36C25819R0003-019.pdf

VA Phoenix/CVS Minute Clinics/TriWest Medication Formulary

GENERIC PRODUCT DESCRIPTION OTC STATUS CONDITION ON LIST

ACETAMINOPHEN 325 MG TAB OTC YES

ACETAMINOPHEN 500 MG TAB OTC YES

ACYCLOVIR 200 MG CAP YES

ACYCLOVIR 400 MG TAB YES

ACYCLOVIR 800 MG TAB YES

ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90 MCG BASE EQUIV) YES

ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3 ML) YES

ALOH/MGOH/SIMETH EXTRA STRENGTH SUSP OTC YES

AMOXICILLIN & K CLAVULANATE 500-125 MG TAB YES

AMOXICILLIN & K CLAVULANATE 875-125 MG TAB YES

AMOXICILLIN (TRIHYDRATE) 250 MG CAP YES

AMOXICILLIN (TRIHYDRATE) 500 MG CAP YES

AZITHROMYCIN 250 MG TAB YES

BACITRACIN-POLYMYXIN B OPHTH OINT YES

BACITRACIN-POLYMYXIN B TOPICAL OINT OTC YES

CARBAMIDE PEROXIDE/GLYCERIN OTIC SOLUTION OTC YES

CEPHALEXIN 250 MG CAP YES

CEPHALEXIN 500 MG CAP YES

CHLORPHENIRAMINE 4 MG TAB OTC YES

CIPROFLOXACIN 250 MG TAB YES

CIPROFLOXACIN 500 MG TAB YES

CLINDAMYCIN HCL 150 MG CAP YES

CLOTRIMAZOLE 1% CREAM YES

COLCHICINE 0.6 MG TAB RESTRICTED TO NMT #10 QUANTITY YES

CYCLOBENZAPRINE 10 MG TAB YES

DEXAMETHASONE NA PHOS/NEOMYCIN OPHTH SUSP YES

DICLOXACILLIN 250 MG CAP YES

DICLOXACILLIN 500 MG CAP YES

DIPHENHYDRAMINE HCL 25 MG CAP OTC YES

DIPHENHYDRAMINE HCL 50 MG CAP YES

DOXYCYCLINE HYCLATE 100 MG CAP YES

EPINEPHRINE 0.3ML AUTO-INJECTOR YES

ERYTHROMYCIN OPHTH OINT 5 MG/GM YES

ERYTHROMYCIN STEARATE 250 MG TAB YES

FLUTICASONE 50MCG/SPRAY 120D NASAL INHL SPRAY YES

GUAIFENESIN DM LIQUID 100 MG/5 ML (may prescribe sugar free) YES

GUAIFENESIN LIQUID 100 MG/5 ML (may prescribe sugar free) YES

HYDROCORTISONE 1% CREAM OTC YES

HYDROCORTISONE 2.5% CREAM YES

IBUPROFEN 200 MG TAB OTC YES

IBUPROFEN 400 MG TAB YES

IBUPROFEN 800 MG TAB YES

INDOMETHACIN 25 MG CAP YES

INDOMETHACIN 50 MG CAP YES

IPRATROPIUM-ALBUTEROL INHAL SOLN 20-100 MCG/ACT (COMBIVENT RESPIMAT) YES

LIDOCAINE 2% VISCOUS ORAL SOLN 100 ML YES

Version date: 4/18/17

VA Phoenix/CVS Minute Clinics/TriWest Medication Formulary

LOPERAMIDE 2 MG TAB OTC YES

LORATADINE 10 MG TAB OTC YES

METHYLPREDNISOLONE 4 MG TAB (1 DOSE PAK) YES

METRONIDAZOLE 250 MG TAB YES

METRONIDAZOLE 500 MG TAB YES

MILK OF MAGNESIA ORAL SUSP OTC YES

NAPROXEN 250 MG TAB OTC YES

NAPROXEN 375 MG TAB YES

NAPROXEN 500 MG TAB YES

NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1% YES

NITROFURANTOIN MONOHYDRATE (MACROBID) YES

NYSTATIN 100,000 UNITS/ML ORAL SUSP 60 ML SIZE MAX YES

OFLOXACIN 0.3% OPH SOLN YES

OMEPRAZOLE DELAYED RELEASE CAP 20 MG OTC YES

OSELTAMIVIR 75 MG CAP YES

PENICILLIN V POTASSIUM 250 MG TAB YES

PENICILLIN V POTASSIUM 500 MG TAB YES

PHENAZOPYRIDINE 100 MG TAB YES

PREDNISONE 1 MG TAB YES

PREDNISONE 10 MG TAB YES

PREDNISONE 2.5 MG TAB YES

PREDNISONE 20 MG TAB YES

PREDNISONE 5 MG TAB YES

PSEUDOEPHEDRINE HCL 30 MG TAB OTC YES

RANITIDINE 150 MG TAB OTC YES

SENNOSIDES 8.6 MG TAB OTC YES

SILVER SULFADIAZINE CREAM 1% 50GM YES

SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG TAB YES

SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG TAB YES

SUMATRIPTAN - 25mg, 50mg, 100mg w/ quantity limit of two tabs / MDD = 200mg YES

TRIAMCINOLONE ACETONIDE CREAM 0.1% 15GM SIZE ONLY YES

WELLNESS VACCINATIONS (If clinically indicated): YES

HAEMOPHILUS B CONJUGATE VACCINE (HIBERIX) - Hib YES

HEPATITIS A VACCINE (HAVRIX, VAQTA) YES

HEPATITIS B VACCINE (ENGERIX-B, RECOMBIVAX-HB) YES

HEPATITIS A/HEPATITIS B RECOMB INJ (TWINRIX) YES

INFLUENZA VACCINE, INJ YES

MEASLES, MUMPS AND RUBELLA (M-M-R II SINGLE DOSE VACCINE) – MMR YES

MENINGOCOCCAL VACCINE (MENACTRA, MENOMUNE) YES

PNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE (PREVNAR 13) YES

PNEUMOCOCCAL 23-VALENT POLYSACC VACCINE (PNEUMOVAX) YES

TETANUS/DIPHTH. 0.5ML SYR (TENIVAC) - Td YES

TET/DIPHTH/PERTUS (ADACEL, BOOSTRIX) - Tdap YES

VARICELLA VIRUS VACCINE LIVE (VARIVAX) - Chicken Pox YES

ZOSTER VACCINE LIVE (OKA/MERCK) INJ (ZOSTAVAX) - Shingles YES

Version date: 4/18/17