Formulary (updated jul 11)


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The 95th Medical Group Pharmacy Formulary.

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Formulary (updated jul 11)

  1. 1. Edwards Air Force Base Pharmacy Formulary Current as of 1 Oct 2011
  2. 2. Table of ContentsWelcome Letter from Flight Commander 4General Pharmacy Information 5How do I get my Refills? 6Pharmacy Benefits 7New to our Formulary 9Formulary Listing by alphabetical order (generic names) 10Listing by Common Use (not a complete listing) 21Quick Reference Phone Guide 22 2
  3. 3. Welcome to Edwards AFB and the 95th Medical Group!We, the military and civilian pharmacy staff at the 95th Medical Group, are always striving toprovide you and your family the best pharmaceutical care available. All of us are committed toproviding quality services, and to ensure that the care you receive is and continues to be the bestyou’ve ever experienced.The pharmacy handbook/frequently asked questions has been created to hopefully makeaccessing pharmacy services easier and less confusing for beneficiaries. While it does notanswer every question, it does provide guidance on most of our services.I would like to extend on behalf of my staff and self, a special thank you to all of you inuniform who are defending our country and to all the veterans who have made majorcontributions to our nation. We also thank the families who have and continue to support all ofyou. Vanthy Pham Vanthy B. Pham, Maj, USAF, BSC, PharmD Diagnostics and Therapeutics Flight Commander 3
  4. 4. Pharmacy General InformationWhat are the hours for the Pharmacy?Pharmacy hours are below.Monday 0730-1630Tuesday 0730-1630Wednesday 0730-1630Thursday 0730-1630Friday 0730-1630Closed the first Monday of each month, weekends, federal holidays, AFMC approvedfamily days and Military down days.Where is the Pharmacy?The Pharmacy is located in the main clinic on 30 Nightingale Rd in building 5525.It is located in the south end of the first floor.Eligible beneficiaries include: Active duty service members and their families Activated National Guard and Reserve Members and their families (on Title 10 or Title 32 [federal] orders) Retired service members and their families Survivors, widows/widowers and certain former spouses Medal of Honor recipients and their families Beneficiaries enrolled in TRICARE Reserve Select or the Continued Health Care Benefit Program Other beneficiaries listed in DEERS as eligible for TRICARE, including foreign force members and their familiesWhen updating DEERS with your personal information, be sure to update your address with aphysical address. 4
  5. 5. How do I get medication refills? If you have an existing prescription that is still active with refills left, call the Pharmacyat 661-277-9896. Prescriptions called into the refill line will be available for pickup withintwo duty days at the main pharmacy or at the APM located in BX lobby (*certain medicationsonly*). If you present to the pharmacy window for a refill you may be asked to come back lateror the next duty day. Please make every effort to call in prescription refills to avoid delays.Typically, if you’re running out of a medication (down to last refill or last set of doses), itmeans your provider is expecting you to follow-up for a re-evaluation. Please make a follow-upappointment prior to running out so your provider can see how you are doing.If your prescription has expired or you have no refills left and you see a provider on base,please call PCC at 661-277-7118 at least one week prior to running out of your medication.Ask to leave a telephone consult for your provider’s nurse. Please have the name and dosage ofthe medication ready to provide to the phone clerk, as it makes renewing your prescriptioneasier. As long as the provider determines that you do not need a follow-up appointment priorto prescription renewal, your refill request will typically be taken care of within 72 businesshours.If you see a civilian provider off base you will have to contact your provider for a newprescription. The pharmacy does NOT accept fax or phone-in prescription orders or refills.Any questions regarding your medications that can be handled by the pharmacy should bedirected to their staff at 661-277-9896 (option 1 clinic pharmacy, option 5 speak to pharmacypersonnel)Can’t make it to the pharmacy during normal duty hours? Sign up today to use ourAutomated Prescription Machine (APM) located in the BX food lobby to pick up yourprescription refills. The APM is available during BX hours including weekends. 5
  6. 6. YOUR PHARMACY BenefitsAll formulary medication at EDWARDS Pharmacy:$0 cost for up to a 90 day SupplyOther Military Treatment Facility (MTF) PharmaciesAn MTF pharmacy provides those medications listed on its local formulary (drug listing). MostMTF pharmacies accept prescriptions written by both civilian and military providers.To check the availability of a particular drug, contact you’re nearest MTF if not stationed atEdwards AFB in person or by phone.TRICARE Mail Order Pharmacy (TMOP)You can receive up to a 90-day supply* for most medications you take regularly (for instance,drugs for high blood-pressure, asthma or oral contraceptives) using TMOP.When you use the TMOP service you get:• Savings: You can save up to 66% of retail costs, because yourco-payment for a 90-day supply is the same as for a 30-day supply at a retail pharmacy.• Convenience and safety: Your medication is mailed to your home in a weather-resistantpouch for your privacy and protection and there is no charge for postage.To use the TMOP service, just follow these steps:1) Ask your doctor for a prescription (for up to a 90-day supply*,plus refills for up to one year,if appropriate).2) Complete the TMOP registration/order form which can be downloaded from their website at: Insert your prescription, completed TMOP registration form, and co-payment, if needed, intothe pre-addressed, postage paid envelope (attached to the registration form — use this envelopeonly for your TMOP registration) and mail them. Your prescriptions will be mailed to youwithin 14 days.• For more details on TMOP, please visit or call 1-877-363-1303. 6
  7. 7. DoD TRICARE Retail Pharmacy (TRRx) NetworkAnother option for filling your prescription is to use a DoD TRRx network retail pharmacy.Simply give the network pharmacist your written prescription and your uniformed servicesidentification (ID) card.You will pay a co-payment of:$0 for formulary generic for 30-day supply$9 for formulary brand-name for 30-day supply$25 for non-formulary drugs for 30-day supply.To find a DoD TRICARE Retail Pharmacy near you:• Visit online pharmacy locator is updated on the first day of each month. If a pharmacy joinedafter the first day of the month, it might not appear on the locator until the following month.• Call 1.877.363.1303).Non-Network Retail PharmacyYour medications will cost the most at non-network retail pharmacies because they do notbelong to the DoD TRRx network. At non-network pharmacies you will pay full price for yourmedication. To be reimbursed for non-network pharmacy claims, you must fill out the enclosedclaim form (DD 2642),attach the required paperwork as described on the DD2642,and mail itto:Express ScriptsP.O. Box 66518St. Louis, MO 63166-6518You can download additional claim forms (DD 2642) at pharmacy/claims.cfm. Claim forms may also be obtained atTRICARE Service Centers and MTFs. 7
  8. 8. New to our formulary!Budesonide/formoterol (Symbicort) for Asthma or COPDCetirizine (Zyrtec) chewable tablets for allergiesCetirizine/pseudoephedrine (Zyrtec-D) for allergiesInsulin glargine pen (Lantus SoloStar Pen) for diabetes mellitusScopalamine patches (Transderm Scop) for motion sicknessTamsulosin (Flomax) for enlarged prostate or BPHValsartan (Diovan) for hypertensionValsartan/HCTZ (DiovanHCT) for hypertensionCiprofloxacin/Dexamethasone (Ciprodex) for ear infectionFamotidine (Pepcid) for heartburn, GERDFenofibrate 54mg and 160mg for hyperlipidemia (replacing Fenoglide)Fenofibrate (Tricor) 48mg and 145mg for hyperlipidemiaRovustatin (Crestor) for hyperlipidemia *DoD requires Prior AuthorizationMometasone/Formoterol (Dulera) Inhaler for asthma or COPDErgocalciferol (Vitamin D) 50,000 units for Vit D supplementsCalcium Carbonate + Vit D 500mg (Oscal+D) for calcium supplements 8
  9. 9. Diclofenac (Voltaren) 1% topical gel for painLidocaine (Lidoderm) 5% patch-for painDetemir (Levemir) Insulin-for diabetesPantoprazole (Protonix)-for GERDClindamycin (Cleocin T) 1% Pads-for acneAspart (Novolog FlexPen) Insulin Pen-for diabetes No longer on formulary!Rosiglitazone (Avandia) for diabetesRosiglitazone/Metformin (Avandamet) for diabetesCiprofloxacin/Hydrocortisone (CiproHC) for ear infection 9
  10. 10. Edwards AFB Pharmacy Formulary Alphabetically Listed by Generic NameGeneric Name Brand Name How SuppliedACETAMINOPHEN Tylenol Tabs: 325 mg, 650mg Infant Drops: 80 mg/0.8 ml Soln: 160 mg/5 ml. Supps: 120mg, 650 mgACETAMINOPHEN/BUTALBITAL/ Fioricet Tabs: 325mg/50mg/40mgCAFFEINEACETAMINOPHEN/CODEINE Tylenol w/Codeine C-III Tabs: 30mg/300mgPHOSPHATE Elixir: 12mg/120 mg/5 mlACETAZOLAMIDE Diamox Tabs: 250 mg, 500mgACETIC ACID Domeboro Powder PacketsACYCLOVIR Zovirax Caps: 200mg Tabs: 400mg, 800mg Susp: 200mg/5ml Oint: 15 gADAPALENE GEL Differin 0.1% Gel: 45gALBUTEROL HFA Ventolin HFA Inhaler: 90mcg, 200 sprays/unit Neb Soln: 0.5%, 0.083% Oral Liq: 5mg/5ml.ALBUTEROL/ IPRATROPIUM Combivent Inhaler: 200 sprays/unitALENDRONATE Fosamax Tabs: 5mg, 10 mg, 35 mg, 70 mg Soln: 70mg/75mlALENDRONATE/VITAMIN D Fosamax Plus D Tabs: 70mg/2800 IU, 70mg/5600 IUALFUZOSIN Uroxatral Tabs: 10mgALLOPURINOL Zyloprim Tabs: 100mg, 300mgALPRAZOLAM Xanax C-IV Tabs: 0.25mg, 0.5mg, 1mg, 2mgALUMINUM CHLORIDE Drysol Liq: 37.5mlHEXAHYDRATEAMANTADINE Symmetrel Tabs: 100mg Syrup: 50mg/5 mlAMIODARONE Cordarone/Pacerone Tabs: 200mg, 400mgAMITRIPTYLINE Elavil Tabs: all strengthsAMLODIPINE Norvasc Tabs: all strengthsAMLODIPINE/BENAZEPRIL Lotrel Caps: all strengthsAMMONIUM LACTATE Lac-Hydrin Lotion: 12%AMOXICILLIN Amoxil Susp:125mg/5ml, 250 mg/5ml, 400 mg/5 ml Caps: 250mg, 500mgAMOXICILLIN/ CLAVULANATE Augmentin Susp: 200mg/5ml, 250mg/5ml, 400mg/5ml ES Susp: 600 mg/5 ml Tabs: 250mg/125mg, 500mg/125mg, 875mg/125mg Chew Tabs: 250/62.5mg XR: 1000 mgAMPHETAMINE/ Adderall C-II Tabs: 5, 10, 30 mgDEXTROAMPHETAMINE Adderall XR C-II XR Caps: all strengthsAMPICILLIN Ampicillin Caps: 500 mgANTIPYRINE/ Auralgan Otic soln: 15 mlBENZOCAINE/GLYCERINASPIRIN ENTERIC COATED Ecotrin Tabs: 81mg, 325mgATENOLOL Tenormin Tabs: all strengthsATOMOXETINE Strattera Caps: all strengthsATORVASTATIN Lipitor Tabs: all strengthsAZELASTINE Astelin Nasal spray: 137mcg/spray **DoD Quantity limit 2 per 30 days**AZITHROMYCIN Zithromax Tabs: 250mg, 500mg Packet: 1g Susp: 100mg/5ml, 200mg/5ml 10
  11. 11. BACITRACIN Bacitracin Oph oint Topical ointBACITRACIN/NEOMYCIN/ Polysporin Oph ointPOLYMYXINBACLOFEN Lioresal Tabs: all strenghtsBELLADONNA ALKALOIDS Donnatal Tabs: 16.2mg Liq: 16.2mg/5mlBENAZEPRIL Lotensin Tabs: all strengthsBENZONATATE Tessalon Perles Caps: all strengthsBENZOYL PEROXIDE GEL, Benzac Gel: 42.5g (10%)BENZOYL PEROXIDE WASH Sol: 227g (10%)BENZOYL PEROXIDE/ Benzaclin Gel: 25 g (1-5%)CLINDAMYCINBENZTROPINE Cogentin Tabs: all strengthsBETAMETHASONE Diprosone Cream: 0.05%, 45 gDIPROPRIONATE Oint: 0.05%, 15 gBETAMETHASONE VALERATE Valisone Cream: 0.1%, 15 g, 45 gBETAXOLOL Betoptic S Oph susp: 0.5%, 5 ml.BISACODYL Dulcolax Tabs: 5 mgBRIMONIDE Alphagan P Oph soln: 0.15%, 0.2%BROMOCRIPTINE Parlodel Tabs: all strengthsBUDESONIDE Pulmicort Respules Neb Sol: all strengthsBUDESONIDE/FORMOTEROL Symbicort Inhaler: 160/4.5, 80/4.5 mcgBUPROPRION Wellbutrin Tabs: 75, 100mgBUPROPRION Wellbutrin SR SR Tabs: 100mg, 150mgBUPROPRION Zyban SR Tabs: 150 mgBUSPIRONE HCL Buspar Tabs: all strengthsCALCIUM CARB+VIT D OSCAL+D Tabs: 500mgCANDESARTAN Atacand Tabs: all strenghtsCANDESATAN/HCTZ Atacand HCT Tabs: 16/12.5, 32/12.5mgCAPTOPRIL Capoten Tabs: all strengthsCARBAMAZEPINE Tegretol Chewable tabs: 100mg Tabs: 200mg Tegretol XR XR tabs: all strengths Liq: 100mg/5mlCARBIDOPA/LEVODOPA Sinemet Tabs: 10/100, 25/100, 25/250 mg Sinemet CR CR: 25/100 mgCARBOXYMETHYLCELLULOSE Celluvisc Boxes of 30CARISOPRODOL Soma Tabs: 350 mgCARVEDILOL Coreg Tabs: all strengthsCEFADROXIL Duricef Susp: 250 mg/5 mlCEFDINIR Omnicef Susp: 125 mg/5 ml & 250 mg/5 mlCEFPODOXIME Vantin Susp: 100 mg/5 mlCEFUROXIME Ceftin Susp: 250 mg/5 ml Tabs: 250, 500 mgCELECOXIB Celebrex Caps: all strengthsCEPHALEXIN Keflex Caps: all strengths Susp: 250mg/5mlCETIRIZINE Zyrtec Tabs: 10 mg Liquid: 5 mg/5 ml Chewable: 5mgCETIRIZINE/PSEUDOEPHEDRINE Zyrtec-D Tabs: 5/120 mgCHLORAL HYDRATE Noctec Syrup: 500 mg/5 mlCHLORHEXIDINE RINSE Peridex Rinse: 0.12%CHLOROQUINE Aralen Tabs: 250, 500 mgCHLORTHALIDONE Hygroton Tabs: all strengthsCIMETIDINE Tagamet Tabs: all strengthsCIPROFLOXACIN Cipro Tabs: all strengths Susp: 5gm/100mlCIPROFLOXACIN Ciloxan Opth: 0.3%/2.5 mlCIPROFLOXACIN/DEXAMETHASONE CiproDex Soln: 7.5 ml 11
  12. 12. CITALOPRAM Celexa Tabs: all strengths Soln: 10mg/5mlCLARITHROMYCIN Biaxin Tabs: 250, 500 mgCLINDAMYCIN Cleocin Caps: all strengths Susp: 75 mg/5 ml Top Soln: 1%, 60 ml Top Pads: 1% Vaginal Cream: 2%(40 gm)CLINDINIUM/ Librax Caps: 2.5 mg/5 mgCHLORDIAZEPOXIDECLOBETASOL PROPRIONATE Temovate 0.05% Cream: 15g, 45g 0.05% Oint, 0.05% SolnCLOMIPHENE Clomid Tabs: 50 mgCLONAZEPAM Klonopin C-IV Tabs: all strengthsCLONIDINE Catapres Tabs: all strengthsCLOPIDOGREL Plavix Tabs: 75 mgCLOTRIMAZOLE Lotrimin 1% Cream: 30 g 1% Topical solnCLOTRIMAZOLE / BETAMETHASONE Lotrisone Cream: 15, 45 gDIPCODEINE SULFATE Codeine C-III Tabs: 30 mgCODEINE/ GUAIFENESIN Robitussin AC C-V Liq: 10/100 mg per 5 ml (120 ml) **Qty must be in equivalents of 120 ml**COLESTIPOL Colestid Tabs: 1 g Powder Packets: Box of 90COLOCHICINE Colchicine Tabs: 0.6 mgCONJUGATED ESTROGENS Premarin Tabs: all strengths Vaginal cream 0.625mg/gmCONJUGATED ESTROGEN/ Prempro Tabs: all strengthsMEDROXYPROGESTERONECROMOLYN SODIUM Crolom Oph Soln: 4%, 15 mlCYCLOBENZAPRINE Flexeril Tabs: all strengthsCYCLOPENTOLATE Cyclogel Oph Soln: 0.1%, 5 mlCYPROHEPTADINE Periactin Tabs: 4 mg Syrp: 2mg/5mlDESIPRAMINE Norpramin Tabs: all strengthsDESMOPRESSIN DDAVP Tabs: 0.2 mgDESOGESTREL/ETHINYL Mircette 28 day packsESTRADIOL (Biphasic)DESOGESTREL/ETHINYL ESTRADIOL Desogen 28 day packsDETEMIR Levemir Insulin vialDEXAMETHASONE Decadron Tabs: 0.5 mg, 4 mgDEXTROAMPHETAMINE Dexedrine C-II Tabs: 5, 10 mg SR Caps: 5 mg, 15mgDIAGNOSTIC STRIPS Precision Xtra Boxes of 50 AccuChek AvivaDIAZEPAM Valium C-IV Tabs: all strengthsDICLOFENAC SODIUM Voltaren Tabs: 50, 75 mg Oph soln: 0.1% Top Gel: 1%DICLOXACILLIN Dynapen Caps: all strengthsDICYCLOMINE Bentyl Tabs: all strengths Soln: 10mg/5mlDIGOXIN Lanoxin Tabs: all strengths Soln: 0.05mg/mlDILTIAZEM Tiazac Tabs: 60 mg ER Caps: all strengthsDIPHENOXYLATE W/ATROPINE Lomotil C-V Tabs: 2.5/0.025 mgDIPHENYDRAMINE Benadryl Caps: 25 mg, 50 mg Liq: 12.5 mg/5 mlDISOPYRAMINE Norpace Caps: 100 mg 12
  13. 13. DIVALPROEX Depakote Tabs: all strengths Depakote Sprinkles Caps: 125 mg Depakote ER ER tabs: all strengthsDOCUSATE SODIUM Colace Caps: 100 mgDONEPEZIL Aricept Tabs: all strengthsDORZOLAMIDE Trusopt 2% Oph soln: 10 mlDORZOLAMIDE / TIMOLOL Cosopt Oph soln: 2%-0.05%DOXAZOSIN Cardura Tabs: all strengthsDOXEPIN Adapin Caps: all strengths Soln: 10mg/mlDOXYCYCLINE HYCLATE Vibramycin Tabs: 100 mg Caps: 50, 100mgEPINEPHRINE Epi-Pen/Epi-Pen Jr Auto-injector 0.15mg/dose, 0.3mg/dose TwinjectEPINEPHRINE Ephfrin 2% Oph soln: 15 mlERGOTAMINE TARTRATE Cafergot Tabs: 100 mg/1 mgW/CAFFEINEERYTHROMYCIN Erythrocin Tabs: all strengths Susp: 200 mg/5 ml Romycin Oph oint: 0.5% 5 mg/gm 2% Topical soln: 60 ml 2% gelERGOCALCIFEROL Vitamin D Gel Caps: 50,000 unitsESOMEPERZOLE Nexium Caps: all strengthsESTRADIOL Estrace Tabs: all strengths Estraderm Patch: all strengths Vivelle Dot EsclimESTROGEN/ Estratest HS Tabs: 0.625/1.25 mgMETHYLTESTOSTERONEETHAMBUTOL Myambutol Tabs: all strengthsETHINYL ESTRADIOL/ DESOGESTREL Orthocept (Reclipsen) 0.03 mg EE/.015 mg D 28 day packsETHINYL ESTRADIOL/ Yasmin Tabs: 30 mcg/3 mg; 28 day packsDROSPIRENONE Yaz Tabs: 20 mcg/3 mg; 28 day packsETHINYL ESTRADIOL/ Nuvaring Vaginal ringETONOGESTRELETHINYL ESTRADIOL TriLevlen, TriPhasil, Alesse, Tabs:LEVONORGESTREL Lutera 28 day packsETHINYL ESTRADIOL/ Nordette, Mircette 28 day packsLEVONORGESTRELETHINYL ESTRADIOL/ Ortho Evra Transdermal patchNORELGESTROMILETHINYL ESTRADIOL/ Ortho-Novum 28 day packsNORETHINDRONE Loestrin 1/20 FE Necon 1/35ETHINYL ESTRADIOL/ Ortho-Cyclen 28 day packsNORGESTIMATE Ortho Tri-cyclen Ortho Tri-cyclen LOETHINYL ESTRADIOL/ NORGESTREL Ovral, LoOvral 28 day packsETONORGESTREL Implanon IM deviceEZETMIBE Zetia Tabs: 10 mgFAMOTIDINE Pepcid Tabs: 20mg and 40mgFELODIPINE Plendil Tabs: all strengthsFENOFIBRATE Lofibra, Tricor Tabs: 48mg, 54mg, 145mg, and 160 mgFERROUS SULFATE FeoSol Soln: 25 mg/ml, 50ml. Tabs: 325 mgFEXOFENADINE Allegra Tabs: 60, 180 mgFINASTERIDE Proscar Tabs: 5 mg 13
  14. 14. FLUCONAZOLE Diflucan Tabs: all strengthsFLUDROCORTISONE Florinef Tabs: 0.1 mgFLUNISOLIDE Nasarel Nasal spray: 25 mcg. 200 sprays/unitFLUOCINOLONE Synalar Soln: 1%, 60 mlFLUOCINONIDE Lidex *Cream: 0.05%, 15 g, 60 g Gel: 0.05%, 60 g Oint: 0.05%, 60 gFLUORIDE Prevident 5000+, Luride Gel: 1.1%, 2oz Drops: 1.1 mg/ml Tabs: 1.1 mgFLUOROMETHOLONE Fluor-Op, FML Susp: 0.1%, 15 mlFLUOXETINE Prozac Caps: 10, 20, 40 mg Soln: 20mg/5mlFLUTICASONE Flonase Nasal spray: 50 mcg, 120 sprays/unitFLUTICASONE HFA Flovent HFA Inhaler: 44, 110, 220 mcg **Qty limit 2 per 30 days**FLUTICASONE Diskus Flovent Diskus InhalerFLUTICASONE/ SALMETEROL Advair Inhaler: 100/50 mcg, 250/50mcg, 500/50 mcg Advair HFA Inhaler: 45/21 mcg, 115/21 mcg, 230/21 mcgFOLIC ACID Folic Acid Tabs: 1 mgFUROSEMIDE Lasix Tabs: all strengths Soln: 10mg/mlGABAPENTIN Neurontin Caps: all strengthsGEMFIBROZIL Lopid Tabs: 600 mgGENTAMICIN SULFATE Geramicin Oph soln: 0.3%, 5 ml Oph oint: 3.5 gGLIPIZIDE Glucotrol *Tabs: all strengths Glucotrol XL XL Tabs: all strengthsGLYBURIDE Micronase Tabs: all strengthsGLYBURIDE MICRONIZED Micronized: all strengthsGLYBURIDE/ METFORMIN Glucovance Tabs: all strengthsGLYCOPYRROLATE Robinul Tabs: 1 mgGOSERELIN Zoladex Implants: 3.6 mg, 10.8 mgGRAMICIDIN/NEOMYCIN/POLYMYXIN Soln: 0.025mg/2.5mg/10000unit/mlBGRISEOFULVIN Grispeg, Grifulvin V Tabs: 125, 250 mg Susp: 125 mg/5 mlGUAIFENESIN Mucinex Tabs: 600 mgGUAIFENESIN/PSE MucinexD Tabs: 600/60 mg,GUAIFENSIN/DEXTROMETHORPHAN Robitussin DM Liq: 100/10 mg per 5 mlHALOPERIDOL Haldol Caps: 1 mg, 10 mgHOMATROPINE Isopto Homatropine Liq: 5%, 5 mlHYALURONIC ACID Atopiclair Topical creamHYDRALAZINE Apresoline Tabs: 10, 25, 50 mgHYDROCHLOROTHIAZIDE HCTZ Caps 12.5 mg Tabs 25, 50 mgHYDROCODONE/ Vicodin *Tabs: 5/500 mgACETAMINOPHEN Vicodin ES ES Tabs: 7.5/750 mgHYDROCORTISONE Anusol HC Cream: 2.5% Supps: 25 mgHYDROCORTISONE ACETATE/ Proctofoam Foam: 1%, 10 gPRAMOXINE Cream: 30 gHYDROCORTISONE VALERATE Westcort 0.2% Cream: 15 g, 60 g 0.2% Oint: 45 gHYDROCORTISONE/ Vosol HC Susp: 10 mlACETIC ACIDHYDROXYAMPHETAMINE/ Paremyd Soln: 1%/0.25%TROPICAMIDEHYDROXYCHLOROQUINE Plaquenil Tabs: 200 mgHYDROXYZINE Atarax Tabs: all strengths Liq: 10 mg/5 mlIBANDRONATE Boniva Tabs: all strengths 14
  15. 15. IBUPROFEN Motrin Tabs: all strengths Susp: 100 mg/5 mlIMIPRAMINE Tofranil Tabs: all strengthsINDOMETHACIN Indocin *Caps: all strengths ER Cap: 75 mgINSULIN ASPART Novolog, Novolog Flexpen 100 units/ml, 10 ml vialINSULIN GLARGINE Lantus, Lantus SoloStar Pen 100 units/ml, 10 ml vial 100 units/ml, penINSULIN NPH/REGULAR 70/30 Novolin 70/30 100 units/ml, 10 ml vialINSULIN HUMAN NPH Novolin N 100 units/ml, 10 ml vialINSULIN HUMAN 70/30 Novolog Mix 70/30 100 units/ml, 10 ml vialINSULIN HUMAN REGULAR Novolin R 100 units/ml, 10 ml vialINSULIN SYRINGES Boxes of 100: 0.5 ml, 1 ml 29 G,½”INSULIN PEN NEEDLES **Limit 300 syringes/90 days**IPATROPIUM BROMIDE Atrovent Neb Soln, Nasal spray Atrovent HFA InhalerISONIAZID INH Tabs: all strengths Syrup: 50 mg/5 mlISOSORBIDE DINITRATE Isordil SR Caps: 40 mg Tabs: all strengthsISOSORBIDE MONONITRATE Imdur Tabs: all strengthsISOTRETINOIN Accutane Caps: all strengthsKETOCONAZOLE Nizoral Cream: 30 g Shampoo: 4 ozKETOROLAC TROMETHAMINE Acular Oph soln: 0.5%, 5mlKETOTIFEN Zaditor Oph soln: 0.025 % 5 mlLACTULOSE Cepulac Syrup: 10 g/15 mlLAMOTRIGINE Lamictal Tabs: all strengthsLANCETS Soft-Touch Boxes of 200 Accu-chek Soft ClixLANCET DEVICE Soft-Touch DeviceLATANOPROST Xalatan Oph soln: 0.005%, 2.5 mlLEUCOVORIN Leucovorin Tabs: 5 mgLEVALBUTEROL Xopenex Inhaler: 200 sprays/unitLEVOBUNOLOL Betagan Oph Soln: 0.5%, 5mlLEVOCABASTINE Livostin Oph soln: 0.025%, 5 mlLEVOFLOXACIN Levaquin Tabs: all strengths Soln: 25mg/mlLEVONORGESTREL Plan B One-Step Tabs: 1.5mg Next Choice Tabs: 0.75mgLEVONORGESTREL IUD Mirena IUD *Must have scheduled appt*LEVOTHYROXINE Synthroid Tabs: all strengthsLIDOCAINE HCL Xylocaine Gel: 2%, 30 ml Soln: 2%, 100 ml Lidoderm Top Patch: 5%LISINOPRIL Zestril Tabs: all strengthsLISINOPRIL/HCTZ Zestoretic Tabs: all strengthsLITHIUM CARBONATE Lithium Tabs: all strengths Lithium citrate Syrp: 8mEq/5mlLOPERAMIDE Imodium Caps: 2 mgLORATADINE Claritin Tabs: 10 mg Syrup: 1 mg/mlLORAZEPAM Ativan Tabs: all strengthsLOSARTAN Cozaar Tabs: all strengthsLOSARTAN/HCTZ Hyzaar Tabs: all strengthsLOTEPREDNOL Alrex Susp: 0.2%, 5 mlLUBRICANT Lacrilube Opth oint: 3.5 gLUVOXAMINE Luvox Tabs: 100 mgMEBENDAZOLE Vermox Chew Tabs: 100 mgMECLIZINE Antivert Tabs: all strengths 15
  16. 16. MEDROXYPROGESTERONE Depo Provera Injection: 150 mg **Must have appt for administration**MEDROXYPROGESTERONE Provera Tabs: all strengthsMEFLOQUINE Lariam Tabs: 250 mgMELOXICAM Mobic Tabs: 7.5, 15 mgMETAXOLONE Skelaxin Tabs: 800 mgMETFORMIN HCL Glucophage Tabs: all strengths Glucophage XR XR Tabs: all strengthsMETHOCARBAMOL Robaxin Tabs: all strengthsMETHOTREXATE Rhemstrex Tabs: 2.5 mgMETHYLDOPA Aldomet Tabs: all strengthsMETHYLPHENIDATE Ritalin C-II *Tabs: all strengths SR Tabs: 20 mgMETHYLPHENIDATE XR Concerta C-II Tabs: all strengthsMETHYLPREDNISOLONE Medrol Tabs: 4 mg, dosepackMETOCLOPRAMIDE HCL Reglan Tabs: all strengths Liq: 5 mg/5 mlMETOPROLOL Lopressor Tabs: all strengths Toprol XL Tabs: all strengthsMETRONIDAZOLE Flagyl Tabs: all strengthsMETRONIDAZOLE Metrogel-Vaginal Gel: 0.75%, 70 gMINOCYCLINE Minocin Caps: all strengthsMI PASTE PLUS MI Paste Dental pasteMOISTURIZING CREAM Eucerin cream CreamMOMETASONE Elocon Cream: 15g, 30gMOMETASONE Nasonex Nasal spray Asmanex TwisthalerMOMETASONE/FORMOTEROL Dulera InhalerMONITOR, BLOODGLUCOSE Precision Xtra Kit AccuCheck AvivaMONTELUKAST Singulair Tabs: all strengths Oral granules: 4 mgMORPHINE SULFATE IR Morphine C-II Tabs: all strengthsMORPHINE SULFATE ER MS Contin C-II ER Tabs: all strengthsMOXIFLOXACIN Vigamox Oph Soln: 0.5%, 5mlMULTIVITAMIN PEDIATRIC Poly Vi Sol w/Iron Soln: 50 mlSOLUTION W/IRONMULTIVITAMIN W/ FLUORIDE Poly Vi Flor Soln: 50 ml Chew Tab: 0.25mg, 0.5 mgMUPIROCIN Bactroban Oint: 15 gNAPROXEN Naprosyn Tabs: all strengths Naproxen sodium Tabs: all strengths Susp: 125mg/ 5mlNEFAZODONE Serzone Tabs: 150 mgNEOMYCIN/POLYMYXIN/HC Cortisporin HC Soln, Susp: 10 mlNEOMYCIN/POLYMYXIN/ Neosporin Ophth ointBACITRACINNEOMYCIN/POLYMYXIN/ Neosporin Oph soln 10 mlGRAMICIDINNIACIN Niaspan *CR Tabs: all strengthsNICOTINE Nicoderm Patches: all strengthsNIFEDIPINE Adalat CC *SR Tabs: all strengths Procardia Caps: 10 mgNITROFURANTOIN Macrobid Caps: 100 mg Macrodantin Caps: all strengthsNITROGLYCERIN Nitrostat, Nitrobid, Nitro SL Tabs: 0.4 mg Dur SL Spray: 0.4 mg SR Caps: all strengths Patches: all strengthsNORETHINDRONE Micronor 28 day packs 16
  17. 17. NORTRIPTYLINE Pamelor Caps: all strengths Soln: 10mg/5mlNYSTATIN Niastat Cream: 15 g Oint: 15 g Powder 100,000 unit Susp: 100,000 units/60 mlOFLOXACIN Ocuflox Oph Soln: 0.3% 5 mlOFLOXACIN Floxin Otic Soln: 5 mLOLANZAPINE Zyprexa Tabs: all strengthsOLOPATADINE Patanol Oph soln: 0.1 % 5 mlOMEPRAZOLE Priolosec Caps: all strengthsOXYBUTYNIN Ditropan Tabs: 5mgOXYBUTYNIN ER Ditropan XL Tabs: all strengthsOXYCODONE/ Percocet Tabs: 5/325 mgACETAMINOPHENOXYMETAZOLINE Afrin nasal spray Soln: 0.05% (15 ml)PANTOPRAZOLE Protonix Tabs: 40mgPAROXETINE Paxil Tabs: all strengthsPENICILLIN VK PenV K, Veetids Susp: 125mg/5ml, 250 mg/5 ml Tabs: all strengthsPERMETHRIN Elimite, Nix Cream: 5%, 60 g Cream: 1%, twinpack 60 mlPHENAZOPYRIDINE Pyridium Tabs: all strengthsPHENOBARBITAL Phenobarbital Tabs: 15, 30, 60, 100 mg Liq: 20 mg/5 mlPHENYLEPHRINE Mycifrin Oph soln: 2.5%, 15 mlPHENYTOIN Dilantin Caps: 100 mg Tabs Chew: 50 mg Susp: 125mg/5mlPILOCARPINE Pilocar Oph Soln: all strengths Oph Gel 4%PIMECROLIMUS Elidel Tube: 15 g, 30 gPIOGLITAZONE Actos Tabs: all strengthsPIOGLITAZONE/ Actoplus met Tabs: 15/850, 15/500 mgMETFORMINPOLYETHYLENE GLYCOL Trilyte Pwd for Reconst: 4 LPOLYETHYLENE GLYCOL 3350 Miralax Powder: 527, 255 gPOLYMYXIN B/TRIMETHOPRIM Polytrim Oph soln: 5 mlPOTASSIUM BICARBONATE/POT Klorvess Packets: 20 mEqCHLORIDE Box of 30POTASSIUM CHLORIDE Klor-con ER Tabs: all strengths Powder packet: 20 mEq Soln: 20 mEq/15 ml Micro K CR Caps: 10 mEqPRAVASTATIN Pravachol Tabs: all strengthsPRAZOSIN Minipress Caps: all strengthsPREDNISOLONE Prelone/Orapred Liq: 15 mg/5 mlPREDNISOLONE ACETATE Pred Forte Oph Susp: 1%, 5 ml Pred Mild Oph Susp: 0.12%PREDNISOLONE ACETATE/ AKCide Oph ointSULFACETAMIDEPREDNISONE Orasone, Deltasone Tabs: all strengths Syrup: 5mg/5mlPRENATAL VITAMINS + FOLIC ACID Natalins Tabs : PNV with 1mg folic acid **Limited to women age 45 and younger**PRENISOLONE SODIUM PHOSPHATE Inflamase Susp: 1/8%, 1%, 5 mlPRIMAQUINE Primaquine Tabs: 23.6 mgPRIMIDONE Mysoline Tabs: all strengthsPROBENECID Benemid Tabs: 500 mgPROCHLORPERAZINE Compazine Tabs: all strengths Supps: 25 mgPROGESTERONE Prometrium Caps: 100, 200 mg 17
  18. 18. PROMETHAZINE Phenergan Tabs: all strengths Supps: all strengths Syrp: 6.25mg/5mlPROMETHAZINE/DEXTROMETHORPH Phenergan DM Syrp: 120 mlANPROPARACAINE Ophthaine Soln: 0.5%, 15 mlPROPOXYPHENE/ Darvocet-N 100 Tabs: 100/650 mgACETAMINOPHENPROPRANOLOL Inderal Tabs: 10, 40 mg Inderal LA LA Caps: 80 mgPROPYLTHIOURACIL PTU Tabs: 50 mgPSEUDOEPHEDRINE Sudafed Tabs: 30, 120 mg Liq: 30 mg/5 mlPYRAZINAMIDE PZA Tabs: 500 mgPYRIDOSTIGMINE Mestinon Tabs: 60 mgPYRIDOXINE Vitamin B6 Tabs: all strengthsQUETIAPINE Seroquel Tabs: all strengths Seroquel XR XR: all strengthsRALOXIFENE Evista Tabs: 90 mgRANITIDINE Zantac Tabs: all strengths Syrup: 15 mg/mlRIFAMPIN Rifadin Caps: 300 mgRIMEXOLONE Vexol Oph Susp: 1%RISPERIDONE Risperdal Tabs: all strengths Soln 1mg/mlRIZATRIPTAN Maxalt Tabs: all strengths Maxalt MLT MLT tabs: all strengths **DoD Quantity limit 36 tablets/90 days**ROVUSTATIN Crestor Tabs: all strengths **DoD requires Prior Authorization from MDSALICYLIC ACID Clear Away Plasters: 40%SALINE NASAL SPRAY Sea-mist Soln: 0.65%SALMETEROL Serevent Diskus *Inhaler: 18 mcg, 200 sprays/unit Serevent Neb Soln: 0.02%/2.5 ml, 30 unitSALISALATE Disalcid Tabs: 500, 750 mgSCOPOLAMINE Transderm Scop Patch: 1.5 mgSELENIUM SULFIDE Selsun Shampoo: 2.5% 120 mlSERTRALINE Zoloft Tabs: all strengths Liq: 20mg/mlSILVER SULFADIAZINE Silvadene 1% creamSIMVASTATIN Zocor Tabs: all strengthsSIMVASTATIN/EZETIMIBE Vytorin Tabs: all strengthsSODIUM CHLORIDE 0.9% Normal saline 3ml vials for NebulizationSPACER Optichamber Device Optichamber w/mask Aerochamber w/maskSPIRONOLACTONE Aldactone Tabs: all strengthsSUCRALFATE Carafate Tabs: 1 g Liq: 1 g/10 mlSULFACETAMIDE Sulamyd, Bleph-10 Oph soln: 10%, 15 ml Opth oint: 3.5 gSULFACETAMIDE SODIUM/ Vasocine Opth oint: 10%/0.5%PREDNISOLONE ACETATESULFACETAMIDE SODIUM/ Isopto Catapred Susp: 10%/0.25%, 15ml.PREDNISOLONE ACETATESULFACETAMIDE/ Plexion Cleanser: 6ozSULFUR CLEANSERSULFAMETHOXAZOLE/ Pediazole Susp:600/200 mg/5 mlERYTHROMYCIN 18
  19. 19. SULFAMETHOXISOLE/ Bactrim, Septra, Bactrim DS Tabs: all strengths TRIMETHOPRIM Sulfatrim Susp:40/200 mg /5 ml SULFASALAZINE Azulfidine Tabs: 500 mg EC Tabs: 500mg SUMATRIPTAN Imitrex Tabs: 25, 50 mg **DoD Quantity limit 54 tablets/90 days** Tabs: 100 mg **DoD Quantity limit 27 tablets/90 days** SUMATRIPTAN Imitrex Stat Dose Kit all strengths TAMOXIFEN Nolvadex Tabs: all strengths TAMSULOSIN Flomax Caps: 0.4mg TELMISARTAN Micardis, Tabs: all strengths TELMISARTAN/HCTZ Micardis HCT Tabs: all strengths TEMAZEPAM Restoril C-IV Caps: all strengths TERAZOSIN Hytrin Caps: all strengths TERBUTALINE Brethine Tabs: 5 mg TERCONAZOLE Terazol 7 Cream: 0.4%, 20 g TETRACYCLINE Achromycin Caps: all strengths THEOPHYLLINE Theo-24 24 hr Caps: all strengths Theodur *12 hr Tabs: all strengths *Liq: 80 mg/15 ml Uniphyl *24 hr Tabs: 400mg THIAMINE Vitamin B1 Tabs: all strengths TIMOLOL MALEATE Timolol Oph soln: all strengths Timoptic XE Gel: all strengths TIOTROPIUM Spiriva Inh w/ device: 18 mcg TOBRAMYCIN Tobrex Soln: 0.3%, 5 ml TOBRAMYCIN/DEXAMETHASONE Tobradex Susp: 0.3%/0.1%, 2.5 ml Opth Oint: 3.5 g TOLNAFTATE Tinactin Soln: 1%, 10 ml TOLTERODINE Detrol LA SR Caps: all strengths TOPIRAMATE Topamax Tabs: all strengths TRAMADOL Ultram Tabs: all strengths **DoD Quantity Limit 240 tabs per 30 days** TRAZADONE Desyrel Tabs: 50, 100, 150, 300 mg TRETINOIN Retin A, Avita Cream: all strengths **Limited to persons <36 yrs of age** TRIAMCINOLONE Kenalog in Orabase Paste: 0.1% 5 gT TRIAMCINOLONE Kenalog *Cream: 1%, 5% Spray: 15 mcg/spray. 63g Ointment: 1% TRIAMTERENE/HCTZ Maxzide Tabs: 37.5/25, 75/50 mg TRIHEXYPHENIDYL Artane Tabs: all strengths *Elixir: 0.4mg/ml TRIMETHOBENZAMIDE Tigan Caps: 300 mg TRIMETHOPRIM/POLYMYXIN B Polytrim Soln: 10 ml TROPICAMIDE Mydriacyl Soln: 1%, 15 ml VALACYCLOVIR Valtrex Tabs: all strengths VALPROIC ACID Depakene Liq: 250 mg/5ml VALSARTAN Diovan Tabs: all strengths VALSARTAN/HCTZ DiovanHCT Tabs: all strengths VARDENAFIL Levitra Tabs: all strengths Under 40? Need prior authorization form **DoD Quantity limit 18 tablets/90 days** VARENECLINE Chantix Tabs: Starter pack, continuing treatment pack (0.5, 1 mg tabs) **Must be enrolled in Smoking Cessation class** VENLAFAXINE Effexor, Effexor XR XR Caps: all strengths VERAPAMIL Calan Tabs: 80 mg SR Tabs: all strengths 19
  20. 20. WARFARIN Coumadin Tabs: all strengthsXYLITOL Spry Gum Dental chewing gumZIPRASIDONE Geodon Caps: all strengthsZOLPIDEM Ambien C-IV Tabs: all strengthsZOMITRIPTAN Zomig/Zomig ZMT Tabs: all strengths/Oral disintegrating tabs **DoD Quantity limit 36 tablets/90 days** 20
  21. 21. Quick List for Common Uses For Asthma/Allergies For Blood pressure For CholesterolInhalers: Albuterol (Ventolin/Proventil ACEs: benazepril (Lotensin), captopril Statins: atorvastatin (Lipitor),HFA), levalbuterol (Xopenex) MDI, (Capoten), lisinopril (Zestril) pravastatin (Pravachol), simvastatinsalmeterol (Serevent Diskus) (Zocor) ARBs: candesartan (Atacand), losartanNebulizer solutions: albuterol, (Cozaar), telmisartan (Micardis), Other: Ezetimibe (Zetia), fenofibratebudesonide (Pulmicort), ipratropium valsartan (Diovan) (Lofibra), niacin (Niaspan), gemfibrozil (Lopid)Other: montelukast (Singulair) BBs: atenolol (Tenormin), carvedilol (Coreg), metoprolol succinate (Toprol Combo: ezetimibe/simvastatinSteroids: fluticasone (Flovent HFA) XL), metoprolol tartrate (Lopressor) (Vytorin)mometasone (Asmanex) CCBs: amlodipine (Norvasc), diltiazemCombo: albuterol/salmeterol (Advair & ER (Tiazac), felodipine (Plendil),Advair HFA), budesonide/formoterol nifedipine SR (Adalat CC), verapamil(Symbicort) (Calan SR)Allergies: cetirizine (Zyrtec), loratadine Diuretics: furosemide (Lasix), HCTZ,(Claritin), fexofenadine (Allegra), spironolactone, triamterene/HCTZcetirizine/pseudoephedrine (Zyrtec-D) (Maxzide)Nasal: azelastine (Astelin), fluticasone Combos: benazepril/amlodipine(Flonase), mometasone (Nasonex), (Lotrel), lisinopril/HCTZ (Zestoretic)fluocinonide (Nasarel) losartan/HCTZ (Hyzaar), telmisartan/HCTZ (Micardis HCT), valsartan/HCTZ (Diovan HCT) For Diabetes For Migraines Controlled SubstancesOral Agents: Glipizide (Glucotrol & Triptans: rizatriptan (Maxalt & Maxalt The state of California requiresGlucotrol XL), Glyburide (Micronase), MLT), sumatriptan (Imitrex), that controlled substances MUSTMetformin (Glucophage & Glucophage zolmitriptan (Zomig & Zomig ZMT) be written on a California SecurityXR), pioglitazone (Actos), [Please note DoD quantity limitations] Prescription pad.pioglitazone/metformin (Actoplusmet) Acetaminophen/butalbital/caffeine C-II: Adderall and Adderall XR, Ritalin,Insulin: Novolog (aspart), Novolin N (Fioricet) Concerta, Morphine IR, MS Contin,(NPH), Novolin R (regular), Novolin Percocet70/30 (NPH/Reg), Novolog Mix 70/30(NPH/Reg), Lantus (glargine) C-III: Tylenol w/ codeine #3, Codeine sulfate, Vicodin, and Vicodin ESSyringes: 0.5 ml, 1ml. BD Sharpscontainer for disposal. Insulin Pen C-IV: Alprazolam (Xanax), Clonazepamneedles (Klonapin), diazepam (Valium), lorazepam (Ativan), temazepamBlood glucose monitors/test strips: (Restoril), zolpidem (Ambien).Accu-chek Aviva, Precision Xtra (box of50 test strips) C-V: Robitussin AC (qty of 120ml), LomotilLancets (box of 200): Accu-chekSoftclix for Aviva Accu-check Soft NOTE: C-II: no refills allowed C-III-V:touch plus lancet device for Precision prescription only valid for 6 months.Xtra. Refills are allowed but may not exceed 6 months 21
  22. 22. Quick Reference Telephone ListEmergencies............................................................ 911Emergencies from cell phone on base................... 661- 277- 4541Poison Control ...................................................... 800-222-1222Appointments:Family practice ...................................................... 661-277-7118, option 1, then 1Pediatrics................................................................ 661-277-7118, option 1, then 2Flight Surgeon’s Office.......................................... 661-277-7118, option 1, then 3Optometry.............................................................. 661-277-7118, option 1, then 4Physical Therapy.................................................... 661-277-7118, option 1, then 5Dental Clinic.......................................................... 661-277-2872Family Advocacy................................................... 661-277-5292Flight Surgeon’s Office.......................................... 661-277-7118 option 3Health and Wellness Center.................................... 661-277-8480Immunizations.........................................................661-277-3427Laboratory............................................................... 661-277-2306Mental Health..........................................................661-277-5291Managed Care......................................................... 661-277-6969NurseLine................................................................ 661- 275-6877, or 888-762-3842Patient Administration........................................... 661-275-2668Pharmacy................................................................ 661-277-9896Physical Therapy.................................................... 661-277-3891Primary Care Clinic............................................... 661-277-7118Public Health.......................................................... 661-275-2694Radiology................................................................ 661-277-2681TriWest/TRICARE................................................. 888-874-9378 Base Exchange: Main Store 258-1078 Commissary 277-4589 Family Child Care Program 275-4FCC/275-4322 Golf Course 275-PUTT/275-7888 Information, Tickets and Travel (leisure) 275-TRIP/275-8747 Base Schools Switchboard 258-4411 Security Forces 277-3340 Retiree Activity Office 277-4931 22