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Library > Fact Sheets > Pharmacy Information

PHARMACY INFORMATION

Posted 5/6/2015 Printable Fact Sheet


To better serve you, the 375 MDG operates two pharmacies, the Clinic and Satellite. Both pharmacies have recently been renovated and feature the latest in Air Force prescription automation technology. Although we do not stock every drug, our formulary is very robust and is designed to meet the majority of our beneficiaries' prescription needs. We realize that you, as a TRICARE beneficiary, have a choice as to where you have your prescription filled. Our goal is to provide a superior level of customer service so that we become your pharmacy of choice. We look forward to serving you.

Office Hours:
The normal pharmacy hours of operation for the Clinic Pharmacy are: 8:00 a.m. - 5:00 p.m., Monday - Friday and for the Satellite Pharmacy 9:00 a.m. - 5:00 p.m., Monday - Friday, except for holidays and approved AMC family days.

Location:
The Clinic Pharmacy clinic is located in building 1530 (375th Medical Group). The Satellite Pharmacy is located in building 1948 (312 W. Winters St)

Contact Information:
You can contact the pharmacy by calling 618-256-7345/DSN576-7345 for the Clinic Pharmacy and 618-256-7335/DSN576-7335 for the Satellite Pharmacy.

Clinic Leadership/Clinic Patient Advocate/Contact Information:

Pharmacy Commander:
618-256-4741/DSN576-4741

Pharmacy Deputy Commander: 618-256-3271/DSN576-3271

Pharmacy Sup: 618-256-7655/DSN576-7655

Clinic Pharmacy Patient Advocate: 618-256-7345/DSN576-7345

Satellite Pharmacy Patient Advocate: 618-256-7335/DSN576-7335

Important Notes:
The Clinic Pharmacy fills prescriptions ordered by doctors assigned to the medical group. The Satellite Pharmacy fills prescriptions written by off-base doctors, as well as, all prescription refills. All refill requests must be called in to the automated refill line (618) 256-7400 or toll-free at 1-866-683-2778.

SCOTT AIR FORCE BASE FORMULARY
 DEPARTMENT OF THE AIR FORCE
HEADQUARTERS 375TH MEDICAL GROUP (AMC)
16 April 2015

Dear Health Care Provider,

This list contains the current medications stocked at Scott Air Force Base Pharmacy. This list can also be accessed online at http://www.scott.af.mil/library/factsheets/factsheet.asp?id=16369.  Our formulary system is designed to provide the most therapeutic and cost-effective medications that will treat the patients seen by Scott AFB providers.  Since all medications are dispensed generically, please prescribe allowing generic substitution. Please note, this listing is subject to change.    
      Our pharmacy's policy is to dispense up to a 3 month supply when the medication is used in treating a chronic disease.  However, the prescription must reflect that a 3 month supply is desired.  We do have a few quantity limits based on TRICARE restrictions and our disease state management protocols.  These medications are identified with the quantity limits in the formulary.  Some prescriptions may be refilled for 1-year if indicated on the prescription.  Medications used to treat acute problems should be prescribed for the minimum amount required.  If your patient requires a drug not on our formulary, that medication will have to be purchased by the patient via TRICARE network pharmacies for 30-day supply or, preferably, the TRICARE Mail Order Pharmacy (TMOP) where a 90-day supply can be received for a single co pay. The TMOP can be reached at http://www.express-scripts.com, or toll free at 1-866-DOD.TMOP (866-363-8667).  If you have questions regarding medication availability, cost share/co pays and alternatives under the TRICARE pharmacy benefit, help is available at:  http://pec.ha.osd.mil/formulary_search.php?submenuheader=1

Dear Patient,
     Welcome to the Scott Air Force Base Pharmacy.  All civilian prescriptions and all refills called in to the automated refill line are filled at our Satellite Pharmacy, which is located at 312 W. Winters St.  It is very important that you review your written prescription before leaving your provider's office to ensure legibility and completeness to include name, date, signature, quantity, refills, and provider's DEA number (required for controlled medications and for providers not in our database).  If you can't read it, chances are that we will not be able to either.  Altering a written prescription is illegal and has led to involvement with Security Forces.
     The Main Pharmacy will only fill prescriptions entered into the computer by 375th Medical Group providers in the clinic or at the Belleville Family Practice Clinic.  Prescriptions are not automatically filled when the provider enters them into the computer.  YOU MUST TAKE A NUMBER AT THE PHARMACY WINDOW TO ACTIVATE YOUR PRESCRIPTION AND START THE FILLING PROCESS.  The modification is in conjunction with an Air Force-wide technology change and is an effort to better serve the patient that is present at the facility.
     REFILLS MUST BE CALLED IN USING OUR AUTOMATED REFILL LINE AT (618) 256-7400. When calling in your prescription, please listen carefully in order to determine when your refills will be available for pick-up.  Generally, this is between 1 and 2 duty days.  Holidays and down days do not count as duty days.  Refills will be held for two weeks.  You do not need to take a number for a refill pick-up.  Thank you for your cooperation.  If you have a question, contact us at (618) 256 7335.
    
   
     Sincerely,


       ROBERT W. RAINEY, Lt Col, USAF, BSC
       Pharmacy Flight Commander

ADHD (NON-NARCOTIC) AGENTS
TENEX 1MG & 2MG TAB
INTUNIV ER (ALL STRENGTHS) TAB
STRATTERA (ALL STRENGTHS) CAPS

ALLERGY/COUGH & COLD AGENTS
ALLEGRA 60MG & 180MG TAB; 30MG ODT
ALLEGRA-D 12 HR & 24 HR SR TAB
ATARAX 10MG, 25MG & 10MG/5ML SYRUP
BENADRYL 25MG, 50MG & 12.5MG/5ML ELIXIR
CHLOR-TRIMETON 4MG TAB
CLARITIN 10MG TAB & 1MG/ML SYRUP
EPIPEN 0.3MG/EPIPEN JR 0.15MG
MUCINEX 600MG TAB
MUCINEX D (REGULAR & MAX STRENGTH) TABLETS
PERIACTIN 4MG TAB
ROBITUSSIN PLAIN & DM SYRUP
SUDAFED 30MG/5ML SYRUP, SUDAFED 30MG TABS
TESSALON 100MG & 200MG CAPS
ZYRTEC 10MG TAB & CHEWABLE, 1MG/ML SYRUP
ZYRTEC-D 12 HOUR TAB

ANALGESIC AND ANTIPYRETIC AGENTS
ANAPROX 275MG & 550MG TAB
ASPIRIN 325MGTAB
ASPIRIN EC 81MG & 325MG TAB
CELEBREX 100MG, 200MG & 400MG CAP
CEPACOL LOZENGES
DICLOFENAC 25MG, 50MG, 75MG TAB; 100MG ER TAB
DISALCID 500MG & 750MG TAB 
FELDENE 20MG CAP
INDOCIN 25MG, 50MG & 75MG SR CAP
LIDODERM 5% PATCHES    
MOBIC 7.5MG & 15MG TAB
MOTRIN 100MG/5ML SUSP
MOTRIN 400MG, 600MG & 800MG TAB
MOTRIN 100MG CHEWABLE TAB
NAPROSYN 250MG, 375MG & 500MG TAB
TYLENOL 325MG, 500MG, 650MG TAB; 80MG SUPPOSITORY; 80MG MELTAWAYS
TYLENOL 160MG/5ML ELIXIR
VOLTAREN 1% TOPICAL GEL

ANTIANGINAL/VASODILATOR AGENTS
IMDUR 30MG, 60MG & 120MG TAB
ISORDIL 10MG & 20MG TAB; 40MG SR TAB
NITROBID 6.5MG CAP; 2% OINTMENT
NITRO-DUR 0.1MG, 0.2MG, 0.3MG, & 0.4MG TDRM
NITROGLYCERIN 0.3MG& 0.4MG SL TAB
NITROLINGUAL SPRAY
RANEXA 500MG & 1000MG TAB

ANTIARRHYTHMIC AGENTS
CORDARONE 200MG TAB 
LANOXIN 0.125MG & 0.25MG TAB
LANOXIN 0.25MG/ML SOLUTION
MULTAQ 400MG TAB
SOTOLOL 80MG, 120MG, 160MG, &  240MG TAB
TAMBOCOR 100MG TAB

ANTICONVULSANT AGENTS
CARBATROL 100MG, 200MG & 300MG CAP
DEPAKENE 250MG CAP & 250MG/5ML SYRUP
DEPAKOTE 125MG SPRINKLE CAP
DEPAKOTE 125MG, 250MG, & 500MG TAB
DEPAKOTE ER 250MG & 500MG TAB
DILANTIN 125MG/5ML SUSP
DILANTIN 30MG & 100MG CAP 
DILANTIN 50MG CHEW TAB
FELBATOL 400MG & 600MG TAB
FELBATOL 600MG/5ML SUSP
KEPPRA 250MG, 500MG, 1000MG TAB; 100MG/ML SOLN
LAMCITAL TABS (ALL STRENGTHS)
MYSOLINE 50MG & 250MG TAB
NEURONTIN TABS & CAPS (ALL STRENGTHS)
PHENOBARBITAL 15MG, 30MG, 100MG TAB; 20MG/5ML ELIXIR
TEGRETOL 100MG CHEW TAB; 200MG TAB; 200MG & 400MG XR TAB
TEGRETOL 100MG/5ML SUSP
TOPAMAX 25MG, 50MG, 100MG, 200MG TAB

ANTIDIABETIC AGENTS/TESTING SUPPLIES
ACTOS 15MG, 30MG & 45MG TAB
ALCOHOL PADS
AMARYL 2MG & 4MG TAB
BYETTA 5MCG & 10MCG
BYDUREON 2MG/VIAL
FREESTYLE LITE METER FREESTYLE LITE TEST STRIPS
GLYBURIDE 1.25MG, 2.5MG & 5MG TAB
GLYNASE 1.5MG, 3MG, 6MG PRESTAB
GLUCATROL 5MG, 10MG TAB; XL 2.5MG, 5MG & 10MG
GLUCAGON 1MG INJECTION KIT
GLUCOPHAGE 500MG, 850MG, & 1000MG TAB
GLUCOPHAGE XR 500MG & 750MG TAB
GLUCOVANCE TAB (ALL STRENGTHS)
JANUVIA 25MG, 50MG, & 100MG TAB
JANUMET (ALL STRENGTHS) TAB
JANUMET XR (ALL STRENGTHS) TAB
LANTUS (GLARGINE) INSULIN
LANTUS SoloSTAR INSULIN PEN
LANCETS
NOVOLIN NPH AND REG INSULIN (VIALS ONLY)
NOVOLOG & NOVOLOG MIX 70/30 (VIALS AND FLEXPENS)
PEN NEEDLES 30G & 31G
PRECISION XTRA GLUCOSE TEST STRIPS
PRECISION XTRA GLUCOSE MONITOR
PRECISION XTRA BLOOD ß-KETONE STRIPS
INSULIN SYRINGE
--0.3ML, 0.5ML & 1ML 31G 5/16"
--0.5ML & 1ML 30G 1/2"

ANTIHYPERTENSIVE AGENTS
ACCUPRIL 10MG & 40MG TAB
ADALAT CC 30MG, 60MG & 90MG TAB
ALDOMET 250MG TAB
APRESOLINE 10MG, 25MG & 50MG TAB
BETAPACE 80MG, 120MG & 160MG
CAPOTEN 12.5MG, 25MG, 50MG & 100MG TAB
CARDIZEM CD (ALL STRENGTHS)
CARDURA 2MG, 4MG & 8MG TAB
CATAPRES 0.1MG, 0.2MG & 0.3MG TAB
CATAPRES TTS-1, TTS-2 & TTS-3 TDRM
COREG 3.125MG, 6.25MG, 12.5MG & 25MG TAB
COZAAR 25MG, 50MG & 100MG TAB
DILTIAZEM 60MG TAB
DIOVAN (ALL STRENGTHS) TAB
DIOVAN HCT (ALL STRENGTHS) TAB
ENALAPRIL (ALL STRENGTHS) TAB; 1MG/ML SOLN
HYTRIN 1MG, 2MG, 5MG & 10MG CAP
HYZAAR TAB (ALL STRENGTHS)
INDERAL 10MG, 20MG, 40MG & 80MG TAB
INDERAL LA 60MG, 80MG, 120MG & 160MG CAP
LOPRESSOR 25MG, 50MG & 100MG TAB
LOTREL CAPS (ALL STRENGTHS)
MICARDIS (ALL STRENGTHS) TAB
MICARDIS HCT (ALL STRENGTHS) TAB
MINIPRESS 1MG, 2MG, 5MG CAPS
MINOXIDIL 2.5MG & 10MG TAB
MONOPRIL 10MG, 20MG & 40MG TAB
NIFEDIPINE 10MG CAP
NORVASC 2.5MG, 5MG, & 10MG TAB
PLENDIL 2.5MG, 5MG & 10MG TAB
TEKTURNA 150MG & 300MG TAB
TEKTURNA HCT 150/12.5, 150/25, 300/12.5, 300/25MG TAB
TENORETIC 50/25MG & 100/25MG TAB
TENORMIN (ALL STRENGTHS) TAB
TIAZAC (ALL STRENGTHS) CAP
TOPROL-XL (ALL STRENGTHS) TAB
TRANDATE 200MG TAB
VERAPAMIL 80MG & 120MG TAB
VERAPAMIL SR 120MG, 180MG & 240MG TAB
ZESTRIL/PRINIVIL (ALL STRENGTHS) TAB
ZESTORETIC/PRINZIDE (ALL STRENGTHS) TAB

ANTI-INFECTIVE AGENTS (LIQUID)
AMOXIL SUSP (ALL STRENGTHS)
AMOXIL CHEWABLE TABS (125MG, 250MG)
AUGMENTIN SUSP (ALL STRENGTHS)
BACTRIM SUSP
CEFZIL SUSP
CLEOCIN SUSP
ANTI-INFECTIVE AGENTS (LIQUID, CONT)
DIFLUCAN SUSP
DURICEF SUSP
E.E.S. SUSP
FURADANTIN SUSP
GRIFULVIN SUSP
KEFLEX SUSP
NYSTATIN SUSP
OMNICEF SUSP
PENICILLIN VK  SUSP
VANTIN  SUSP
ZITHROMAX SUSP (ALL STRENGTHS)

ANTI-INFECTIVE AGENTS
ALBENZA 200MG TAB
AMOXIL (ALL STRENGTHS)
AUGMENTIN TAB  (ALL STRENGTHS)
AVELOX 400MG TAB
BACTRIM & BACTRIM DS TAB
BIAXIN TAB (ALL STRENGTHS)
BICILLIN LA 600,000 & 1,200,000 INJ
CEFTIN 250 & 500MG TAB
CEFZIL 250MG &500MG TAB
CLEOCIN 150mg & 300MG CAP
CIPRO TAB (ALL STRENGTHS)
DAPSONE 25mg TAB
DICLOXACILLIN CAP (ALL STRENGTHS)
DIFLUCAN TAB
DURICEF 500mg CAP
DYNAPEN 250MG CAP
ERYTAB 250MG & 400MG TAB 
ETHAMBUTAL 100MG & 400MG TAB
FLAGYL 250MG & 500MG TAB 
GRIS-PEG 125MG & 250MG TAB
ISONIAZID TAB; 50MG/5ML SYRUP
KEFLEX 250MG & 500MG CAP
LEVAQUIN TAB (ALL STRENGTHS)
LAMISIL 250MG TAB
MACROBID 100MG CAP
MACRODANTIN CAP (ALL STRENGTHS)
MINOCIN 50MG& 100MG CAP
MYCELEX 10MG TROCHES
NIZORAL 200MG TAB
NYSTATIN TABS 500,000 UNITS
OMNICEF 300MG CAP
PENICILLIN VK 250MG, 500MG TAB
PERIOSTAT 20MG TAB
PYRAZINAMIDE 500MG TAB
RIFAMPIN 150MG, 300MG CAP
VANTIN 100MG, 200MG TAB
VIBRAMYCIN 100MG TAB & 100mg CAP
ZITHROMAX 250MG, 500MG TAB

ANTIHYPERLIPIDEMIC AGENTS
COLESTID GRANULES & 1 GM TAB
CRESTOR (ALL STRENGTHS) TAB
FENOFIBRATE (TRICOR) 48MG & 145MG TAB
FENOFIBRATE 54MG & 160MG TAB
FISH OIL CAPS 1000 MG (OMEGA-3 340 MG)
LIPITOR TAB (ALL STRENGTHS)
LOPID 600MG TAB
LOVASTATIN 20MG & 40MG TAB
NIACIN 50MG & 500MG TAB
NIASPAN TAB (ALL STRENGTHS) 
PRAVACHOL TAB (ALL STRENGTHS)
QUESTRAN 4GM/SCOOP POWDER
QUESTRAN LIGHT 4G/SCOOP POWDER
ZETIA 10MG TAB
ZOCOR TAB (ALL STRENGTHS)

ANTIMALARIAL AGENTS
CHLOROQUINE 500MG TAB
MEFLOQUINE 250MG TAB
PLAQUENIL 200MG TAB
PRIMAQUINE 26.3MG TAB

ANTINEOPLASTIC AGENTS
EULEXIN 125MG CAP
FEMARA 2.5MG TAB
HYDREA 500MG CAP
IMURAN 50MG TAB
MEGACE 40MG TAB & 40MG/ML SUSP
METHOTREXATE 2.5MG TAB 
TAMOXIFEN 10MG & 20MG TAB
ZOLADEX 3.6MG & 10.8MG IMPLANT


ANTI-OSTEOPOROTIC AGENTS
BONIVA 150MG TAB
FORTICAL NASAL SPRAY
FOSAMAX TAB (ALL STRENGTHS)

ANTIPARKINSONIAN AGENTS
SYMATREL 100MG CAP; 50MG/5ML SYRUP
ARTANE 2MG TAB; 0.4MG/ML ELIXIR
COGENTIN TAB (ALL STRENGTHS)
ELDEPRYL 5MG TAB
PARLODEL 2.5MG TAB
REQUIP TAB (ALL STRENGTHS)
SINEMET TAB & CR TAB (ALL STRENGTHS)

ANTIPLATELET/ANTICOAGULANTAGENTS
AGGRENOX 25/200MG CAP
ASPIRIN 325MG TAB; 81MG & 325MG EC TAB
COUMADIN TAB (ALL STRENGTHS)
LOVENOX INJ (ALL STRENGTHS)
MEPHYTON 5MG TAB
PERSANTINE TAB (ALL STRENGTHS)
PLAVIX 75MG TAB
PRADAXA 75MG & 150MG CAP
TRENTAL 400MG TAB
XARELTO TAB (ALL STRENGTHS)

ANTIVIRAL AGENTS
SYMMETREL 100MG CAP; 50MG/5ML SYRUP
TAMIFLU CAP (ALL STRENGTHS)
ZOVIRAX (ALL STRENGTHS)
VALTREX 500MG, 1000MG TAB

AUTONOMIC/ CHOLINERGIC AGENTS
ARICEPT 5MG & 10MG TABS
EXELON PATCH
MESTINON 60MG TAB & 180MG SR TAB
NAMENDA (ALL STRENGTHS)
NAMENDA XR (ALL STRENGTHS) CAP
URECHOLINE 10MG & 25MG TAB

DENTAL AGENTS
PERIDEX 0.12% ORAL RINSE
PERIOSTAT 20MG TAB
PREVIDENT 5000 PLUS & BRUSH-ON GEL
SODIUM FLUORIDE 1.1MG/ML DROPS; 1.1MG TAB
TRIAMCINOLONE DENTAL PASTE

DIURETICS
ALDACTAZIDE 25MG/25MG TAB
ALDACTONE 25MG, 100MG TAB
BUMEX TAB (ALL STRENGTHS)
DEMADEX 100MG TAB
DIAMOX 250MG TAB, 500MG SR CAPS
HYDROCHLOROTHIAZIDE (ALL STRENGTHS)
HYGROTON 25MG, 50MG TAB
LASIX TAB (ALL STRENGTHS); 10MG/ML SOLN
MAXZIDE TABS (ALL STRENGTHS)
ZAROXOLYN 2.5MG & 5MG TAB

EAR AGENTS
AURALGAN OTIC SOLN
CIPRODEX OTIC SUSP
COLYMCIN-S OTIC SUSP
CORTISPORIN OTIC SOLN & SUSP 
DOMEBORO OTIC SOLN
FLOXIN OTIC 0.3% SOLN
VOSOL & VOSOL HC OTIC DROPS

EYE AGENTS
ACULAR 0.5% OPH SOLUTION
ALPHAGAN-P 0.1%, 0.15%  OPH SOL
ATROPINE 1% OPH SOLUTION
BACITRACIN OPH OINTMENT
BLEPH-10 10% OPH SUSP
BLEPHAMIDE OPH SUSPENSION
CILOXAN OPH 0.3% SOLU
COMBIGAN OPH SOLUTION
CORTISPORIN OPH SUSPENSION
COSOPT 2%/0.5% OPH SOLUTION
CYCLOGYL 0.5% & 1% OPH SOLUTION
FLUOROMETHALONE 0.1% OPH SOLUTION
GARAMYCIN OPH SOLUTION & OINTMENT
ILEVRO 0.3% OPH SUSPENSION
ILOTYCIN OPH OINTMENT
ISOPTO HOMATROPINE 2% & 5% OPH SOL
LOTEMAX 0.5% OPH SUSP & GEL
LUMIGAN OPH SOLUTION
MAXITROL OPH OINTMENT & SOLN
MURO-128 5% OPH SOLUTION & OINTMENT
MYDRIACYL 1% OPH SOLUTION
NAPHCON A OPH SOLUTION
NEOSPORIN OPH OINTMENT & SOLUTION
NEOSYNEPHRINE 2.5% & 10% OPH SOLUTION
NEVANAC 0.1% OPH SUSPENSION
PATADAY 0.2% OPH SOLUTION
PATANOL 0.1% OPH SOLUTION
PILOCARPINE 1%, 2%, 4% OPH SOL
PILOPINE HS 4% OPH GEL
POLYSPORIN OPH OINTMENT
POLYTRIM OPH SOLUTION 
PRED FORTE 1% OPH SUSPENSION
PRED MILD 0.12% OPH SOLUTION
REFRESH CLASSIC OPH SOLN
REFRESH PM OPH OINTMENT
REFRESH PLUS 0.5% OPH SOLN
REFRESH TEARS 0.5% OPH SOLN
RESTASIS OPH EMULSION
TIMOPTIC 0.25% & 0.5% OPH SOLN
TIMOPTIC-XE 0.25 & 0.5% OPH SOLUTION
TOBRADEX OPH SUSP
TOBREX OPH 0.3% SOLN
TRUSOPT OPH SOLUTION
VIGAMOX OPH SOLUTION
VIROPTIC 1% OPH SOLUTION
XALATAN 0.005% OPH SOLUTION
ZYLET OPH SUSPENSION

ELECTROLYTE MISC AGENTS
UROCIT-K (ALL STRENGTHS)
K-PHOS NEUTRAL TAB
KLOR CON M10 & M20 TAB
PHOSLO 667MG CAP
POTASSIUM CHLORIDE ER 10 mEq CAP
POTASSIUM CHLORIDE 20MEQ/PACKET
POTASSIUM CHLORIDE 10% ELIXIR

GASTROINTESTINAL AGENTS
ANTIVERT 25mg TABS
AZULFIDINE 500MG TAB
AZULFIDINE-EN 500MG TAB 
BENTYL (ALL STRENGTHS)
CARAFATE 1GM TAB
CIMETIDINE 300MG, 400MG TAB
COLACE 100MG CAP
COLYTE SOLN
COMPAZINE 5MG & 10MG TAB; 25MG SUPP
CYTOTEC 200MG TAB
DELIZICOL 400MG CAP
DICLEGIS TAB
DONNATAL ELIXIR & TAB
DULCOLAX 5MG TABS; 10MG SUPP
FAMOTIDINE 20MG & 40MG TABS
FIRST-OMEPRAZOLE 2MG/ML SUSP
FLEETS ENEMA & PEDIATRIC ENEMA
GOLYTELY SOLUTION
IMODIUM 2MG CAP
KONSYL-D (PSYLLIUM/DEXTROSE) POWD
LACTULOSE 10GM/15ML SOLN
LEVBID 0.375MG SR TAB
LEVSIN 0.125MG TAB
LIALDA 1.2GM TAB
LINZESS 145MG & 290MG CAP
METOCLOPRAMIDE 10MG TAB; 5MG/5ML SOLN
MIRALAX POWDER (255GM/527GM)
NEXIUM (ALL STRENGTHS-CAPS AND PACKETS)
PANCREASE (CREON) CAP 
PEPTO-BISMOL CHEW TAB
PHENERGAN 25MG TAB; 6.5MG/ML SYRUP
PHENERGAN 12.5MG & 25MG SUPP
PRILOSEC CAPS (ALL STRENGTHS)
ROWASA 4GM/60ML ENEMA
SIMETHICONE 80MG TABS
RANITIDINE 150MG & 300 MG TAB; 15MG/ML SOLN
TIGAN 300MG CAP
TRILYTE SOLUTION
TRANSDERM SCOP 1.5MG PATCH
ZOFRAN (ALL STRENGTHS-TAB&SOLN) ZOFRAN ODT 4MG & 8MG TAB

GOUT PREVENTION/TREATMENT AGENTS
COLCRYS 0.6MG TAB
INDOMETHACIN 25MG & 50MG CAP
ZYLOPRIM 100MG & 300MG TAB

HORMONES
-Androgens
FORTESTA 2% GEL
METHYLTESTOSTERONE 10MG CAP
TESTOSTERONE CYPIONATE 200MG/ML INJ
TESTOSTERONE ENANTHATE 200MG/ML INJ
TESTOSTERONE TRANSDERM 2MG & 4MG

HORMONES/FERTILITY
Contraceptives
ALESSE TAB
DEMULEN 1-35 TAB
DEPO-PROVERA 150MG/ML VIAL
DESOGEN TAB
IMPLANON SYSTEM
LEVLEN 28 TAB
LO-ESTRIN FE 1.5/30 & 1/20
LO/OVRAL 28 TAB
MICRONOR 28 TAB 
MIRENA IUD
NEXPLANON DEVICE
NORA-BE TAB
NORDETTE 28 TAB
NORINYL 1-35 TAB
NUVARING
ORTHO-NOVUM 7/7/7 TAB
ORTHO-NOVUM 1/35 TAB
ORTHO-CYLEN 28 TAB
ORTHO-EVRA PATCH
ORTHO-TRI-CYCLEN 28 TAB
ORTHO-TRI-CYCLEN LO 28 TAB
OVRAL TAB
PARAGUARD IUD
PLAN B
TRI-LEVLEN/TRIPHASIL TAB
YASMIN TAB
YAZ TAB
Estrogens
ALORA PATCH 0.05MG & 0.1MG
CLIMARA PATCH 0.025MG, 0.0375MG, 0.05MG, 0.1MG
ESTRACE 1MG & 2MG TAB
EVISTA 60MG TAB
FEMHRT 0.5/2.5MG & 1/5MGTAB
PREMPRO TAB (ALL STRENGTHS)
PREMARIN TAB (ALL STRENGTHS)
PREMARIN VAGINAL CREAM
Progestins
AYGESTIN 5MG TAB
PROVERA TAB (ALL STRENGTHS)
Miscellaneous
CLOMID 50MG TAB
BROMOCRIPTINE 2.5MG TAB
Vaginal Preparations
CLEOCIN VAGINAL CREAM
CLOTRIMAZOLE VAGINAL CREAM
METROGEL 0.75% VAGINAL GEL
PREMARIN VAGINAL CREAM
TERAZOL-7 VAGINAL CREAM
VAGIFEM 10MCG VAGINAL TAB

INJECTABLE AGENTS
EDEX 20MCG & 40MCG KIT (2/PACK)
CYANOCOBALAMIN 1000MCG/ML (1ML VIAL)
LUPRON DEPOT 3.75MG, 7.5MG, 11.25MG KIT
EUFLEXXA 10mg/mL

MIGRAINE AGENTS
FIORICET TAB
IMITREX 25MG & 50MG TAB (54 TABS/90DAYS)
IMITREX 100MG TAB (27 TABS/90DAYS)
IMITREX 6MG INJ (2 SYR/BOX) (8/90 DAYS)
MAXALT MLT 5MG & 10MG (36 TABS/90 DAYS)
MAXALT 5MG &10MG (36 TABS/90DAYS)
RELPAX 20MG &40MG (36 TABS/90DAYS)
ZOMIG 2.5MG & 5MG TAB (36 TABS/90DAYS)
ZOMIG ZMT 2.5MG & 5MG (36 TABS/90DAYS)

MISCELLANEOUS AGENTS
BD INTEGRA 3ML 1.5" 21 G SYRINGE/NEEDLE
CHANTIX (ALL STRENGTHS)
CUPRIMINE 250MG CAP
GENGRAF 25MG & 100MG CAP
KAYEXALATE 15GM/60ML SUSPENSION
LYSTEDA 650MG TAB
NICOTINE 7MG, 14MG & 21MG PATCH
NICOTINE 2MG & 4MG GUM
PROBIOTIC SUPPLEMENT
SHARPS CONTAINER
TABLET SPLITTER
VIAGRA (ALL STRENGTHS) TAB (18 TABS/90DAYS) age < 40 requires Prior Authorization

MUSCLE RELAXANT AGENTS
BACLOFEN 10MG & 20MG TAB
FLEXERIL 5MG & 10MG TAB 
NORFLEX 100MG TAB
ROBAXIN 500MG & 750MG TAB
SKELAXIN 800MG TAB
ZANAFLEX 2MG & 4MG TAB

NASAL AGENTS
AFRIN NASAL SPRAY
ASTELIN NASAL SPRAY (MAX 4/90 DAYS)
ATROVENT NASAL SPRAY
AYR SINUS RINSE KIT & REFILL PACKETS
DDAVP NASAL SPRAY
FLONASE NASAL SPRAY (MAX 3/90 DAYS)
FORTICAL NASAL SPRAY
OCEAN 0.65% NASAL SPRAY
NASALCROM NASAL SPRAY

PSYCHOTHERAPEUTIC AGENTS
ABILIFY TAB (ALL STRENGTHS)
AMITRIPTYLINE TAB (ALL STRENGTHS)
BUSPAR TAB (ALL STRENGTHS)
CELEXA TAB (ALL STRENGTHS)
CYMBALTA 20MG, 30MG, 60MG
EFFEXOR 25MG, 37.5MG, 50MG, 75MG & 100MG TAB
EFFEXOR XR 37.5MG, 75MG & 150MG CAP; 225MG TAB
HALDOL 1MG & 5MG TAB
LEXAPRO TAB (ALL STRENGTHS)
LITHIUM CARBONATE 150MG & 300MG CAP; 300mg TAB
NORPRAMIN 25MG & 50MG TAB
PAMELOR 10MG & 25MG CAP; 10MG/5ML SOL
PAXIL TAB (ALL STRENGTHS)
PROZAC CAP (ALL STRENGTHS); 20mg/5ml SOLN
REMERON TAB (ALL STRENGTHS)
RISPERDAL TAB (ALL STRENGTHS); 1mg/mL SOLN
SEROQUEL TAB (ALL STRENGTHS)
SEROQUEL XR TAB (ALL STRENGTHS)
SERZONE TAB (ALL STRENGTHS) 
SINEQUAN (ALL STRENGTHS-CAPS & SOLN)
THORAZINE 25MG, 50MG & 100MG TAB
TOFRANIL 10MG & 25MG TAB
TOFRANIL PM 75MG CAP
TRAZODONE TAB (ALL STRENGTHS)
WELLBUTRIN SR TAB (ALL STRENGTHS) 
WELLBUTRIN XL 150MG & 300MG TAB
ZOLOFT (ALL STRENGTHS-TABS & SOLN)
ZYPREXA TAB (ALL STRENGTHS)
ZYPREXA ZYDIS TAB (ALL STRENGTHS)

RECTAL AGENTS
ACETAMINOPHEN SUPP
ANUSOL HC 25MG SUPP & 2.5% CREAM 
BISACODYL 10MG SUPP
COMPAZINE 25MG SUPP
FLEET & FLEET PEDIATRIC ENEMA
PHENERGAN 12.5MG & 25MG SUPP
PRAMOSONE CREAM
PROCTOFOAM HC FOAM
ROWASA ENEMA

RESPIRATORY AGENTS/DEVICES
ADVAIR DISKUS (ALL STRENGTHS)
ADVAIR HFA (MAX 6/90DAYS)
ATROVENT HFA INHALER (MAX 6/90 DAYS) 
ATROVENT INH SOL 0.02% ------(MAX 540 AMPS/90 DAYS)
BRETHINE 5mg TAB
COMBIVENT RESPIMAT
DUONEB INHALATION SOLUTION
EASIVENT HOLDING CHAMBER 
EASIVENT MASK (SM, MED, LG)
FLOVENT HFA INH (ALL STRENGTHS) -----(MAX 6/ 90 DAYS)
FLOVENT DISKUS (MAX 3)
OPTIHALER INHALER SPACER
PEAK FLOW METERS (LOW & HIGH RANGE)
PROAIR (ALBUTEROL) HFA INH (6/90 DAYS)
PULMICORT RESPULES 0.25MG & 0.5MG -----(MAX 360 AMPS/90 DAYS)
SEREVENT DISKUS (MAX 3/90 DAYS)
SINGULAIR 5MG CHEW TABS & 10MG TABS
SINGULAIR 4mg CHEW TABS & GRANULES
SPIRIVA 18mcg HANDIHALER
THEOPHYLLINE 300MG, 400MG CAPS; 80MG/15mL ELIXIR
VENTOLIN 0.5% NEB SOL ----- (MAX 9 BOX/90 DAYS)
VENTOLIN 2mg TAB
VENTOLIN 2mg/5mL SYRUP

SCHEDULE II AGENTS (no refills allowed, EXPIRE 90 DAYS FROM DATE WRITTEN)
ADDERALL 5MG, 10MG,15MG, 20MG & 30MG TAB
ADDERALL XR CAP (ALL STRENGTHS)
CONCERTA TAB (ALL STRENGTHS)
CODEINE SULFATE 30MG TAB
DEMEROL 50MG & 100MG TAB
DEXEDRINE 5MG TAB
DILAUDID 2MG & 4MG TAB
METHADONE 5MG & 10MG TAB
METHYLIN ER 10MG & 20MG TAB
METHYLPHENIDATE 5MG, 10MG TAB; 20MG SR TAB 
MORPHINE SULF (MSIR) 15MG & 30MG TAB 
MS CONTIN TAB (ALL STRENGTHS)
NORCO 5/325MG, 7.5/325MG, 10/325MG TAB
OXYCONTIN 10MG, 20MG, 40MG & 80MG TAB
PERCOCET 5/325MG, 7.5/325MG, 10/325MG TAB
ROXICODONE 5MG TAB
TUSSIONEX PENNKINETIC SUSP

SCHEDULE III, IV & V AGENTS
(Up to a 90 day supply, refills for a total of 6 months from the date written or a max of 5 refills)
AMBIEN 5MG & 10MG TAB
ATIVAN 0.5MG, 1MG & 2MG TAB
FIORICET TAB
HALCION 0.125MG & 0.25MG TAB
KLONOPIN 0.5MG, 1MG & 2MG TAB
LOMOTIL TAB
LUNESTA 1MG, 2MG & 3MG TAB
METHYLTESTOSTERONE 10MG CAP
MODAFANIL 100MG & 200MG TAB
PHENOBARBITAL 15MG, 30MG & 100MG TAB 
RESTORIL 7.5MG, 15MG & 30MG CAP
ROBITUSSIN AC SYRUP (120ML BOTTLES)
TESTOSTERONE TRANSDERM SYSTEM 2MG/DAY & 4MG/DAY
TESTOSTERONE TOPICAL GEL 2% (FORTESTA)
TESTOSTERONE CYPIONATE 200MG/ML INJ (1ML & 10ML VIALS)
TESTOSTERONE ENANTHATE 200MG/ML INJ
TRAMADOL 50MG TAB (MAX 720/90 DAYS)
TUSSIONEX SUSPENSION
TYLENOL #3 TABS & 120MG/5ML ELIXIR
VALIUM 2MG, 5MG, 10MG TABS
XANAX 0.25MG, 0.5MG, 1MG, 2MG TAB

STEROID AGENTS
CORTEF 5MG & 10MG TAB
DECADRON 0.5MG, 0.75MG & 4MG TAB
FLORINEF 0.1MG TAB
MEDROL 4MG TAB & DOSEPAK
ORAPRED PREDNISOLONE 15MG/5ML SOLN
PREDNISONE 1MG, 5MG, 10MG & 20MG TAB 
PRELONE 5MG/5ML SOLN 

THYROID-RELATED AGENTS
CYTOMEL TAB (ALL STRENGTHS)
PROPYLTHIOURACIL 50MG TAB
SYNTHROID TAB (ALL STRENGTHS)


TOPICAL AGENTS
ALDARA 5% CREAM
BACITRACIN OINTMENT
BACTROBAN OINTMENT
BENZOYL PEROXIDE 5% WASH
BENZOYL PEROXIDE 10% GEL
BENZACLIN 1%/5% GEL
BOUDREAUX'S BUTT PASTE (16% ZINC OXIDE)
CARAC 0.5% CREAM
CARMOL 20% & 40% CREAM
CLEOCIN 1% TOPICAL SOLUTION
CONDYLOX 0.5% SOLUTION
CORDRAN TAPE
DERMA-SMOOTHE/FS
DESONIDE 0.05% CREAM & OINTMENT
DIFFERIN 0.1%, 0.3%  GEL
DOVONEX 5% CREAM; 2%
DRYSOL 20% SOLUTION
DUAC GEL
EFUDEX 5% CREAM
ELDOQUIN 2% & 4% CREAM
ELIDEL 1% CREAM
ELIMITE 5% CREAM
ELOCON 0.1% CREAM
ERYTHROMYCIN TOPICAL 2% SOLN & GEL
HYDROCORTISONE 1%, 2.5% CREAM & 1% OINT
KENALOG 0.1% CREAM & OINTMENT
KENALOG SPRAY
KLARON 10% LOTION
LAC-HYDRIN 12% LOTION
LAMISIL 1% CREAM
LIDEX 0.05% CREAM, GEL, OINT, SOLN
LIDOCAINE VISCOUS 2% SOLUTION
LIDOCAINE 2% JELLY
LIDOCAINE 5% OINT
LIDOCAINE 4% SOLN
LOTRIMIN 1% CREAM & SOLUTION
LOTRISONE CREAM & LOTION
LUXIQ FOAM 0.12%
METROGEL 1% GEL; 0.75% CREAM
MYCOLOG II CREAM
NITROBID 2% OINTMENT
NIZORAL 2% CREAM & SHAMPOO
NYSTATIN CREAM, OINTMENT & POWDER
PENLAC 8% TOP SOLN
PRAMOSONE CREAM
PROTOPIC 0.1% & 0.03% OINTMENT
RETIN-A CREAM, GEL & MICRO GEL
SELSUN SHAMPOO
SILVADENE 1% CREAM 
SYNALAR 0.01% SOLUTION
TAZORAC 0.1% & 0.05% GEL
TAZORAC 0.1% & 0.05% CREAM 
TEMOVATE 0.05% CRM, OINTMENT, SOLN & GEL
VANICREAM
WESTCORT 0.2% CREAM

URILOGICAL AGENTS
DETROL LA 2MG & 4MG CAP
DITROPAN 5MG TAB
DITROPAN XL 5MG, 10MG, 15MG TAB
FLOMAX 0.4MG CAP
PROSCAR 5MG TAB
PYRIDIUM 100MG & 200MG TAB 
URISPAS 100MG TAB
UROXATRAL 10MG TAB 

VITAMINS/MINERALS
CALCIUM 600MG TAB
CALCIUM +  VIT D 600MG/800IU TAB
CERTAVITE SENIOR MULTIVITAMIN
ERGOCALCIFEROL 50,000 UNIT CAP
FER-IN-SOL SOLUTION
FERROUS GLUCONATE 324MG
FERROUS SULFATE 325MG TAB
FOLIC ACID 1MG TAB
MEPHYTON 5MG TAB
MULTIVITAMIN WITH AND WITHOUT IRON
MULTIVITAMIN SOL WITH FLUOR & IRON
MULTIVITAMIN DROP
MULTIVITAMIN DROP WITH IRON
PRENATAL VITAMIN 
PRENATAL VITAMIN w/ DHA
NIACIN 50MG & 500MG TAB
PYRIDOXINE 50MG TAB
ROCALTROL 0.25MG & 0.5MG CAP
THIAMINE 50MG & 100MG TAB
VITAMIN B-12 1000MCG/ML INJ (1ML VIAL)
VITAMIN D 400IU/ML SOLUTION
VITAMIN D 1000 IU TAB
VITAMIN D 5000 IU CAP
WELLCOVORIN 5MG TAB








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