Naval Hospital Jacksonville Formulary Alphabetical Listing ...

1 1 Alphabetical Listing by NameNaval Hospital Jacksonville Formulary Updated Sept. 27, 2021 The availability of Formulary items is subject to changeAcamprosateOutpatientDosageFormsTa bletDelayedRelease,Oral,ascalcium:Generi c:333mgAcarboseOutpatientDosageFormsTabl et,Oral:Generic:25mg,50mg,100mgAcetamino phenOutpatientDosageFormsSuppository, Rectal:Generic:120mg,650mgSuspension,Ora l:Generic:160mg/5mLTablet,Oral:Generic:3 25mgAcetaminophenand CodeineOutpatientDosageFormsSolution,Ora l[C-V]:Generic:Acetaminophen120mgandcode inephosphate12mgper5 mLTablet,Oral[C-III]:Generic:Acetaminoph en300mgandcodeinephosphate30mgAcetaminop henand TramadolOutpatientDosageFormsTablet,Oral : :Maximum:30tabletsin22daysor90tabletsin 68daysAcetaZOLAMIDEO utpatientDosageFormsCapsuleExtendedRelea se12 Hour, Oral:Generic:500mgTablet,Oral:Generic:12 5mg,250mgAceticAcid (Otic)OutpatientDosageFormsSolution,Otic :Generic:2%AcitretinOutpatientDosageForm sCapsule,Oral:Generic:10mg,25mgAcyclovir (Systemic)OutpatientDosageFormsCapsule,O ral:Generic.

2 200mgSuspension,Oral:Generic:200mg/5mLTa blet,Oral:Generic:400mg,800mgAcyclovir(T opical)OutpatientDosageFormsOintment,Ext ernal:Generic:5%QuantityLimits-Adalimuma bOutpatientDosageFormsPen-injectorKit,Su bcutaneous[preservativefree]:HumiraPen:4 0 ;40 [containspolysorbate80]HumiraPen:80 (1ea)[citratefree]HumiraPen-CD/UC/HSStar ter:40 ;80 [containspoly-sorbate80]HumiraPen-Ps/UV/ AdolHSStart:40 ;80 40 [containspolysorbate80]PrefilledSyringeK it,Subcutaneous[preservativefree]:Humira :10 ;20 ;40 ;10 ;20 ;40 [containspolysorbate80]HumiraPediatricCr ohnsStart:40 ;80 ;80 [containspolysorbate80]FormularyComments Humira:PriorAuthorizationRequiredAlbenda zoleOutpatientDosageFormsTablet,Oral:Alb enza:200mg[containssaccharinsodium]Albut erolOutpatientDosageFormsAerosolSolution ,Inhalation[CFCfree]:ProAirHFA:90mcg/act uationNebulizationSolution,Inhalation[pr eservativefree]: [ ] ; (Isopropyl)OutpatientDosageFormsPad,Exte rnal:Generic:70%AlendronateOutpatientDos ageFormsSolution,Oral:Generic:70mg/75mLT ablet,Oral:Generic:5 mg,10mg,35mg,70mgAlfuzosinOutpatientDosa geFormsTabletExtendedRelease24 Hour, Oral,ashydrochloride:Generic:10mgAllopur inolOutpatientDosageFormsTablet,Oral,ass odium:Generic:100mg,300mgALPRAZ olamOutpatientDosageFormsTablet,Oral: , ,1 mgAlprostadilOutpatientDosageFormsKit,In tracavernosal:Edex:10mcg,20mcg,40mcgForm ularyCommentsMuse:LimitedtoNHJaxEnrollee sonlyQuantityLimitsEdexKit (PS 2):Maximum:3 unitsin23daysor9 unitsin68days.

3 (PS 6)Maximum:1 unitin23daysor3 unitsin68daysAluminumAcetateOutpatientDo sageFormsPowder, forSolution,External:Generic:Aluminumsul fate1191mgandcalciumacetate839mgperpacke tGeneric:Aluminumsulfatetetradecahydrate 1347mgandcalciumacetatemonohydrate952mgp erpacketAluminumChlorideHexahydrateOutpa tientDosageFormsSolution,External:Drysol :20%AluminumHydroxideOutpatientDosageFor msSuspension,Oral:Generic:320mg/5mLAlumi numHydroxideand MagnesiumTrisilicateOutpatientDosageForm sTablet,Chewable,Oral:Aluminumhydroxide8 0mgandmagnesiumtrisilicate20mgAmantadine OutpatientDosageFormsCapsule,Oral,ashydr ochloride:Generic:100mgSyrup,Oral,ashydr ochloride:Generic:50mg/5mLAminocaproicAc idOutpatientDosageFormsTablet,Oral:Gener ic:500mgAmiodaroneOutpatientDosageFormsT ablet,Oral,ashydrochloride:Generic:200mg AmitriptylineOutpatientDosageFormsTablet ,Oral,ashydrochloride:Generic:10mg,25mg, 50mg,75mgACAMPROSATE2 Amitriptylineand PerphenazineOutpatientDosageFormsTablet, Oral:Generic:Amitriptylinehydrochloride2 5mgandperphenazine2 mgGeneric:Amitriptylinehydrochloride25mg andperphenazine4 mgAmLODIPineOutpatientDosageFormsTablet, Oral: ,5 mg,10mgAmlodipineand BenazeprilOutpatientDosageFormsCapsule,O ral: :5/10:Amlodipine5 mgandbenazeprilhydrochloride10mgGeneric: 5/20:Amlodipine5 mgandbenazeprilhydrochloride20mgGeneric: 5/40:Amlodipine5 mgandbenazeprilhydrochloride40mgGeneric: 10/20:Amlodipine10mgandbenazeprilhydroch loride20mgGeneric:10/40:Amlodipine10mgan dbenazeprilhydrochloride40mgAmoxapineOut patientDosageFormsTablet,Oral:Generic:50 mgAmoxicillinOutpatientDosageFormsCapsul e,Oral:Generic:250mg,500mgSuspensionReco nstituted,Oral:Generic:125mg/5mL;250mg/5 mL;400mg/5mLTabletChewable,Oral:Generic: 125mg,250mgAmoxicillinand ClavulanateOutpatientDosageFormsPowderfo rSuspension,Oral:Augmentin:125 mL[.]

4 Bananaflavor]Generic:200 mLGeneric:250 mLGeneric:400:Amoxicillin400mgandclavula natepotassium57mgper5 mLGeneric:600 mLTablet,Oral:Generic:250:Amoxicillin250 mgandclavulanatepotassium125mgGeneric:50 0:Amoxicillin500mgandclavulanatepotassiu m125mgGeneric:875:Amoxicillin875mgandcla vulanatepotassium125mgTablet,ExtendedRel ease,Oral: ,Oral:Generic:250mg,500mgAnastrozoleOutp atientDosageFormsTablet,Oral:Generic:1 mgApixabanOutpatientDosageFormsTablet,Or al: ,5 mgEliquisStarterPack:5 mgQuantityLimitsEliquisdosepack:Maximum: 74tablets(1pack)perdispensingatretailorm ailARIP iprazoleOutpatientDosageFormsTablet,Oral :Generic:2 mg,5 mg,10mg,15mg,20mg,30mgArtificialTearsOut patientDosageFormsOintment, ,Ophthalmic:LiquifilmTearsAspirinOutpati entDosageFormsTablet,Oral:Generic:325mgT ablet,DelayedRelease,Oral:Generic:81mg,3 25mgAtenololOutpatientDosageFormsTablet, Oral:Generic:25mg,50mg,100mgAtoMOXetineO utpatientDosageFormsCapsule,Oral:Stratte ra:10mg,18mg,25mg,40mg,60mg,80mg,100mgAt orvaSTATinOutpatientDosageFormsTablet,Or al:Generic:10mg,20mg,40mg,80mgAtropine(O phthalmic)OutpatientDosageFormsOintment, Ophthalmic,assulfate:Generic:1%Solution, Ophthalmic,assulfate:Generic:1%AzaTHIO prineOutpatientDosageFormsTablet,Oral:Ge neric:50mgAzelaicAcidOutpatientDosageFor msGel,External:Finacea:15%[containsbenzo icacid,disodiumedta,polysorbate80,propy- leneglycol]Azelastine(Nasal)OutpatientDo sageFormsSolution,Nasal,ashydrochloride: Generic:137mcg/sprayQuantityLimits-Azith romycin(Systemic)OutpatientDosageFormsPa cket,Oral,asdihydrate[strengthexpresseda sbase]:Generic:1 gSuspensionReconstituted,Oral[strengthex pressedasbase]:Generic:100mg/5mL.

5 200mg/5mLTablet,Oral:Generic:250mg,500mg Bacitracin,Neomycin,and PolymyxinB (Ophthalmic)OutpatientDosageFormsOintmen t,Ophthalmic:Generic:Bacitracin400units, ,andpolymyxinB 10,000unitspergBacitracin(Topical)Outpat ientDosageFormsOintment,External,aszinc[ strengthexpressedasbase]:Generic:500unit s/g(14g)BaclofenOutpatientDosageFormsTab let,Oral:Generic:10mg,20mgBelladonnaand OpiumOutpatientDosageFormsSuppository, Rectal: ,Oral,ashydrochloride:Generic:5 mg,10mg,20mg,40mgBenzocaineand MentholOutpatientDosageFormsLozenge,Mout h/Throat: ,Oral:Generic:100mgBENZONATATE3 BenzoylPeroxideOutpatientDosageFormsGel, External:Generic:5%;10%Liquid,External[w ash]:Generic:5%,10%BenztropineOutpatient DosageFormsTablet,Oral,asmesylate: ,1 mg,2 mgBetamethasone(Topical)OutpatientDosage FormsCream,External,asdipropionate[stren gthexpressedasbase]: ,External,asdipropionate[strengthexpress edasbase]: ,External,asdipropionate[strengthexpress edasbase]: ,External,asdipropionateaugmented[streng thexpressedasbase]: (Ophthalmic)OutpatientDosageFormsSuspens ion,Ophthalmic:Betoptic- ,Oral,aschloride:Generic:10mg,25mgBicalu tamideOutpatientDosageFormsTablet,Oral:C asodex:50mgGeneric:50mgBimatoprostOutpat ientDosageFormsSolution,Ophthalmic: , Rectal:Generic:10mgTabletDelayedRelease, Oral:Generic:5 mgBismuthSubcitrate,Metronidazole,and TetracyclineOutpatientDosageFormsCapsule ,Oral:Pylera:Bismuthsubcitratepotassium1 40mg,metronidazole125mg,andtetracyclineh ydrochloride125mgBismuthSubsalicylateOut patientDosageFormsTablet,Chewable,Oral:G eneric.

6 262mgBrimonidineand TimololOutpatientDosageFormsSolution,Oph thalmic: [containsbenzalko-niumchloride]Brimonidi ne(Ophthalmic)OutpatientDosageFormsSolut ion,Ophthalmic,astartrate: ; ,Oral: (Oral Inhalation)OutpatientDosageFormsSuspensi on,Inhalation: ; ;1 mg/2mLQuantityLimits-Budesonide(Systemic )OutpatientDosageFormsCapsuleDelayedRele aseParticles,Oral:Generic:3 mgBumetanideOutpatientDosageFormsTablet, Oral:Generic:1 mg,2 mgBuPROPionOutpatientDosageFormsTablet,O ral,ashydrochloride:Generic:75mg,100mgTa bletExtendedRelease12 Hour, Oral,ashydrochloride:Generic:100mg,150mg ,200mgTabletExtendedRelease24 Hour, Oral,ashydrochloride:Generic:150mg,300mg BusPIRoneOutpatientDosageFormsTablet,Ora l,ashydrochloride:Generic:5 mg,10mg,15mgBusulfanOutpatientDosageForm sTablet,Oral:Myleran:2 mgButalbital,Acetaminophen,and CaffeineOutpatientDosageFormsTablet,Oral :Generic:Butalbital50mg,acetaminophen325 mg,andcaffeine40mgCabergolineOutpatientD osageFormsTablet,Oral: ,External: ,External: ,External: ,Nasal:Fortical:200units/actuationCalcit riol(Systemic)OutpatientDosageFormsCapsu le,Oral: , ,Oral:Generic:1 mcg/mLCalciumAcetateOutpatientDosageForm sCapsule,Oral:Generic.

7 667mgCalciumand VitaminDOutpatientDosageFormsTablet,Oral :Generic:Calcium500mgandvitaminD 200unitsCalciumCarbonateOutpatientDosage FormsTablet,Oral:Generic:500mgCandesarta nOutpatientDosageFormsTablet,Oral,ascile xetil:Generic:4 mg,8 mg,16mg,32mgCapsaicinOutpatientDosageFor msCream,External: ,Oral: ,25mg,50mg,100mgBENZOYLPEROXIDE4 CarBAMazepineOutpatientDosageFormsCapsul eExtendedRelease12 Hour, Oral:Generic:100mg,300mgSuspension,Oral: Generic:100mg/5mLTablet,Oral:Generic:200 mgTablet,Chewable,Oral:Generic:100mgTabl etExtendedRelease12 Hour, Oral:Generic:100mg,200mg,400mgCarbidopaa nd LevodopaOutpatientDosageFormsTablet,Oral :Generic:10/100:Carbidopa10mgandlevodopa 100mg[scored]Generic:25/100:Carbidopa25m gandlevodopa100mg[scored]Generic:25/250: Carbidopa25mgandlevodopa250mg[scored]Tab letExtendedRelease,Oral:Generic:Carbidop a25mgandlevodopa100mgGeneric:Carbidopa50 mgandlevodopa200mgCarboxymethylcellulose OutpatientDosageFormsSolution,Ophthalmic ,assodium: :1%CarisoprodolOutpatientDosageFormsTabl et,Oral:Generic:350mgCarvedilolOutpatien tDosageFormsCapsuleExtendedRelease24 Hour, Oral,asphosphate:Generic:10mg,20mg,40mg, 80mgTablet,Oral: , , ,25mgCefdinirOutpatientDosageFormsCapsul e,Oral:Generic:300mgSuspensionReconstitu ted,Oral:Generic:125mg/5mL,250mg/5mLCefi ximeOutpatientDosageFormsSuspensionRecon stituted,Oral:Generic:100mg/5mL(50mL);20 0mg/5mL(50mL,75mL)TabletChewable,Oral:Su prax:200mgCefpodoximeOutpatientDosageFor msSuspensionReconstituted,Oral:Generic:1 00mg/5mL(50mL,100mL)Tablet,Oral:Generic: 100mg,200mgCefprozilOutpatientDosageForm sSuspensionReconstituted,Oral:Generic:12 5mg/5mL.

8 250mg/5mLCefuroximeOutpatientDosageForms Tablet,Oral,asaxetil[strengthexpressedas base]:Generic:250mg,500mgCelecoxibOutpat ientDosageFormsCapsule,Oral:CeleBREX:100 mg,200mgGeneric:50mgCephalexinOutpatient DosageFormsCapsule,Oral:Generic:250mg,50 0mgSuspensionReconstituted,Oral:Generic: 125mg/5mL,250mg/5mLCetirizine(Systemic)O utpatientDosageFormsSyrup,Oral,ashydroch loride:Generic:1 mg/mLTablet,Oral,ashydrochloride:Generic :5 mg,10mgChlorambucilOutpatientDosageForms Tablet,Oral:Leukeran:2 mgChlordiazePOXIDEO utpatientDosageFormsCapsule,Oral,ashydro chloride:Generic:5 mg,10mg,25mgChlorhexidineGluconate(Oral) OutpatientDosageFormsSolution,Mouth/Thro at: ,Oral,asphosphate:Generic:250mg[equivale ntto chloroquinebase150mg],500mg[equivalentto chloroquinebase300mg]ChlorpheniramineOut patientDosageFormsTablet,Oral,asmaleate: Generic:4 mgChlorproMAZINEO utpatientDosageFormsTablet,Oral,ashydroc hloride:Generic:25mg,50mg,100mgChlorthal idoneOutpatientDosageFormsTablet,Oral:Ge neric:25mg,50mgChlorzoxazoneOutpatientDo sageFormsTablet,Oral:Generic:500mgCholec alciferolOutpatientDosageFormsLiquid,Ora l:Generic:400units/mLTablet,Oral:Generic :400units,1000unitsCholestyramineResinOu tpatientDosageFormsPowder, Oral:Generic:4 g/doseChorionicGonadotropin(Human)Outpat ientDosageFormsSolutionReconstituted,Int ramuscular:Generic:10,000unitsCiclopirox OutpatientDosageFormsSolution,External:G eneric:8%CilostazolOutpatientDosageForms Tablet,Oral:Generic:50mg,100mgCimetidine OutpatientDosageFormsSolution,Oral,ashyd rochloride[strengthexpressedasbase]:Gene ric:300mg/5mLTablet,Oral:Generic:400mgCi profloxacinand DexamethasoneOutpatientDosageFormsSuspen sion,Otic: [containsbenzalko-niumchloride,edetatedi sodium,tyloxapol]Ciprofloxacin(Ophthalmi c)OutpatientDosageFormsSolution,Ophthalm ic,ashydrochloride.

9 ( ,5 mL,10mL)CIPROFLOXACIN(OPHTHALMIC)5 Ciprofloxacin(Systemic)OutpatientDosageF ormsTablet,Oral,ashydrochloride[strength expressedasbase]:Generic:100mg,250mg,500 mg,750mgCitalopramOutpatientDosageFormsS olution,Oral:Generic:10mg/5mLTablet,Oral :Generic:10mg,20mg,40mgClarithromycinOut patientDosageFormsTablet,Oral:Generic:25 0mg,500mgTabletExtendedRelease24 Hour, Oral:Generic:500mgClindamycinand BenzoylPeroxideOutpatientDosageFormsGel, External: (Systemic)OutpatientDosageFormsCapsule,O ral,ashydrochloride[strengthexpressedasb ase]:Generic:150mg,300mgSolutionReconsti tuted,Oral,aspalmitatehydrochloride[stre ngthexpressedasbase]:Generic:75mg/5mLCli ndamycin(Topical)OutpatientDosageFormsCr eam,Vaginal,asphosphate[strengthexpresse dasbase]:Generic:2%Gel,External,asphosph ate[strengthexpressedasbase]:Generic:1%L otion,External,asphosphate[strengthexpre ssedasbase]:Generic:1%Solution,External, asphosphate[strengthexpressedasbase]:Gen eric:1%Swab,External,asphosphate[strengt hexpressedasbase]:Generic:1%ClobetasolOu tpatientDosageFormsCream,External,asprop ionate: [BCF]Foam,External,aspropionate: ,External,aspropionate: (59mL,118mL)Ointment,External,aspropiona te: [BCF]QuantityLimits-ClomiPHENEO utpatientDosageFormsTablet,Oral,ascitrat e:Generic:50mgClomiPRAMINEO utpatientDosageFormsCapsule,Oral,ashydro chloride:Generic:25g,50mgClonazePAMO utpatientDosageFormsTablet,Oral: ,1 mgCloNIDineOutpatientDosageFormsPatchWee kly, Transdermal.

10 ,Oral,ashydrochloride: , , , Oral,ashydrochloride: ,Oral:Generic:75mgClorazepateOutpatientD osageFormsTablet,Oral,asdipotassium: (Oral)OutpatientDosageFormsLozenge,Mouth /Throat:Generic:10mgClotrimazole(Topical )OutpatientDosageFormsCream,External:Gen eric:1%Cream,Vaginal:Generic:1%Solution, External:Generic:1%ColchicineOutpatientD osageFormsTablet,Oral: [scored]ColestipolOutpatientDosageFormsT ablet,Oral,ashydrochloride:Generic:1 gContraceptiveDevicesOutpatientDosageFor msDiaphragm,Vaginal:Generic:Varioussizes QuantityLimitsDoDsingledoseMeds>30daysCo rtisoneOutpatientDosageFormsTablet,Oral, asacetate:Generic:25mgCromolyn(Nasal)Out patientDosageFormsAerosolSolution,Nasal, assodium: (OralInhalation)OutpatientDosageFormsNeb ulizationSolution,Inhalation,assodium:Ge neric:20mg/2mLQuantityLimits-Cyanocobala minOutpatient