Ciprofloxacin Opth Sol 5ml
Citalopram 20, 40mg tabs
Claritin 10mg
Clarithromycin 125/5, 250mg/5ml
Cleocin 2% Vag Cr 40gm
Cleocin cap 150 & 300mg
Cleocin-T 1% topical Soln 60ml
Clindamycin 150 & 300mg Cap
Clindamycin 2% Vag Cr 40gm
Clindamycin 1% Top Sol 60ml
Clomid 50mg tab
Clomiphene 50mg tab
Clonazepam 0.5 & 1mg tab-@
Clonidine 0.1, 0.2mg tab
Clopidogrel 75mg tab
Clotrimazole 1% top crm/vag / topical
Codeine sulfate 30mg tab (C-II)*
Cogentin 2mg tab
Colchicine 0.6 mg tab
Colestid 1gm tab
Colestipol 1gm tab
Co-Lyte powder (mix to 4,000ml)
Combivent Oral Inhaler
Concerta 18, 27, 36, 54mg (C-II)*
Condylox 0.5% topical solution
Cordarone 200 mg tab
Cortisporin Otic Susp 10ml
Cosopt Ophth Soln
Coumadin tablets 1, 2, 2.5, 5mg
Crolom 4% Ophth Soln 10 ml
Cromolyn ophth soln
Cromolyn Oral Inh sol 2ml amps;4% ophth solution
Cyanocobalamin Inj 1000 mcg/ml
Cyanocobalamin tablets 500 mcg
Cyclobenzaprine 10mg tab
Cyproheptadine 4mg tab
Cytomel 25mcg
Cytotec 200mcg tab
Darvocet N-100-@
DDAVP Spray
Decadron 0.5 & 4mg tab
Deconamine SR cap
Demerol 50mg tab (C-II)*
Demulen 1/35
Depakene Syrup 250mg/5ml
Depakote 125, 250, 500 mg
Depakote ER 500mg
Desogen
Desyrel 100, 150mg tab
Detrol LA 2, 4 mg cap
Dexamethasone 0.5 & 4mg tab
Dexedrine 5mg tab (C-II)*
Diabeta 2.5mg, 5mg tab
Diazepam 5mg tab-@
Diclofenac Ophth Sol 0.1% 5ml
Dicloxicillin 250mg cap
Dicyclomine 20mg tab
# Diflucan 150mg SINGLE DOSE
Digoxin 0.125, 0.25mg tab
Dilantin 50, 100mg cap; 125/5 liq
Diltiazem 60mg tab
Diltiazem ER 120, 180, 240, 300
Diovan 80, 160, 320 mg tab
Diovan HCT 80/12.5, 160/12.5, 160/25 tab
Dipyridamole 25mg tab
Disalcid 500mg tab
Ditropan 5mg tab; 1mg/ml soln
Divalproex 125, 250, 500mg
Divalproex ER 500mg
Docusate calcium 240 mg cap
Domeboro Topical Packets
Domeboro Otic Solution
Donepezil tablets 5, 10 mg
Donnatal tab & elixir
Doxazosin 2, 4, 8mg tab
Doxepin 10, 25 mg cap
Doxycycline 100mg cap
Drysol topical soln 30ml
Duricef Susp 250/5, 500/5
Effexor XR 37.5, 75, 150mg tab
Efudex 5% top Cream
Elavil 25mg tab
Elidel 1% top cream
Elimite top cr 5%, 60gm
Enoxaparin inj 30mg/0.3ml, 40mg/0.4ml, 100mg/1ml
Entex PSE tablet
Epipen; Epipen Jr autoinj
Erythromycin (EES) 200mg/5ml
Erythromycin 250mg base tab
Erythromycin Ophth Oint 3.5gm
Erythromycin top soln 2% 60ml
Esclim transdermal system
Estrace 1mg tab
Estradiol 1mg tab
Estradiol transdermal system
Estratest, Estratest HS tabs
Estrogen Conj 0.3, 0.45, 0.625, 0.9, 1.25mg
Estrogen Vag Cr 0.625mg/Gm
Ethambutol 100, 400mg tab
Evista 60mg tab
Ezetimibe 10mg tab
Felodipine 2.5, 5, 10mg tab
FemHrt 1mg/5mcg tab
Fenofibrate 48 & 145 mg
Ferro-Sequels
Ferrous Sulfate 325mg tab
Ferrous Sulf sol 15mg elem iron/0.6ml
Finasteride 5mg tab
Fioricet tab
Flagyl 250, 500mg tab
Flavoxate 100 mg tab
Fleet Enema
Fleet Bowel Prep Kit
Flexeril 10mg tab
Flonase Nasal Spray
Florinef 0.1mg tab
Flovent 44, 110, 220mcg
Floxin Otic Sol
# Fluconazole 150mg single dose
Fluocinonide 0.05% Cr & oint
Fluoride drops 0.5mg/ml 50ml
Fluorometholone opht susp 0.1%
Fluorouracil 5% top cr 30gm
Fluoxetine 20mg cap
Fluticasone Nasal spray; Oral Inh
FML 0.1% opht susp 5ml
Folic Acid 1mg tab
Fosamax 5, 10, 35, 70mg tabs
Fosamax PlusD 70mg/2800 IU
Fosinopril 10, 20, 40mg tab
Fosinopril/HCTZ 10/12.5
Furosemide 20 & 40mg tab
Furoxone susp 50mg/15ml
Gabapentin 100, 300 & 400mg
Gemfibrozil 600mg tab
Gentamycin Opht Sol 0.3%; Oint
Glimepiride 1, 2, 4 mg tab
Glipizide 5, 10mg tab
Glipizide XL 5mg, 10mg tabs
Glucagon 1mg inj
Glucophage 500, 1000 mg tab
Glucophage XR 500mg tabs
Glucotrol 5, 10 mg
Glucotrol XL 5, 10mg tab
Glucovance 1.25/250, 2.5/500, 5/500
Glyburide 2.5, 5mg tab
Glyburide/Metformin 1.25/250, 2.5/250, 5/500
Glynase 3 & 6 mg tab
# Goserelin 3.6, 10.8 mg implants
# Granisetron 1mg tab
Grispeg Susp 125/5; tablets 125mg
Griseofulvin 125, 500mg tab; Griseofulvin 125/5 susp
Haldol 0.5, 2 & 5mg tab
Haloperidol 0.5, 2 & 5mg tab
Hemorrhoidal HC 25 mg supp
Homatropine 5% opht Soln 15ml
Hydralazine 25mg tab
Hydrochlorothiazide 25, 50mg
HCTZ 25 and 50mg
Hydrocodone/APAP tab 5/500, 7.5/500, 10/500mg @
Hydrocortisone top cr 1%, 2.5%
Hydrocortisone 2.5% rectal cr
Hydrocortisone supp 25 mg
Hydrodiuril 25, 50 mg tab
Hydroxychloroquine 200mg tab
Hydroxyzine 10, 25mg tab
Hydroxyzine 10mg/5ml syrup
Hygroton 25mg tab
Hytrin 2 & 5mg cap
Ibandronate Sodium tab150mg
Ibuprofen 400, 600, 800mg tabs
Imdur 30, 60 mg tabs
Imipramine 25 mg tabs
Imitrex Nasal Spray 20 mg
Imitrex Autoinjector 2/kit, 6 mg
Imodium 2mg cap
Imuran 50mg tab
Inderal 10, 40mg tab
Inderal LA 80, 120mg cap
Inspirease inhaler device
Insulins:
Novolin R (Regular);
Novolin NPH; Novolin 70/30
Lantus (Insulin Glargine)
Novolog (Insulin Aspart)
Humalog (Insulin Lispro)
Intal neb ampules 2 ml
Ipecac syrup 30ml
Ipratropium Oral Inh & Inh Soln
Isoniazid susp 50/5ml; 300mg tab
Isordil tab 10mg
Isordil tembid 40mg SR cap
Isosorbide Dinitrate 10mg
Isosorbide Mononit SR 30, 60 mg
Isotretinoin 20 & 40mg caps
KCL 8, 10 and 20mg
Keflex cap 250 & 500mg
Keflex susp 125 & 250mg/5ml
Kenalog in Orabase 5gm
Ketoconazole 200mg tab
Ketoconazole cr 2% 15gm
Klonopin 0.5 &1mg tab-@
Kytril 1mg tab
Lac-Hydrin 12% top Lotion
Lactulose syrup 473ml
Lancets
Lanoxin 0.125, 0.25mg tab
Lasix 20 & 40mg tab
Latanoprost Opth Soln
Levaquin 250, 500, 750 mg tab
Levofloxacin 250, 500, 750 mg
Levothyroxine 50, 75, 88, 100, 112, 125, 150, 175 mcg
Librax cap
Lidex top cream; oint 0.05%
Lidocaine 5% top Oint
Lidocaine viscous 2% soln
Liothyronine 25 mcg tab
Lisinopril 5, 20mg tab
Lisinopril/HCTZ 10/12.5, 20/12.5, 20/25
Lithium 300mg cap
Loestrin FE 1/20; 1.5/30
Lomotil tab @
Lo-Ovral (Low-Orgestrel)
Loperamide 2mg cap
Lopid 600mg tab
Lopressor 50 & 100mg tab
Loratadine 10mg tab
Lorazepam 1mg tab-@
Lortab 5, 7.5, 10 mg tab-@
Lortab Elixir 2.5mg/5mL-@
Lotrel 5/10, 5/20, 10/20,5/40,5/40mg cap
Lotrimin 1% topical cream 15gm
Lotrimin Vag cream 1% 45gm
Lovenox 30/0.3ml, 40/0.4ml, 100mg/1ml Inj
Macrobid 100mg cap
Macrodantin 25mg/5ml Susp
Macrodantin 50mg cap
Maxalt 5, 10mg; -MLT 5, 10mg
Maxzide 25 & 50 mg tab
Mebendazole 100mg tab
Meclizine 25mg tab
Medrol Dose Pack
Medroxyprogesterone 2.5, 10mg
Meloxicam 7.5 & 15mg tab
Meperidine 50 mg tab (C-II)*
Mephyton 5mg tab
Mesalamine 400mg tab
Metformin XR 500 mg tab
Metformin 500 & 1000mg tabs
Methocarbamol 500 mg tab
Methotrexate 2.5mg tab
Methylphenidate 5, 10mg (C-II)*
Methylphenidate 20mg SR (C-II)*
Methylphenidate XR 18, 27, 36, 54mg tabs (C-II)*
Methylprednisolone 4mg dose pack
Metoclopramide 10mg tab; 5/5 liq
Metoprolol tartrate 50, 100mg tab
Metoprolol succinate XL 25, 50, 100mg tabs
Metrogel 0.75% Vag Gel 70gm
Metronidazole 250, 500mg tab
Metronidazole 0.75% vag gel
Micardis 40, 80 mg tab
Micardis HCT 12.5/40, 12.5/80, 25/80
Miconazole 2% top Cream 15gm
Micronase 2.5, 5mg tab
Micronor tab
Midrin cap @
Minipress 1, 2 & 5mg cap
Mircette
Misoprostol 200mcg tab
Mobic 7.5 & 15mg tab
Mometasone Nasal Spray
Monopril 10, 20 & 40mg tab
Monopril HCT 10/12.5 mg tab
Montelukast 4, 5, 10 mg tab
Montelukast granules 4 mg
Morphine SR 15, 30, 60mg (C-II)*
Motrin tablets 400, 600, 800mg
Moxifloxacin HCl 400mg tablets
MS Contin 15, 30, 60 mg (C-II)*
Mupirocin 2% Top Oint 15gm
Muro 128 opht oint, soln
Mycolog II top cr 15gm
Mysoline tab 250mg
NACL for Inhal 0.9% 3ml Amps
Naproxen tablet 500 mg
Nasonex Nasal Spray
Neurontin 100, 300 & 400mg
Niacin 100 & 500mg tab
Niacin ER 500, 750, 1000 mg cap
Niaspan 500, 750, 1000mg cap
Nifedipine ER 30, 60 and 90mg
Nisoldipine 10, 20, 30 mg tab
Nitrofurantoin 25mg/5ml Susp
Nitrofurantoin 50mg cap
Nitrofurantoin SR cap 100 mg
Nitroglycerin patch 0.2, 0.4mg/hr
Nitroglycerin subling tab 1/150
Nitroglycerin SL spray 400 mcg
Nitro-Stat 1/150 tablets 25's
Nitrolingual spray 400 mcg
Nix Shampoo 1%
Nizoral 2% top Cream 15gm
Nizoral tab 200mg
Nolvadex 10mg tab
Nordette
Norethindrone 0.35 mg tab
Nortriptyline 25mg cap
Nor-QD
Novahistine w/codeine 120ml-@
Nystatin topical cream15gm/oint
Nystatin w/triamcinolone top cr
Nystatin oral susp 60ml
Ofloxacin Otic Sol
Olopatadine ophth sol
Omeprazole 20 mg capsule
Omnicef 125/5; 250/5 susp
Ortho-Cyclen
Ortho Evra Patch
Ortho-Novum 1/35; 777
Ortho-Novum 1/50
Ortho-Tri-Cyclen
Ortho-Tri-Cyclen Lo
Ovral
Oxybutynin 5mg tab;1mg/ml soln
Oxymetazoline 0.05% Nasal spray
Pacerone 200mg tab
Pamelor 25mg cap
Pancrelipase cap
Patanol ophth sol
Paroxetine 20mg tab
Paxil 20mg tab
Pediaflor oral drops 1.1mg/ml
Pediazole Susp
Penicillin VK Susp 250mg/5ml
Penicillin VK tab 250 & 500mg
Percocet 5/325 tab (C-II)*
Periactin 4mg tab
Peridex dental rinse 473ml
Permethrin 5% top Cream 60gm
Permethrin Shampoo 1%
Persantine 25mg tab
Phenazopyridine 100mg tab
Phenergan 25mg tab
Phenergan 12.5 & 25 mg supp
Phenobarbital 30mg tab-@
Phenobarbital 20/5ml elix-@
Phenytoin 50, 100mg cap
Phenytoin susp 125mg/5ml
Phytonadione 5mg tab
Pilocarpine 1, 2 & 4% opht Soln
Pilocarpine ophth Gel 4%
Pimecrolimus top cream 1%
Pioglitazone 30 and 45 mg
Plaquenil 200mg tab
Plavix 75mg tab
Plendil 2.5, 5 & 10mg tab
Podofilox 0.5% top soln
Polytrim ophth Sol 10ml
Potassium ER 8, 10, 20 mEq tab
Pravastatin 20mg, 40mg
Prazosin 1, 2, 5mg cap
Precision XTRA Test Machine
Precision XTRA Test Strips 100
Pred Forte Ophth Susp 1% 5ml
Prednisolone ophth susp1%
Prednisolone oral sol 15mg/5ml
Prednisone 1, 5, 10 & 20mg tab
Premarin 0.3, 0.45, 0.625, 0.9, 1.25mg
Premarin Vag cream 0.625mg
Prempro 0.3/1.5, 0.45/1.5, 0.625/2.5, 0.625/5 mg tab
Prenatal Vitamin w/minerals
Prevident dental Gel 60gm
Prevident 5000 Plus T/P 51gm
Prilosec 20 mg capsule
Primaquine tab 26.3mg
Primidone 250mg tab
Probenecid 500mg tab
Procan SR 500mg tabs
Procanamide SR 500mg tabs
Promethazine 25mg tab
Promethazine supp 12.5, 25 mg
Propoxyphene/APAP 100/650
Propranolol 10, 40mg Tab
Propranolol LA 80, 120mg Cap
Propylthiouracil 50mg tab
Proscar 5mg tab
Proventil 0.083% UD for Neb
Proventil MDI; inh soln. 0.5%
Proventil 4mg tab; syrup 2mg/5ml
Provera 2.5 & 10mg tab
Prozac 20mg cap
Pulmicort Respules 0.25/2,0.5/2ml
Pyridoxine (B6) 50 mg tab
Pyridium 100mg tab
Quetiapine 25, 100, 200, 300mg
Quinaglute 324mg tab
Quinidine gluconate 324 mg tab
Rabeprazole Sodium 20mg
Raloxifene 60mg tab
Ranitidine 150mg tab
Reglan 10mg tab & 5mg/5ml liq
Restoril cap 15 & 30mg-@
Retin-A 0.05%, 0.025 % Cream
Rifampin cap 300mg
Risedronate 5, 35mg tab
Risperdal .025, 0.5, 1, 2, 3, 4 mg
Risperidone 0.25, 0.5, 1, 2, 3, 4mg
Ritalin 5, 10, SR 20mg (C-II)*
Rizatriptan 5, 10mg; -MLT 5, 10
Robaxin 500mg tab
Robitussin AC Syrup-@
Rosiglitazone 2, 4, 8mg tab
Salmeterol oral inh diskus
Salsalate 500mg tab
Scopolamine transderm patch
Selenium sulfide 2.5% shampoo
Selsun shampoo 2.5%
Septra DS tab 800/160
Septra Pediatric Susp 200-40/5ml
Serevent Diskus
Seroquel 25, 100, 200, 300mg
Sertraline 25, 50, 100mg tab
Silvadene topical cream 1% 20gm
Silver sulfadiazine cream 1%
Simvastatin 5, 10, 20, 40, 80 mg
Sinemet 10/100, 25/100 & 25/250
Sinemet CR 50/200
Sinequan 10mg, 25mg cap
Singulair 4, 5, 10mg tab
Singulair 4mg granules
Sodium Chloride Opth oint/sol 5%
Sodium Chloride inh amps 0.9%
Sodium Fluoride drops 1.1 mg/ml
Soma 350mg tab
Spironolactone 25mg tab
Sudafed 30mg tab
Sular 10, 20, 30 mg tab
Sulfacetamide 10% opht oint; soln
Sulfasalazine 500mg tab
Sumatriptan Nasal Spray 20 mg
Sumatriptan Autoinjector 2/kit
Surfak cap 240mg
Synalar top soln 0.01% 20ml
Synthroid 50, 75, 88, 100, 112, 125, 150, 175 mcg
Syringes, insulin U-100, 0.5, 1 cc
Tamoxifen 10mg tab
Tegaserod Hydrogen tab 2mg,6mg
Tegretol tab 200mg
Telmisartan 40, 80 mg tab
Telmisartan HCT 12.5/40, 12.5/80, 25/80
Temazepam 15, 30mg cap-@
Tenormin 25 & 50mg tab
Terazole-7 vag cream 0.4%
Terazosin 2 and 5mg cap
Terconazole 0.4% vag cream
Tessalon perles 100mg
Testosterone 2% top oint 60gm
Tetracycline cap 250mg
Theophylline 200, 300 mg ER cap
Theophylline 80mg/15ml liq
Thiamine 50mg tab
Thyroid 60mg tab
Tiazac 120, 180 & 240, 300mg
Timolol 0.25%, 0.5% Ophth Soln
Timolol 0.5% XE Ophth
Timoptic-XE 0.5% Ophth
Tobradex Sol 5ml
Tobrex Sol 5ml & Oint 3.5gm
Tofranil 25mg tab
Tolterodine ER 2, 4 mg cap
Toprol XL 25, 50, 100 mg
Tramadol 50mg tab
Trazodone 100, 150mg tab
Tretinoin cream 0.025%, 0.05%
Triamcinalone top cr 0.1%
Triamcinolone Oral Inhaler
Tricor 48 & 145 mg tab
Trihexyphenidyl 2mg tab
Tri-levlin (Triphasil, Trivora)
Tylenol #3 tab (300/30) -@
Tylenol supp 120 & 650mg
Tylenol w/codeine Elixir-@
Ultram 50mg tab
Urispas 100mg tab
Uroxatral 10 mg ER tablet
Valium tab 5mg-@
Valsartan 80, 160, 320 mg tab
Valsartan/HCTZ 80/12.5, 160/12.5, 160/25
Venlafaxine SR 37.5, 75 & 100mg
Verapamil 80 mg tab
Verapamil SR 180, 240 mg tab
Vermox 100 mg tab
Vibramycin 100 mg cap
Viroptic 1% Opth Sol
Viscous Lidocaine oral 2% 100ml
Vitamin B-6 tab 50mg
Vitamin B-12 tablets 500 mcg
Vitamin K 5mg tab
Voltaren Ophth Soln 0.1% 5ml
Vosol-HC Otic soln 15ml
Vytorin 10/10mg, 10/20mg, 10/40mg, 10/80mg
Warfarin 1, 2, 2.5, 5mg tab
# Wellbutrin SR 100, 150 mg tab
Wescort top cr 0.2% 15gm
Xalatan ophth soln
Xopenex HFA MDI
Xylocaine viscous 2% soln
Yasmin
Yaz 3mg
Yocon 5.4 mg tab
Zantac 150 mg tab
Zelnorm Tab 2mg & 6mg
Zestoretic 10/12.5, 20/12.5, 20/25
Zestril 5 & 20 mg tab
Zetia 10 mg Tab
Zithromax 250 mg tab
Zithromax Susp 100/5, 200/5
Zocor 5, 10, 20, 40 & 80mg tab
Zoladex 3.6, 10.8 mg implants
# Zolmitriptan 2.5, 5mg tab
Zoloft 25, 50, 100mg tab
Zolpidem 10 mg tab-@
# Zomig 2.5, 5mg tabs
Zovia 1/35
Zovirax 5% top Ointment 3gm
Zovirax cap 200mg; tab 800mg
Zovirax susp 200mg/5ml
Zyloprim 100 & 300mg tab
Z-Pak 250 mg tablets
Zyrtec 1mg/ml liq (for peds only)
Zyrtec-D 12 Hour Tab


RESTRICTIONS:

Bupropion: Wellbutrin SR is not to be used for tobacco cessation.

Fluconazole SINGLE DOSE
For vaginal yeast only
Limit 3 tablets per 90 days.

Blood Glucose Strips/Syringes
Limit 600 strips/syringes per 90 days.

Transplant and HIV
Call our supply line at 456-6237 for details on eligibility criteria for nonformulary meds under the AF High Dollar Program.

Rizatriptan (Maxalt)
Used as 2nd line after Zomig failed.
Limit 12 tablets a month.

Midrin
Limited to 40 caps per month

Prenatal Vitamins
Limited to women of child-bearing age up to and including age 45.

Goserelin (Zoladex)
For the treatment of prostate cancer

Granisetron (Kytril)
Restricted to chemotherapy.
Max of 8 tablets per month.

Zolmitriptan (Zomig)
Qty limit to 12/month

Imitrex Autoinjector 2/ kit
Qty limit to 8 syringes per month

Imitrex Nasal Spray
Qty limit 6 doses per month



FORMULARY CHANGES:

Deletions
Indomethacin 25mg, Aug06
Rondec Drops, Sep 06
Escitalopram (Lexapro), Jan 06
Paroxetine CR (Paxil CR), Jan 06
Gatifloxacin (Tequin), Mar 06

Additions
Boniva 150mg tab, 27 Nov 06
Zelnorm 2mg, 6mg tab, 27 Nov 06
Vytorin 10/10mg, 10/20mg, 10/40mg, 10/80mg, 1 Nov 06
Pravastatin 20mg, 40mg, 1 Nov 06
Accuhist Drops, Sep 06
Prevident 5000 Plus, Sep 06
Xopenex HFA (MDI), Sep 06
Alesee, Jul 06
Ortho-Cyclen, Jul 06
Ortho-Tricyclen Lo, Jul 06
Nordette, Jul 06
Yaz, Jul 06
Alfuzosin (Uroxatral)
Nisoldipine (Sular), Feb 06
Levofloxacin (Levaquin), Mar 06