Customs and Border Protection Medication Formulary

ICE HEALTH SERVICE CORPS

Fiscal Year 2024 Formulary for US Customs & Border Protection

*Maximum 30-Day Supply for all medications*

This formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs.

Brand names with generic equivalents are considered non-formulary.

Changes from FY2023. Last revised 10/2/2023

Page 1 | 3

Drug Category

Formulary Agents: generics, BRANDS

OTC (Over-the Counter) Medications

All OTC (over-the-counter) medications that are prescribed by a qualified, licensed, healthcare provider and dispensed by a

pharmacist are covered by IHSC/USBP/USCBP, unless otherwise restricted below.

Anti-Infectives

Antifungal

clotrimazole, fluconazole, griseofulvin, ketoconazole, miconazole, terbinafine

Anthelmintic

albendazole, ivermectin, *EMVERM **Restricted to under 18 years old**, mebendazole

Anti-herpetic

acyclovir, acyclovir cream, famciclovir

Anti-influenza

amantadine, oseltamivir, XOFLUZA

Antimycobacterial

Ethambutol, isoniazid, pyrazinamide, rifampin, streptomycin, rifapentine

Antiretrovirals

All agents are formulary

Cephalosporins

cefaclor, cefadroxil, cefdinir, cefprozil, cefuroxime, cephalexin, *cefpodoxime, ceftriaxone, cefixime

Ketolides

All agents require an approved Non-Formulary Request/Prior Authorization

Macrolides

azithromycin, clarithromycin, clindamycin, ERY-TAB

Miscellaneous antibiotics

metronidazole, sulfamethoxazole/trimethoprim, nitrofurantoin

Penicillins

amoxicillin, amoxicillin/clavulanate, BICILLIN-LA, dicloxacillin, penicillin VK

Quinolones

ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin

Tetracyclines

doxycycline, minocycline

Cardiovascular

ACE inhibitor

benazepril, captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril

Alpha & Beta Blockers

carvedilol, labetalol

Alpha2-Adrenergic Agonist

clonidine, methyldopa

Angiotensin Receptor Blockers (ARBs)

candesartan, irbesartan, losartan, telmisartan, olmesartan, valsartan

Anti-arrhythmic

Amiodarone, ranolazine ER

Anticoagulants

apixaban, enoxaparin, rivaroxaban, warfarin

Anti-hypertensive combos

All agents require an approved Non-Formulary Request/Prior Authorization

Beta blockers, nonselective

nadolol, propranolol, sotalol/-AF, pindolol, timolol

Beta-1 blockers, selective

acebutolol, atenolol, betaxolol, bisoprolol, metoprolol

Cardiotonic

digoxin

Calcium Channel Blockers

amlodipine, diltiazem, diltiazem ER, felodipine, nicardipine, nifedipine, nifedipine XL, verapamil SR/XR

Diuretic

bumetanide, chlorthalidone, furosemide, hydrochlorothiazide, metolazone, spironolactone,

triamterene/hydrochlorothiazide

HMG-CoA reductase inhibitors

atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Cholesterol – other

cholestyramine, fenofibrate, gemfibrozil

Nitrates

isosorbide dinitrate, isosorbide mononitrate, nitroglycerin SL tabs

Platelet Aggregation Inhibitors

clopidogrel, BRILINTA

Central Nervous System

Alzheimer’s/ Dementia

donepezil, memantine

Anti-Anxiety

alprazolam, buspirone, chlordiazepoxide, clorazepate, diazepam, lorazepam, oxazepam

Anticholinergic

benztropine

Anticonvulsant/Mood Stabilizer

carbamazepine, clonazepam, divalproex, gabapentin, levetiracetam, lithium, phenobarbital,

phenytoin, topiramate, valproic acid

Antidepressant – SSRI

citalopram, escitalopram, fluoxetine, paroxetine, sertraline

Antidepressant – Tricyclic

amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline

Antidepressant – other bupropion HCl, bupropion SR/ER/XL, duloxetine, mirtazapine, nefazodone, trazadone, venlafaxine

Antimigraine

sumatriptan, aspirin/acetaminophen/caffeine

Anti-Parkinson/Dopamine Agonist

carbidopa/levodopa, pramipexole

Antipsychotic – 1

gen

chlorpromazine, fluphenazine, haloperidol (PO, lactate, & decanoate), loxapine, perphenazine,

thioridazine, thiothixene, trifluoperazine

Antipsychotic – 2

gen aripiprazole, clozapine, lurasidone, quetiapine, risperidone, olanzapine, ziprasidone, INVEGA

Antihistamine

hydroxyzine

ICE HEALTH SERVICE CORPS

Fiscal Year 2024 Formulary for US Customs & Border Protection

*Maximum 30-Day Supply for all medications*

This formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs.

Brand names with generic equivalents are considered non-formulary.

Changes from FY2023. Last revised 10/2/2023

Page 2 | 3

Stimulants/ ADHD

All agents require an approved Non-Formulary Request/Prior Authorization

Dermatologic

Acne Products

benzoyl peroxide, clindamycin lotion, erythromycin gel, tretinoin

Antibiotics

gentamicin, metronidazole, mupirocin ointment only

Antifungals

clotrimazole, nystatin, terbinafine

Miscellaneous

Calamine lotion, lidocaine viscous soln

Pediculicides

permethrin cream, ivermectin

Steroids

clobetasol, fluocinonide, hydrocortisone, betamethasone valerate, triamcinolone

Endocrine/ Hormone

Contraceptives

levonorgestrel/ethinyl estradiol, norethindrone/ethinyl estradiol, norethindrone, norgestrel/ethinyl

estradiol, norgestimate/ethinyl estradiol

Emergency Contraceptives

levonorgestrel emergency contraceptive, ELLA, MY WAY, PLAN B, PLAN B ONE-STEP

Osteoporosis

alendronate

Estrogen blockers

*anastrozole, tamoxifen

Estrogens

estradiol, PREMARIN, estradiol valerate, estradiol cypionate

Estrogen, combinations

All agents require an approved Non-Formulary Request/Prior Authorization

Estrogen, topical

All agents require an approved Non-Formulary Request/Prior Authorization

Pituitary disorders

cabergoline, bromocriptine

Insulin

HUMULIN, HUMALOG, LANTUS, NOVOLOG, NOVOLIN

Anti-hypoglycemics

Glucose tablets, glucose gel, GLUCAGON (max 2 kits per 30 days)

Progesterones

medroxyprogesterone

Diabetes – sulfonylureas

glimepiride, glipizide, glipizide ER, glyburide, glyburide micronized, tolazamide

Diabetes – biguanides

metformin

Diabetes – glitazones

AVANDIA - Restricted access, pioglitazone

Diabetes – DPP-4 inhibitors alogliptin, JANUVIA

Diabetes – GLP-1 agonists &

SGLT-2 inhibitors

All agents require an approved Non-Formulary Request/Prior Authorization

Corticosteroids

dexamethasone, fludrocortisone, methylprednisolone, hydrocortisone, prednisolone, prednisone,

triamcinolone IM inj

Thyroid

levothyroxine, thyroid

Testosterone

testosterone cypionate injectable

Gastrointestinal

Antacid

calcium carbonate, aluminum hydroxide/magnesium hydroxide

Antidiarrheal

diphenoxylate/atropine, loperamide

Antiemetic

dimenhydrinate, meclizine, ondansetron + ODT, promethazine

Antispasmodic

dicyclomine, hyoscyamine

Anti-ulcer

sucralfate

Enzymes

pancrelipase - All formulations covered

Histamine 2 antagonists

cimetidine, famotidine, ranitidine

IBS agents

All agents require an approved Non-Formulary Request/Prior Authorization

Laxative

bisacodyl, docusate sodium, calcium polycarbophil, lactulose, magnesium hydroxide, polyethylene

glycol, polyethylene glycol w/ electrolytes

Proton Pump Inhibitors

esomeprazole, lansoprazole, omeprazole, pantoprazole

Stimulants

metoclopramide

Ulcerative colitis

sulfasalazine, mesalamine - All formulations covered

Musculoskeletal, Analgesics

Opioids, long acting

All agents require an approved Non-Formulary Request/Prior Authorization

Opioids, short acting

codeine/acetaminophen, hydrocodone/acetaminophen, oxycodone (max 60-tablet or 300mL),

oxycodone/acetaminophen, tramadol

Opioids, partial agonist

SUBOXONE

Opioid antagonist/antidote

naloxone

ICE HEALTH SERVICE CORPS

Fiscal Year 2024 Formulary for US Customs & Border Protection

*Maximum 30-Day Supply for all medications*

This formulary list is not intended to be all-inclusive and lists only the most commonly prescribed drugs.

Brand names with generic equivalents are considered non-formulary.

Changes from FY2023. Last revised 10/2/2023

Page 3 | 3

NSAIDs, nonselective

aspirin, diclofenac, etodolac, ibuprofen, indomethacin + SR, ketoprofen, ketorolac, meloxicam,

nabumetone, naproxen + NA, oxaprozin, piroxicam, salsalate, sulindac

COX-2, selective

celecoxib

Local anesthetic

lidocaine

Skeletal Muscle Relaxants

baclofen, cyclobenzaprine, methocarbamol

Ophthalmics

Anti-infectives

ciprofloxacin, erythromycin ointment, gentamicin, moxifloxacin,

sulfacetamide, tobramycin, neomycin/polymyxin/dexamethasone

Allergic Conjunctivitis

ketotifen, olopatadine

Glaucoma

brimonidine, carteolol, dorzolamide, dorzolamide/timolol, latanoprost, timolol

Anti-inflammatory

ketorolac, prednisolone acetate

Otic

Anti-Infective

ciprofloxacin/dexamethasone, neomycin/polymyxin/hydrocortisone, ofloxacin

Respiratory, Allergy

Beta agonist

albuterol, levalbuterol HFA, metaproterenol solution, PRO AIR, PROVENTIL HFA, SEREVENT, VENTOLIN

HFA

Inhaled Steroids

FLOVENT HFA, PULMICORT, QVAR

Inhaled Steroid/ Beta agonist combo

fluticasone/salmeterol, SYMBICORT

Spacers

aerochamber, optichamber

Leukotriene

montelukast

Nasals

azelastine, flunisolide, fluticasone, mometasone, sodium chloride (saline), triamcinolone

Antihistamine

chlorpheniramine, clemastine, cyproheptadine, diphenhydramine, loratadine, cetirizine, fexofenadine

**Decongestants and antihistamine/decongestant combinations are restricted to ages 6 and up.**

Antitussive

benzonatate, guaifenesin*

Xanthine derivatives

theophylline

Cough/cold

guaifenesin, dextromethorphan **Restricted to ages 12 and up**,

honey cough syrup (ZARBEE’S, LITTLE REMEDIES - Covered for patients ages 1-18)

Cough/cold combinations

guaifenesin/dextromethorphan, brompheniramine/pseudoephedrine/dextromethorphan

**Cough/cold combinations are restricted to ages 12 and up.**

Genitourinary

BPH

doxazosin, finasteride *5mg only*, prazosin, tamsulosin, terazosin

Erectile dysfunction

All agents require an approved Non-Formulary Request/Prior Authorization

Antispasmodic

oxybutynin, solifenacin*, tolterodine

Analgesic

phenazopyridine

Alkalizing agent

potassium citrate

Miscellaneous

Vitamins

calcitriol, cholecalciferol, cyanocobalamin, ergocalciferol, ferrous sulfate, leucovorin, prenatal

vitamins, multivitamins, pyridoxine, renal vitamins

Gout

allopurinol, colchicine

Potassium binders

patiromer

Phosphate binders

sevelamer, RENAGEL, RENVELA, calcium acetate, lanthanum

Myasthenia gravis

pyridostigmine

DMARDs

hydroxychloroquine, hydroxyurea, methotrexate

Dental

chlorhexidine gluconate (alcohol free), triamcinolone paste

Minerals & electrolytes

potassium chloride, sodium bicarbonate, sodium chloride, oral rehydration solution, pediatric

electrolyte replacements - All formulations covered

Gallstone Dissolution agent

ursodiol

Immunosuppressant

mycophenolate, tacrolimus

Vaccines

All FDA-approved and FDA-authorized vaccinations are covered by Customs & Border Protection.