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June 10, 2022, 04:49 EDT

Chapter 9: Pharmacy Appendix E: DMAS 90 DAY SUPPLY LIST

Updated: 6/10/2022

ADHD AGENTS

Atomoxetine

Clonidine ER

Guanfacine ER

ANTIBIOTICS-ANTI-INFECTIVES

Sulfonamide-Antibiotics

Sulfamethoxazole- trimethoprim susp

Sulfamethoxazole/trimethoprim SS tab

Sulfamethoxazole- trimethoprim DS tab

Azole-Antifungals

Fluconazole 50, 100, 150, 200 mg tab

Fluconazole 10 mg/ml 40 mg/ml susp

Griseofulvin 125 mg/5 ml susp

Nystatin 100,000 unit/ml susp

Nystatin 500,000-unit oral tab

Terbinafine 250 mg tab

ANTIVIRALS

Herpes Oral

Acyclovir 200 mg cap

Acyclovir 200 mg/5 ml susp

Acyclovir 400, 800 mg tab

Famciclovir 125, 250, 500 mg tab

Valacyclovir 500 mg, 1 gram tab

HIV Oral

All Preferred Agents

BLOOD MODIFIERS

Bile Salts

Ursodiol

Phosphate Binders

Calcium Acetate 667mg cap

Sevelamer carbonate tab

BONE RESORPTION SUPPRESSION

Bisphosphonates

Alendronate 5, 10, 35, 70 mg tab

Ibandronate

Calcitonins

Calcitonin-salmon nasal spray

Others

Raloxifene

CARDIAC AGENTS

ACE Inhibitors

Benazepril 5, 10,20, 40 mg

Enalapril 2.5, 5, 10, 20 mg

Lisinopril 2.5, 5, 10, 20, 30, 40 mg

Ramipril 1.25, 2.5, 5, 10 mg

Quinapril 5, 10, 20, 40 mg

ACE Combinations

Benazepril-HCTZ 5-6.25, 10-12.5, 20-12.5, 20-25 mg

Lisinopril- HCTZ 20-12.5, 20-25, 10-12.5 mg

Enalapril- HCTZ 5-12.5, 10-25 mg

Amlodipine-Benazepril 2.5-10, 5-10, 5-20, 5-40,10-20, 10-40mg

Anticoagulants and Antiplatelets

Brilinta 60, 90 mg tab

Eliquis (dose pack excluded)

Jantoven

Pradaxa

Warfarin Sodium 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg tab

Xarelto (dose pack excluded)

ARBs

Losartan Potassium 25, 50, 100 mg

Irbesartan 75, 150, 300 mg

Olmesartan Medoxomil 5, 20, 40 mg

Valsartan 40, 80, 160, 320 mg

ARB Combinations

Amlodipine-Valsartan 5-160, 5-320, 10-160, 10-320 mg

Amlodipine-Olmesartan 5-20, 10-20, 5-40, 10-40 mg

Irbesartan-HCTZ 150-12.5, 300-12.5 mg tab

Losartan-HCTZ 50-12.5, 100-12.5, 100-25 mg tab

Olmesartan-HCTZ 20-12.5, 40-12.5, 40-25 mg tab

Valsartan-HCTZ 80-12.5, 160-12.5, 160-25,320-12.5,320-25mg

Beta Blockers

Atenolol 25, 50, 100 mg

Bisoprolol Fumarate 5, 10 mg

Carvedilol 3.125, 6.25, 12.5, 25 mg tab

Carvedilol ER 10, 20, 40, 80 mg cap

Labetalol 100, 200, 300 mg tab

Metoprolol Tartrate 25, 37.5, 50, 75, 100 mg

Metoprolol Succinate ER 25, 50, 100, 200 mg

Propranolol 10, 20, 40, 60, 80 mg tab

Propranolol 20 Mg/5, 40 Mg/5 ml soln

Propranolol ER 60, 80, 120, 160 mg cap

Sotalol AF 80, 160 mg tab

Sotalol 120,160, 240 mg tab

Sorine 80, 120, 160, 240 mg tab

Calcium Channel Blockers

Amlodipine Besylate 2.5, 5, 10 mg tab

Nifedipine 10, 20 Mg Capsule

Nifedipine ER 30, 60, 90 mg tab

Cartia XT 120, 180, 240, 300 mg cap

Diltiazem 30, 60, 90, 120 mg tab

Diltiazem 12HR ER 60, 90,120 mg cap

Diltiazem 24HR ER 120, 180, 240, 300, 360, 420 mg cap

Diltiazem 24h ER(XR) 120, 180, 240 mg cap

Diltiazem 24HR CD 360 MG CAP

Taztia XT 120, 180, 240, 300, 360 MG cap

Verapamil 40, 80, 120 Mg Tab

Verapamil ER 120, 180, 240 Mg Tab

Cardiac Glycosides

Digoxin 0.05 mg/ml, 0.125 mg/2.5 ml solution

Digoxin 125, 250 mcg tab

Loop Diuretics

Bumetanide tab 0.5, 1, 2mg tab

Furosemide 20, 40, 80 mg tab

Torsemide 5, 10, 20, 100 mg tab

Nitrates and Nitrites

Isosorbide Dinitrate 5, 10, 20, 30, 40 mg tab

Isosorbide Dinitrate ER 40 mg tab

Isosorbide Mononitrate 10, 20 mg tab

Isosorbide Mononitrate ER 30, 60, 120 mg tab

Nitroglycerin 400 mcg Spray

Nitroglycerin 2.5, 6.5, 9 mg cap SA

Nitroglycerin 2% ointment

Nitroglycerin 0.1, 0.2, 0.3, 0.4, 0.6, mg/hr. patch Nitroglycerin 0.3, 0.4, 0.6 mg sl tab

Nitroglycerin Lingual 0.4 mg

Platelet Inhibitors

Clopidogrel 75, 300 mg tab

Dipyridamole 25, 50, 75 mg tab

Prasugrel 5, 10 mg tab

Potassium Sparing Diuretics

Eplerenone 25, 50 mg tab

Spironolactone 25, 50, 100 mg tab

Triamterene-Hctz 37.5/25, 75-50 mg tab & cap

Selective Cholesterol Absorption Inhibitors

Ezetimibe 10 mg tab

Fibrates

Fenofibrate 48, 145 mg tab

Gemfibrozil 600 mg tab

Statins

Atorvastatin 10, 20. 40. 80 mg tab

Rosuvastatin Calcium 5, 10, 20, 40 mg tab

Simvastatin 5, 10, 20, 40, 80 mg tab

Lovastatin 10, 20, 40 mg tab

Pravastatin 10, 20, 40, 80 mg tab

Sympatholtic Antihypertensives

Catapres-TTS 1, 2, 3 Patch

Clonidine HCL 0.1, 0.2, 0.3 mg tab

Guanfacine 1, 2 mg tab

Methyldopa 250, 500 mg tab

Thiazide Diuretics

Chlorthalidone 25, 50 mg tab

Hydrochlorothiazide 12.5, 25, 50,100 mg

Potassium Supplements

Potassium Chloride 8, 10 Meq cap SA

Potassium Chloride 10% liq S-F

Potassium Chloride 15%, 20% liq

Potassium Chloride 10, 20 meq tab

Potassium Chloride ER 10, 15, 20 meq tab

Vasodilators

Hydralazine HCL 10, 25, 50, 100 mg tab

CNS AGENTS

Alzheimer's Disease Agents

Donepezil 5, 10, 23 mg tab

Donepezil ODT 5 mg, 10 mg tab

Exelon 4.6 mg/24hr, 9.5, 13.3 mg/24hr patch

Memantine 5, 10 mg tab

Memantine 5-10 mg titration pack

Memantine ER 14, 21, 28 mg cap

Memantine 2 mg/ml, 10 mg/5 ml soln

Memantine ER 7 mg cap

Antidepressants

Bupropion 75, 100 mg tab

Bupropion SR 100, 150, 200 mg tab

Bupropion XL 150, 300 mg tab

Bupropion SR 150 mg tab

Citalopram 20 mg/10 ml sol

Citalopram 10, 20, 40 mg tab

Desvenlafaxine ER 50, 100 mg tab

Desvenlafaxine SUC ER 25 mg tab

Escitalopram 5, 10, 20 mg tab

Fluoxetine 10, 20, 40 mg cap

Fluoxetine 20 mg/5 ml soln

Fluvoxamine maleate 25, 50, 100 mg tab

Mirtazapine 15, 30, 45 mg tab

Mirtazapine 15, 30, 45 mg ODT

Mirtazapine 7.5 mg tab

Paroxetine 10 mg, 20, 30, 40 mg tab

Sertraline 25, 50, 100 mg tab

Sertraline 20 mg/ml oral conc

Sertraline 20 mg/ml oral soln

Trazodone 50, 100, 150, 300 mg tab

Venlafaxine 25, 37.5, 50, 75, 100 mg tab

Venlafaxine ER 37.5, 75, 150 mg cap

Anticonvulsants

Carbamazepine 100 mg tab

Carbamazepine 100 mg tab chew

Carbamazepine 100 mg/5 ml susp

Carbamazepine ER 100, 200, 300 mg cap

Carbamazepine ER 100, 300, 400 mg tab

Divalproex DR 125 mg cap sprinkle

Divalproex DR 125, 250, 500 mg tab

Divalproex ER 250, 500 mg tab

Ethosuximide 250 mg capsule

Ethosuximide 250 mg/5 ml sol

Lamotrigine 150, 200 mg tab

Lamotrigine 25, 100 mg tab

Lamotrigine 5, 25 mg ODT

Lamotrigine ER 25, 50, 100, 200, 250, 300 mg tab

Levetiracetam 100 mg/ml, 500 mg/5 ml sol

Levetiracetam 250, 500, 750, 1000 mg tab

Levetiracetam ER 500, 750 mg tab

Oxcarbazepine 150, 300, 600 mg tab

Oxcarbazepine 300 mg/5 ml susp

Phenytoin 100 mg/4ml, 125 mg/5 ml susp

Phenytoin 50 mg tab chew

Phenytoin sod ext 100, 200, 300 mg cap

Primidone 50, 250 mg tab

Roweepra 500, 750, 1,000 mg tab

Topiramate 15, 25 mg sprinkle cap

Topiramate 25, 50, 100, 200, mg tab

Valproic acid 250 mg cap

Valproic acid 250 mg capsule

Valproic acid 250 mg/5 ml sol

Valproic acid 250 mg/5, 500 mg/10 ml sol

Zonisamide 25, 50, 100 mg cap

Antimanic Agents

Lithium carbonate 150, 300, 600 mg cap

Lithium carbonate 300 mg tab

Lithium carbonate er 300, 450 mg tab

Lithium citrate 8 meq/5 ml sol & syrup

Atypical Antipsychotics

Aripiprazole 2, 5, 10, 15, 20, 30 mg tab

Latuda 20, 40, 60, 80,120 mg tab

Olanzapine 2.5, 5, 7.5, 10, 15, 20 mg tab

Olanzapine ODT 5, 10, 15, 20 mg tab

Olanzapine 10 mg vial

Quetiapine 25, 50, 100, 200, 300, 400 mg tab

Quetiapine er 50, 150, 200,300, 400 mg tab

Risperidone 0.25, 0.5, 1, 2,3, 4 mg tab

Risperidone 1 mg/ml solution

Risperidone 0.25, 0.50 1, 2, 3, 4 mg ODT

Ziprasidone 20, 40, 60, 80 mg cap

Parkinson’s Disease Agents

Benztropine 0.5, 1, 2, 2.5, 5 mg tab

Pramipexole 0.125, 0.25, 5.0, 0.75, 1, 1.5 mg tab

Pramipexole er 0.375, 0.75, 1.5, 2.25, 3, 3.75, 4.5 mg tab

Ropinirole 0.25, 0.5, 1, 2, 3, 4, 5 mg tab

Ropinirole ER 2, 4, 6, 8, 12 mg tab

Typical Antipsychotics

Chlorpromazine 10, 25, 50, 100. 200 mg tab

Fluphenazine 1, 2.5, 5, 10 mg tab

Fluphenazine 2.5 mg/5 ml elixir

Fluphenazine 5 mg/ml conc

Fluphenazine dec 125 mg/5 ml

Haloperidol 0.5, 1, 2. 5, 10, 20 mg tab

Haloperidol decanoate 50 mg/ml, 100 mg/mg vial

Haloperidol decanoate 250 mg/5 ml, 500 mg/5 ml vial

Haloperidol decanoate 50 mg/ml, 100 mg/ml amp

Haloperidol lactate 2 mg/ml conc

Loxapine 5, 10, 25, 50 mg cap

Perphenazine-amitriptyline 2-10, 2-25, 4-10, 4-25, 4-50 mg tab

Perphenazine 2, 4, 8, 16 mg tab

Thioridazine 10, 25, 50, 100 mg tab

Thiothixene 1, 2, 5, 10 mg caps

Trifluoperazine 1, 2, 5, 10 mg tab

CORTICOSTEROIDS

Prednisone 5 mg/5 ml solution

Prednisone 1, 2.5, 5, 10. 20, 50 mg tab

Prednisone 50 mg tab

Prednisone 5, 10 mg tab dose pack

DIABETES AGENTS

Orals

Acarbose25, 50, 100 mg tab

Farxiga 5, 10 mg tab

Glimepiride 1,2,4 mg tab

Glipizide 5, 10 mg tab

Glipizide ER 2,5, 5, 10 mg tab

Glyburide 1.25, 2.5, 5 mg tab

Glyburide Micro 1.5, 3, 6 mg tab

Glyburide-metformin 2.5-500

Invokamet XR 50-500, 50-1000,150-500, 150-1000 mg

Invokana 100, 300 mg tab

Janumet 50- 500, 50-1000 mg tab

Janumet XR 50-500, 50-1000, 100-1000 mg tab

Januvia 25, 50, 100 mg tab

Jardiance 10, 25 mg tab

Jentadueto 2.5-500, 2,50850, 2.5-1000 mg tab

Metformin 500, 850, 1,000 mg tab

Metformin ER 500, 750 mg tab

Nateglinide 60, 120 mg tab

Repaglinide 0,5, 1, 2 mg tab

Synjardy 12.5-500, 12.5-1000, 5-500, 5-1000mg tab

Tradjenta 5 mg tab

Xigduo 2.5-1000, 5-500, 10-500, 5-1000, 10-1,000 mg tab

Injectables

Bydureon 2 mg pen

Byetta 5, 10 mcg pen

Humalog 100 Units/ml vial & cartridge

Humalog Mix 50-50, 75-25 vial

Humulin 70-30 Vial & Kwikpen

Humulin N 100 u/ml vial & Kwikpen

Humulin R 100 Units/ml vial

Humulin R 500 Units/ml vial & Kwikpen

Insulin Aspart Cartridge Pen and Vial SQ

Insulin Aspart/Insulin Aspart Protamine Insulin Pen SQ

Insulin Aspart/Insulin Aspart Protamine Vial SQ

Insulin Lispro 100 Unit/ml vial

Insulin Lispro Junior Kwikpen SQ

Insulin Lispro Pen SQ

Insulin Lispro Protamine Mix Kwikpen SQ

Lantus 100 Unit/ml vial

Levemir Flextouch 100 Units/ml & Vial

Novolog 100 Unit/ml Cartridge & Vial

Novolog 100 Units/ml Flexpen

Trulicity 0.75mg/0.5ml, 1.5mg/0.5ml, 3mg-0.5ml, 4mg/0.5ml pen

Victoza 2-Pak 18 Mg/3 ml pen

Diabetic Supplies

Diabetic Needles

Diabetic Pen Needles

Diabetic Syringes

ESTROGENS

Estradiol 0.5, 1, 2 mg tab

GASTROINTESTINAL AGENTS

Chronic Motility Agents

Amitiza

Linzess

Movantik

H2 Receptor Antagonists

Famotidine 10, 20, 40 mg tab

Famotidine 40 mg/5 ml susp

Proton Pump Inhibitors

Omeprazole DR 10, 20, 40 mg cap

Pantoprazole sod DR 20, 40 mg tab

Pantoprazole 40 mg susp

Ulcerative Colitis Agents

Apriso

Balsalazide disodium

Pentasa

Sulfasalazine DR & IR

GENITOURINARY

Benign Prostatic HyperplasiaAgents

Alfuzosin ER 10 mg tab

Doxazosin mesylate 1, 2, 4, 8 mg tab

Dutasteride 0.5 mg cap

Finasteride 5 mg tab

Tamsulosin 0.4 mg cap

Terazosin 1, 2, 5, 10 mg cap

Terazosin 1, 2, 5, 10 mg tab

Urinary Antispasmodics

Oxybutynin tab/syr

Oxybutynin ER

Solifenacin

Toviaz

GOUT AGENTS

Allopurinol 100, 300 mg tab

Colchicine 0.6 mg tab

Probenecid 500 mg tab

Probenecid-Colchicine tab

HYPOTHYROIDISM AGENTS

Levothyroxine 25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300 mcg tab

Levothyroxine 13, 25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200 mcg cap

IMMUNOLOGICAL AGENTS

Azathioprine 50 mg tab

Methotrexate 2.5 mg tab

Methotrexate 1 gm vial

Methotrexate 1 gram/40 ml vial

Methotrexate 25 mg/ml vial

Methotrexate 250 mg/10 ml vial

Methotrexate 50 mg/2 ml vial

NSAIDS

Children’s Motrin® susp (OTC)

Diclofenac sodium 1% (RX & OTC)

Ibuprofen cap

Ibuprofen tab (OTC & Rx)

Infant’s ibuprofen drops

Meloxicam tab

Naproxen tab

Naproxen sodium (OTC)

Naproxen EC (Rx)

Sulindac

PANCREATIC ENZYMES

Creon DR 3,000, 6,000, 1200, 24000, 36000 u cap

Zenpep DR 3,000, 5,000, 10,000, 15,000, 20,000, 25,000, 40,000 u cap

RESPIRATORY AGENTS

Antihistamines

Cetirizine liquid 1mg/1mL (RX & OTC)

Cetirizine tab OTC

Levocetirizine tab (OTC)

Loratadine syr (OTC)

Loratadine tab (OTC)

Inhalers

Advair HFA 45-21, 115-21, 230-21 mcg

Anoro Ellipta 62.5-25 mcg

Asmanex twisthaler 110 mcg, 220 mcg

Atrovent HFA

Bevespi Aerosphere

Combivent Respimat

Dulera 50, 100, 200 mcg/5 mcg

Flovent Diskus 50, 100, 250 mcg

Flovent HFA 44, 90, 110, 180, 220 mcg

Proair HFA 90 mcg

Serevent Diskus 50 Mcg

Spiriva Handihaler 18 mcg

Spiriva Respimat

Stiolto Respimat inhaler Spray

Symbicort 80-4.5, 160-4.5 mcg

Ventolin HFA 90 mcg

Leukotriene Receptor Antagonists

Montelukast tab

Montelukast chewable tab

Nebulizer Solutions

Ipratropium bromide 0.02%

Ipratropium/albuterol 0.5-3(2.5) mg/3 ml