Top Banner
UPDATED JAN-20 BRAND GENERIC STRENGTH DOSAGE FORM A & D OINTMENT VITAMIN A & D TOPICAL OINTMENT ABILIFY ARIPIPRAZOLE ALL STRENGTHS TABLET ACCOLATE ZAFIRLUKAST 10MG, 20MG TABLET ACCUPRIL QUINAPRIL 5 MG, 10 MG, 20 MG, 40 MG TABLET ACCURETIC QUINAPRIL/HYDROCHLOROTHAIZIDE 10-12.5MG, 20-12.5MG, 20-25MG TABLET ACIPHEX RABEPRAZOLE 20MG TABLET ACTIFED PSEUDOEPHEDRINE/TRIPROLIDINE 60 MG-2.5 MG TABLET ACTIGALL URSODIOL 300MG CAPSULE ACTIVELLA ESTRADIOL/NORETHINEDRONE ALL STRENGTHS TABLET ACTOPLUS MET PIOGLITAZONE/METFORMIN 15 MG-500 MG, 15 MG-850 MG TABLET ACTOS PIOGLITAZONE 15 MG, 30 MG, 45 MG TABLET ACULAR KETOROLAC 0.5% OPHTHALMIC SOLUTION ACULAR LS KETOROLAC 0.4% OPHTHALMIC SOLUTION ADALAT CC NIFEDIPINE 30MG, 60MG, 90MG TABLET ADDERALL AMPHETAMINE SALTS 5MG, 7.5MG,10MG, 12.5MG, 20MG,30MG TABLET ADDERALL XR` MIXED AMPHETAMINE SALTS 5MG, 10MG, 15MG, 20MG, 25MG, 30MG CAPSULE ADVAIR DISCUS FLUTICASONE/ SALMETEROL ALL STRENGTHS INHALATION POWDER ADVAIR HFA FLUTICASONE/ SALMETEROL ALL STRENGTHS INHALATION AEROSOL AFRIN OXYMETAZOLINE 0.05% NASAL SPRAY AGGRENOX ASPIRIN/DIPYRIDAMOLE 25MG-200MG CAPSULE AGRYLIN ANAGRELIDE 0.5MG, 1MG CAPSULE ALBENZA ALBENDAZOLE 200MG TABLET ALCAINE PROPARACAINE 0.5% OPHTHALMIC SOLUTION ALCOHOL ALCOHOL PREP TOPICAL PAD ALDACTAZIDE SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 25-25MG TABLET ALDACTONE SPIRONOLACTONE 25MG, 50MG, 100MG TABLET ALDARA IMIQUIMOD 5% TOPICAL CREAM ALDOMET METHYLDOPA 250MG, 500MG TABLET ALLEGRA FEXOFENADINE 60MG, 180MG TABLET ALLEGRA-D 12 HOUR FEXOFENADINE/PSEUDOEPHEDRINE 60 MG-120 MG TABLET ALLEGRA-D 24 HOUR FEXOFENADINE/PSEUDOEPHEDRINE 180 MG-240 MG TABLET ALLER-CHLOR CHLORPHENIRAMINE 2MG/5ML SYRUP ALLER-CHLOR CHLORPHENIRAMINE 4MG TABLET ALORA ESTRADIOL ALL STRENGTHS TRANSDERMAL PATCH ALPHAGAN BRIMONIDINE 0.2% OPHTHALMIC SOLUTION ALPHAGAN-P BRIMONIDINE 0.1%, 0.15% OPHTHALMIC SOLUTION ALREX LOTEPREDNOL 0.2% OPHTHALMIC SUSPENSION AMARYL GLIMEPIRIDE 1MG, 2MG, 4MG TABLET AMBIEN ZOLPIDEM 5 MG, 10 MG TABLET AMBIEN CR ZOLPIDEM 6.25 MG, 12.5 MG TABLET NAVAL HEALTH CLINIC CORPUS CHRISTI FORMULARY *** USE OF BRAND NAME IS FOR REFERENCE PURPOSES ONLY, A GENERICALLY EQUIVALENT PRODUCT WILL BE DISPENSED WHENEVER POSSIBLE*** Formulary is subject to change
24

NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

Feb 28, 2021

Download

Documents

dariahiddleston
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

UPDATED JAN-20

BRAND GENERIC STRENGTH DOSAGE FORMA & D OINTMENT VITAMIN A & D TOPICAL OINTMENTABILIFY ARIPIPRAZOLE ALL STRENGTHS TABLETACCOLATE ZAFIRLUKAST 10MG, 20MG TABLETACCUPRIL QUINAPRIL 5 MG, 10 MG, 20 MG, 40 MG TABLETACCURETIC QUINAPRIL/HYDROCHLOROTHAIZIDE 10-12.5MG, 20-12.5MG, 20-25MG TABLETACIPHEX RABEPRAZOLE 20MG TABLETACTIFED PSEUDOEPHEDRINE/TRIPROLIDINE 60 MG-2.5 MG TABLETACTIGALL URSODIOL 300MG CAPSULEACTIVELLA ESTRADIOL/NORETHINEDRONE ALL STRENGTHS TABLETACTOPLUS MET PIOGLITAZONE/METFORMIN 15 MG-500 MG, 15 MG-850 MG TABLETACTOS PIOGLITAZONE 15 MG, 30 MG, 45 MG TABLETACULAR KETOROLAC 0.5% OPHTHALMIC SOLUTIONACULAR LS KETOROLAC 0.4% OPHTHALMIC SOLUTIONADALAT CC NIFEDIPINE 30MG, 60MG, 90MG TABLETADDERALL AMPHETAMINE SALTS 5MG, 7.5MG,10MG, 12.5MG, 20MG,30MG TABLETADDERALL XR` MIXED AMPHETAMINE SALTS 5MG, 10MG, 15MG, 20MG, 25MG, 30MG CAPSULEADVAIR DISCUS FLUTICASONE/ SALMETEROL ALL STRENGTHS INHALATION POWDERADVAIR HFA FLUTICASONE/ SALMETEROL ALL STRENGTHS INHALATION AEROSOLAFRIN OXYMETAZOLINE 0.05% NASAL SPRAYAGGRENOX ASPIRIN/DIPYRIDAMOLE 25MG-200MG CAPSULEAGRYLIN ANAGRELIDE 0.5MG, 1MG CAPSULEALBENZA ALBENDAZOLE 200MG TABLETALCAINE PROPARACAINE 0.5% OPHTHALMIC SOLUTIONALCOHOL ALCOHOL PREP TOPICAL PADALDACTAZIDE SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 25-25MG TABLETALDACTONE SPIRONOLACTONE 25MG, 50MG, 100MG TABLETALDARA IMIQUIMOD 5% TOPICAL CREAMALDOMET METHYLDOPA 250MG, 500MG TABLETALLEGRA FEXOFENADINE 60MG, 180MG TABLETALLEGRA-D 12 HOUR FEXOFENADINE/PSEUDOEPHEDRINE 60 MG-120 MG TABLETALLEGRA-D 24 HOUR FEXOFENADINE/PSEUDOEPHEDRINE 180 MG-240 MG TABLETALLER-CHLOR CHLORPHENIRAMINE 2MG/5ML SYRUPALLER-CHLOR CHLORPHENIRAMINE 4MG TABLETALORA ESTRADIOL ALL STRENGTHS TRANSDERMAL PATCHALPHAGAN BRIMONIDINE 0.2% OPHTHALMIC SOLUTIONALPHAGAN-P BRIMONIDINE 0.1%, 0.15% OPHTHALMIC SOLUTIONALREX LOTEPREDNOL 0.2% OPHTHALMIC SUSPENSIONAMARYL GLIMEPIRIDE 1MG, 2MG, 4MG TABLETAMBIEN ZOLPIDEM 5 MG, 10 MG TABLETAMBIEN CR ZOLPIDEM 6.25 MG, 12.5 MG TABLET

NAVAL HEALTH CLINIC CORPUS CHRISTI FORMULARY*** USE OF BRAND NAME IS FOR REFERENCE PURPOSES ONLY, A GENERICALLY EQUIVALENT PRODUCT WILL BE DISPENSED WHENEVER POSSIBLE***

Formulary is subject to change

Page 2: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMAMITIZA LUBIPROSTONE 8 MCG, 24 MCG CAPSULEAMOXIL AMOXICILLIN 250MG CHEWABLE TABLETAMOXIL AMOXICILLIN 250MG/5MG, 400MG/5ML SUSPENSIONAMOXIL AMOXICILLIN 875MG TABLETAMOXIL AMOXICILLIN 250MG, 500MG CAPSULEANAFRANIL CLOMIPRAMINE 25MG, 50MG, 75MG CAPSULEANALPRAM HYDROCORTISONE/PRAMOXINE 2.5%-1% RECTAL CREAMANAPROX NAPROXEN SODIUM 275MG TABLETANAPROX DS NAPROXEN SODIUM 550MG TABLETANDRODERM TESTOSTERONE 2 MG/24 HR, 4 MG/24 HR TRANSDERMAL PATCHANGELIQ DROSPERIDOL/ESTRADIOL ALL STRENGTHS TABLETANORO UMECLIDINIUM/VILANTEROL 62.5/25MCG/ACTUATION INHALATION POWDERANTABUSE DISULFIRAM 250MG TABLETANTIVERT MECLIZINE 12.5MG TABLETANTIVERT MECLIZINE 25MG CHEWABLE TABLETANUCORT HYDROCORTISONE 25MG% SUPPOSITORYAPIDRA INSULIN GLULISINE PEN INJECTIONAPIDRA INSULIN GLULISINE VIAL INJECTIONAPRESOLINE HYDRALAZINE 10MG, 25MG, 50MG, 100MG TABLETAPRISO MESALAMINE 0.375GM CAPSULEARALEN CHLOROQUINE 500MG TABLETARAVA LEFUNOMIDE 10MG, 20MG TABLETARICEPT DONEPEZIL 5MG, 10MG TABLETARICEPT ODT DONEPEZIL 5MG, 10MG SUBLINGUAL TABLETARIMIDEX ANASTROZOLE 1MG TABLETARMOUR THYROID THYROID ALL STRENGTHS TABLETARTANE TRIHEXYPHENIDYL 2 MG, 5 MG TABLETARTANE TRIHEXYPHENIDYL 2 MG/5 ML ELIXIRARTHROTEC DICLOFENAC/MISOPROSTAL 50MG-200MCG, 75MG-200MCG TABLETASTELIN AZELASTINE 137MCG NASAL SPRAYATACAND CANDESARTAN ALL STRENGTHS TABLETATACAND HCT CANDESARTAN/HYDROCHLOROTHIAZIDE ALL STRENGTHS TABLETATARAX HYDROXYZINE HCL 10MG, 25MG, 50MG TABLETATARAX HYDROXYZINE HCL 10MG/5ML SYRUPATIVAN LORAZEPAM 0.5 MG, 1 MG, 2 MG TABLETATROPINE ATROPINE 1% OPHTHALMIC OINTMENTATROPINE ATROPINE 1% OPHTHALMIC SOLUTIONATROVENT IPRATROPIUM 0.03%, 0.06% NASAL SPRAYATROVENT IPRATROPIUM 0.02% INHALATION SOLUTIONATROVENT HFA IPRATROPIUM 17MCG INHALATION AEROSOLAUGMENTIN AMOXICILLIN/CLAVULANIC ACID 250MG, 400MG, SUSPENSIONAUGMENTIN AMOXICILLIN/CLAVULANIC ACID 250MG, 500MG, 875MG TABLETAUGMENTIN ES AMOXICILLIN/CLAVULANIC ACID 600MG SUSPENSIONAUGMENTIN XR AMOXICILLIN/CLAVULANIC ACID 1000MG TABLET

Page 3: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMAVALIDE IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG, 300-12.5MG TABLETAVAPRO IRBESARTAN 75MG, 150MG, 300MG TABLETAVELOX MOXIFLOXACIN 400MG TABLETAVONEX INTERFERON BETA-1A SYRINGE INJECTIONAVONEX INTERFERON BETA-1A PEN INJECTIONAZASITE AZITHROMYCIN 1% OPHTHALMIC SOLUTIONAZILECT RASAGILINE 0.5MG, 1MG TABLETAZOR AMLODIPINE/OLMESARTAN ALL STRENGTHS TABLETAZULFIDINE SULFASALAZINE 500 MG TABLETAZULFIDINE EN TAB SULFASALAZINE EC 500 MG TABLETAZURETTE DESOGESTREL/ETHINYL ESTRADIOL 0.15 MG-20 MCG-10 MCG TABLETBACITRACIN BACITRACIN 500U/GM OPHTHALMIC OINTMENTBACITRACIN BACITRACIN 500U/GM TOPICAL OINTMENTBACTROBAN MUPIROCIN 2% TOPICAL CREAMBACTROBAN MUPIROCIN 2% TOPICAL OINTMENTBENADRYL DIPHENHYDRAMINE 12.5MG/5ML SOLUTIONBENADRYL DIPHENHYDRAMINE 25MG, 50MG CAPSULEBENEMID PROBENECID 500 MG TABLETBENICAR OLMESARTAN 5MG, 20MG, 40MG TABLETBENICAR HCT OLMESARTAN/HYDROCHLOROTHIAZIDE 20-12.5MG, 40-12.5MG, 40-25MG TABLETBENTYL DICYCLOMINE 10MG CAPSULEBENTYL DICYCLOMINE 10MG/5ML SYRUPBENTYL DICYCLOMINE 20MG TABLETBENZACLIN CLINDAMYCIN/BENZOYL PEROXIDE 1%-5% TOPICAL GELBEPREVE BEPOSTINE 1.5% OPHTHALMIC SOLUTIONBETADINE POVIDINE IODINE 5% OPHTHALMIC SOLUTIONBETAGAN LEVOBUNOLOL 0.5% OPHTHALMIC SOLUTIONBETAPACE SOTALOL 80 MG, 120 MG, 160 MG, 240 MG TABLETBETOPTIC BETAXOLOL 0.5% OPHTHALMIC SOLUTIONBETOPTIC S BETAXOLOL 0.25% OPHTHALMIC SUSPENSIONBIAXIN CLARITHROMYCIN 250MG, 500MG TABLETBIAXIN CLARITHROMYCIN 250MG/5ML SUSPENSIONBIAXIN XL CLARITHROMYCIN 500MG TABLETBIDIL ISOSORBIDE DINITRATE/HYDRALAZINE 20-37.5MG TABLETBILTIRCIDE PRAZIQUANTEL 500 MG TABLETBLEPH 10 SULFACETAMIDE 10% OPHTHALMIC SOLUTIONBLEPHAMIDE SULFACETAMIDE/PREDNISOLONE 10%-0.2% OPHTHALMIC OINTMENTBLEPHAMIDE SULFACETAMIDE/PREDNISOLONE 10%-0.2% OPHTHALMIC SUSPENSIONBONIVA IBANDRONATE 150MG TABLETBP GEL BENZOYL PEROXIDE 5%, 10% TOPICAL GELBRILINTA TICAGRELOR 90MG TABLETBROMDAY BROMFENAC 0.09% OPHTHALMIC SOLUTIONBROMFED-DM BROMPHENIRAMINE/PSEUDOEPHEDRINE/DM 2MG-30MG-100MG/5ML SYRUPBROVANA ARFORMOTEROL 15MCG/2ML INHALATION SOLUTION

Page 4: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMBUMEX BUMETANIDE 0.5MG, 1MG, 2MG TABLETBUSPAR BUSPIRONE 5MG, 10MG, 15MG TABLETBUTRANS BUPRENORPHINE 5MCG, 10MCG,15MCG, 20MCG TRANSDERMAL PATCHBYDUREON EXENATIDE MICROSPHERES 2MG PEN INJECTIONBYDUREON (BCISE) EXENATIDE MICROSPHERES 2MG AUTOINJECTOR INJECTIONCALAN VERAPAMIL 40 MG, 80 MG, 120 MG TABLETCALAN SR VERAPAMIL 120 MG, 180 MG, 240 MG TABLETCALPHRON CALCIUM ACETATE 667MG TABLETCAMPRAL ACAMPROSATE 333MG TABLETCANASA MESALAMINE 1000MG RECTAL SUPPOSITORYCAPOTEN CAPTOPRIL 12.5MG, 25MG, 50MG TABLETCARAC FLUOROURACIL 0.5% TOPICAL CREAMCARAFATE SUCRALFATE 1 GM TABLETCARAFATE SUCRALFATE 1 GM/10 ML SUSPENSIONCARDIZEM DILTIAZEM 30MG, 60MG, 90MG, 120MG TABLETCARDIZEM CD DILTIAZEM ALL STRENGTHS CAPSULECARDURA DOXAZOSIN 1MG, 2MG, 4MG, 8MG TABLETCARMOL UREA 20%, 40% TOPICAL CREAMCASODEX BICALUTAMIDE 50MG TABLETCATAFLAM DICLOFENAC POTASSIUM 50MG TABLETCATAPRES CLONIDINE 0.1MG, 0.2MG, 0.3MG TABLETCATAPRES TTS CLONIDINE ALL STRENGTHS TRANSDERMAL PATCHCEFTIN CEFUROXIME 250MG, 500MG TABLETCELEBREX CELECOXIB ALL STRENGTHS CAPSULECELEXA CITALOPRAM 10MG, 20MG, 40MG TABLETCELEXA CITALOPRAM 10MG/5ML SOLUTIONCEPACOL BENZOCAINE/MENTHOL 15 MG-2.6 MG LOZENGECILOXAN CIPROFLOXACIN 0.3% OPHTHALMIC OINTMENTCILOXAN CIPROFLOXACIN 0.3% OPHTHALMIC SOLUTIONCIPRO CIPROFLOXACIN 250MG, 500MG, 750MG TABLETCIPRO CIPROFLOXACIN 250MG/5ML SUSPENSIONCIPRODEX CIPROFLOXACIN/DEXAMETHASONE 0.3%-0.1% OTIC SUSPENSIONCLARITIN LORATADINE 10 MG/10 ML SOLUTIONCLARITIN LORATADINE 10 MG TABLETCLARITIN D 24 HOUR LORATADINE/PSEUDOEPHEDRINE 10 MG-240 MG TABLETCLEOCIN CLINDAMYCIN 2% VAGINAL CREAMCLEOCIN CLINDAMYCIN 75MG/5ML SUSPENSIONCLEOCIN CLINDAMYCIN 150MG, 300MG CAPSULECLEOCIN T CLINDAMYCIN 1% TOPICAL FOAMCLEOCIN T CLINDAMYCIN 1% TOPICAL LOTIONCLEOCIN T CLINDAMYCIN 1% TOPICAL SOLUTIONCLEOCIN T CLINDAMYCIN 1% TOPICAL GELCLIMARA ESTRADIOL ALL STRENGTHS TRANSDERMAL PATCHCLIMARA PRO ESTRADIOL/LEVONORGESTREL 0.045 mg-0.015 mg/24 hour TRANSDERMAL PATCH

Page 5: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMCLINORIL SULINDAC 150 MG, 200 MG TABLETCLINPRO SODIUM FLUORIDE 1.1% DENTAL TOOTHPASTECLOBEX CLOBETASOL 0.05% TOPICAL FOAMCLOBEX CLOBETASOL 0.05% TOPICAL LOTIONCLOBEX CLOBETASOL 0.05% TOPICAL SHAMPOOCLOBEX CLOBETASOL 0.05% TOPICAL SPRAYCLOMID CLOMIPHENE 50MG TABLETCLOTRIMAZOLE 3 CLOTRIMAZOLE 2% VAGINAL CREAMCODEINE CODEINE 30MG TABLETCOGENTIN BENZTROPINE 0.5MG, 1MG, 2MG TABLETCOLACE DOCUSATE SODIUM 100MG CAPSULECOLACE DOCUSATE SODIUM 50MG/ML SOLUTIONCOLAZAL BALSALAZIDE 750MG CAPSULECOLCRYS COLCHICINE 0.6MG TABLETCOLESTID COLESTIPOL 1GM TABLETCOLESTID COLESTIPOL 5GM/PACKET, 7.5GM/PACKET POWDERCO-LYTE ELECTROLYTE LAVAGE SOLUTIONCOMBIGAN BRIMONIDINE/TIMOLOL 0.2%-0.5% OPHTHALMIC SOLUTIONCOMBIPATCH ESTRADIOL/NORETHINEDRONE ALL STRENGTHS TRANSDERMAL PATCHCOMBIVENT RESPIMAT IPRATROPIUM/ALBUTEROL 20 MCG-100 MCG INHALATION AEROSOLCOMPAZINE PROCHLORPERAZINE 25 MG SUPPOSITORYCOMPAZINE PROCHLORPERAZINE 5 MG, 10 MG TABLETCONCERTA METHYLPHENIDATE ALL STRENGTHS TABLETCONDYLOX PODOFILOX 0.5% TOPICAL GELCONDYLOX PODOFILOX 0.5% TOPICAL SOLUTION COPAXONE GLATIRAMER 20MG/ML, 40MG/ML INJECTIONCOREG CARVEDILOL ALL STRENGTHS TABLETCOREG CR CARVEDILOL ALL STRENGTHS CAPSULECORGARD NADOLOL 20MG, 40MG, 80MG TABLETCORTEF HYDROCORTISONE 5MG, 10MG, 20MG TABLETCORTENEMA HYDROCORTISONE 100MG/60ML RECTAL ENEMACORTISPORIN NEOMYCIN/BACITRACIN/POLYMYXIN B/HYDROCORTISONE 3.5 MG-400 UNIT-10,000 UNIT/GM-1 % OPHTHALMIC OINTMENTCORTISPORIN NEOMYCIN/POLYMYCIN B/HYDROCORTISONE 3.5 MG/ML-10,000 UNITS/ML-1% OTIC SOLUTIONCORTISPORIN NEOMYCIN/POLYMYCIN B/HYDROCORTISONE 3.5 MG/ML-10,000 UNITS/ML-1% OTIC SUSPENSIONCORTISPORIN NEOMYCIN/POLYMYXIN B/HYDROCORTISONE 3.5 MG-10,000 UNIT-10 MG/ML OPHTHALMIC SUSPENSIONCOSOPT DORZOLAMIDE/TIMOLOL 2%-0.5% OPHTHALMIC SOLUTIONCOSOPT PF DORZOLAMIDE/TIMOLOL 2%-0.5% OPHTHALMIC SOLUTIONCOUMADIN WARFARIN ALL STRENGTHS TABLETCOZAAR LOSARTAN 25 MG, 50 MG, 100 MG TABLETCREON LIPASE/PROTEASE/AMYLASE 12,000 UNITS-38,000 UNITS-60,000 UNITS CAPSULECREON LIPASE/PROTEASE/AMYLASE 24,000 UNITS-76,000 UNITS-130,000 UNITS CAPSULECREON LIPASE/PROTEASE/AMYLASE 3000 UNITS-9,500 UNITS-15,000 UNITS CAPSULECREON LIPASE/PROTEASE/AMYLASE 6,000 UNITS-19,000 UNITS- 35,000 UNITS CAPSULECRESTOR ROSUVASTATIN 5 MG, 10 MG, 20MG, 40 MG TABLET

Page 6: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMCROLOM CROMOLYN 4% OPHTHALMIC SOLUTIONCUTIVATE FLUTICASONE 0.05% TOPICAL CREAMCYCLOGYL CYCLOPENTOLATE 0.5%, 1%, 2% OPHTHALMIC SOLUTIONCYCLOMYDRIL CYCLOPENTOLATE/PHENYLEPHRINE 0.2%/1% OPHTHALMIC SOLUTIONCYMBALTA DULOXETINE 20MG, 30MG, 60MG CAPSULECYTOMEL LIOTHYRONINE 5MCG, 25MCG, 50MCG TABLETCYTOTEC MISOPROSTOL 100MCG, 200MCG TABLETDALIRESP ROFLUMILAST 500 MCG TABLETDAPSONE DAPSONE 25MG, 100MG TABLETDAYPRO OXAPROZIN 600 MG TABLETDDAVP DESMOPRESSIN 0.01% NASAL SPRAYDDAVP DESMOPRESSIN 0.1MG, 0.2MG TABLETDEBROX CARBAMIDE PEROXIDE 6.5% OTIC SOLUTIONDECADRON DEXAMETHASONE 0.5MG, 0.75MG, 1MG, 1.5MG, 2MG, 4MG, 6MG TABLETDECADRON DEXAMETHASONE 0.5MG/5ML ELIXIRDECADRON DEXAMETHASONE 0.5MG/5ML SOLUTIONDEEP SEA SODIUM CHLORIDE 0.65% NASAL SPRAYDELATESTRYL TESTOSTERONE ENANTHATE 200 MG/ML INJECTIONDELESTROGEN ESTRADIOL VALERATE 10MG/ML, 20MG/ML INJECTIONDELSYM DEXTROMETHORPHAM 30MG/5ML SUSPENSIONDELTASONE PREDNISONE 1 MG, 2.5, 5 MG, 10 MG, 20 MG, 50 MG TABLETDELZICOL MESALAMINE 400MG CAPSULEDEMADEX TORSEMIDE 10 MG, 20 MG, 100 MG TABLETDEPAKENE VALPROIC ACID 250 MG/5 ML SOLUTIONDEPAKENE VALPROIC ACID 250 MG CAPSULEDEPAKOTE DIVALPROEX ALL STRENGTHS TABLETDEPAKOTE ER DIVALPROEX ALL STRENGTHS TABLETDEPAKOTE SPRINKLE DIVALPROEX 125MG CAPSULEDEPO TESTOSTERONE TESTOSTERONE CYPIONATE 100 MG/ML, 200 MG/ML INJECTIONDEPO-PROVERA MEDROXYPROGESTERONE 150MG/ML INJECTIONDERMA-SMOOTHE F/S FLUOCINOLONE 0.01% BODY OILDERMOTIC FLUOCINOLONE 0.01% OTIC SOLUTIONDESOGEN DESOGESTREL/ETHINYL ESTRADIOL 0.15 MG-30 MCG TABLETDESOWEN DESONIDE 0.05% TOPICAL CREAMDESOWEN DESONIDE 0.05% TOPICAL OINTMENTDESQUAM-X BENZOYL PEROXIDE 5%, 10% TOPICAL WASHDESYREL TRAZODONE 50 MG, 100 MG, 150 MG TABLETDETROL TOLTERODINE 2 MG, 4 MG TABLETDETROL LA TOLTERODINE 2 MG, 4 MG CAPSULEDEXAMETHASONE INTENSOL DEXAMETHASONE 1MG/ML SOLUTIONDEXEDRINE DEXTROAMHETAMINE 5MG TABLETDIAMOX ACETAZOLAMIDE 250MG TABLETDIAMOX SEQUELS ACETAZOLAMIDE 500MG CAPSULEDIASTAT DIAZEPAM 10MG RECTAL KIT

Page 7: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMDIFFERIN ADAPALENE 0.1% TOPICAL CREAMDIFFERIN ADAPALENE 0.1% TOPICAL LOTIONDIFFERIN ADAPALENE 0.1%, 0.3% TOPICAL GELDIFLUCAN FLUCONAZOLE 100MG, 150MG, 200MG TABLETDIFLUCAN FLUCONAZOLE 10MG/ML, 40MG/ML SUSPENSIONDILANTIN PHENYTOIN 125MG/5ML SUSPENSIONDILANTIN PHENYTOIN 30MG, 100MG CAPSULEDILANTIN PHENYTOIN 50MG CHEWABLE TABLETDILAUDID HYDROMORPHONE 2MG, 4MG TABLETDILITRATE SR ISOSORBIDE DINITRATE 40MG CAPSULEDILTIAZEM ER DILTIAZEM 60MG, 90MG CAPSULEDIOVAN VALSARTAN ALL STRENGTHS TABLETDIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE ALL STRENGTHS TABLETDIPROLENE BETAMETHASONE DIPROPIONATE 0.05% TOPICAL CREAMDIPROLENE BETAMETHASONE DIPROPIONATE 0.05% TOPICAL OINTMENTDIPROLENE AF BETAMETHASONE DIPROPIONATE "AUGMENTED" 0.05% TOPICAL CREAMDISALSID SALSALATE 500 MG, 750 MG TABLETDITROPAN OXYBUTYNIN 5 MG/5 ML SYRUPDITROPAN OXYBUTYNIN 5 MG TABLETDITROPAN XL OXYBUTYNIN 5 MG, 10 MG, 15 MG TABLETDIVIGEL ESTRADIOL ALL STRENGTHS TOPICAL GELDOMEBORO ACETIC ACID/ALUMINIUM ACETATE 2% OTIC SOLUTIONDOMEBORO CALCIUM ACETATE/ALUMINUM SULFATE TOPICAL POWDERDONNATAL PHENOBARBITAL-ATROPINE-SCOPALAMINE-HYOSCYAMINE 16.2MG-0.1037MG-0.0194MG-0.0065MG TABLETDONNATAL PHENOBARBITAL-ATROPINE-SCOPALAMINE-HYOSCYAMINE 16.2MG-0.1037MG-0.0194MG-0.0065MG/5ML ELIXIRDOSTINEX CABERGOLINE 0.5MG TABLETDOVONEX CALCIPOTRIENE 0.005% TOPICAL CREAMDOVONEX CALCIPOTRIENE 0.005% TOPICAL OINTMENTDOVONEX CALCIPOTRIENE 0.005% TOPICAL SOLUTIONDRYSOL ALUMINUM CHLORIDE 20% TOPICAL SOLUTIONDUAC CLINDAMYCIN/BENZOYL PEROXIDE 1.2%-5% TOPICAL GELDULCOLAX BISACODYL 5MG TABLETDUOFILM SALICYLIC ACID 17% TOPICAL SOLUTION DUONEB IPRATROPIUM/ALBUTEROL 0.5-3MG/3ML INHALATION SOLUTIONDUOTAB HYOSCYAMINE 0.125-0.25MG TABLETDURAGESIC FENTANYL ALL STRENGTHS TRANSDERMAL PATCHDUREZOL DIFLUPREDNATE 0.05% OPHTHALMIC SOLUTIONDYNAPEN DICLOXACILLIN 250MG CAPSULEDYRENIUM TRIAMTERENE 50MG, 100MG CAPSULEE.E.S. ERYTHROMYCIN ETHYLSUCCINATE 200MG/5ML SUSPENSIONECOTRIN ASPIRIN ENTERIC COATED 81MG, 325MG TABLETEDARBI AZILSARTAN 40MG, 80MG TABLETEDARBYCLOR AZILSARTAN/CHLORTHALIDONE 40-12.5MG, 40-25MG TABLETEDECRIN ETHACRYNIC ACID 25MG TABLET

Page 8: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMEFFER-K POTASSIUM BICARBONATE/CITRIC ACID 10MEQ, 20MEQ, 25MEQ TABLETEFFEXOR VENLAFAXINE 25MG, 37.5 MG, 50 MG, 75 MG, 100MG TABLETEFFEXOR ER VENLAFAXINE 225MG TABLETEFFEXOR XR VENLAFAXINE 37.5 MG, 75 MG, 150 MG CAPSULEEFFIENT PRASUGREL 5 MG, 10 MG TABLETEFUDEX FLUOROURACIL 5% TOPICAL CREAMEFUDEX FLUOROURACIL 5% TOPICAL SOLUTIONELAVIL AMITRIPTYLINE 10MG, 25MG, 50MG, 75MG, 100MG TABLETELESTRIN ESTRADIOL 0.06% TOPICAL GELELIDEL PIMECROLIMUS 1% TOPICAL CREAMELIMITE PERMETHRIN 5% TOPICAL CREAMELIXOPHYLLIN THEOPHYLLINE 80 MG/15 ML ELIXIRELMIRON PENTOSAN POLYSULFATE 100 MG CAPSULEELOCON MOMETASONE 0.1% TOPICAL CREAMELOCON MOMETASONE 0.1% TOPICAL OINTMENTELOCON MOMETASONE 0.1% TOPICAL SOLUTIONEMLA LIDOCAINE/PRILOCAINE 2.5%-2.5% TOPICAL CREAMENDOMETRIN PROGESTERONE 100MG VAGINAL SUPPOSITORYENTOCORT EC BUDESONIDE 3MG CAPSULEENULOSE LACTULOSE 10 GM/15 ML SOLUTIONEPI-PEN EPINEPHRINE 0.3MG/0.3ML INJECTIONEPI-PEN JR EPINEPHRINE 0.15MG/0.3ML INJECTIONEQUETRO CARBAMAZEPINE 100MG, 200MG, 300MG CAPSULEERYDERM ERYTHROMYCIN 2% TOPICAL SOLUTIONERYGEL ERYTHROMYCIN 2% TOPICAL GELERY-TAB ERYTHROMYCIN BASE 250MG TABLETERYTHROMYCIN ERYTHROMYCIN STEARATE 250MG TABLETESTRACE ESTRADIOL 0.01% VAGINAL CREAMESTRACE ESTRADIOL 0.5MG, 1MG, 2MG TABLETESTRING ESTRADIOL 7.5MCG/24 HOUR VAGINAL RINGESTROGEL ESTRADIOL 0.06% TOPICAL GELEUCERIN MINERAL OIL/PETROLATUM TOPICAL CREAMEVISTA RALOXIFENE 60 MG TABLETEVOXAC CEVIMELINE 30MG CAPSULEEXELON RIVASTIGMINE ALL STRENGTHS CAPSULEEXELON RIVASTIGMINE ALL STRENGTHS TRANSDERMAL PATCHEXFORGE AMLODIPINE/VALSARTAN ALL STRENGTHS TABLETEXFORGE HCT AMLODIPINE/VALSARTAN/HYDROCHLORTHIAZIDE ALL TABLETFAMVIR FAMCICLOVIR ALL STRENGTHS TABLETFELDENE PIROXICAM 10MG, 20MG CAPSULEFEMARA LETROZOLE 2.5MG TABLETFEMHRT NORETHINDRONE/ETHINYL ESTRADOIL ALL STRENGTHS TABLETFEMRING ESTRADIOL ALL STRENGTHS VAGINAL RINGFEOSOL FERROUS SULFATE 220 MG (44 MG IRON)/5 ML SOLUTION

Page 9: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMFEOSOL FERROUS SULFATE 325MG TABLETFER-IN-SOL FERROUS SULFATE 15MG/ML DROPSFINACEA AZELAIC ACID 15% TOPICAL GELFIORICET ACETAMINIOPHEN/BUTALBITAL/CAFFEINE 325MG-50MG-40MG TABLETFIORICET W/CODEINE BUTALBITAL/ACETAMINIOPHEN/CAFFEINE/CODEINE 50 MG-325 MG-40 MG-30 MG CAPSULEFIORINAL BUTALBITAL/ASPIRIN/CAFFEINE 50MG-325MG-40MG CAPSULEFLAGYL METRONIDAZOLE 250MG, 500MG TABLETFLAREX FLUOROMETHOLONE ACETATE 0.1% OPHTHALMIC SUSPENSIONFLEET ENEMA SODIUM PHOSPHATE PEDIATRIC, ADULT ENEMAFLEXERIL CYCLOBENZAPRINE 5MG, 10MG TABLETFLOMAX TAMSULOSIN 0.4 MG CAPSULEFLONASE FLUTICASONE 50MCG NASAL SPRAYFLORINEF FLUDROCORTISONE 0.1MG TABLETFLOVENT DISKUS FLUTICASONE ALL STRENGTHS INHALATION POWDERFLOVENT HFA FLUTICASONE ALL STRENGTHS INHALATION AEROSOLFML FLUOROMETHOLONE 0.1% OPHTHALMIC SUSPENSIONFOCALIN DEXMETHYLPHENIDATE 5MG, 10MG TABLETFOCALIN XR DEXMETHYLPHENIDATE XR ALL STRENGTHS CAPSULEFOLIC ACID FOLIC ACID 1MG TABLETFORTEO TERIPARATIDE 20 MCG/DOSE INJECTIONFORTESTA TESTOSTERONE 2% TOPICAL GELFORTICAL CALCITONIN 200IU/DOSE NASAL SPRAYFOSAMAX ALENDRONATE 70MG/75ML SOLUTIONFOSAMAX ALENDRONATE ALL STRENGTHS TABLETFREESTYLE LITE MONITOR BLOOD GLUCOSE MONITOR DEVICEFREESTYLE LITE STRIPS BLOOD GLUCOSE STRIPS DEVICEGARAMYCIN GENTAMICIN 0.3% OPHTHALMIC OINTMENTGARAMYCIN GENTAMICIN 0.3% OPHTHALMIC SOLUTIONGENTAMICIN GENTAMICIN 0.1% TOPICAL CREAMGENTAMICIN GENTAMICIN 0.1% TOPICAL OINTMENTGENTEAL HYPROMELLOSE OPHTHALMIC SOLUTION 0.3%GEODON ZIPRASIDONE ALL STRENGTHS CAPSULEGLEEVEC IMATINIB 100MG, 400MG TABLETGLUCAGON EMERGENCY KIT GLUCAGON,HUMAN RECOMBINANT 1MG INJECTIONGLUCOPHAGE METFORMIN 500MG, 850MG, 1000MG TABLETGLUCOPHAGE XR METFORMIN 500MG, 750MG TABLETGLUCOTROL GLIPIZIDE 5MG, 10MG TABLETGLUCOTROL XL GLIPIZIDE 2.5MG, 5MG, 10MG TABLETGLUCOVANCE GLYBURIDE/METFORMIN ALL STRENGTHS TABLETGLYNASE GLYBURIDE, MICRONIZED 1.5MG, 3MG, 6MG TABLETGOLYTELY ELECTROLYTE LAVAGE SOLUTIONGRISEOFULVIN GRISEOFULVIN 125MG/5ML SUSPENSIONGRIS-PEG GRISEOFULVIN 125MG, 250MG TABLETGYNE-LOTRIMIN CLOTRIMAZOLE 1% VAGINAL CREAM

Page 10: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMHALCION TRIAZOLAM 0.25 MG TABLETHALDOL HALOPERIDOL 0.05MG, 1MG, 2MG, 5MG, 10MG TABLETHUMALOG INSULIN LISPRO KWIKPEN INJECTIONHUMALOG INSULIN LISPRO VIAL INJECTIONHUMALOG MIX 50/50 INSULIN N/INSULIN LISPRO KWIKPEN INJECTIONHUMALOG MIX 50/50 INSULIN N/INSULIN LISPRO VIAL INJECTIONHUMALOG MIX 75/25 INSULIN N/INSULIN LISPRO KWIKPEN INJECTIONHUMALOG MIX 75/25 INSULIN N/INSULIN LISPRO VIAL INJECTIONHUMIRA PEN ADALIMUMAB 40MG/0.8ML, 40MG/0.4ML INJECTIONHUMIRA SYRINGE ADALIMUMAB 40MG/0.8ML.40MG/0.4ML INJECTIONHUMULIN 70/30 INSULIN NPH/REGULAR KWIKPEN INJECTIONHUMULIN 70/30 INSULIN NPH/REGULAR VIAL INJECTIONHUMULIN N INSULIN ISOPHANE KWIKPEN INJECTIONHUMULIN N INSULIN ISOPHANE VIAL INJECTIONHUMULIN R INSULIN REGULAR VIAL INJECTIONHYCET HYDROCODONE/ACETAMINOPHEN 7.5MG-325MG/15ML SOLUTIONHYDREA HYDROXYUREA 500MG CAPSULEHYDROCORTISONE HYDROCORTISONE 2.5% TOPICAL LOTIONHYDROCORTISONE HYDROCORTISONE 1%, 2.5% TOPICAL CREAMHYDROCORTISONE HYDROCORTISONE 1%, 2.5% TOPICAL OINTMENTHYDRODIURIL HYDROCHLOROTHIAZIDE 12.5MG, 25MG, 50MG TABLETHYGROTON CHLORTHALIDONE 25MG, 50MG TABLETHYTRIN TERAZOSIN ALL STRENGTHS CAPSULEHYZAAR LOSARTAN/HYDROCHLOROTHIAZIDE ALL STRENGTHS TABLETILOTYCIN ERYTHROMYCIN 5MG/GM OPHTHALMIC OINTMENTIMDUR ISOSORBIDE MONONITRATE 30MG, 60MG, 120MG TABLETIMITREX SUMATRIPTAN 25 MG, 50MG, 100 MG TABLETIMITREX SUMATRIPTAN 5 MG, 20MG NASAL SPRAYIMITREX STAT KIT SUMATRIPTAN 6 MG/0.5ML INJECTIONIMODIUM LOPERAMIDE 2MG CAPSULEIMURAN AZATHIOPRINE 50MG TABLETINCRUSE ELLIPTA UMECLIDINIUM 62.5MCG/ACTUATION INHALATION POWDERINDERAL PROPRANOLOL 10 MG, 20 MG, 40 MG, 60MG, 80 MG TABLETINDERAL LA PROPRANOLOL 60 MG, 80 MG, 120 MG, 160MG CAPSULEINDOCIN INDOMETHACIN 25MG, 50MG CAPSULEINDOCIN SR INDOMETHACIN 75MG CAPSULEINSPRA EPLERENONE 25MG, 50MG TABLETINSULIN SYRINGE LONG NEEDLE SYRINGE, INSULIN LONG NEEDLE 0.3 ML, 0.5 ML, 1 ML DEVICEINSULIN SYRINGE SHORT NEEDLE SYRINGE, INSULIN SHORT NEEDLE 0.3 ML, 0.5 ML, 1 ML DEVICEINTUNIV GUANFACINE ALL STRENGTHS TABLETISMO ISOSORBIDE MONONITRATE 10MG, 20MG TABLETISONIAZID ISONIAZID 100MG, 300MG TABLETISONIAZID ISONIAZID 50MG/5ML SUSPENSIONISOSORDIL ISOSORBIDE DINITRATE 10MG, 20MG, 30MG 40MG TABLET

Page 11: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMJANUMET SITAGLIPTIN/METFORMIN ALL STRENGTHS TABLETJANUMET XR SITAGLIPTIN/METFORMIN ALL STRENGTHS TABLETJANUVIA SITAGLIPTIN ALL STRENGTHS TABLETJENTADUETO LINAGLIPTIN/METFORMIN 2.5-500MG, 2.5-500MG, 2.5-1000MG TABLETJOLESSA/SEASONALE LEVONORGESTREL-ETHINYL ESTRADIOL 0.15 MG-30 MCG TABLETKAPVAY CLONIDINE ER 0.1MG TABLETK-DUR POTASSIUM CHLORIDE 10 mEq, 15 mEq, 20 mEq TABLETKEFLEX CEPHALEXIN 250MG, 500MG CAPSULEKEFLEX CEPHALEXIN 250MG/5ML SUSPENSIONKENALOG IN ORABASE TRIAMCINOLONE/ORABASE 0.1% DENTAL PASTEKENALOG SPRAY TRIAMCINOLONE 0.147 MG/GM TOPICAL SPRAYKEPPRA LEVETIRACETAM 100MG/ML SOLUTIONKEPPRA LEVETIRACETAM 250MG, 500MG, 750MG, 1000MG TABLETKLARON SULFACETAMIDE SODIUM 10% TOPICAL SUSPENSIONKLONOPIN CLONAZEPAM 0.5MG, 1MG TABLETKLOR-CON POTASSIUM CHLORIDE 20MEQ, 25MEQ POWDERKLOR-CON POTASSIUM CHLORIDE 8 mEq, 10 mEq, 20MEQ TABLETLACHYDRIN AMMONIUM LACTATE 12% LOTIONLACRI-LUBE MINERAL OIL/PETROLATUM,WHITE 42.5 %-56.8 % OPHTHALMIC OINTMENTLAMICTAL LAMOTRIGINE 25MG, 100MG, 150MG, 200MG TABLETLAMISIL TERBINAFINE 1% CREAMLAMISIL TERBINAFINE 250 MG TABLETLANCET LANCET DEVICELANOXIN DIGOXIN 0.05MG/ML SOLUTIONLANOXIN DIGOXIN ALL STRENGTHS TABLETLANTUS INSULIN GLARGINE VIAL INJECTIONLANTUS SOLOSTAR INSULIN GLARGINE PEN INJECTIONLASIX FUROSEMIDE 10MG/ML SOLUTIONLASIX FUROSEMIDE 20MG, 40MG, 80MG TABLETLEENA NORETHINDRONE-ETHINYL ESTRADIOL 0.5 MG-35 MCG TABLETLESCOL FLUVASTATIN 20MG, 40MG CAPSULELEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 5MG, 25MG TABLETLEVAQUIN LEVOFLOXACIN 250MG, 500MG, 750MG TABLETLEVAQUIN LEVOFLOXACIN 25MG/ML SOLUTIONLEVBID HYOSCYAMINE ER 0.375MG TABLETLEVEMIR INSULIN DETEMIR VIAL INJECTIONLEVLEN LEVONORGESTERONE-ETHINYL ESTRADIOL 0.15 MG-30 MCG TABLETLEVSIN HYOSCYAMINE 0.125MG SUBLINGUAL TABLETLEVSIN HYOSCYAMINE 0.125MG TABLETLEXAPRO ESCITALOPRAM 5MG, 10MG, 20MG TABLETLEXAPRO ESCITALOPRAM 5MG/5ML SOLUTIONLIALDA MESALAMINE 1.2GM TABLETLIBRAX CHLORDIAZEPOXIDE/CLIDINIUM 5MG-2.5MG CAPSULELIBRIUM CHLORDIAZEPOXIDE 5MG, 10MG CAPSULE

Page 12: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMLIDEX FLUOCINONIDE 0.05% TOPICAL CREAMLIDEX FLUOCINONIDE 0.05% TOPICAL GELLIDEX FLUOCINONIDE 0.05% TOPICAL OINTMENTLIDEX-E FLUOCINONIDE EMOLLIENT 0.05% TOPICAL CREAMLIDOCAINE VISCOUS LIDOCAINE VISCOUS 2% SOLUTIONLIDODERM LIDOCAINE 5% TRANSDERMAL PATCHLIORESAL BACLOFEN 10MG, 20MG TABLETLIPITOR ATORVASTATIN ALL STRENGTHS TABLETLIQUIFILM TEARS POLYVINYL ALCOHOL 1.4% OPHTHALMIC SOLUTIONLITHIUM CARBONATE LITHIUM CARBONATE 150MG, 300MG CAPSULELITHIUM CITRATE LITHIUM CITRATE 8MEQ/5ML SOLUTIONLOCOID HYDROCORTISONE BUTYRATE 0.1% TOPICAL OINTMENTLOCOID HYDROCORTISONE BUTYRATE 0.1% TOPICAL SOLUTIONLODINE ETODOLAC 200MG, 300MG CAPSULELODINE ETODOLAC 400MG, 500MG TABLETLODINE ER ETODOLAC 400MG, 500MG, 600MG TABLETLODOSYN CARBIDOPA 25MG TABLETLOFIBRA FENOFIBRATE 67MG, 134MG, 200MG CAPSULELOFIBRA FENOFIBRATE 54MG,160MG TABLETLOHIST D PSEUDOEPHEDRINE/CHLORPHENIRAMINE 30 MG-2 MG/5 ML SOLUTIONLOMOTIL DIPHENOXYLATE HCL/ATROPINE 2.5 MG-0.025 MG TABLETLO-OVRAL NORGESTEROL/ETHINYL ESTRADIOL 0.3 MG-30 MCG TABLETLOPID GEMFIBROZIL 600MG TABLETLOPRESSOR METOPROLOL TARTRATE 25MG, 50MG, 100MG TABLETLOTEMAX LOTEPREDNOL 0.5% OPHTHALMIC GELLOTEMAX LOTEPREDNOL 0.5% OPHTHALMIC OINTMENTLOTEMAX LOTEPREDNOL 0.5% OPHTHALMIC SUSPENSIONLOTENSIN BENAZEPRIL 5MG, 10MG, 20MG, 40MG TABLETLOTENSIN HCT BENAZEPRIL/HYDROCHLORTHIAZIDE 10-12.5MG, 20-12.5MG, 20-25MG TABLETLOTREL AMLODIPINE/BENAZEPRIL ALL STRENGTHS CAPSULELOTRISONE CLOTRIMAZOLE/BETAMETHASONE 1%-0.05% TOPICAL CREAMLOVAZA OMEGA-3-ACID 1GM CAPSULELOVENOX ENOXAPARIN ALL STRENGTHS INJECTIONLOZOL INDAPAMIDE 1.25MG, 2.5MG TABLETLUMIGAN BIMATOPROST 0.01% OPHTHALMIC SOLUTIONLUNESTA ESZOICLONE ALL STRENGTHS TABLETLURIDE SODIUM FLUORIDE 0.5 MG/ML DROPSLUVOX FLUVOXAMINE 25MG, 50MG, 100MG TABLETLUVOX CR FLUVOXAMINE 100MG, 150MG CAPSULELYSTEDA TRANEXAMIC ACID 650 MG TABLETMAALOX MAGNESIUM HYDROXIDE/ALUMINUM/SIMETHICONE 200 MG-200 MG-20 MG SUSPENSIONMAALOX EXTRA STRENGTH MAGNESIUM HYDROXIDE/ALUMINUM/SIMETHICONE 400 MG-400 MG-40 MG SUSPENSIONMACROBID NITROFURANTON 100MG CAPSULEMACRODANTIN NITROFURANTON 50MG CAPSULE

Page 13: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMMALARONE ATOVAQUONE/PROGUANIL 250MG-100MG TABLETMAXALT RIZATRIPTAN 5 MG, 10 MG TABLETMAXALT MLT RIZATRIPTAN 5 MG, 10 MG SUBLINGUAL TABLETMAXIDEX DEXAMETHASONE 0.1% OPHTHALMIC SOLUTIONMAXITROL NEOMYCIN/POLYMYCIN B/DEXAMETHASONE 3.5 mg-10,000 unit-0.1 % OPHTHALMIC OINTMENTMAXITROL NEOMYCIN/POLYMYCIN B/DEXAMETHASONE 3.5 mg-10,000 unit-0.1 % OPHTHALMIC SUSPENSIONMAXZIDE TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5MG-25 MG, 75 MG-50 MG TABLETMEDROL METHYLPREDNISOLONE 4MG TABLETMEDROL DOSPAK METHYLPREDNISOLONE 4MG TABLETMEGACE MEGESTROL 20MG, 40MG TABLETMEGACE MEGESTROL 40MG/ML SUSPENSIONMELATONIN MELATONIN 5mg TABLETMENOSTAR ESTRADIOL 14MCG TRANSDERMAL PATCHMENTAX BUTENAFINE 1% CREAMMESTINON PYRIDOSTIGMINE 60 MG, 180 MG TABLETMETADONE METHADONE 5MG, 10MG TABLETMETAGLIP GLIPIZIDE/METFORMIN 5MG/500MG TABLETMETAMUCIL PSYLLIUM SEED 3.4 GM/5 ML POWDERMETHOTREXATE METHOTREXATE 2.5MG TABLETMETHOTREXATE METHOTREXATE 25MG/ML INJECTIONMETROCREAM METRONIDAZOLE 0.75% TOPICAL CREAMMETROGEL METRONIDAZOLE 0.75% VAGINAL GELMETROGEL METRONIDAZOLE 0.75%, 1% TOPICAL GELMETROLOTION METRONIDAZOLE 0.75% TOPICAL LOTIONMEVACOR LOVASTATIN 10 MG, 20 MG, 40 MG TABLETMEXITIL MEXILETINE 150MG, 200MG, 250MG CAPSULEMICARDIS TELMISARTAN ALL STRENGTHS TABLETMICARDIS HCT TELMISARTAN/HYDROCHLOROTHIAZIDE ALL STRENGTHS TABLETMICRO-K POTASSIUM CHLORIDE 8 mEq, 10 mEq CAPSULEMICROGESTIN FE NORETHINDRONE/ETHINYL ESTRADIOL/FER FUMERATE 1 MG-20 MCG-75MG, 1.5 MG-30 MCG-75 MG TABLETMICRONASE GLYBURIDE 1.25MG, 2.5MG, 5MG TABLETMICRONOR NORETHINDRONE 0.35 MG TABLETMICROZIDE HYDROCHLOROTHIAZIDE 12.5MG CAPSULEMIDAMOR AMILORIDE 5MG TABLETMILK OF MAGNESIA MAGNESIUM HYDROXIDE 400 MG/5 ML SUSPENSIONMINIPRESS PRAZOSIN 1 MG, 2 MG, 5 MG CAPSULEMINIVELLE ESTRADIOL ALL STRENGTHS TRANSDERMAL PATCHMINOCIN MINOCYCLINE 50MG, 75MG, 100MG CAPSULEMINOXIDIL MINOXIDIL 2.5MG, 10MG TABLETMIRALAX POLYETHYLENE GLYCOL3500 POWDERMIRAPEX PRAMIPEXOLE ALL STRENGTHS TABLETMOBIC MELOXICAM 7.5MG, 15MG TABLETMONOPRIL FOSINOPRIL 10MG, 20MG, 40MG TABLETMORPHINE MORPHINE (IMMEDIATE RELEASE) 15MG, 30MG TABLET

Page 14: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMMOTRIN IBUPROFEN 100MG/5ML SUSPENSIONMOTRIN IBUPROFEN 200MG, 400MG, 600MG, 800MG TABLETMOVIPREP ELECTROLYE LAVAGE SUSPENSIONMOXEZA MOXIFLOXACIN 0.5% OPHTHALMIC SOLUTIONMS CONTIN MORPHINE 15MG, 30MG, 60MG TABLETMUCINEX GUAIFENESIN 600MG TABLETMUCINEX-D GUAIFENESIN/PSEUDOEPHEDRINE 600MG-60MG TABLETMULTAQ DRONEDARONE 400MG TABLETMULTIVITAMIN MULTIVITAMIN CHEWABLE TABLETMULTIVITAMIN MULTIVITAMIN TABLETMULTIVITAMIN/IRON MULTIVITAMIN/IRON CHEWABLE TABLETMULTIVITAMIN/IRON MULTIVITAMIN/IRON TABLETMURO-128 SODIUM CHLORIDE 5% OPHTHALMIC OINTMENTMURO-128 SODIUM CHLORIDE 5% OPHTHALMIC SOLUTIONMYAMBUTOL ETHAMBUTOL 100MG, 400MG TABLETMYCELEX CLOTRIMAZOLE 1% TOPICAL CREAMMYCELEX CLOTRIMAZOLE 10MG TROCHEMYCOLOG II NYSTATIN/TRIAMCINOLONE 100,000 UNITS/GM-0.1% TOPICAL CREAMMYDRIACYL TROPICAMIDE 0.5%, 1% OPHTHALMIC SOLUTIONMYDRIFIN PHENYLEPHRINE 2.5% OPHTHALMIC SOLUTIONMYRBETRIQ MIRABEGRON 25MG, 50MG TABLETMYSOLINE PRIMIDONE 50 MG, 250 MG TABLETNAFTIN NAFTIFINE 1%, 2% TOPICAL CREAMNALFON FENOPROFEN 400MG CAPSULENAMENDA MEMANTINE 5MG, 10MG TABLETNAPROSYN NAPROXEN 125MG/5ML SUSPENSIONNAPROSYN NAPROXEN 250MG, 375MG, 500MG TABLETNAPROSYN-EC NAPROXEN 375MG, 500MG TABLETNARCAN NASAL SPRAY NALOXONE 4MG NASAL SPRAYNASALIDE FLUNISOLIDE 0.025% NASAL SPRAYNASCOBAL CYANOCOBALAMIN 500MCG NASAL SPRAYNATURE THYROID THYROID 32.5MG, 48.75MG 65 MG, 112.75MG TABLETNEOFRIN PHENYLEPHRINE 10% OPHTHALMIC SOLUTIONNEOMYCIN NEOMYCIN SULFATE 500 MG TABLETNEOSPORIN NEOMYCIN/BACITRACIN/POLYMYXIN B 3.5 MG-400 UNITS-10000 UNITS/GM OPHTHALMIC OINTMENTNEOSPORIN NEOMYCIN/POLYMYXN B/GRAMICIDIN 1.75 MG-10000 UNITS-0.025MG/ML OPHTHALMIC SOLUTIONNEO-SYNEPHRINE PHENYLEPHRINE 0.125% BNASAL DROPSNEO-SYNEPHRINE PHENYLEPHRINE 0.25%, 0.5% NASAL SPRAYNEPTAZANE METHAZOLAMIDE 25MG, 50MG TABLETNEUPRO ROTIGOTINE ALL STRENGTHS TRANSDERMAL PATCHNEURONTIN GABAPENTIN 100MG, 300MG, 400MG CAPSULENEURONTIN GABAPENTIN 600MG, 800MG TABLETNEVANAC NEPAFENAC 0.1% OPHTHALMIC SUSPENSIONNIASPAN NIACIN ALL STRENGTHS TABLET

Page 15: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMNICODERM NICOTINE ALL STRENGTHS TRANSDERMAL PATCHNICORETTE NICOTINE 2MG, 4MG BUCCAL GUMNITROBID NITROGLYCERIN 2% TOPICAL OINTMENTNITRO-DUR NITROGLYCERIN ALL STRENGTHS TRANSDERMAL PATCHNITRO-SPRAY NITROGLYCERIN 0.4 MG/SPRAY SUBLINGUAL SPRAYNITROSTAT NITROGLYCERIN 0.3 MG, 0.4 MG, 0.6 MG SUBLINGUAL TABLETNITRO-TIME NITROGLYCERIN 2.5 MG, 6.5 MG CAPSULENIX PERMETHRIN 1& TOPICAL SHAMPOONIZORAL KETOCONAZOLE 2% SHAMPOONIZORAL KETOCONAZOLE 2% TOPICAL CREAMNIZORAL KETOCONAZOLE 200MG TABLETNOLVADEX TAMOXIFEN 10 MG, 20MG TABLETNORCO HYDROCODONE/ACETAMINOPHEN 5-325MG, 7.5-325MG, 10-325MG TABLETNORFLEX ORPHENADRINE 100MG TABLETNORPRAMIN DESIPRAMINE 10MG, 25MG, 50MG, 75MG, 100MG, 150MG TABLETNORVASC AMLODIPINE ALL STRENGTHS TABLETNOVOLIN INSULIN, HUMAN REGULAR, NPH, 70/30 INJECTIONNOVOLOG INSULIN ASPART FLEXPEN INJECTIONNOVOLOG INSULIN ASPART VIAL INJECTIONNOVOLOG 70/30 INSULIN ASPART PROTAMINE/INSULIN ASPART FLEXPEN INJECTIONNOVOLOG 70/30 INSULIN ASPART PROTAMINE/INSULIN ASPART VIAL INJECTIONNULYTE ELECTROLYE LAVAGE SOLUTIONNUVARING ETONOGESTREL/ETHINYL ESTRADIOL 0.12 MG-0.015 MG VAGINAL RINGNYCYNTA ER TAPENTADOL 150 MG TABLETNYSTATIN NYSTATIN 100,000 UNITS/GM TOPICAL CREAMNYSTATIN NYSTATIN 100,000 UNITS/GM TOPICAL OINTMENTNYSTATIN NYSTATIN 100,000 UNITS/ML SUSPENSIONNYSTATIN NYSTATIN 500,000 UNITS TABLETNYSTOP NYSTATIN 100,000 UNITS/GM TOPICAL POWDEROCUFEN FLURBIPROFEN 0.03% OPHTHALMIC SOLUTIONOCUFLOX OFLOXACIN 0.3% OPHTHALMIC SOLUTIONOMNICEF CEFDINIR 125MG/5ML, 250MG/5ML SUSPENSIONOMNICEF CEFDINIR 300MG CAPSULEOPTICHAMBER SPACER, INHALATION DEVICE DEVICEOPTICHAMBER SPACER, INHALATION DEVICE WITH MASK ALL SIZES DEVICEOPTIPRANOLOL METIPRANOLOL 0.3% OPHTHALMIC SOLUTIONOPTIVAR AZELASTINE 0.05% OPHTHALMIC SOLUTIONORAPRED PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML SOLUTIONORAPRED ODT PREDNISOLONE 10 MG, 15 MG, 30 MG SUBLINGUAL TABLETORTHO CYCLEN NORGESTIMATE/ETHINYL ESTRADIOL 0.25 MG-35 MCG TABLETORTHO EVRA NORELGESTROMIN/ETHINYL ESTRADIOL 150MCG-20 MCG TRANSDERMAL PATCHORTHO NOVUM 1/35 NORETHINDRONE/ETHINYL ESTRADIOL 1 MG-35 MCG TABLETORTHO NOVUM 1/50 NORETHINDRONE/MESTRANOL 1 MG-50 MCG TABLETORTHO NOVUM 7/7/7 NORETHINDRONE/ETHINYL ESTRADIOL 0.5 mg-35 mcg/0.75 mg-35 mcg/1 mg-35 mcg TABLET

Page 16: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMORTHO TRI CYCLEN NORGESTIMATE/ETHINYL ESTRADIOL 0.18mg-35mcg/0.215mg-35mcg/0.25mg-35mcg TABLETORTHO TRI CYCLEN LO NORGESTIMATE/ETHINYL ESTRADIOL 0.18mg-25mcg/0.215mg-25mcg/0.25mg-25mcg TABLETOSCAL CALCIUM CARBONATE 500MG, 600MG TABLETOSCAL-D CALCIUM CARBONATE/VITAMIN D 500MG-200IU, 600MG-400IU TABLETOSPHENA OSPEMIFENE 60MG CAPSULEOVIDE MALATHION 0.5% TOPICAL LOTIONOXYCODONE OXYCODONE IR 5 MG, 15 MG, 30 MG TABLETOXYCONTIN OXYCODONE 10 MG, 15 MG, 20 MG, 30MG, 40 MG, 80 MG TABLETPACERONE AMIODARONE 200MG TABLETPAMELOR NORTRIPTYLINE 10 MG, 25 MG, 50 MG, 75 MG CAPSULEPARAFON FORTE CHLORZOXAZONE 500MG TABLETPARCOPA CARBIDOPA/LEVODOPA ALL STRENGTHS SUBLINGUAL TABLETPARLODEL BROMOCRIPTINE 2.5MG TABLETPATANOL OLOPATADINE 0.1% OPHTHALMIC SOLUTIONPAXIL PAROXETINE 10 MG, 20 MG, 30 MG, 40 MG TABLETPAXIL CR PAROXETINE 12.5MG, 25MG, 37.5MGPAZEO OLOPATADINE 0.7% OPHTHALMIC SOLUTIONPEN NEEDLE PEN NEEDLE DEVICEPEN V K PENICILLIN 250MG, 500MG TABLETPENLAC CICLOPIROX 8% TOPICAL SOLUTIONPEN-V-K PENICILLIN 250 MG/5ML SUSPENSIONPEPCID FAMOTIDINE 20MG, 40MG TABLETPEPCID FAMOTIDINE 40MG/5ML SUSPENSIONPEPTO BISMOL BISMUTH SUBSALICYLATE 262MG TABLETPEPTO BISMOL BISMUTH SUBSALICYLATE 262MG/5ML SUSPENSIONPERCOCET-10 OXYCODONE/ACETAMINOPHEN 10 MG- 325 MG TABLETPERCOCET-5 OXYCODONE/ACETAMINOPHEN 5 MG- 325 MG TABLETPERIACTIN CYPROHEPTADINE 2MG/5ML SYRUPPERIACTIN CYPROHEPTADINE 4MG TABLETPERIDEX CHLORHEXIDINE 0.12% SOLUTIONPERIOSTAT DOXYCYCLINE HYCLATE 20MG TABLETPERSANTINE DIPYRIDAMOLE 25MG, 75MG TABLETPHENERGAN PROMETHAZINE 12.5 MG, 25 MG RECTAL SUPPOSITORYPHENERGAN PROMETHAZINE 25 MG TABLETPHENERGAN PROMETHAZINE 6.25 MG/5 ML SYRUPPHENERGAN W/CODEINE PROMETHAZINE/CODEINE 6.25 MG-10 MG/5 ML SYRUPPHENOBARBITAL PHENOBARBITAL 16.2 MG, 32.4 MG, 64.8 MG, 97.2 MG TABLETPHENOBARBITAL PHENOBARBITAL 20 MG/5 ML ELIXIRPHOSLO CALCIUM ACETATE 667MG CAPSULEPHRELIN ACETAMINOPHEN/BUTALBITAL 325MG/50MG TABLETPILOCAR PILOCARPINE 1%, 2%, 4% OPHTHALMIC SOLUTIONPLAN B ONE STEP LEVONORGESTREL 1.5MG TABLETPLAQUENIL HYDROXYCHLOROQUINE 200MG TABLETPLAVIX CLOPIDOGREL 75MG, 300MG TABLET

Page 17: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMPLENDIL FELODIPINE 2.5MG, 5MG, 10MG TABLETPLETAL CILOSTAZOL 50MG, 100MG TABLETPOLYTRIM POLYMYXIN B/TRIMETHOPRIM 10,000 UNITS/ML-0.1% OPHTHALMIC SOLUTIONPONTOCAINE TETRACAINE 0.5% OPHTHALMIC SOLUTIONPOTASSIUM CLORIDE POTASSIUM CHLORIDE 10%, 20% SOLUTIONPRADAXA DABIGATRAN 75MG, 150MG CAPSULEPRAMOSONE HYDROCORTISONE/PRAMOXINE 1%-1% RECTAL CREAMPRANDIN REPAGLINIDE 0.5 MG, 1 MG, 2 MG TABLETPRAVACHOL PRAVASTATIN 10 MG, 20 MG, 40 MG, 80 MG TABLETPRECISION *XTRA* BLOOD GLUCOSE STRIPS STRIPSPRECOSE AACARBOSE ALL STRENGTHS TABLETPRED FORTE PREDNISOLONE 1% OPHTHALMIC SUSPENSIONPRED MILD PREDNISOLONE 0.125% OPHTHALMIC SUSPENSIONPREDNISONE PREDNISONE 5 MG/5 ML SOLUTIONPRELONE PREDNISOLONE 15MG/5ML SOLUTIONPREMARIN ESTROGEN, CONJUGATED 0.625MG/GM VAGINAL CREAMPREMARIN ESTROGEN, CONJUGATED ALL STRENGTHS TABLETPREMPHASE ESTROGEN,CONJGATED/MEDROXYPROGESTERONE 0.625 mg (14)/0.625 mg-5 mg (14) TABLETPREMPRO ESTROGEN,CONJGATED/MEDROXYPROGESTERONE ALL STRENGTHS TABLETPREPOPIK SOD PICOSULFATE/MAG OXIDE/CITRIC ACID KITPREVALITE CHOLESTYRAMINE 4GM/PACKET POWDERPREVIDENT PLUS SODIUM FLUORIDE 1.1% DENTAL CREAMPREVIDENT 5000 SENSITIVE SODIUM FLUORIDE/POTASSIUM NITRATE 1.2=5% DENTAL PASTEPREVPAK LANSOPROZOLE/AMOXICILLIN/CLARITHOMYCIN 30 MG-500 MG-500MG CAPSULEPRILOSEC OMEPRAZOLE 10MG, 20MG, 40MG CAPSULEPRIMAQUINE PRIMAQUINE 26.3 MG TABLETPROAIR ALBUTEROL 90MCG INHALATION AEROSOLPROAMATINE MIDODRINE 2.5MG, 5MG, 10MG TABLETPROCARDIA NIFEDIPINE 10MG CAPSULEPROCARDIA XL NIFEDIPINE 30MG, 60MG, 90MG TABLETPROCTOCREAM HC HYDROCORTISONE 2.5% RECTAL CREAMPROCTOFOAM HC HYDROCORTISONE/PRAMOXINE 1%-1% RECTAL FOAMPROMETHAZINE VC PROMETHAZINE/PHENYLEPHRINE 6.25 MG-5 MG/5 ML SYRUPPROMETHAZINE VC W/CODEINE PROMETHAZINE/PHENYLEPHRINE/CODEINE 6.25 MG-5 MG-10 MG/5 ML SYRUPPROMETRIUM PROGESTERONE 100 MG, 200 MG CAPSULEPROSCAR FINASTERIDE 5MG TABLETPROTONIX PANTOPRAZOLE 20 MG, 40 MG TABLETPROTONIX PANTOPRAZOLE 40MG SUSPENSIONPROTOPIC TACROLIMUS 0.03%, 0.1% TOPICAL OINTMENTPROVENTIL ALBUTEROL 0.5% INHALATION SOLUTIONPROVENTIL ALBUTEROL 0.042%, 0.83% INHALATION SOLUTIONPROVENTIL ALBUTEROL 2MG, 4MG TABLETPROVENTIL ALBUTEROL 2MG/5ML SYRUPPROVERA MEDROXYPROGESTERONE 2.5MG, 5MG, 10MG TABLET

Page 18: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMPROZAC FLUOXETINE 10MG, 20MG, 40MG CAPSULEPROZAC FLUOXETINE 20MG/5ML SOLUTIONPTU PROPYLTHIOURACIL 50 MG TABLETPULMICORT BUDESONIDE ALL INHALATION SOLUTIONPYRAZINAMIDE PYRAZINAMIDE 500 MG TABLETPYRIDIUM PHENAZOPYRIDINE 100 MG, 200MG TABLETPYRIDOXINE PYRIDOXINE 50 MG TABLETRANEXA RANOLAZINE 500 MG, 1000 MG TABLETRAZADYNE GALANTAMINE 4MG, 8MG, 12MG TABLETRAZADYNE ER GALANTAMINE 8MG, 16MG, 24MG CAPSULERECTIV NITROGLYCERIN 0.4% RECTAL OINTMENTREFRESH CELLUVISC CARBOXYMETHYLCELLULOSE OPHTHALMIC SOLUTION 1%REFRESH CLASSIC POLYVINYL ALCOHOL/POVIDONE/PF OPHTHALMIC SOLUTION 1.4%-0.6%REFRESH PLUS CARBOXYMETHYLCELLULOSE OPHTHALMIC SOLUTION 0.5%REGLAN METOCLOPRAMIDE 10MG TABLETREGLAN METOCLOPRAMIDE 5MG/5ML SYRUPRELAFEN NABUMETONE 500MG, 750MG TABLETRELPAX ELETRIPTAN 20MG, 40MG TABLETREMERON MIRTAZEPINE 15MG, 30MG, 45MG TABLETREMERON ODT MIRTAZEPINE 15MG, 30MG, 45MG SUBLINGUAL TABLETRENAGEL SEVELAMER 800 MG TABLETREQUIP ROPINIROLE 0.25 MG, 5 MG, 1 MG, 2 MG, 3 MG TABLETRESTASIS CYCLOSPORINE OPHTHALMIC SOLUTION 0.05%RESTORIL TEMAZEPAM 15 MG, 30 MG CAPSULERETIN A TRETINOIN 0.025%, 0.1% TOPICAL GELRETIN A TRETINOIN 0.025%. 0.05%, 0.1% TOPICAL CREAMREVIA NALTREXONE 50MG TABLETRID LICE TREATMENT PIPERONYL-PYRETHINS TOPICAL SHAMPOORIFADIN RIFAMPIN 300 MG CAPSULERISPERDAL RISPERIDONE ALL STRENGTHS TABLETRISPERDAL M-TAB RISPERIDONE ALL STRENGTHS SUBLINGUAL TABLETRITALIN METHYLPHENIDATE 5MG, 10MG, 20MG TABLETRITALIN ER METHYLPHENIDATE 20MG TABLETRITALIN LA METHYLPHENIDATE 10MG, 20MG, 30MG 40MG CAPSULEROBAXIN METHOCARBAMOL 500MG, 750MG TABLETROBINUL GLYCOPYRROLATE 1MG TABLETROBINUL FORTE GLYCOPYRROLATE 2MG TABLETROBITUSSIN GUAIFENESIN 100MG/5ML SYRUPROBITUSSIN AC GUAIFENESIN/CODEINE 100 MG-10 MG/5 ML SYRUPROBITUSSIN DM GUAIFENESIN/DEXTROMETHORPHAN 100 MG-10 MG/5ML SYRUPROCATROL CALCITRIOL 0.25MCG, 0.5MCG CAPSULEROWASA MESALAMINE 4GM/60ML RECTAL ENEMARYTHMOL PROPAFENONE 150 MG, 225MG, 300 MG TABLETRYTHMOL SR PROPAFENONE 225MG, 325MG, 425MG CAPSULE

Page 19: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMSALAGEN PILOCARPINE 5 MG, 7.5 MG TABLETSANCTURA TROSPIUM 20MG TABLETSANCTURA XR TROSPIUM 60 MG CAPSULESANI-SUP GLYCERIN PEDIATRIC RECTAL SUPPOSITORYSECTRAL ACEBUTOLOL 200MG, 400MG CAPSULESELSUN SELENIUM SULFIDE 2.5% TOPICAL SHAMPOOSEPTRA SULFAMETHOXAZOLE/TRIMETHOPRIM 40 MG-8 MG/5 ML SUSPENSIONSEPTRA SULFAMETHOXAZOLE/TRIMETHOPRIM 400 MG-80 MG TABLETSEPTRA DS SULFAMETHOXAZOLE/TRIMETHOPRIM 800 MG- 160 MG TABLETSEREVENT SALMETEROL 50 MCG INHALATION POWDERSEROQUEL QUETIAPINE ALL STRENGTHS TABLETSEROQUEL XR QUETIAPINE ALL STRENGTHS TABLETSILVADENE SILVER SULFATE 1% TOPICAL CREAMSIMBRINZA BRINZOLAMIDE/BRIMONIDINE 1%-0.2% OPHTHALMIC SUSPENSIONSINEMET CARBIDOPA/LEVODOPA ALL STRENGTHS TABLETSINEMET CR CARBIDOPA/LEVODOPA 25MG-100MG, 50MG-200MG TABLETSINEQUAN DOXEPIN 10MG, 25MG, 50MG, 75MG, 100MG CAPSULESINEQUAN DOXEPIN 10MG/ML SOLUTIONSINGULAIR MONTELUKAST 10MG TABLETSINGULAIR MONTELUKAST 4GM SUSPENSIONSINGULAIR MONTELUKAST 4MG, 5MG CHEWABLE TABLETSKELAXIN METAXALONE 800MG TABLETSKLICE IVERMECTIN 0.50% TOPICAL LOTIONSODIUM CHLORIDE SODIUM CHLORIDE 0.9%, 3%, 7% INHALATION SOLUTIONSOMA CARISOPRODOL 250MG, 350MG TABLETSONATA ZALEPLON 5MG, 10MG CAPSULESPIRIVA TIOTROPIUM 1.25MCG, 2.5MCG INHALERSPIRIVA RESPIMAT TIOTROPIUM 18 MCG INHALATION POWDERSPORANOX ITRACONAZOLE 100MG CAPSULESRONYX/ALESSE LEVONORGESTERONE-ETHINYL ESTRADIOL 0.1 MG-20 MCG TABLETSTALEVO CARBIDOPA/LEVODOPA/ENTACAPONE ALL STRENGTHS TABLETSTARLIX NATEGLINIDE 60MG, 120MG TABLETSTRATTERA ATOMOXETINE ALL STRENGTHS CAPSULESTROMECTOL IVERMECTIN 3MG TABLETSUDAFED PSEUDOEPHEDRINE 30 MG TABLETSUDAFED PSEUDOEPHEDRINE 30 MG/5 ML SOLUTIONSUDAFED-12 HOUR PSEUDOEPHEDRINE 120 MG TABLETSULFACETAMIDE/SULFUR SULFACETAMIDE/SULFUR 10%-5% TOPICAL LOTIONSULFACETAMIDE/SULFUR SULFACETAMIDE/SULFUR 10%-5% TOPICAL WASHSUPRAX CEFIXIME 100MG/5ML, 200MG/5ML SUSPENSIONSUPRAX CEFIXIME 400MG TABLETSUPREP ELECTROLYE LAVAGE SOLUTIONSWIMMERS EAR ISOPROPYL ALCOHOL/GLYCERIN 95%-5% OTIC SOLUTIONSYMMETREL AMANTADINE 100MG CAPSULE

Page 20: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMSYMMETREL AMANTADINE 50MG/5ML SYRUPSYNALAR FLUOCINOLONE 0.01% TOPICAL SOLUTIONSYNALAR FLUOCINOLONE 0.025% TOPICAL CREAMSYNTHROID LEVOTHYROXINE ALL STRENGTHS TABLETSYNVISC HYLAN G-F 20 16MG/2ML SYRINGESYNVISC-ONE HYLAN G-F 20 48MG/6ML SYRINGESYRINGE, 3 ML W/NEEDLE SYRINGE, 3 ML DEVICETAGAMET CIMETIDINE 300MG, 400MG,800MG TABLETTAMBOCOR FLECAINIDE 50MG, 100MG, 150MG TABLETTAMIFLU OSELTAMIVIR 30 MG, 45 MG, 75 MG CAPSULETAMIFLU OSELTAMIVIR 6 MG/ML SUSPENSIONTAPAZOLE METHIMAZOLE 5MG, 10MG TABLETTARKA TRANDOLAPRIL/VERAPAMIL 2MG/180MG, 2MG/240MG, 4MG/240MG TABLETTAZORAC TAZAROTENE 0.05% TOPICAL CREAMTAZORAC TAZAROTENE 0.1% TOPICAL GELTEGRETOL CARBAMAZEPINE 100MG/5ML SUSPENSIONTEGRETOL CARBAMAZEPINE 200MG TABLETTEGRETOL CARBAMAZEPINE 100MG CHEWABLE TABLETTEGRETOL XR CARBAMAZEPINE ER 100MG, 200MG, 400MG TABLETTEKTURNA ALISKIREN ALL STRENGTHS TABLETTEKTURNA HCT ALISKIREN/HYDROCHLOROTHIAZIDE ALL STRENGTHS TABLETTEMOVATE CLOBETASOL 0.05% TOPICAL CREAMTEMOVATE CLOBETASOL 0.05% TOPICAL OINTMENTTEMOVATE CLOBETASOL 0.05% TOPICAL SOLUTIONTENEX GUANFACINE 1MG, 2MG TABLETTENORMIN ATENOLOL 25MG, 50MG, 100MG TABLETTERAZOL 3 TERCONAZOLE 0.8% VAGINAL CREAMTESSALON PERLE BENZONATATE 100MG, 200MG CAPSULETESTIM TESTOSTERONE 1% TOPICAL GELTHEO-24 THEOPHYLLINE ALL STRENGTHS CAPSULETHEO-DUR THEOPHYLLINE 100 MG, 200 MG, 300 MG TABLETTHIAMINE THIAMINE 100 MG TABLETTHORAZINE CHLORPROMAZINE 25MG, 50MG, 100MG, 200MG TABLETTIAZAC DILTIAZEM ALL STRENGTHS CAPSULETIMOPTIC TIMOLOL 0.25%, 0.5% OPHTHALMIC SOLUTIONTIMOPTIC XE TIMOLOL 0.25%, 0.5% OPHTHALMIC GEL SOLUTIONTINDAMAX TINIDAZOLE 250 MG, 500 MG TABLETTIROSINT LEVOTHYROXINE ALL STRENGTHS CAPSULETOBRADEX TOBRAMYCIN/DEXAMETHASONE 0.3%-0.1% OPHTHALMIC OINTMENTTOBRADEX TOBRAMYCIN/DEXAMETHASONE 0.3%-0.1% OPHTHALMIC SUSPENSIONTOBREX TOBRAMYCIN 0.3% OPHTHALMIC OINTMENTTOBREX TOBRAMYCIN 0.3% OPHTHALMIC SOLUTIONTOFRANIL IMIPRAMINE 10MG, 25MG, 50MG TABLETTOPAMAX TOPIRAMATE 25 MG, 50 MG, 100 MG, 200 MG TABLET

Page 21: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMTOPAMAX SPRINKLES TOPIRAMATE 15 MG CAPSULETOPICORT DESOXIMETASONE 0.05%, 0.25% TOPICAL CREAMTOPICORT DESOXIMETASONE 0.05%, 0.25% TOPICAL OINTMENTTOPROL XL METOPROLOL SUCCINATE ALL STRENGTHS TABLETTORADOL KETOROLAC 10MG TABLETTRADJENTA LINAGLIPTIN 5MG TABLETTRANDATE LABETALOL 100MG, 200MG, 300MG TABLETTRANSDERM SCOP SCOPALAMINE 1.5MG TRANSDERMAL PATCHTRANXENE CLORAZEPATE 3.75MG, 7.5MG TABLETTRENTAL PENTOXIFYLLINE 400 MG TABLETTRIAMCINOLONE TRIAMCINOLONE 0.025%, 0.1%, TOPICAL OINTMENTTRIAMCINOLONE TRIAMCINOLONE 0.025%, 0.1%, 0.5% TOPICAL CREAMTRICOR FENOFIBRATE NANOCRYSTALLIZED 48MG, 145MG TABLETTRILEPTAL OXCARBAZEPINE 150 MG, 300 MG, 600 MG TABLETTRILEVLEN/TRIVORA LEVONORGESTREL/ETHINYL ESTRADIOL 50MCG-30MCG/75MCG-40MCG/125MCG-30MCG TABLETTRILIPIX FENOFIBRIC ACID 45MG, 135MG CAPSULETRI-PAK AZITHROMYCIN 500MG TABLETTRI-VI-SOL VITAMIN A, C, D DROPS 1,500 UNITS-35 MG-400 UNITS/ML DROPSTRUSOPT DORZOLAMIDE 2% OPHTHALMIC SOLUTIONT-STAT ERYTHROMYCIN 2% TOPICAL PADTUCKS GLYCERIN/WITCH HAZEL TOPICAL PADTUDORZA ACLIDINIUM 400MCG INHALATION POWDERTUSSIONEX HYDROCODONE/CHLORPHENIRAMINE 10 MG- 8 MG/5 ML SUSPENSIONTWYNSTA TELMISARTAN/AMLODIPINE 40-5MG, 40-10MG, 80-5MG, 80-10MG TABLETTYLENOL ACETAMINOPHEN 120MG SUPPOSITORYTYLENOL ACETAMINOPHEN 160MG/5ML SUSPENSIONTYLENOL ACETAMINOPHEN 325MG TABLETTYLENOL ACETAMINOPHEN 80MG CHEWABLE TABLETTYLENOL #3 ACETAMINOPHEN/CODEINE 300MG-30MG TABLETTYLENOL #4 ACETAMINOPHEN/CODEINE 300MG-60MG TABLETTYLENOL/CODEINE ACETAMINOPHEN/CODEINE 120MG-12.5MG/5ML ELIXIRULTRACET TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLETULTRAM TRAMADOL 50 MG TABLETULTRAVATE HALOBETASOL 0.05% TOPICAL OINTMENTUNIPHYL THEOPHYLLINE 400 MG, 600MG TABLETURAMAXIN UREA 45% TOPICAL CREAMURECHOLINE BETHANECHOL 10MG, 25MG TABLETUROCIT-K POTASSIUM CITRATE 5 mEq, 10 mEq, 15 mEq TABLETUROXATRAL ALFUZOSIN 10MG TABLETURSO URSODIOL 250MG TABLETURSO FORTE URSODIOL 500MG TABLETVAGIFEM ESTRADIOL 10MCG VAGINAL TABLETVALISONE BETAMETHASONE VALERATE 0.1% TOPICAL CREAMVALISONE BETAMETHASONE VALERATE 0.1% TOPICAL LOTION

Page 22: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMVALIUM DIAZEPAM 2MG, 5MG, 10MG TABLETVALIUM DIAZEPAM 5MG/5ML SOLUTIONVALTREX VALACYCLOVIR 500 MG, 1000 MG TABLETVANTIN CEFPODOXIME 100MG, 200MG TABLETVASERETIC ENALAPRIL/HYDROCHLOROTHIAZIDE 5-12.5MG, 10-25MG TABLETVASOTEC ENALAPRIL 2.5MG, 5MG, 10MG, 20MG TABLETVERIPRED PREDNISOLONE SODIUM PHOSPHATE 20 MG/5 ML SOLUTIONVESICARE SOLIFENACIN 5 MG, 10 MG TABLETVIAGRA SILDENAFIL 25 MG, 50 MG, 100 MG TABLETVIBRAMYCIN DOXYCYCLINE HYCLATE 50MG, 100MG CAPSULEVIBRAMYCIN DOXYCYCLINE HYCLATE 75MG, 100MG TABLETVICOPROFEN HYDROCODONE/IBUPROFEN 7.5-200MG TABLETVI-DAYLIN MULTIVITAMIN DROPSVI-DAYLIN PLUS IRON MULTIVITAMIN/IRON DROPSVIGAMOX MOXIFLOXACIN 0.5% OPHTHALMIC SOLUTIONVIROPTIC TRIFLURIDINE 1% OPHTHALMIC SOLUTIONVISTARIL HYDROXYZINE PAMOATE 25MG, 50MG CAPSULEVITAMIN B-12 CYANOCOBALAMIN 1,000MCG/ML INJECTIONVITAMIN B-12 CYANOCOBALAMIN 100MCG, 500MCG, 1000MCG TABLETVITAMIN B-3 NIACIN 500MG TABLETVITAMIN C ASCORBIC ACID 500MG TABLETVITAMIN D ERGOCALCIFEROL 50,000 UNITS CAPSULEVIVELLE-DOT ESTRADIOL ALL STRENGTHS TRANSDERMAL PATCHVOLTAREN DICLOFENAC 0.1% OPHTHALMIC SOLUTIONVOLTAREN DICLOFENAC SODIUM 1% TOPICAL GELVOLTAREN DICLOFENAC SODIUM 25MG, 50MG, 75MG TABLETVOLTAREN XR DICLOFENAC SODIUM 100MG TABLETVOSOL ACETIC ACID 2% OTIC SOLUTIONVOSOL HC ACETIC ACID/HYDROCORTISONE 2%/1% OTIC SOLUTIONVOSPIRE ALBUTEROL ER 4MG, 8MG TABLETWELLBUTRIN BUPROPION 75MG, 100MG TABLETWELLBUTRIN SR BUPROPION 100MG, 150MG, 200MG TABLETWELLBUTRIN XL BUPROPION 150MG, 300MG TABLETWESTCORT HYDROCORTISONE VALERATE 0.2% TOPICAL CREAMWESTCORT HYDROCORTISONE VALERATE 0.2% TOPICAL OINTMENTXALATAN LATANOPROST 0.005% OPHTHALMIC SOLUTIONXANAX ALPRAZOLAM 0.25MG, 0.5MG, 1MG TABLETXANAX XR ALPRAZOLAM ER 1MG, 2MG TABLETXARELTO RIVAROXABAN 10 MG, 15 MG, 20 MG TABLETXELODA CAPECITABINE 150MG, 500MG TABLETXOPENEX LEVALBUTEROL 0.31MG, 0.63MG,1.25MG INHALATION SOLUTIONXYLOCAINE LIDOCAINE 2% TOPICAL GELXYLOCAINE LIDOCAINE 5% TOPICAL OINTMENTYASMIN ETHINYL ESTRADIOL/DROSPIRENONE 0.03-0.03 TABLET

Page 23: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORMYAZ ETHINYL ESTRADIOL/DROSPIRENONE 0.02 MG-3 MG TABLETZANAFLEX TIZANIDINE 2 MG, 4 MG TABLETZANAFLEX TIZANIDINE 2 MG, 4 MG, 6MG CAPSULEZANTAC RANITIDINE 15 MG/ML SYRUPZANTAC RANITIDINE 150 MG, 300MG TABLETZARONTIN ETHOSUXIMIDE 250MG CAPSULEZARONTIN ETHOSUXIMIDE 250MG/5ML SYRUPZAROXOLYN METOLAZONE 2.5MG, 5MG, 10MG TABLETZEBETA BISOPROLOL 5MG, 10MG TABLETZEMPLAR PARICALCITOL 1 MG, 2MG, 4 MG CAPSULEZESTORETIC LISINOPRIL/HYDROCHLOROTHIAZIDE ALL STRENGTHS TABLETZESTRIL LISINOPRIL 2.5MG, 5MG, 10MG, 20MG, 30MG, 40MG TABLETZETIA EZETIMIBE 10MG TABLETZIAC BISOPROLOL/HYDROCHLOROTHIAZIDE 2.5MG-6.25MG, 5MG-6.25MG, 10MG-6.25MG TABLETZINC OXIDE ZINC OXIDE 20 % TOPICAL OINTMENTZINCATE ZINC SULFATE 220 MG CAPSULEZIRGAN GANCICLOVIR 0.15% OPHTHALMIC GELZITHROMAX AZITHROMYCIN 1GM/PACKET POWDERZITHROMAX AZITHROMYCIN 200MG/5ML SUSPENSIONZITHROMAX AZITHROMYCIN 250MG, 500MG TABLETZOCOR SIMVASTATIN ALL STRENGTHS TABLETZOFRAN ONDANSETRON 4MG, 8MG TABLETZOFRAN ONDANSETRON 4MG/5ML SOLUTIONZOFRAN ODT ONDANSETRON 4MG, 8MG SUBLINGUAL TABLETZOLOFT SERTRALINE 20 MG/ML SOLUTIONZOLOFT SERTRALINE 25 MG, 50 MG, 100 MG TABLETZOMIG ZOLMITRIPTAN 2.5 MG, 5 MG TABLETZOMIG ZOLMITRIPTAN 5 MG NASAL SPRAYZOMIG ZMT ZOLMITRIPTAN 2.5 MG, 5 MG SUBLINGUAL TABLETZONEGRAN ZONISAMIDE 25MG, 50MG, 100MG CAPSULEZOVIA/DEMULEN ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL 1 MG-35 MCG, 1 MG- 50 MCG TABLETZOVIRAX ACYCLOVIR 5% TOPICAL CREAMZOVIRAX ACYCLOVIR 5% TOPICAL OINTMENTZOVIRAX ACYCLOVIR 200MG CAPSULEZOVIRAX ACYCLOVIR 200MG/5ML SUSPENSIONZOVIRAX ACYCLOVIR 400MG, 800MG TABLETZ-PAK AZITHROMYCIN 250MG TABLETZYLOPRIM ALLOPURINOL 100MG, 300MG TABLETZYPREXA OLANZAPINE ALL STRENGTHS TABLETZYRTEC CETIRIZINE 10MG TABLETZYRTEC CETIRIZINE 1MG/ML SOLUTIONZYRTEC-D CETIRIZINE/PSEUDOEPHEDRINE 5MG-120MG TABLETZYVOX LINEZOLID 600MG TABLET

Page 24: NHCCC FORMULARY REV 01-20 - TRICARE · 2020. 8. 31. · Z E ' E Z/ ^dZ E'd, K^ ' &KZD s >/ /Z ^ Zd E l,z ZK ,>KZKd,/ / í ñ ì r í î X ñD' U ï ì ì r í î X ñD'd > d s WZK

BRAND GENERIC STRENGTH DOSAGE FORM

PRENATAL PLUS PRENATAL VITAMIN TABLETPRENATAL PLUS LOW IRON PRENATAL VITAMIN TABLETPREPLUS TABLET PRENATAL VITAMIN TABLET

RESTRICTED TO FEMALES UNDER 45 YEARS OF AGE