FORT KNOX MEDDAC GENERAL FORMULARY SEARCH

Additional formulary information is available at,

http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

“A-Z” QUICK REFERENCE DRUG LIST

ACETAMINOPHEN (TYLENOL) 325MG TAB BETAXOLOL (BETOPIC-S)-0.25% SUSP 5ML
ACETAMINOPHEN-120MG & 650MG SUPP BETHANECHOL-10MG & 25MG TAB
ACETAMINOPHEN-160MG/5ML SUSP 120ML BICALUTAMIDE (CASODEX)--PO 50MG TAB
ACETAMINOPHEN-80MG/0.8ML SOLN 15ML BIMATOPROST (LUMIGAN)--OPT 0.03% SOLN
ACETAZOLAMIDE (DIAMOX)-250MG TAB & 500MG CPSR **RESTRICTED TO OPHTHALMOLOGY
ACYCLOVIR (ZOVIRAX)-200MG CAP & 800MG TAB BISACODYL (DULCOLAX)-5MG TAB, 10MG SUPP
ACYCLOVIR 200MG/5ML SUSP BISMUTH SUBSALICYLATE (PEPTO-BISMOL) 262MG TAB
ADAPALENE (DIFFERIN) 0.1% GEL,CREAM *2nd Line (1Box = 30 tabs)
ADDERALL XR-10,20,30MG CAPS (Max 30 Day Supply,No Refills) BRIMONIDINE (ALPHAGAN-P)-0.1% SUSP 5ML
ADVAIR DISKUS(FLUTICASONE/SALMETEROL)-100/50, BROMOCRIPTINE (PARLODEL)-2.5MG TAB, 5MG CAP
250/50,500/50 BUDESONIDE (PULMICORT RESPULES)-ORDER BY BOX 0.25 &
ADVAIR *HFA*--INH 45/21MCG AERP 0.5MG/2ML AMP
AEROCHAMBER SPACER #1 BUPROPION (WELLBUTRIN SR)--PO 100, 150MG TABSR
ALBUTEROL (VENTOLIN) HFA -17GM INH #1 *NOT APPROVED FOR SMOKING CESSATION*
ALBUTEROL--5MG/ML INH SOLN 20ML BUPROPION (WELLBUTRIN)--PO 75, 100MG TAB *NOT
ALBUTEROL/IPRATROPIUM (COMBIVENT)-ORAL INHALER APPROVED FOR SMOKING CESSATION*
ALBUTEROL-2MG/5ML SYRP BUSPIRONE (BUSPAR)-15 MG TAB
ALBUTEROL--INH 2.5MG/3ML SOLN *Pre-Mix* Neb Sol CAFFERGOT-TAB
ALDACTAZIDE 25MG/25MG-TAB CALCIPOTRIENE (DOVONEX)--TOP 0.005% CREAM
ALENDRONATE (FOSAMAX)-5,10,35,70MG TABS CALCITONON-SALMON (FORTICAL)-200IU NASAL SPR AY
FOSAMAX *PLUS VIT D*-PO 70MG/2800, 70MG/5600 IU TAB CALCITRIOL (ROCALTROL)-0.25MCG CAP
ALFUZOSIN (UROXATRAL)--PO 10MG TBSR CALCIUM CARBONATE 500mg/VIT D 200units-TAB (1 Bottle = 60
ALISKIREN (TEKTURNA)--PO 150, 300MG TAB ** tabs)
** RESTRICTED TO CARDIOLOGY CALCIUM CARBONATE-500MG TAB (1 Bottle = 60tabs)
ALLOPURINOL (ZYLOPRIM)-100MG & 300MG TAB ACAMPROSATE CALCIUM (CAMPRAL)--PO 333MG
ALPRAZOLAM (XANAX)-0.25MG & 0. 5MG TAB (Max 30 days) CANDESARTAN (ATACAND)—PO 4, 8, 16, 32MG TAB
ALUMINUM CHLORIDE-TOP 20% SOLN 37.5ML CANDESARTAN/HCTZ—PO 16/12.5MG, 32/12.5MG TAB
AMANTADINE (SYMMETREL)-100MG CAP CAPSAICIN (ZOSTRIX)-0.025% CRM 1.5OZ
AMCINONIDE (CYCLOCORT)-O.1% CRM AND OINT 15 & 60GM CAPSAICIN (ZOSTRIX-HP)-0.075% CRM 60GM
AMINOCAPROIC ACID-500MG TAB CAPTOPRIL (CAPOTEN)-12.5MG & 25MG TABS
AMIODARONE (CORDARONE)-200MG TAB CARBAMAZEPINE (TEGRETOL XR)-100MG & 200MG TAB
AMITRIPTYLINE-10MG, 25MG & 50MG TAB CARBAMAZEPINE (TEGRETOL)-100MG TBCH, 200MG TAB,
AMLODIPINE (NORVASC EQ)--PO 2.5, 5, 10MG TABS 100MG/5ML SUSP
AMMONIUM LACTATE(LAC-HYDRIN EQ)--TOP LOT CARVEDILOL (COREG)—PO 12.5, 3.125, 6.25, 25mg TABS
AMOXICILLIN-250MG & 500MG CAPS, 875mg TAB, 250MG/5ML, CARTEOLOL (OCUPRESS)-10ML SOLN
400MG/5ML SUSP, 200 & 400MG Chewable Tabs CEFDINIR (OMNICEF EQ)—PO 300MG CAPS,
APRACLONIDINE (IOPIDINE) 0.5% OPTH 5ML SOLN 125MG & 250MG/5ML LIQ
ARIPIPRAZOLE (ABILIFY)--PO 5,10,15,20MG TABS CEFIXIME (SUPRAX)--PO 400MG TAB **1 DOSE ONLY FOR STD
ASPIRIN (ECOTRIN)- 81MG, 325MG TAB EC CEFPODOXIME (VANTIN)-200MG TABS, 100MG/5ML 50ML BTL
ASPIRIN 325MG, 81MG TAB CEFUROXIME (CEFTIN EQ)—PO 250, 500MG TABS
ATENOLOL (TENORMIN) 50MG &100MG TAB 125MG & 250MG/5ML SUSP
ATOMOXETINE (STRATTERA) 10,18,25,40,60MG TABS CELECOXIB (CELEBREX)-100MG & 200MG CAPS ***
ATORVASTATIN (LIPITOR)—PO 10, 20, 40, 80MG TABS **PRIOR AUTHORIZATION REQUIRED****
**MUST FAIL ZOCOR FIRST CELLUVISC (CMC) --OPT 1% SOLN
ATROPINE SULFATE-1% OPTH OINT 3.5GM, SOLN 15ML CEPHALEXIN (KEFLEX)-250MG CAP, 250MG/5ML SUSP
AUGMENTIN-500 & 875MG TABS, 400MG/5ML SUSP CEPROZIL (CEFZIL)-250 & 500MG TABS, 250MG/5ML SUSP
AUGMENTIN-600-ES SUSP CETIRIZINE (ZYRTEC)-5MG,10MG TABS(MUST HAVE FAILED
AURALGAN-OTIC SOLN 15ML (Generic) CLARITIN AND ALLEGRA FIRST), 1MG/ML SYRUP –FOR
AVANDAMET (ROSIGLITAZONE/METFORMIN) – 1MG/500MG, PEDIATRIC USE
2MG/500MG, 4MG/500MG TABS CHLORAL HYDRATE-100MG/ML SYRP (MAX: 30 day supply)
AVC-VAGINAL CRM CHLORDIAZEPOXIDE/CLIDINIUM-PO 5/2.5MG CAP
AZATHIOPRINE (IMURAN)-50MG TAB CHLOROQUINE –500MG TABS
AZELASTINE (ASTELIN)--NAS 137MCG SPRA CHLORPHENIRAMINE- 2MG/5ML SYRUP, 4MG TAB, 8MG CPSR
AZITHROMYCIN (ZITHROMAX)-250MG TAB, 1GM ORAL SUSP CHLORSOXAZONE (PARAFON FORTE EQ) – 500MG TAB
PACKET & 200MG/5ML 30 ML SUSP CHLORTHALIDONE (HYGROTON)- 25, 100MG TAB
BACITRACIN-OPTH OINT 3.5GM CIMETIDINE –300MG, 400MG, & 300MG/5ML SOLN
BACITRACIN-TOP OINT 15GM TUBE CIPROFLOXACIN (CILOXAN)-0.3% SOLN 5ml
BACLOFEN (LIORESAL)-10MG TAB CIPROFLOXACIN (CIPRO EQ) – 250, 500MG TABS
BENAZEPRIL (LOTENSIN)-5, 10, 20 & 40MG TABS CIPROFLOXACIN/DEXAMETH--OTIC 0.3/0.1% SUSP
BENZONATATE (TESSALON)-100MG CAP (Max: 30 caps, no CITALOPRAM (CELEXA)- 20MG (use for 10mg doses) & 40MG
refills) (use for 20mg doses) SCORED TABLETS
BENZOYL PEROXIDE CLEANSING-5% LIQ 5OZ CLARITHROMYCIN (BIAXIN)-250MG & 500MG TAB, 250 &
BENZOYL PEROXIDE-5% (H20 BASE) & 10% GEL 42.5 GM 500MG XL TAB
BENZTROPINE (COGENTIN) –2MG TAB CLIMARA 0.025, 0.0375, 0.05, 0.075, 0.1 MG/HR PATCH
BETAMETHASONE VALERATE--TOP 0.1% LOTN CLINDAMYCIN (CLEOCIN) –150MG CAP

1 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

“A-Z” QUICK REFERENCE DRUG LIST

CLINDAMYCIN (CLEOCIN)--PO 75MG/5ML SOLN DOXYCYCLINE (VIBRAMYCIN)-100MG CAP
CLINDAMYCIN (CLEOCIN-T)-1% SOLN CLINDAMYCIN/BP (DUAC)--TOP 1%/5% GEL
CLINDAMYCIN 2% VAGINAL GRM 40GM TUBE EPINEPHRINE (EPI-PEN)-1MG/ML SYRN
CLOBETASOL (TEMOVATE)-0.05% CRM, OINT, GEL 15GM EPINEPHRINE JR (EPIPEN JR)-0.15MG IM INJ
CLOMIPHENE (CLOMID)-50MG TAB ERTHYROMYCIN -200MG/5ML SUSP (EES), 250MG CAP (base)
CLONAZEPAM (KLONOPIN)-0.5MG & 1MG TAB (Max: 30 day) ERYTHROMYCIN (STATICIN)-2% TOP SOLN 60ML
CLONIDINE (CATAPRES)-0.1MG & 0.2MG TAB ERYTHROMYCIN-5MG/GM OPTH OINT 3.5GM
CLOPIDOGREL (PLAVIX)-75MG TAB ESOMEPRAZOLE (NEXIUM)--PO 40MG CAP
CLOTRIMAZOLE-1% TOP CRM 15GM ESTRADIOL (ESTRACE EQ)--PO 1MG TAB
CLOTRIMAZOLE-1% TOP SOLN 30ML ESTROGEN/MEDROXYPROGESTERONE (PREMPRO)-0.625/2.5,
CLOTRIMAZOLE-1% VAG CRM 45G TUBE 0.625/5mg, 0.3/1.5mg, 0.45/1.5mg TABS (1 month =28 Tabs)
CODEINE SULFATE-30MG TAB (Max: 30 day supply) ESTROGENS (PREMARIN)-0.3,0.625, 0.9, & 1.25MG TAB
COLCHICINE-0.65MG TAB ESTROGENS (PREMARIN)-0.625mg/gm VAG CRM 42.5GM TUBE
COLESTIPOL (COLESTID)- 1GM TAB, POWDER ESTROPIPATE (OGEN)-0.625, 1.25, 2.5mg TAB
COLYTE-4 LITER SOLN ESZOPICLONE (LUNESTA)—PO 1, 2, 3MG TABS (Max: 30 Days)
CONDYLOX 0.5% 3.5ML (Derm, OB/GYN & Urology only) EXENATIDE (BYETTA)--SQ INJ 5, 10MEQ PEN
CORTISPORIN-OTIC SUSP 10ML EZETIMIBE (ZETIA)--PO 10MG TAB
COSOPT-OPHTH SOLN 5ML FELODIPINE (PLENDIL) 2.5MG, 5MG & 10MG TBSR
CROMOLYN SODIUM 4% OPHTHALMIC SOLUTION FENOFIBRATE (FENOGLIDE)—PO 40, 120MG TABS
CYCLOBENZAPRINE (FLEXERIL)-10MG TAB FENTANYL (DURAGESIC)-25, 50, 75, 100MCG/HR PATCH
CYCLOPENTOLATE (CYCLOGYL)-1%, 2% OPTH SOLN 15ML FERROUS SULFATE-325MG TAB, 75MG/0.6ML 50ML SOLN
CYCLOPHOSPHAMIDE (CYTOXAN) 25 & 50MG TAB FEXOFENADINE (ALLEGRA)-30MG, 60MG, 180MG TAB
CYPROHEPTADINE (PERIACTIN)-2MG/5ML SYRP, 4MG TAB (TRY CLARITIN FIRST)
DARVOCET-N 100-TAB (generic) (Max 60 day supply) FEXOFENADINE (ALLEGRA)--PO 30MG/5ML SUSR
DEBROX-OTIC SOLN #1 BTL FEXOFEN/PSEUDO (ALLEGRA-D24)--PO 180/240
DECONAMINE-CPSR (TRY CLARITIN FIRST)
DESMOPRESSIN (DDAVP)--PO 0.1,02MG TAB FINASTERIDE (PROSCAR)--PO 5MG TAB
DEMULEN 1/35-28 DAY TAB FIORICET-TAB (generic) (Max: 30-day supply)
DESIPRAMINE (NORPRAMIN)-25MG TAB FIORINAL-TAB (generic) (Max: 30-day supply)
DESOGEN-28 DAY-TAB FISH OIL (OMEGA-3 EQ)--PO 1,000MG CAP
DESONIDE (TRIDESILON)-0.05% CRM & OINT 15GM, 60GM FLEETS PHOSPHO SODA-90 ML BOTTLE
DEXAMETHASONE-0.5MG, 0.75MG, & 4MG TAB FLUCOINOLONE (SYNALAR)-0.01% TOP SOLN 60ML
DEXAMETHASONE-0.5MG/5ML ELIX FLUCONAZOLE (DIFLUCAN)-100,150 & 200MG TABS
DEXTROAMEPHETAMINE (DEXEDRINE)-5MG, 10MG, & 15MG FLUDROCORTISONE (FLORINEF)-0.1MG TAB
CPSR, 5MG TAB (MAX: 30 day supply) Restricted to FLUNISOLIDE (NASAREL EQ)--NAS 25MCG SPRA
hyperkinesis/narcolepsy FLUOCINOLINE (FS)-0.01% SHAMPOO 4 Oz
DIAZEPAM (VALIUM)-5MG TAB (Max: 30 day supply) FLUOCINONIDE (LIDEX)-0.05% CRM 15GM & 60GM, 0.05%
DIBUCAINE-1% OINT 30GM OINT 15GM & 60GM
DICLOFENAC (VOLTAREN EQ)--PO 50,75MG TABS FLUOROMETHOLONE (FML)-0.05MG/GTT 10ML OPTH SUSP
DICLOXACILLIN (DYNAPEN)-250MG CAP FLUOROURACIL (CARAC) – 0.5% CRM 30GM
DICYCLOMINE (BENTYL)-20MG TAB FLUOROURACIL (EFUDEX) - 5% CRM 25GM
DIFLUCAN SUSP (FLUCONAZOLE)--PO 10MG/ML Oral Susp FLUOXETINE (PROZAC)- 10MG scored tab, 20MG CAP
Second line to Nystatin Susp FLURANDRENOLIDE (CORDRAN)-4MCG/SQCM 80 INCH TAPE
DIGOXIN (LANOXIN)-0.05MG/ML ELIX 60ML BTL FLURBIPROFEN (OCUFEN)-0.03% OPHTH SOLN 2.5ML
DIGOXIN-0.125MG & 0.25MG FLUTICASONE (FLONASE)-50MCG NAS SPRAY
DILTIAZEM (CARDIZEM)-30MG & 60MG TABS FLUTICASONE (FLOVENT) HFA-44,110,220MCG ORAL INHALER
DILTIAZEM (TIAZAC)- 120, 180, 240, 300, & 360MG CPSR FOLIC ACID-400MCG & 1MG TAB
DILVAPROEX (DEPAKOTE SPRINKLES)-125MG CAP FORMOTEROL FUMARATE (FORADIL)- 12MCG INH CAP+DEV
DIMENHYDRINATE (DRAMAMINE)-50MG TABS FOSINOPRIL (MONOPRIL)-10MG, 20MG & 40MG TABS
DIMETAPP EQ-ELIX FUROSEMIDE (LASIX)-40MG TAB, 10MG/ML SOLN 60ML
DIPHENHYDRAMINE (BENADRYL)-12.5/5ML SYRP 120ML BTL GABAPENTIN (NEURONTIN)- 100MG Caps, 600, 800MG Tabs
DIPHENHYDRAMINE (BENADRYL)-25MG, 50MG CAP GEMFIBROZIL (LOPID)-600MG TAB (generic)
DIPYRIDAMOLE (PERSANTINE)-25MG, 75MG TAB GENTAMICIN-0.3% OPHTH SOLN 5ML, OPTH OINT 3.5GM
DIVALPROEX (DEPAKOTE)-250MG & 500MG TBEC GLIMEPIRIDE (AMARYL)-2 & 4MG TABS
DIVALPROEX (DEPAKOTE)-500MG ER GLIPIZIDE (GLUCOTROL Immediate Release)-5mg & 10mg tabs
DOCUSATE SODIUM (COLACE) 100MG CAP GLUCOVANCE (GLYBURIDE/METFORMIN)- 1.25/250MG
DOCUSATE SODIUM PED-1% SOLN 30ML BTL 2.5/500MG & 5/500MG TABS
DOMEBORO-OTIC SOLN 60ML GLYBURIDE (MICRONASE)-2.5MG & 5MG TAB
DONEPEZIL (ARICEPT)--PO 5MG, 10MG TABS GLYBURIDE MICRONIZIED (GLYNASE)-1.5, 3 & 6MG TABS
DONNATAL-ELIXIR & TABLETS GOSERELIN (ZOLADEX)-INJ FOR PROSTATE CANCER
DORZOLAMIDE (TRUSOPT)-2% 10ML GRISEOFULVIN-125MG/5MG SUSP 118ML BTL
DOXAZOSIN (CARDURA)- 2MG & 8MG TAB GRISPEG ULTRAMICROSIZE-250MG TAB
DOXEPIN (ZONALON EQ)--TOP 5% CREA GUAIFENESIN (ROBITUSSIN)-100MG/5ML SYRP
DOXEPIN-25MG, 75MG, & 100MG CAPS HALOPERIDOL – 2MG, 5MG TAB & 2MG/ML CONC 120ML
DOXYCYCLINE (PERIOSTAT)-20MG CAP HEMORRHOIDAL (ANUSOL)-RECT SUPP (ORDER BY BOX)

2 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

“A-Z” QUICK REFERENCE DRUG LIST

HEMORRHOIDAL HC (ANUSOL HC, EQ) RECT SUPP (ORDER LO OVRAL-28-TAB
BY BOX (12supp/box), 2.5% RECTAL CRM 30GM LOESTRIN FE1/20, 1.5/30-28 DAY-TAB
HOMATROPINE-2.5MG/GTT OPTH SOLN 2ML LOPERAMIDE (IMODIUM)-2MG CAP
HYDRALAZINE (APRESOLINE)-10, 25, 100MG TAB LORATADINE (CLARITIN)-10MG TAB, 5MG/5ML SYRUP
HYDROCHLOROTHIAZIDE-25MG & 50MG TAB LORAZEPAM (ATIVAN)-0.5MG & 1MG TAB (Max: 30 day supply)
HYDROCODONE & ACET--PO 5/500MG TAB Max: 30 days LOSARTAN (COZAAR)—PO 25, 50, 100MG TABS
HYDROCODONE & ACET--PO 7.5/500MG TAB Max: 30 days LOSARTAN/HCTZ(HYZAAR)-PO 50/12.5, 100/12.5, 100/25MG TB
HYDROCORTISONE VAL (WESTCORT)-0.2% CRM 15GM & LOTREL-2.5/10, 5/10 , 10/20 & 5/20MG CAP
45GM, 0.2% OINT 15GM LUTERA/LEVLITE/ALESSE 28 DAY - TAB
HYDROCORTISONE-1% CRM & OINT, LOTN 120ML MAGNESIUM GLUCONATE-500MG TAB
HYDROCORTISONE-5MG, 20MG TAB & 100MG ENEM 60ML MAGNESIUM OXIDE-400MG TAB
HYDROMORPHONE-2MG TAB ( MAX 30 day supply) MAXITROL-OPTH OINT 3.5GM, OPTH SUSP 5ML
HYDROQUINONE (ELDOQUINE FORTE)-4% TOP CRM MAXZIDE (TRIAMTERENE/HCTZ)-50/75MG TAB
HYDROXYCHLOROQUINE (PLAQUENIL)-200MG TABS MEBENDAZOLE (VERMOX)-100MG TBCH
HYDROXYZINE (ATARAX)-10 & 25MG TAB, 10MG/5ML SYRP MECLIZINE (ANTIVERT)-25MG TAB
HYOSCYAMINE (LEVSIN)-0.125MG TABS MECLIZINE-25MG TAB
HYOSCYAMINE (LEVSIN)-0.125MG TABS MEDROXYPROGESTERONE ACET (PROVERA)-2.5 & 10mg tab
HYOSCYAMINE (LEVSIN)--PO 0.125MG/5ML ELIXIR MEFLOQUINE (LARIUM)-250MG TAB
HYPROMELLOSE (TEARISOL) 0.5% OPHT SOLN 15ML MEGESTROL (MEGACE)-40MG TAB
IBANDRONATE (BONIVA)--PO 150MG TAB ONCE MONTHLY MELOXICAM (MOBIC)-7.5,15MG TABS
IBUPROFEN (MOTRIN)-400MG, 600MG & 800MG TAB MELPHALAN (ALKERAN)-2MG TAB
IBUPROFEN-100MG/5ML SUSP 120ML BTL MEPERIDINE (DEMEROL)-50MG TAB (MAX: 30 TABS)
IMIPRAMINE-10MG &25MG TABS MESALAMINE (ASACOL)--PO 400MG TBSR
IMIQUIMOD (ALDARA)--TOP 5% CREA MESALAMINE (PENTASA)--PO 250MG CPSR
INDAPAMIDE (LOZOL)-1.25MG & 2.5MG TAB METFORMIN (GLUCOPHAGE)-500, 850, 1000MG TAB
INDOMETHACIN (INDOCIN)-25MG CAP METFORMIN *ER* (GLUCOPHAGE)--PO 500MG TBSR
INSULIN 70/30 HUMAN (Novolin)-100U/ML 10ML SUSP METHAZOLAMIDE-50MG TAB (Ophthalmology only)
INSULIN ASPART (NOVOLOG) – 10ML VIAL, PEN METHOCARBAMOL (ROBAXIN)-500MG TAB
INSULIN DETEMIR (LEVEMIR)--SQ PEN, VIAL INJ METHOTREXATE-2.5MG TAB
INSULIN GLARGINE (LANTUS)-10 ML VIAL, PEN METHYLCELLULOSE (ISOPTO PLAIN)-15ML OPTH SOLN
INSULIN LENTE HUMAN (Novolin)-100U/ML 10ML SUSP METHYLDOPA (ALDOMET)-250MG TAB
INSULIN NPH HUMAN (Novolin)-100U/ML 10ML SUSP METHYLERGONOVINE (METHERGINE)-0.2MG TAB
INSULIN REG HUMAN (Novolin)-100U/ML 10ML SUSP METHYLPHENIDATE (CONCERTA)-18MG,27MG, 36MG,54MG
IPRATROPIUM (ATROVENT)-0.03% NAS SPRAY TAB SR (Max: 30-day supply, No Refills)
IPRATROPIUM (ATROVENT)-18MCG/DOSE ORAL INHALER METHYLPHENIDATE (RITALIN)-5MG & 10MG TAB, 20MG SR Tab
IPRATROPIUM (ATROVENT)-SOLN FOR INH (1 box=25 2.5 vial) (Max: 30-day supply, No Refills)
ISONIAZID-100MG, 300MG & 50MG/5ML SYRP METHYLPREDNISOLONE (MEDROL)-4MG TABS
ISOSORBID MONONITRATE (IMDUR) 30mg, 60mg, 120mg tabs METOCLOPRAMIDE (REGLAN)-10MG TAB & 1MG/ML SYRP
ISOSORBIDE DINITRATE (ISORDIL)-10MG TAB, 40MG TBSR METOLAZONE (ZAROXOLYN)-2.5MG, 5MG TAB
KETOCONAZOLE (NIZORAL)-200MG TAB METOPROLOL (LOPRESSOR)-50MG &100MG TAB
KETOCONAZOLE (NIZORAL)--TOP 2% CREA 15GM METOPROLOL XL (TOPROL XL)-25,50,100MG TABS
KETOCONAZOLE (NIZORAL)--TOP 2% SHAM METROGEL 0.75%-VAG GEL 28.4GM TUBE
KETOROLAC (ACULAR) OPTH SOLN 5ML METRO-GEL 1% 45GM TUBE
(Opthalmology/Optometry only) METRONIDAZOLE (FLAGYL)-250, 500MG TAB
KETOTIFEN (ZADITOR)--OPT 0.025% SOLN 5ML MICONAZOLE (MONISTAT DERM)-2% TOP CRM 15GM
LACRI-LUBE-OPHTH OINT 3.5GM MICRONOR/NOR QD TAB
LACTOBACILLUS ACIDOPHILUS-CAP MIDRIN-CAP (Max: 30-day supply)
LACTULOSE (ENULOSE)-10GM/15ML SYRP MINOCYCLINE(MINOCIN)-50MG CAPS
LAMOTRIGINE (LAMICTAL)--PO 25, 100, 150, 200MG TABS MINOXIDIL-10MG TAB
**Restricted to Psych and Neurology MIRALAX --PO POWD
LATANOPROST (XALATAN)-0.05% 2.5ML SOLN MIRTAZAPINE (REMERON)-15,30,45MG TABS
LEUPROLIDE AC DEPOT-3.75MG, 7.5MG & 22.5MG (OB/GYN, MOMETASONE (ASMANEX)--INH 220MCG INHA
Urology & Family Practice only) New starts for prostate cancer MOMETASONE (NASONEX)-50MCG/DOSE INH
Zoladex first MONTELUKAST (SINGULAIR)-4MG, 5MG TBCH, 10MG TAB
LEVALBUTEROL (XOPENEX HFA)--INH 45MCG MORPHINE SULFATE (MS CONTIN)- 15MG, 30MG, 60MG TAB
LEVETIRACETAM (KEPPRA)—PO 250, 500, 750, 1000MG TABS MORPHINE SULFATE IR--PO 30MG TAB
100MG/ML SOL MOXIFLOXICIN (Vigamox) OPTH Drops
LEVOFLOXACIN (LEVAQUIN)--PO 250, 500 750MG TABS MUCINEX D--PO 600/60MG TBSR
LIDOCAINE-TOP 2% GEL 30GM; 5% OINT 35GM MUPIROCIN (BACTROBAN)--TOP 2% OINT 22GM
LIDOCAINE-VISCOUS-MTH 2% SOLN 100ML BTL MURO-128 5% SOLN-OPTH SOLN 15ML, 5% OPTH OINT 3.5GM
LIOTHYRONINE (CYTOMEL)-25MCG TAB NAFTIFINE (NAFTIN)--TOP 1% CREA 30GM
LISINOPRIL -5MG, 10MG, 20MG,30MG & 40MG TABS NAPHAZOLINE/ANTAZOLINE (VASOCON-A EQ) OPTH SOLN
LISINOPRIL/HCTZ (ZESTORETIC EQ)-10/12.5, 20/12.5, 20/25MG NAPHAZOLINE/PHENIR (OPCON-A)--OPT SOLN
TABS NAPROXEN (NAPROSYN)-500MG TAB
LITHIUM CARBONATE-300MG TAB NEOMYCIN SULFATE-500MG TAB

3 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

“A-Z” QUICK REFERENCE DRUG LIST

NEOSPORIN TOP OINT 15GM TUBE POTASSIUM CHLOR-20MEQ/15ML ELIX
NEOSPORIN-OPTH SOLN 10ML, OPTH OINT 3.5GM POTASSIUM IODIDE-1GM/ML SOLN (40DROPS/ML) (SSKI)
NIACIN-50MG & 500MG TAB PRAMOXINE (PRAX)-1% TOP CRM 30GM
NIASPAN-500MG,750MG, & 1000MG TABS PRAVASTATIN (PRAVACHOL)-10,20,40,80MG TABS
NIFEDIPINE (PROCARDIA)-10MG CAP PRAZOSIN (MINIPRESS)-1, 2, & 5MG CAPS
NIFEDIPINE LONG ACTING (ADALAT CC)-30, 60 & 90MG TABS PRECISION EXTRA TEST STRIPS-#100/BOX
NILUTAMIDE (NILANDRON)-150MG TAB PREDNISOLONE (PRED-FORTE)-1% SUSP 5ML
NITROFURANTOIN (MACROBID)-100MG CAP PREDNISOLONE-15MG/5ML SOL
NITROFURANTOIN- 25MG/5ML SUSP PREDNISONE-1MG, 5MG, 10MG & 20MG TAB
NITROFURANTOIN-50MG CAP PREMPHASE-0.625MG/5MG TABS
NITROGLYCERIN--2% OINT 60GM PRIMIDONE (MYSOLINE)-50MG & 250MG TABS,
NITROGLYCERIN LINGUAL SPRAY-200DOSES/BTL 250MG/5ML SUSP
NITROGLYCERIN-0.2MG/HR, 0.4MG/HR TDS PRIMIQUINE-26.3 MG TABS
NITROGLYCERIN-0.4MG SL TAB 25TABS/BTL PROBENECID (BENEMID)-500MG TAB
NITROGLYCERIN-2.5MG, 6.5MG CPSR PROCHLORPERAZINE (COMPAZINE)-5MG TAB, 25MG SUPP
NORDETTE/LEVLEN 28DAY-TAB PROCTOFOAM HC-RECT AERO
NORETHINDRONE (AYGESTIN) 5MG TAB PROMETHAZINE (PHENERGAN)-25MG TABS,
NORTRIPTYLINE (PAMELOR)-10, 25 & 75MG CAP 12.5 & 25MG SUPP
NUVARING (0.12/0.015MG)--VAG DEVI PROPAFENONE (RYTHMOL)-150MG TAB
NYSTATIN-100,000U/GM-- 15GM Cream PROPARACAINE (OPHTHETIC)-0.5% OPTH SOLN 15ML
NYSTATIN-100,000U/ML SUSP 60ML BTL PROPRANOLOL (INDERAL)-10, 40MG Tabs,
OCUVITE PRESERVISION-(Ophthalmology/Optometry only) 80,120,160mg LA Caps
OFLOXACIN (FLOXIN)-0.3% OTIC DROPS PROPYLTHIOURACIL (PTU)-50MG TAB
OLANZAPINE (ZYPREXA)-2.5, 5 & 10MG TABS PROTOPIC TACROLIMUS (PROTOPIC)- 0.1%, 0.03% OINT
OLOPATADINE (PATANOL)-O.1% OPTH SOLN 5ml *1 **Must Fail Elidel First
BTL/MONTH PURALUBE-OINTMENT
OMEPRAZOLE (PRILOSEC)--PO 20MG CAPS PYIDOSTIGMINE (MESTINON)-60MG TAB, 180MG TBSR
ONDANSETRON (ZOFRAN)—PO 4, 8MG TABS PYRAZINAMIDE-500MG TAB
**MAX OF 60 TABS/30 DAYS OR 180 TABS/90DAYS PYRIDOXINE (B-6)-50MG TAB
ORTHO EVRA-TRANSDERMAL PATCH QUETIAPINE (SEROQUEL)-- 25, 100, 200, 300MG TABS
ORTHO NOVUM 1/50-28 DAY –TAB QUETIAPINE (SEROQUEL *XR)—50,200, 300, 400MG TBSR
ORTHO NOVUM 7/7/7-28 DAY-TAB QUINIDINE (QUINAGLUTE)-324MG TAB
ORTHO NOVUM/NORINYL 1/35-28 DAY-TAB RALOXIFENE (EVISTA)--PO 60MG TAB
ORTHO TRI-CYCLEN **LO** 28 DAY -TAB RANITIDINE (ZANTAC EQ)-150MG TAB
ORTHO TRI-CYCLEN 28 DAY- TAB RANITIDINE (ZANTAC)--PO 15MG/ML SYRP
ORTHO-CYCLEN 28DAY- TAB REFRESH PLUS (CMC)--OPT 0.5% SOLN AMPS
OXAPROZIN (DAYPRO)-600MG TAB REFRESH TEARS (CMC)-- 0.5% OPT SOLN 15ML
OXCARBAZEPINE (TRILEPTAL)—PO 150, 300, 600MG TABS RIFAMPIN-300MG CAP, 100MG/5ML SUSP
300MG/5ML SUSP RISEDRONATE (ACTONEL)--PO 5MG TAB
OXYBUTIN (DITROPAN)-5MG TAB & 5MG/5ML SYRUP RISEDRONATE (ACTONEL)--PO 35MG TAB Once Weekly
OXYBUTIN (DITROPAN XL)-5, 10, 15MG TAB RISEDRONATE (ACTONEL)--PO 75MG TAB
PAROXETINE (PAXIL) – 20MG TAB *1 TAB DAILY FOR 2 CONSECUTIVE DAYS EACH MONTH
PEDIAZOLE-SUSP RISEDRONATE (ACTONEL)--PO 150MG TAB ONCE MONTHLY
PENBUTOLOL (LEVATOL)-20MG TAB RISPERIDONE (RISPERDAL)-0.5, 1, 2MG TABS ; 1MG/ML SOLN
PENCICLOVIR (DENAVIR)-1% CREAM RIZATRIPTAN (MAXALT-MLT)-10MG TAB (max of 3 months with 1
PENICILLIN VK-250MG TAB, 250MG/5ML SUSP refill per Rx, max of 12 tabs/month)
PENTOSAN (ELMIRON)--PO 100MG CAP ROBITUSSIN AC-SYRP 120ML
*FOR INTERSTITIAL CYSTITIS ONLY ROBITUSSIN DM –SYRP 120ML
PENTOXIFYLLINE (TRENTAL)-400MG TAB ROPINIROLE (REQUIP)—PO 0.25,0.5,1,2MG TABS
PERCOCET-TAB (generic)- 5/325mg ONLY (Max: 60-day supply) ROSIGLITAZONE (AVANDIA)-2,4, & 8MG TABS
PERMETHRIN (ELIMITE)-5% TOP CRM 60GM SALICYLIC ACID (OCCLUSAL HP SOL)-17% EXT 15ML
PHENAZOPYRIDINE (PYRIDIUM)-100MG TAB SALICYLIC ACID PLASTER-40% PSTE TOP
PHENOBARBITAL-30MG TAB, 20MG/5ML ELIX (Max: 60 Days) SALMETEROL (SEREVENT)-21MCG/DOSE DISKUS
PHENYTOIN (DILANTIN)-100MG CAPS & 50MG TBCH SALSALATE (DISALCID)-500MG TAB
PHYTONADIONE (MEPHYTON)-5MG TAB SCOPOLAMINE (HYOSCINE)-OPTH 0.25% SOLN 5ML
PILOCARPINE (OCUSERT)-20MCG & 40MCG SELENIUM SULFIDE (SELSUN)-2.5% LOTN 120ML BTL
PILOCARPINE-1%, 2%, 4%, 6% OPTH SOLN 15ML, 4% OPTH SEPTRA/BACTRIM DS-TAB (Generic)
GEL 4GM TUBE SEPTRA/BACTRIM-SUSP (Generic)
PIMECROLIMUS (ELIDEL) 1% CREAM SERTRALINE (ZOLOFT)-50MG (for ½ tab-25mg dose only),
PIOGLITAZONE (ACTOS)-15, 30, 45MG TAB 100MG TAB (for 100 & 50mg doses)
PIROXICAM (FELDENE)-20MG CAP SILVER SULFADIAZINE-1% TOP CRM, 20GM, 85GM, 400GM
POLYTRIM(Polymixin B/trimethoprim)-OPTH SOLN 10ML SIMVASTATIN (ZOCOR) – 5, 10, 20, 40 & 80MG TABS
POLYVINYL ALCOHOL (TEARGEN)-1.4% OPTH SOLN 15ML SINEMET 25/100-TAB, 25/250 TAB
POTASSIUM CHLOR (K-DUR)-20MEQ TBSR SINEMET CR-50/200 TAB
POTASSIUM CHLOR (SLOW K)-8MEQ TBSR SITAGLIPTIN (JANUVIA)—PO 25, 50, 100MG TABS

4 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

“A-Z” QUICK REFERENCE DRUG LIST

SODIUM CHLORIDE (OCEAN)-NAS SPRA 45ML BTL TOBRAMYCIN (TOBREX)-0.3% OPTH SOLN 5ML (Ophthalmology
SODIUM CHLORIDE-0.9% SOLN INH (ORDER BY BOX) & Optometry/ENT only)
SODIUM FLUORIDE (PREVIDENT 5000 PLUS) 1.1% 1.8OZ TUBE TOLNAFTATE (TINACTIN)-1% TOP SOLN 10ML
SODIUM FLUORIDE-0.125MG/GROP #1 BOTTLE TOLTERDINE (DETROL LA)- 2, 4MG CAPS
SOLIFENACIN (VESICARE)--PO 5, 10MG TABS TOPIRAMATE (TOPAMAX)-25, 50, 100, 200MG TAB
SORBITOL-70% SOLN TRAMADOL (ULTRAM)-50MG TAB
SOTALOL (SORINE)-80MG &160MG TABS *MAX 30 DAYS SUPPLY
SPIRONOLACTONE (ALDACTONE)-25MG TAB TRAZODONE (DESYREL)-50MG (for ½ tab – 25mg dose only) &
STANNOUS FLUORIDE (GEL KAM)-0.4% DENT G 60ML 100MG TABS (for 100mg & 50mg doses)
SUCRALFATE (CARAFATE)-1GM TAB (generic) TRETINOIN (RETIN A)-0.025, 0.05, 0.1%crm 20gm, 0.025% gel
SUCRALFATE (CARAFATE)--PO 1G/10ML SUSR 15gm
SULFACETAMIDE-10% OPTH SOLN 15ML, OPTH OINT 3.5GM TRIAMCINOLINE (KENALOG)-SPRAY 63 GM
SULFACET/SULFUR (CLENIA)--TOP 10/5% SOAP TRIAMCINOLONE-0.1% CRM & OINT 15GM,80GM
SULFASALAZINE (AZULFIDINE)-500MG TAB & 500MG TAB EC TRIFLURIDINE (VIROPTIC)-0.5MG/GTT OPTH 7.5ML
SULFISOXAZOLE(GANTRISIN)-500MG/5ML SUSP (Ophthalmology only)
SULFUR/SALICYLIC (SEBEX)-TOP SHAMPOO 120ML TRIHEXYPHENIDYL (ARTANE)—2MG,5MG TAB
SUMATRIPTAN (IMITREX) 6MG SYR (1box = 2 syr) TRI-LEVLEN-28-TAB
SYNTHROID-0.025, 0.05, 0.075, 0.088, 0.1, 0.112, 0.125, 0.15, TROPICAMIDE (MYDRIACYL)-1% OPTH 0.5MG/GTT 15ML
0.175 MG TAB TYLENOL #3-TAB (generic), Max: 30-day supply
SYRINGE, INSULIN LOW DOSE-0.5ML (MAX: 300/90 DAYS) TYLENOL W/ CODEINE-12MG/5ML ELIXIR (Max: 30 day supply)
SYRINGE, INSULIN U100-1ML (MAX: 300/90 DAYS) TYLOX 5/500MG-CAP (Max: 60 day supply)
TAMOXIFEN (NOLVADEX)-10MG TAB UNDECYLENIC ACID + CPD-PWED (DESENEX EQ) 45GM
TAZAROTENE (TAZORAC) 0.05% Cream UREA (CARMOL)-20% CRM
TAZAROTENE (TAZORAC) 0.1% gel,crm URINE CONTENTS (N-MULTISTIX) TEST STRIPS-#1 BTL
TEGASEROD (ZELNORM)-6MG TABS URINE SUGAR/PROTEIN TEST STRIPS (URISTIX)-#1 BTL
TELMISARTAN (MICARDIS)- 20,40,80MG TABS VALACYCLOVIR (VALTREX)--PO 500MG, 1GM TABS
TELMISARTAN/HCTZ (MICARDIS HCT)– PO 40/12.5MG, VALPROIC ACID (DEPAKENE)-250MG CAP & 25MG/5ML SUSP
80/12.5MG, 80/25MG TAB VENLAFAXINE(EFFEXOR XR)- 37.5,75MG, & 150MG XR CAPS
TEMAZEPAM (RESTORIL) 15MG CAP (Max: 30 day) VERAPAMIL (CALAN SR) 120, 180, 240MG, TBSR
TERAZOSIN (HYTRIN)-1, 2, 5 & 10MG CAPS VERAPAMIL (CALAN)-80MG &120MG TAB
TERBINAFINE (LAMISIL)-250MG VITAMIN E - 400 IU CAP
TERBUTALINE (BRETHINE)-5MG TAB VITAMINS MULTIPLE WITH IRON--SOLN #1 BOTTLE
TESTOSTERONE (ANDROGEL PKT)--TDRM 1% GEL VITAMINS MULTIPLE --SOLN #1 BOTTLE
TESTOSTERONE CYPIONATE--IM 200MG/ML INJ. 1ML VIAL VOLSOL HC-OTIC SOLN 10ML
TETRACYCLINE-250MG CAP VYTORIN (EZETIMIBE/SIMVASTATIN)- 10/20,40,80MG TABS
THEOPHYLLINE ER--100, 200, &300MG TBSR WARFARIN (COUMADIN)-1, 2, 2.5, 5, 10MG TABS
THIAMINE-50MG TAB YASMIN – 28 DAY TAB
THYROID (ARMOUR)-32MG & 65MG TAB YAZ - 28 DAY TAB
TIMOLOL(TIMOPTIC XE) -0.25% & 0.5% GEL ZIPRASIDONE (GEODON)--PO 20,60,80MG CAPS
TIMOLOL(TIMPOPTIC)-0.25% & 0.5% OPTH SOLN 10ML ZOLMITRIPTIAN (ZOMIG) 2.5mg & 5mg MLT (max of 3 months
TIOTROPIUM BROMIDE (SPIRIVA)-18MCG POWDER FOR INHA with 1 refill per Rx, max of 12 tabs/month)
TOBRADEX-OPTH SOLN 5ML, 3.5GM OPTH OINT ZOLPIDEM (AMBIEN)-5 & 10MG TAB (Max: 30 day supply)
(Ophthalmology/optometry/ENT only)

5 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

FORMULARY DRUG LIST BY CLASSIFICATION

ANALGESIC/ANTI-INFLAMMATORY NYSTATIN-100,000U/ML SUSP 60ML BTL

TERBINAFINE (LAMISIL)-250MG TABS
NON-NARCOTIC ANALGESICS ANTIHELMINTICS
ACETAMINOPHEN (TYLENOL) 325MG TAB
MEBENDAZOLE (VERMOX)-100MG TBCH
ACETAMINOPHEN-160MG/5ML SUSP 120ML
ACETAMINOPHEN-80MG/0.8ML SOLN 15ML ANTIMALARIAL AGENTS
ACETAMINOPHEN-120MG & 650MG SUPP CHLOROQUINE –500MG TABS
TRAMADOL (ULTRAM)-50MG TAB *MAX 30 DAY SUPPLY HYDROXYCHLOROQUINE (PLAQUENIL)-200MG TABS
MEFLOQUINE (LARIUM)-250MG TAB
NONSTEROIDAL ANTI-INFLAMMATORY PRIMIQUINE-26.3 MG TABS
ASPIRIN 325MG, 81MG TAB
ASPIRIN (ECOTRIN)- 81MG, 325MG TAB EC CEPHALOSPORINS
CELECOXIB (CELEBREX)-100MG & 200MG CAPS *** CEFDINIR (OMNICEF EQ)—PO 300MG CAPS, 125MG &
**PRIOR AUTHORIZATION REQUIRED**** 250MG/5ML LIQ
DICLOFENAC (VOLTAREN EQ)--PO 50,75MG TABS CEFIXIME (SUPRAX)--PO 400MG TAB **1 DOSE ONLY FOR STD
IBUPROFEN (MOTRIN)-400MG, 600MG & 800MG TAB CEFPODOXIME (VANTIN)-200MG TABS, 100MG/5ML 50ML BTL
IBUPROFEN-100MG/5ML SUSP 120ML BTL CEPHALEXIN (KEFLEX)-250MG CAP, 250MG/5ML SUSP
INDOMETHACIN (INDOCIN)-25MG CAP CEPROZIL (CEFZIL)-250 & 500MG TABS, 250MG/5ML SUSP
MELOXICAM (MOBIC)-7.5, 15MG TABS RESTRICTED TO CEFUROXIME (CEFTIN EQ)—PO 250, 500MG TABS
PATIENTS WITH G.I. INTOLERANCE TO TRADITIONAL NSAIDS 125MG & 250MG/5ML SUSP
NAPROXEN (NAPROSYN)-500MG TAB LINCOMYCINS
OXAPROZIN (DAYPRO)-600MG TAB CLINDAMYCIN (CLEOCIN) –150MG CAP, 75MG/5ML ORAL SUSP
PIROXICAM (FELDENE)-20MG CAP MACROLIDES
SALSALATE (DISALCID)-500MG TAB AZITHROMYCIN (ZITHROMAX)-250MG TAB, 1GM ORAL SUSP
NARCOTIC ANALGESICS PACKET & 200MG/5ML 30 ML SUSP
CODEINE SULFATE-30MG TAB (Max: 30 day supply) CLARITHROMYCIN (BIAXIN)-250MG & 500MG TAB, 250 &
DARVOCET-N 100-TAB (generic) (Max 60 day supply) 500MG XL TAB
FENTANYL (DURAGESIC)-25, 50, 75, 100MCG/HR PATCH ERTHYROMYCIN -200MG/5ML SUSP (EES), 250MG CAP (base)
HYDROCODONE & ACET--PO 5/500MG TAB Max: 30 day supply PEDIAZOLE-SUSP
HYDROCODONE & ACET--PO 7.5/500MG TAB Max: 30 day supply MISCELLANEOUS ANTIBIOTICS
HYDROMORPHONE-2MG TAB ( MAX 30 day supply) METRONIDAZOLE (FLAGYL)-250, 500MG TAB
MEPERIDINE (DEMEROL)-50MG TAB (MAX: 30 TABS)
MORPHINE SULFATE (MS CONTIN)- 15MG, 30MG, 60MG TAB
NITROFURANTOINS
NITROFURANTOIN-50MG CAP
MORPHINE SULFATE IR--PO 30MG TAB
NITROFURANTOIN (MACROBID)-100MG CAP
PERCOCET-TAB (generic)- 5/325mg ONLY (Max: 60-day supply)
NITROFURANTOIN- 25MG/5ML SUSP
TYLENOL #3-TAB (generic), Max: 30-day supply
TYLENOL W/ CODEINE-12MG/5ML ELIXIR (Max: 30 day supply) OPHTHALMIC ANTIBIOTICS
TYLOX 5/500MG-CAP (Max: 60 day supply) see OPHTHALMICS
STEROIDAL ANTI-INFLAMMATORIES PENICILLINS
AMOXICILLIN-250MG & 500MG CAPS, 875mg TAB
(CORTICOSTEROIDS) 250MG/5ML, 400MG/5ML SUSP, 200 & 400MG Chewable
DEXAMETHASONE-0.5MG, 0.75MG, & 4MG TAB
AUGMENTIN-500 & 875MG TABS, 400MG/5ML SUSP
DEXAMETHASONE-0.5MG/5ML ELIX
AUGMENTIN-600-ES SUSP
FLUDROCORTISONE (FLORINEF)-0.1MG TAB
DICLOXACILLIN (DYNAPEN)-250MG CAP
HYDROCORTISONE-5MG, 20MG TAB & 100MG ENEM 60ML
PENICILLIN VK-250MG TAB, 250MG/5ML SUSP
METHYLPREDNISOLONE (MEDROL)-4MG TABS
PREDNISOLONE -15MG/5ML SOL QUINOLONES
PREDNISONE-1MG, 5MG, 10MG & 20MG TAB CIPROFLOXACIN (CIPRO EQ) – 250, 500MG TABS
LEVOFLOXACIN (LEVAQUIN)--PO 250, 500 750MG TABS
TOPICAL ANTI-INFLAMMATORIES
see TOPICALS SULFA
SEPTRA/BACTRIM-SUSP (Generic)
ANESTHETICS SEPTRA/BACTRIM DS-TAB (Generic)
LIDOCAINE-VISCOUS-MTH 2% SOLN 100ML BTL SULFISOXAZOLE(GANTRISIN)-500MG/5ML SUSP
TOPICAL ANESTHETICS TETRACYCLINES
see TOPICALS DOXYCYCLINE (PERIOSTAT)-20MG CAP
ANTIBIOTICS/ANTI-INFECTIVES DOXYCYCLINE (VIBRAMYCIN)-100MG CAP
MINOCYCLINE(MINOCIN)-50MG CAPS
AMINOGLYCOSIDES TETRACYCLINE-250MG CAP
NEOMYCIN SULFATE-500MG TAB
ANTIFUNGALS TOPICAL ANTIBIOTIC/ANTI-INFECTIVES
see TOPICALS
FLUCONAZOLE (DIFLUCAN)-100,150 & 200MG TABS
DIFLUCAN SUSP (FLUCONAZOLE)--PO 10MG/ML Oral Susp ANTICOAGULANTS
Second line to Nystatin Susp WARFARIN (COUMADIN) -- 1, 2, 2.5, 5, 10MG TABS
GRISEOFULVIN-125MG/5MG SUSP 118ML BTL ANTICONVULSANTS
GRISPEG ULTRAMICROSIZE-250MG TAB
CARBAMAZEPINE (TEGRETOL)-100MG TBCH, 200MG TAB,
KETOCONAZOLE (NIZORAL)-200MG TAB
100MG/5ML SUSP

6 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

FORMULARY DRUG LIST BY CLASSIFICATION

CARBAMAZEPINE (TEGRETOL XR)-100MG & 200MG TAB ANTIHYPERLIPIDEMICS
DILVAPROEX (DEPAKOTE SPRINKLES)-125MG CAP
ATORVASTATIN (LIPITOR)—PO 10, 20, 40, 80MG TABS
DIVALPROEX (DEPAKOTE)-250MG & 500MG TBEC
**MUST FAIL ZOCOR FIRST
DIVALPROEX (DEPAKOTE)-500MG ER
COLESTIPOL (COLESTID)- 1GM TAB, POWDER
GABAPENTIN (NEURONTIN)- 100MG Caps, 600, 800MG Tabs
EZETIMIBE (ZETIA)--PO 10MG TAB
LAMOTRIGINE (LAMICTAL)--PO 25, 100, 150, 200MG TABS
FENOFIBRATE (FENOGLIDE)—PO 40, 120MG TABS
**Restricted to Psych and Neurology
FISH OIL (OMEGA-3 EQ)--PO 1,000MG CAP
LEVETIRACETAM (KEPPRA)—PO 250, 500, 750, 1000MG TABS
GEMFIBROZIL (LOPID)-600MG TAB (generic)
100MG/ML SOL
NIACIN-50MG & 500MG TAB
OXCARBAZEPINE (TRILEPTAL)—PO 150, 300, 600MG TABS
NIASPAN-500MG,750MG, & 1000MG TABS
300MG/5ML SUSP
PRAVASTATIN (PRAVACHOL)-10,20,40,80MG TABS
PHENOBARBITAL-30MG TAB, 20MG/5ML ELIX
SIMVASTATIN (ZOCOR) – 5, 10, 20, 40 & 80MG TABS
*(Max: 60 day supply)
VYTORIN (EZETIMIBE/SIMVASTATIN)- 10/20,40,80MG TABS
PHENYTOIN (DILANTIN)-100MG CAPS & 50MG TBCH
PRIMIDONE (MYSOLINE)-50MG & 250MG TABS, ANTIHYPERTENSIVES
250MG/5ML SUSP *SEE CARDIAC AGENTS
TOPIRAMATE (TOPAMAX)-25, 50, 100, 200MG TAB
VALPROIC ACID (DEPAKENE)-250MG CAP & 25MG/5ML SUSP ANTIMIGRAINE
CAFFERGOT-TAB
ANTIDIARRHEA AGENTS FIORICET-TAB (generic) (Max: 30-day supply)
BISMUTH SUBSALICYLATE (PEPTO-BISMOL) 262MG TAB FIORINAL-TAB (generic) (Max: 30-day supply)
(1Box = 30 tabs) MIDRIN-CAP (Max: 30-day supply)
LACTOBACILLUS ACIDOPHILUS-CAP RIZATRIPTAN (MAXALT-MLT)-10MG TAB (max of 3 months with 1
LOPERAMIDE (IMODIUM)-2MG CAP refill per Rx, max of 12 tabs/month)
ANTIEMETICS SUMATRIPTAN (IMITREX) 6MG SYR (1box = 2 syr)
MECLIZINE-25MG TAB ZOLMITRIPTIAN (ZOMIG) 2.5mg & 5mg MLT (max of 3 months with
ONDANSETRON (ZOFRAN)—PO 4, 8MG TABS 1 refill per Rx, max of 12 tabs/month)
**MAX OF 60 TABS/30 DAYS OR 180 TABS/90DAYS ANTINEOPLASTIC AGENTS
PROCHLORPERAZINE (COMPAZINE)-5MG TAB, 25MG SUPP AZATHIOPRINE (IMURAN)-50MG TAB
PROMETHAZINE (PHENERGAN)-25MG TABS, 12.5 & 25MG SUPP BICALUTAMIDE (CASODEX)--PO 50MG TAB
ANTIGOUT CYCLOPHOSPHAMIDE (CYTOXAN) 25 & 50MG TAB
ALLOPURINOL (ZYLOPRIM)-100MG & 300MG TAB GOSERELIN (ZOLADEX)-INJ FOR PROSTATE CANCER
COLCHICINE-0.65MG TAB LEUPROLIDE AC DEPOT-3.75MG, 7.5MG & 22.5MG
PROBENECID (BENEMID)-500MG TAB (OB/GYN, Urology & Family Practice only) New starts for prostate
cancer use Zoladex first
ANTIHISTAMINES/DECONGESTANTS & MEGESTROL (MEGACE)-40MG TAB
COUGH MELPHALAN (ALKERAN)-2MG TAB
METHOTREXATE-2.5MG TAB
ANTIHISTAMINE DRUGS NILUTAMIDE (NILANDRON)-150MG TAB
CETIRIZINE (ZYRTEC)-5MG,10MG TABS(MUST HAVE FAILED
TAMOXIFEN (NOLVADEX)-10MG TAB
CLARITIN AND ALLEGRA FIRST), 1MG/ML SYRUP –FOR
PEDIATRIC USE (TRY CLARITIN SYRUP FIRST) ANTIPARKINSON AGENTS
CHLORPHENIRAMINE- 2MG/5ML SYRUP, 4MG TAB, 8MG CPSR BROMOCRIPTINE (PARLODEL)-2.5MG TAB, 5MG CAP
CYPROHEPTADINE (PERIACTIN)-2MG/5ML SYRP, 4MG TAB BENZTROPINE (COGENTIN) –2MG TAB
DIPHENHYDRAMINE (BENADRYL)-25MG, 50MG CAP ROPINIROLE (REQUIP)--PO 0.25,0.5,1,2MG TABS
DIPHENHYDRAMINE (BENADRYL)-12.5/5ML SYRP 120ML BTL SINEMET 25/100-TAB, 25/250 TAB
FEXOFENADINE (ALLEGRA)-30MG, 60MG, 180MG TAB (TRY SINEMET CR-50/200 TAB
CLARITIN FIRST) TRIHEXYPHENIDYL (ARTANE)—2MG,5MG TAB
FEXOFENADINE (ALLEGRA)--PO 30MG/5ML SUSR ANTIPLATELET AGENTS
FEXOFEN/PSEUDO (ALLEGRA-D24)--PO 180/240
CLOPIDOGREL (PLAVIX)-75MG TAB
(TRY CLARITIN FIRST)
DIPYRIDAMOLE (PERSANTINE)-25MG, 75MG TAB
HYDROXYZINE (ATARAX)-10 & 25MG TAB, 10MG/5ML SYRP
LORATADINE (CLARITIN)-10MG TAB, 5MG/5ML SYRUP ANTITUBERCULOSIS AGENTS
ANTITUSSIVES ISONIAZID-100MG, 300MG & 50MG/5ML SYRP
BENZONATATE (TESSALON)-100MG CAP (Max: 30 caps, no refills) PYRAZINAMIDE-500MG TAB
ROBITUSSIN AC-SYRP 120ML RIFAMPIN-300MG CAP, 100MG/5ML SUSP
ROBITUSSIN DM –SYRP 120ML ANTIVIRALS
DECONGESTANTS ACYCLOVIR (ZOVIRAX)-200MG CAP & 800MG TAB
DECONAMINE-CPSR ACYCLOVIR 200MG/5ML SUSP
DIMETAPP EQ-ELIX AMANTADINE (SYMMETREL)-100MG CAP
MUCINEX D--PO 600/60MG TBSR VALACYCLOVIR HCL (VALTREX)--PO 500MG, 1GM TABS
EXPECTORANTS OPHTHALMIC ANTIVIRALS
GUAIFENESIN--PO 200MG TAB SEE OPHTHALMICS
GUAIFENESIN (ROBITUSSIN)-100MG/5ML SYRP

7 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

FORMULARY DRUG LIST BY CLASSIFICATION

ASTHMA/ALLERGY/RESPIRATORY ALPHA-BLOCKERS
ALBUTEROL-2MG/5ML SYRP ALFUZOSIN (UROXATRAL)--PO 10MG TBSR
MONTELUKAST (SINGULAIR)-4MG, 5MG TBCH, 10MG TAB CLONIDINE (CATAPRES)-0.1MG & 0.2MG TAB
TERBUTALINE (BRETHINE)-5MG TAB DOXAZOSIN (CARDURA)- 2MG & 8MG TAB
THEOPHYLLINE ER--100, 200, &300MG TBSR METHYLDOPA (ALDOMET)-250MG TAB
PRAZOSIN (MINIPRESS)-1, 2, & 5MG CAPS
NASAL INHALANTS TERAZOSIN (HYTRIN)-1, 2, 5 & 10MG CAPS
AZELASTINE (ASTELIN)--NAS 137MCG SPRA
FLUTICASONE (FLONASE)-50MCG NAS SPRAY ANGIOTENSIN-II RECEPTOR ANTAGONIST
FLUNISOLIDE (NASAREL EQ)--NAS 25MCG SPRA CANDESARTAN (ATACAND)—PO 4, 8, 16, 32MG TAB
IPRATROPIUM (ATROVENT)-0.03% NAS SPRAY CANDESARTAN/HCTZ—PO 16/12.5MG, 32/12.5MG TAB
MOMETASONE (NASONEX)-50MCG/DOSE INH LOSARTAN (COZAAR)—PO 25, 50, 100MG TABS
SODIUM CHLORIDE (OCEAN)-NAS SPRA 45ML BTL LOSARTAN/HCTZ(HYZAAR)-PO 50/12.5, 100/12.5, 100/25MG TB
TELMISARTAN (MICARDIS)- 20,40,80MG TABS
ORAL INHALANTS TELMISARTAN/HCTZ (MICARDIS HCT)– PO 40/12.5MG,
ADVAIR DISKUS(FLUTICASONE/SALMETEROL)-100/50,
80/12.5MG, 80/25MG TAB
250/50,500/50
ADVAIR *HFA*--INH 45/21MCG AERP ANTIANGINALS
AEROCHAMBER SPACER #1 ISOSORBIDE DINITRATE (ISORDIL)-10MG TAB, 40MG TBSR
ALBUTEROL (VENTOLIN) HFA -17GM INH #1 ISOSORBID MONONITRATE (IMDUR) 30mg, 60mg, 120mg tabs
ALBUTEROL -- 5MG/ML INH SOLN 20ML NITROGLYCERIN--2% OINT 60GM
ALBUTEROL--INH 2.5MG/3ML SOLN *Pre-Mix* Neb Sol NITROGLYCERIN-2.5MG, 6.5MG CPSR
ALBUTEROL/IPRATROPIUM (COMBIVENT)-ORAL INHALER NITROGLYCERIN-0.4MG SL TAB 25TABS/BTL
FLUTICASONE (FLOVENT) HFA-44,110,220MCG ORAL INHALER NITROGLYCERIN LINGUAL SPRAY-200DOSES/BTL
FORMOTEROL FUMARATE (FORADIL)- 12MCG INH CAP+DEV NITROGLYCERIN-0.2MG/HR, 0.4MG/HR TDS
IPRATROPIUM (ATROVENT)-18MCG/DOSE ORAL INHALER ANTIARRHYTHMICS
IPRATROPIUM (ATROVENT)-SOLN FOR INH (1 box=25 2.5 vial) AMIODARONE (CORDARONE)-200MG TAB
LEVALBUTEROL (XOPENEX HFA)--INH 45MCG DIGOXIN (LANOXIN)-0.05MG/ML ELIX 60ML BTL
MOMETASONE (ASMANEX)--INH 220MCG INHA DIGOXIN-0.125MG & 0.25MG
SALMETEROL (SEREVENT)-21MCG/DOSE DISKUS PROPAFENONE (RYTHMOL)-150MG TAB
SODIUM CHLORIDE-0.9% SOLN INH (ORDER BY BOX) QUINIDINE (QUINAGLUTE)-324MG TAB
TIOTROPIUM BROMIDE (SPIRIVA)-18MCG POWDER FOR INHA SOTALOL (SORINE)-80MG &160MG TABS
BUDESONIDE (PULMICORT RESPULES)-ORDER BY BOX 0.25 & BETA-BLOCKERS
0.5MG/2ML AMP ATENOLOL (TENORMIN) 50MG &100MG TAB
BIRTH CONTROL CARVEDILOL (COREG)—PO 3.125, 6.25, 12.5, 25MG TABS
METOPROLOL (LOPRESSOR)-50MG &100MG TAB
ORAL-MONOPHASIC METOPROLOL XL (TOPROL XL)-25,50,100MG TABS
DEMULEN 1/35-28 DAY TAB
PENBUTOLOL (LEVATOL)-20MG TAB
DESOGEN-28 DAY-TAB
PROPRANOLOL (INDERAL)-10,40MG Tabs, 80,120,160mg LA Caps
LOESTRIN FE1/20, 1.5/30-28 DAY-TAB
LO OVRAL-28-TAB CALCIUM CHANNEL BLOCKERS
LUTERA/LEVLITE/ALESSE 28 DAY - TAB AMLODIPINE (NORVASC EQ)--PO 2.5, 5, 10MG TABS
MICRONOR/NOR QD TAB DILTIAZEM (CARDIZEM)-30MG & 60MG TABS
NORDETTE/LEVLEN 28DAY-TAB DILTIAZEM (TIAZAC)- 120, 180, 240, 300, & 360MG CPSR
ORTHO-CYCLEN 28DAY- TAB FELODIPINE (PLENDIL) 2.5MG, 5MG & 10MG TBSR
ORTHO NOVUM/NORINYL 1/35-28 DAY-TAB NIFEDIPINE (PROCARDIA)-10MG CAP
ORTHO NOVUM 1/50-28 DAY –TAB NIFEDIPINE LONG ACTING (ADALAT CC)-30, 60 & 90MG TABS
YASMIN – 28 DAY TAB VERAPAMIL (CALAN)-80MG &120MG TAB
YAZ - 28 DAY TAB VERAPAMIL (CALAN SR) 120, 180, 240MG, TBSR
ORAL-TRIPHASIC DIURETICS
ORTHO NOVUM 7/7/7-28 DAY-TAB ALDACTAZIDE 25MG/25MG-TAB
ORTHO TRI-CYCLEN 28 DAY- TAB CHLORTHALIDONE (HYGROTON)- 25, 100MG TAB
ORTHO TRI-CYCLEN **LO** 28 DAY -TAB FUROSEMIDE (LASIX)-40MG TAB, 10MG/ML SOLN 60ML
TRI-LEVLEN-28-TAB HYDROCHLOROTHIAZIDE-25MG & 50MG TAB
INDAPAMIDE (LOZOL)-1.25MG & 2.5MG TAB
TRANSDERMAL MAXZIDE (TRIAMTERENE/HCTZ)-50/75MG TAB
ORTHO EVRA-TRANSDERMAL PATCH
METOLAZONE (ZAROXOLYN)-2.5MG, 5MG TAB
INTRAVAGINAL SPIRONOLACTONE (ALDACTONE)-25MG TAB
NUVARING (0.12/0.015MG)--VAG DEVI
MISCELLANEOUS CARDIOVASCULAR AGENTS
CARDIAC AGENTS PENTOXIFYLLINE (TRENTAL)-400MG TAB
ACE-INHIBITORS MISCELLANEOUS ANTIHYPERTENSIVES
BENAZEPRIL (LOTENSIN)-5, 10, 20 & 40MG TABS ALISKIREN (TEKTURNA)--PO 150, 300MG TAB
CAPTOPRIL (CAPOTEN)-12.5MG & 25MG TABS ** RESTRICTED TO CARDIOLOGY
FOSINOPRIL (MONOPRIL)-10MG, 20MG & 40MG TABS HYDRALAZINE (APRESOLINE)-10, 25, 100MG TAB
LISINOPRIL -5MG, 10MG, 20MG,30MG & 40MG TABS LOTREL-2.5/10, 5/10 , 10/20 & 5/20MG CAP
MINOXIDIL-10MG TAB

8 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

FORMULARY DRUG LIST BY CLASSIFICATION

LISINOPRIL/HCTZ (ZESTORETIC EQ)-10/12.5, 20/12.5, 20/25MG TABS COLITIS
CATHARTICS AND LAXATIVES MESALAMINE (ASACOL)--PO 400MG TBSR
BISACODYL (DULCOLAX)-5MG TAB, 10MG SUPP MESALAMINE (PENTASA)--PO 250MG CPSR
COLYTE-4 LITER SOLN SULFASALAZINE (AZULFIDINE)-500MG TAB & 500MG TAB EC
DOCUSATE SODIUM (COLACE) 100MG CAP GASTROINTESTINALS-MISC
DOCUSATE SODIUM PED-1% SOLN 30ML BTL
CIMETIDINE –300MG, 400MG, & 300MG/5ML SOLN
FLEETS PHOSPHO SODA-90 ML BOTTLE
CHLORDIAZEPOXIDE/CLIDINIUM-PO 5/2.5MG CAP
LACTULOSE (ENULOSE)-10GM/15ML SYRP
DICYCLOMINE (BENTYL)-20MG TAB
MIRALAX --PO POWD
DONNATAL-ELIXIR & TABLETS
SORBITOL-70% SOLN
ESOMEPRAZOLE (NEXIUM)--PO 40MG CAP
CENTRAL NERVOUS SYSTEM HYOSCYAMINE (LEVSIN)-0.125MG TABS
ANTIANXIETY HYOSCYAMINE (LEVSIN)--PO 0.125MG/5ML ELIXIR
BUSPIRONE (BUSPAR)-15 MG TAB METOCLOPRAMIDE (REGLAN)-10MG TAB & 1MG/ML SYRP
OMEPRAZOLE (PRILOSEC)--PO 20MG CAPS
ANTIDEPRESSANTS RANITIDINE (ZANTAC)-150MG TAB
AMITRIPTYLINE-10MG, 25MG & 50MG TAB
RANITIDINE (ZANTAC EQ)--PO 15MG/ML SYRP
BUPROPION (WELLBUTRIN)--PO 75, 100MG TAB
SUCRALFATE (CARAFATE)-1GM TAB (generic)
*NOT APPROVED FOR SMOKING CESSATION*
SUCRALFATE (CARAFATE)--PO 1G/10ML SUSR
BUPROPION (WELLBUTRIN SR)--PO 100, 150MG TABSR
*NOT APPROVED FOR SMOKING CESSATION* HORMONE REPLACEMENT
CITALOPRAM (CELEXA)- 20MG (use for 10mg doses) & CLIMARA 0.025, 0.0375, 0.05, 0.075, 0.1 MG/HR PATCH
40MG (use for 20mg doses) SCORED TABLETS ESTRADIOL (ESTRACE EQ)--PO 1MG TAB
DESIPRAMINE (NORPRAMIN)-25MG TAB ESTROGENS (PREMARIN)-0.3,0.625, 0.9, & 1.25MG TAB
DOXEPIN-25MG, 75MG, & 100MG CAPS ESTROGEN/MEDROXYPROGESTERONE (PREMPRO)-0.625/2.5,
FLUOXETINE (PROZAC)- 10MG scored tab, 20MG CAP 0.625/5mg, 0.3/1.5mg, 0.45/1.5mg TABS (1 month =28 tabs)
IMIPRAMINE-10MG &25MG TABS ESTROGENS (PREMARIN)-0.625mg/gm VAG CRM 42.5GM TUBE
MIRTAZAPINE (REMERON)-15,30,45MG TABS ESTROPIPATE (OGEN)-0.625, 1.25, 2.5mg TAB
NORTRIPTYLINE (PAMELOR)-10, 25 & 75MG CAP MEDROXYPROGESTERONE ACETATE (PROVERA)-2.5 & 10mg tab
PAROXETINE (PAXIL) – 20MG TAB NORETHINDRONE (AYGESTIN) 5MG TAB
SERTRALINE (ZOLOFT)-50MG (for ½ tab-25mg dose only), PREMPHASE-0.625MG/5MG TABS
100MG TAB (for 100 & 50mg doses) TESTOSTERONE (ANDROGEL PKT)--TDRM 1% GEL
TRAZODONE (DESYREL)-50MG (for ½ tab – 25mg dose only) & TESTOSTERONE CYPIONATE--IM 200MG/ML INJ. 1ML VIAL
100MG TABS (for 100mg & 50mg doses) HYPOGLYCEMICS
VENLAFAXINE(EFFEXOR XR)- 37.5,75MG, & 150MG XR CAPS
ANTIMANIC AGENTS ORAL
AVANDAMET (ROSIGLITAZONE/METFORMIN) –
LITHIUM CARBONATE-300MG TAB
1MG/500MG, 2MG/500MG, 4MG/500MG TABS
ANTIPSYCHOTIC AGENTS GLIMEPIRIDE (AMARYL)-2 & 4MG TABS
ARIPIPRAZOLE (ABILIFY)--PO 5,10,15,20MG TABS GLIPIZIDE (GLUCOTROL Immediate Release)-5mg & 10mg tabs
HALOPERIDOL – 2MG, 5MG TAB & 2MG/ML CONC 120ML GLUCOVANCE (GLYBURIDE/METFORMIN)-
OLANZAPINE (ZYPREXA)-2.5, 5 & 10MG TABS 1.25/250MG 2.5/500MG & 5/500MG TABS
QUETIAPINE (SEROQUEL)-- 25, 100, 200, 300MG TABS GLYBURIDE (MICRONASE)-2.5MG & 5MG TAB
QUETIAPINE (SEROQUEL *XR)—50, 200, 300, 400MG TBSR GLYBURIDE MICRONIZIED (GLYNASE)-1.5, 3 & 6MG TABS
RISPERIDONE (RISPERDAL)-0.5, 1, & 2MG TABS ; 1MG/ML SOLN METFORMIN (GLUCOPHAGE)-500, 850, 1000MG TAB
ZIPRASIDONE (GEODON)—PO 20,60,80MG CAPS METFORMIN *ER* (GLUCOPHAGE)--PO 500MG TBSR
BENZODIAZEPINES ROSIGLITAZONE (AVANDIA)-2,4, & 8MG TABS
ALPRAZOLAM (XANAX)-0.25MG & 0. 5MG TAB PIOGLITAZONE (ACTOS)-15, 30, 45MG TAB
(Max 30 day supply) SITAGLIPTIN (JANUVIA)—PO 25, 50, 100MG TABS
CLONAZEPAM (KLONOPIN)-0.5MG & 1MG TAB (Max: 30 day) INSULINS
DIAZEPAM (VALIUM)-5MG TAB (Max: 30 day supply) INSULIN 70/30 HUMAN (Novolin)-100U/ML 10ML SUSP
LORAZEPAM (ATIVAN)-0.5MG & 1MG TAB (Max: 30 day supply) INSULIN ASPART (NOVOLOG) – 10ML VIAL, PEN
HYPNOTIC/SEDATIVES INSULIN DETEMIR (LEVEMIR)--SQ PEN, VIAL INJ
ESZOPICLONE (LUNESTA)—PO 1, 2, 3MG TABS (Max: 30 Days) INSULIN GLARGINE (LANTUS)-10 ML VIAL, PEN
TEMAZEPAM (RESTORIL) 15MG CAP (Max: 30 day) INSULIN LENTE HUMAN (Novolin)-100U/ML 10ML SUSP
ZOLPIDEM (AMBIEN)-5 & 10MG TAB (Max: 30 Days) INSULIN NPH HUMAN (Novolin)-100U/ML 10ML SUSP
STIMULANTS INSULIN REG HUMAN (Novolin)-100U/ML 10ML SUSP
ADDERALL XR-10,20,30MG CAPS (Max: 30-day supply, No Refills) MISCELLANEOUS
ATOMOXETINE (STRATTERA) 10,18,25,40,60MG TABS EXENATIDE (BYETTA)--SQ INJ 5, 10MEQ PEN
DEXTROAMEPHETAMINE (DEXEDRINE)-5MG, 10MG, & 15MG PRECISION EXTRA TEST STRIPS-#100/BOX
CPSR, 5MG TAB (Max: 30-day supply, No Refills) SYRINGE, INSULIN LOW DOSE-0.5ML (MAX: 300/90 DAYS)
METHYLPHENIDATE (CONCERTA)-18MG,27MG, 36MG,54MG SYRINGE, INSULIN U100-1ML (MAX: 300/90 DAYS)
TBSR (Max: 30-day supply, No Refills) URINE CONTENTS (N-MULTISTIX) TEST STRIPS-#1 BTL
METHYLPHENIDATE (RITALIN)-5MG & 10MG TAB, 20MG TBSR URINE SUGAR/PROTEIN TEST STRIPS (URISTIX)-#1 BTL
(Max: 30-day supply, No Refills)

9 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

FORMULARY DRUG LIST BY CLASSIFICATION

MISCELLANEOUS TOBRAMYCIN (TOBREX)-0.3% OPTH SOLN 5ML (Ophthalmology

& Optometry/ENT only)
5-alpha REDUCTASE INHIBITOR
FINASTERIDE (PROSCAR)--PO 5MG TAB ANTI-INFLAMMATORIES
FLUOROMETHOLONE (FML)-0.05MG/GTT 10ML OPTH SUSP
ALLERGIC/ANAPHYLACTIC REACTION FLURBIPROFEN (OCUFEN)-0.03% OPHTH SOLN 2.5ML
EPINEPHRINE (EPI-PEN)-1MG/ML SYRN KETOROLAC (ACULAR) OPTH SOLN 5ML
EPINEPHRINE JR (EPIPEN JR)-0.15MG IM INJ (Opthalmology/Optometry only)
ALZHEIMERS PREDNISOLONE (PRED-FORTE)-1% SUSP 5ML
DONEPEZIL (ARICEPT)--PO 5MG, 10MG TABS ANTI-INFLAMMATORY & ANTIBIOTIC COMB.
ANTICHOLINERGICS MAXITROL-OPTH OINT 3.5GM, OPTH SUSP 5ML
HYOSCYAMINE (LEVSIN)-0.125MG TABS TOBRADEX-OPTH SOLN 5ML, 3.5GM OPTH OINT
PYIDOSTIGMINE (MESTINON)-60MG TAB, 180MG TBSR (Ophthalmology/optometry/ENT only)
ANTIVERTIGO ANTIVIRALS
DIMENHYDRINATE (DRAMAMINE)-50MG TABS TRIFLURIDINE (VIROPTIC)-0.5MG/GTT OPTH 7.5ML
MECLIZINE (ANTIVERT)-25MG TAB (Ophthalmology only)
HEMOSTATICS BETA-BLOCKERS
AMINOCAPROIC ACID-500MG TAB BETAXOLOL (BETOPIC-S)-0.25% SUSP 5ML
IMPOTENCE CARTEOLOL (OCUPRESS)-10ML SOLN
VARDENAFIL (LEVITRA)—PO 5,10,20MG TABS *PA FORM REQ TIMOLOL(TIMPOPTIC)-0.25% & 0.5% OPTH SOLN 10ML
<40 Y/O ONLY TIMOLOL(TIMOPTIC XE) -0.25% & 0.5% GEL
OSTEOPOROSIS CARBONIC ANHYDRASE INHIBITORS
ALENDRONATE (FOSAMAX)-5,10,35,70MG TABS Ophthalmic
FOSAMAX *PLUS VIT D*-PO 70MG/2800, 70MG/5600 IU TAB COSOPT-OPHTH SOLN 5ML
CALCITONON-SALMON (FORTICAL)-200IU NASAL SPRAY DORZOLAMIDE (TRUSOPT)-2% 10ML
IBANDRONATE (BONIVA)--PO 150MG TAB ONCE MONTHLY Oral
RALOXIFENE (EVISTA)--PO 60MG TAB ACETAZOLAMIDE (DIAMOX)-250MG TAB & 500MG CPSR
RISEDRONATE SODIUM (ACTONEL)--PO 5MG TAB METHAZOLAMIDE-50MG TAB (Ophthalmology only)
*35MG TAB (Once Weekly) DECONGESTANTS
*75MG TAB (1 DAILY FOR 2 CONSECUTIVE DAYS MONTHLY) NAPHAZOLINE/ANTAZOLINE (VASOCON-A EQ) OPTH SOLN
*150MG TAB (Once Monthly) 15ML
OVULATION STIMULANTS MIOTICS
CLOMIPHENE (CLOMID)-50MG TAB PILOCARPINE-1%, 2%, 4%, 6% OPTH SOLN 15ML,
OXYTOCICS 4% OPTH GEL 4GM TUBE
METHYLERGONOVINE (METHERGINE)-0.2MG TAB PILOCARPINE (OCUSERT)-20MCG & 40MCG
VASOPRESSIN ANALOGUES/PITUITARY MYDRIATICS
DESMOPRESSIN (DDAVP)--PO 0.1,0.2MG TABS APRACLONIDINE (IOPIDINE) 0.5% OPTH 5ML SOLN
MUSCLE RELAXANTS ATROPINE SULFATE-1% OPTH OINT 3.5GM, SOLN 15ML
BACLOFEN (LIORESAL)-10MG TAB CYCLOPENTOLATE (CYCLOGYL)-1%, 2% OPTH SOLN 15ML
CHLORSOXAZONE (PARAFON FORTE EQ) – 500MG TAB HOMATROPINE-2.5MG/GTT OPTH SOLN 2ML
CYCLOBENZAPRINE (FLEXERIL)-10MG TAB SCOPOLAMINE (HYOSCINE)-OPTH 0.25% SOLN 5ML
METHOCARBAMOL (ROBAXIN)-500MG TAB TROPICAMIDE (MYDRIACYL)-1% OPTH 0.5MG/GTT 15ML
PROSTAGLANDIN AGONIST
OPHTHALMICS LATANOPROST (XALATAN)-0.05% 2.5ML SOLN
ANESTHETICS BIMATOPROST (LUMIGAN)--OPT 0.03% SOLN
PROPARACAINE (OPHTHETIC)-0.5% OPTH SOLN 15ML **RESTRICTED TO OPHTHALMOLOGY
ADRENERGIC AGONIST MISCELLANEOUS OPHTHALMICS
BRIMONIDINE (ALPHAGAN-P)-0.1% SUSP 5ML CELLUVISC (CMC) --OPT 1% SOLN
ANTIALLERGICS HYPROMELLOSE (TEARISOL) 0.5% OPHT SOLN 15ML
CROMOLYN SODIUM 4% OPHTHALMIC SOLUTION LACRI-LUBE-OPHTH OINT 3.5GM
KETOTIFEN (ZADITOR)--OPT 0.025% SOLN 5ML METHYLCELLULOSE (ISOPTO PLAIN)-15ML OPTH SOLN
OLOPATADINE (PATANOL)-O.1% OPTH SOLN 5ml *1 MURO-128 5% SOLN-OPTH SOLN 15ML, 5% OPTH OINT 3.5GM
BTL/MONTH POLYVINYL ALCOHOL (TEARGEN)-1.4% OPTH SOLN 15ML
NAPHAZOLINE/PHENIR (OPCON-A)--OPT SOLN PURALUBE-OINTMENT
ANTIBIOTICS REFRESH TEARS (CMC)-- 0.5% OPT SOLN 15ML
BACITRACIN-OPTH OINT 3.5GM REFRESH PLUS (CMC)--OPT 0.5% SOLN AMPS
CIPROFLOXACIN (CILOXAN)-0.3% SOLN 5ml OTICS
ERYTHROMYCIN-5MG/GM OPTH OINT 3.5GM ANALGESICS
GENTAMICIN-0.3% OPHTH SOLN 5ML, OPTH OINT 3.5GM AURALGAN-OTIC SOLN 15ML (Generic)
MOXIFLOXICIN (Vigamox) OPTH Drops
NEOSPORIN-OPTH SOLN 10ML, OPTH OINT 3.5GM ANTIBIOTIC & ANTI-INFLAMATORY COMB
POLYTRIM(Polymixin B/trimethoprim)-OPTH SOLN 10ML CORTISPORIN-OTIC SUSP 10ML
SULFACETAMIDE-10% OPTH SOLN 15ML, OPTH OINT 3.5GM CIPROFLOXACIN/DEXAMETH--OTIC 0.3/0.1% SUSP

10 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

FORMULARY DRUG LIST BY CLASSIFICATION

ASTRINGENTS DESONIDE (TRIDESILON)-0.05% CRM & OINT 15GM, 60GM
DOMEBORO-OTIC SOLN 60ML FLUCOINOLONE (SYNALAR)-0.01% TOP SOLN 60ML
VOLSOL HC-OTIC SOLN 10ML FLUOCINOLINE (FS)-0.01% SHAMPOO 4 Oz
FLUOCINONIDE (LIDEX)-0.05% CRM 15GM & 60GM,
MISCELLANEOUS 0.05% OINT 15GM & 60GM
OFLOXACIN (FLOXIN)-0.3% OTIC DROPS
FLURANDRENOLIDE (CORDRAN)-4MCG/SQCM 80 INCH TAPE
DEBROX-OTIC SOLN #1 BTL
HYDROCORTISONE-1% CRM & OINT, LOTN 120ML
THYROID PREPARATIONS HYDROCORTISONE VAL (WESTCORT)-0.2% CRM 15GM &
ANTI-HYPERTHYROIDISM 45GM, 0.2% OINT 15GM
PROPYLTHIOURACIL (PTU)-50MG TAB TRIAMCINOLINE (KENALOG)-SPRAY 63 GM
TRIAMCINOLONE-0.1% CRM & OINT 15,80GM
ANTI-HYPOTHYROIDISM
LIOTHYRONINE (CYTOMEL)-25MCG TAB CORTICOSTEROID & ANTI-INFECTIVE COMB
SYNTHROID-0.025, 0.05, 0.075, 0.088, 0.1, 0.112, 0.125, 0.15, 0.175 IMMUNOMODULATOR
MG TAB PIMECROLIMUS (ELIDEL) 1% CREAM
THYROID (ARMOUR)-32MG & 65MG TAB PROTOPIC TACROLIMUS (PROTOPIC)- 0.1%, 0.03% OINT
TOPICALS Must Fail Elidel First
ANESTHETICS KERATOLYTICS
CONDYLOX 0.5% 3.5ML (Derm, OB/GYN & Urology only)
DIBUCAINE-1% OINT 30GM
SALICYLIC ACID (OCCLUSAL HP SOL)-17% EXT 15ML
LIDOCAINE-TOP 2% GEL 30GM; 5% OINT 35GM
SALICYLIC ACID PLASTER-40% PSTE TOP
ANTI-ACNE MISCELLANEOUS TOPICALS
ADAPALENE (DIFFERIN) 0.1% GEL,CREAM *Must try Retin-A First
ALUMINUM CHLORIDE-TOP 20% SOLN 37.5ML
BENZOYL PEROXIDE CLEANSING-5% LIQ 5OZ
AMMONIUM LACTATE(LAC-HYDRIN EQ)--TOP LOT
BENZOYL PEROXIDE-5% (H20 BASE) & 10% GEL 42.5 GM
CALCIPOTRIENE (DOVONEX)--TOP 0.005% CREAM
CLINDAMYCIN (CLEOCIN-T)-1% SOLN
CAPSAICIN (ZOSTRIX)-0.025% CRM 1.5OZ
CLINDAMYCIN/BP (DUAC)--TOP 1%/5% GEL
CAPSAICIN (ZOSTRIX-HP)-0.075% CRM 60GM
ERYTHROMYCIN (STATICIN)-2% TOP SOLN 60ML
DOXEPIN (ZONALON EQ)--TOP 5% CREA
METRO-GEL 1% 45GM TUBE
HYDROQUINONE (ELDOQUINE FORTE)-4% TOP CRM
SULFACET/SULFUR (CLENIA)--TOP 10/5% SOAP
IMIQUIMOD (ALDARA)--TOP 5% CREA
TAZAROTENE (TAZORAC) 0.1% gel,crm
SILVER SULFADIAZINE-1% TOP CRM, 20GM, 85GM, 400GM
TAZAROTENE (TAZORAC) 0.05% Cream
SULFUR/SALICYLIC (SEBEX)-TOP SHAMPOO 120ML
TRETINOIN (RETIN A)-0.025, 0.05, 0.1%crm 20gm, 0.025% gel 15gm
UREA (CARMOL)-20% CRM
ANTI-FUNGALS UREA (CARMOL)-40% CRM
CLOTRIMAZOLE-1% TOP CRM 15GM *RESTRICTED TO DERM OR FAILED CARMOL-20
CLOTRIMAZOLE-1% TOP SOLN 30ML
KETOCONAZOLE (NIZORAL)--TOP 2% CREA 15GM,
PEDICULICIDES
PERMETHRIN (ELIMITE)-5% TOP CRM 60GM
4OZ SHAMPOO
MICONAZOLE (MONISTAT DERM)-2% TOP CRM 15GM URINARY AGENTS
NAFTIFINE (NAFTIN)--TOP 1% CREA 30GM BETHANECHOL-10MG & 25MG TAB
NYSTATIN-100,000U/GM-- 15GM Cream OXYBUTIN (DITROPAN)-5MG TAB & 5MG/5ML SYRUP
SELENIUM SULFIDE (SELSUN)-2.5% LOTN 120ML BTL OXYBUTIN (DITROPAN XL)-5, 10, 15MG TAB
TOLNAFTATE (TINACTIN)-1% TOP SOLN 10ML PHENAZOPYRIDINE (PYRIDIUM)-100MG TAB
UNDECYLENIC ACID + CPD-PWED (DESENEX EQ) 45GM PENTOSAN (ELMIRON)--PO 100MG CAP
ANTIHEMORRHOIDALS *FOR INTERSTITIAL CYSTITIS ONLY
HEMORRHOIDAL HC (ANUSOL HC, EQ) SOLIFENACIN (VESICARE)--PO 5, 10MG TABS
RECT SUPP (ORDER BY BOX (12supp/box), TOLTERDINE (DETROL LA)- 2, 4MG CAPS
2.5% RECTAL CRM 30GM VAGINAL PREPARATIONS
HEMORRHOIDAL (ANUSOL)-RECT SUPP (ORDER BY BOX) AVC-VAGINAL CRM
PRAMOXINE (PRAX)-1% TOP CRM 30GM CLINDAMYCIN 2% VAGINAL GRM 40GM TUBE
PROCTOFOAM HC-RECT AERO CLOTRIMAZOLE-1% VAG CRM 45G TUBE
ANTI-INFECTIVES METROGEL 0.75%-VAG GEL 28.4GM TUBE
BACITRACIN-TOP OINT 15GM TUBE VITAMINS AND MINERALS
MUPIROCIN (BACTROBAN)--TOP 2% OINT 22GM
CALCITRIOL (ROCALTROL)-0.25MCG CAP
NEOSPORIN TOP OINT 15GM TUBE
CALCIUM CARBONATE-500MG TAB (1 Bottle = 60tabs)
ANTINEOPLASTICS CALCIUM CARBONATE 500mg/VIT D 200units-TAB
FLUOROURACIL (EFUDEX) - 5% CRM 25GM (1 Bottle = 60 tabs)
FLUOROURACIL (CARAC) – 0.5% CRM 30GM FERROUS SULFATE-325MG TAB, 75MG/0.6ML 50ML SOLN
ANTI-VIRAL FOLIC ACID-400MCG & 1MG TAB
PENCICLOVIR (DENAVIR)-1% CREAM OCUVITE PRESERVISION-(Ophthalmology/Optometry only)
CORTICOSTEROIDS MAGNESIUM GLUCONATE-500MG TAB
AMCINONIDE (CYCLOCORT)-O.1% CRM AND OINT 15 & 60GM MAGNESIUM OXIDE-400MG TAB
BETAMETHASONE VALERATE--TOP 0.1% LOTN PHYTONADIONE (MEPHYTON)-5MG TAB
CLOBETASOL (TEMOVATE)-0.05% CRM, OINT, GEL 15GM POTASSIUM CHLOR-20MEQ/15ML ELIX

11 Updated: 3/10
 FORT KNOX MEDDAC GENERAL FORMULARY
Additional formulary information is available at,
http://www.iach.knox.amedd.army.mil/pharmacy services.htm
http://www.tricare.mil/mybenefit/home/Prescriptions

FORMULARY DRUG LIST BY CLASSIFICATION

POTASSIUM CHLOR (SLOW K)-8MEQ TBSR SODIUM FLUORIDE (PREVIDENT 5000 PLUS)-1.1% 1.8 OZ TUBE
POTASSIUM CHLOR (K-DUR)-20MEQ TBSR THIAMINE-50MG TAB
POTASSIUM IODIDE-1GM/ML SOLN (40DROPS/ML) (SSKI) VITAMINS MULTIPLE WITH IRON – PEDS SOLN #1 BOTTLE
PYRIDOXINE (B-6)-50MG TAB VITAMINS MULTIPLE –PEDS SOLN #1 BOTTLE
SODIUM FLUORIDE-0.125MG/GROP #1 BOTTLE VITAMIN E - 400 IU CAP
STANNOUS FLUORIDE (GEL KAM)-0.4% DENT G 60ML

Prior Authorization
• Prior Authorization – These items are restricted to approved protocol criteria. Requires a “Prescribing Guidelines and Policy
Form” to be completed by provider and patient and returned to the Chief of Pharmacy for determination of approval. Prior
Authorization Forms can be obtained at IRACH Web site http://www.iach.knox.amedd.army.mil/pharmacy services.htm,
Tricare Web site: https://rxnet.army.mil/pec/forms_criteria.php, at the pharmacy window, or contact the pharmacy at
(502) 624-9655 to obtain a copy/fax of the Protocol.
• ADALIMUMAB (HUMIRA)--SQ 40MG/0.8ML
• CELECOXIB (CELEBREX)-100MG & 200MG CAPS *PA FORM (NOT REQIRED IF PT IS 65 OR OLDER)
• VARDENAFIL (LEVITRA)—PO 5,10,20MG TABS *PA FORM (NOT REQIRED IF PT IS 40 OR OLDER)

Medical Necessity
* Medical Necessity – In accordance with directives from Tricare/DoD P&T Committee some medications are designated as Medical
Necessity Only, Non-Formulary Medications. These medications Can Not be on the Military Pharmacy Formulary and the use of these
medications must meet criteria that show a Medical Necessity to use the non-formulary medication instead of any of the therapeutic
alternatives that are on Formulary.
A complete list of Medical Necessity Criteria Forms and instructions for requesting Medical Necessity are available at the Web Address:
https://rxnet.army.mil/pec/forms_criteria.php

12 Updated: 3/10