S02 - Attachment 18 Prescription Formulary CBOC attachment.pdf

VA BHHCS Restricted Formulary Listing

ACETAMINOPHEN W/ CODEINE TAB 300-30 MG

ACYCLOVIR TAB 400 MG

ACYCLOVIR TAB 800 MG

ALBUTEROL INHAL AEROSOL 90 MCG/ACT

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

albuterol/atrovent (DUONEB)

ALPRAZOLAM TAB 0.5 MG

ALPRAZOLAM TAB 1 MG

AMLODIPINE TAB 10 MG

AMOXICILLIN & K CLAVULANATE TAB 500-125 MG

AMOXICILLIN & K CLAVULANATE TAB 875-125 MG

AMOXICILLIN (TRIHYDRATE) CAP 500 MG

ATENOLOL TAB 100 MG

ATENOLOL TAB 50 MG

AZITHROMYCIN TAB 250 MG

CARBAMAZEPINE TAB 200 MG

CARVEDILOL TAB 6.25 MG

CARVEDILOL TAB 25 MG

CEFUROXINE 250MG

CEFUROXINE 500MG

CEPHALEXIN CAP 500 MG

CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)

CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)

CLINDAMYCIN HCL CAP 150 MG

CLONIDINE HCL TAB 0.1 MG

COLCHICINE TAB 0.6 MG (Restricted to #3 tabs)

CYCLOBENZAPRINE HCL TAB 10 MG

DIAZEPAM TAB 10 MG (Restricted to patients ≤75) DIAZEPAM TAB 5 MG (Restricted to patients ≤75)

DICLOXACILLIN SODIUM CAP 250 MG

DIGOXIN TAB 0.125 MG

DIGOXIN TAB 0.25 MG

DILTIAZEM HCL COATED BEADS CAP SR 24HR 120 MG

DILTIAZEM HCL COATED BEADS CAP SR 24HR 180 MG

DIPHENOXYLATE/ATROPINE TAB 2.5 MG/0.025 MG

DIPHENHYDRAMINE HCL CAP 50 MG

DIVALPROEX SODIUM TAB SR 24 HR 250 MG

DOXAZOSIN MESYLATE TAB 2 MG

DOXYCYCLINE HYCLATE CAP 100 MG

ERYTHROMYCIN TAB 250 MG

ETODOLAC TAB 400 MG

FLUNISOLIDE NASAL SOLN 0.025%

FLUOXETINE 20MG

FORMOTEROL INHALER

FUROSEMIDE TAB 20 MG

FUROSEMIDE TAB 40 MG

GENTAMICIN SULFATE OPTH SOLUTION

GLIPIZIDE TAB 5 MG

GOLYTELY BOWEL PREP

GUAIFENESIN/CODEINE SOLUTION 100/10 MG / 5 ML

HYDROCHLOROTHIAZIDE TAB 25 MG

HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG

HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG

IBUPROFEN TAB 400 MG

IBUPROFEN TAB 800 MG

INSULIN DETEMIR 100 UNIT/ML

INSULIN NPH INJ 100 UNIT/ML

INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML

ISOSORBIDE MONONITRATE TAB 10 MG

ISOSORBIDE MONONITRATE TAB 30 MG

ISOSORBIDE MONONITRATE TAB 60 MG

LEVONORGESTREL PLAN B

LINDANE SHAMPOO 1%

LISINOPRIL TAB 5 MG

LISINOPRIL TAB 10 MG

LISINOPRIL TAB 20 MG

LITHIUM CARBONATE CAP 150 MG

LOPERAMIDE HCL CAP 2 MG

LORAZEPAM TAB 0.5 MG

LORAZEPAM TAB 1 MG

METFORMIN HCL TAB 500 MG

METHADONE TAB 5 MG

METOCLOPRAMIDE TAB 10 MG

METOPROLOL TARTRATE TAB 100 MG

METOPROLOL TARTRATE TAB 50 MG

METRONIDAZOLE TAB 250 MG

METRONIDAZOLE TAB 500 MG

MOMETASONE ORAL INHALER 220 MCG

MORPHINE SULFATE IR TAB 15 MG

MORPHINE SULFATE SR TAB 30 MG

NAPROXEN TAB 375 MG

NAPROXEN TAB 500 MG

NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1%

NITROGLYCERIN SL TAB 0.4 MG

OMEPRAZOLE CAP DELAYED RELEASE 20 MG

ONDANSETRON TAB 4 MG

OSELTAMIVIR 75 MG

OXYBUTYNIN CHLORIDE TAB 5 MG

OXYCODONE IR TAB 5 MG

OXYCODONE/ACETAMINOPHEN TAB 5/325 MG

PENICILLIN VK 500 MG

PERMETHRIN CREAM 5%

PHENAZOPYRIDINE HCL TAB 200 MG

PHENYTOIN SODIUM EXTENDED CAP 100 MG

PHYTADIONE TAB 5 MG

POTASSIUM CHLORIDE TAB CR 8 MEQ (600 MG)

POTASSIUM CHLORIDE TAB CR 10 MEQ

PREDNISONE TAB 5 MG

PROMETHAZINE HCL SUPPOS 25 MG

PROMETHAZINE HCL TAB 25 MG

QUETIAPINE 50MG

QUETIAPINE 100MG

QUETIAPINE 200MG

QUETIAPINE 300MG

RANITIDINE HCL TAB 150 MG

RISPERIDONE TAB 1 MG

RISPERIDONE TAB 4 MG

SERTRALINE HCL TAB 100 MG

SILVER SULFADIAZINE

SULFACETAMIDE SODIUM OPHTH SOLN 10%

SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG

TERAZOSIN CAP 1 MG

TRAMADOL HCL TAB 50 MG

VERAPAMIL HCL TAB CR 120 MG

VERAPAMIL HCL TAB CR 180 MG

VERAPAMIL HCL TAB CR 240 MG

4.13