Holloman AFB Formulary as of 20 feb 2013


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Holloman AFB Formulary as of 20 feb 2013

  1. 1. HOLLOMAN AFB FORMULARYDISPENSING POLICIES / refills. Prescriptions for Schedule 2PROCEDURES medications will be honored for 7 days from the date they were written with no refills.MAIN Pharmacy Providers are reminded to include their DEA280 First St, Bldg 15 number on all controlled prescriptions.Holloman AFB, NM 88330Open: 0730 – 1630, M-F - REFILL POLICY: Refills MUST be calledTEL. NO: (575) 572-2778 opt 4,1, and 4 in through the automated refill system atFAX No: (575) 572-5781 572-7045. They may be called in 7 daysREFILL Pharmacy before the Rx should run out. Please allowTEL. NO: (575) 572-7045 / 1-800-843-4682 for 2 duty days for refills to be ready.The Pharmacy is closed: Saturday, Sunday, - Although medications are provided at noall federal holidays and specially designated cost to our patients, this service is not free— ‘down’ days the American taxpayer pays the bill. Please consider less expensive alternatives-The pharmacy must use generic medication whenever possible when prescribing.whenever possible so please write allmedications generically. TRICARE MAIL ORDER PHARMACY (EXPRESS SCRIPTS): Contact 1-866-363--A prescription written as “Dispense as 8667 or www.express-scripts.com/TRICAREWritten” may not be accepted. for more information. 30 or 90 day supply:-Drugs with narrow therapeutic margins will Active duty: No costnot be generically substituted. All Other Beneficiaries: Generic $0, Formulary Brand-Name: $13; Non-- TELEPHONE PRESCRIPTIONS: Per Air Formulary Brand-Name: $43Force directives, no pharmacy staff membermay receive a prescription called in from a Copayments at Retail Pharmacies are $5 forprovider. This also includes prescription generic drugs, $17 for brand name and $44renewals. The pharmacy can, however, for non-formulary.accept a change or substitution to a non-controlled prescription if the original **The brand name in the listings are forprescription is located within the pharmacy. reference only and do not signify the product dispensed**-Fax’s: New prescriptions for non-controlledsubstances and controlled substances inschedules III-V from providers offices,hospitals, or nursing homes may be faxed.- NON-CONTROLLED PRESCRIPTIONS:Are honored up to 1 year from the date theprescription was written. Antibioticprescriptions over 10 days old will be filled atthe discretion of the pharmacy.Prescriptions for maintenance medicationsmay be written for up to a 90 day supply witha maximum of 3 refills when requested byprescriber. All other non-controlledprescriptions may be written for up to 30days supply with a maximum of 11 refills.- CONTROLLED PRESCRIPTIONS(**):Prescriptions for Schedule 3, 4 or 5medications will be honored for 6 monthsfrom the date they were written with up to 5
  2. 2. HOLLOMAN AFB FORMULARY Amox / Clav (Augmentin) Griseofulvin (Grifulvin-V) I. Anti-Infective Agents Tabs 250mg, 500mg, Oral Susp 125mg / 5 875mg mL (microsized)Cephalosporins Amox / Clav (Augmentin) Griseofulvin Ultra (Gris- Susp 125mg/5ml, Peg) Tabs 125mgCefdinir (Omnicef) Caps 400mg/5ml, Ketoconazole (Nizoral)300 mg 600mg/5ml Tabs 200mgCefdinir (Omnicef) Susp Dicloxacillin (Dynapen) Ketoconazole (Nizoral) 2%125mg/5ml, 250mg/5ml Caps 250mg ShampooCefpodoxime (Vantin) Penicillin V Pot (Pen VK) Nystatin (Mycostatin) TabsTabs 100mg, 200 mg Tabs 250mg, 500mg 500,000 unitsCefpodoxime (Vantin) Penicillin V Pot (Pen VK) Terbinafine (Lamisil) TabsSusp 100mg / 5mL Oral Susp 250mg /5mL 250mgCephalexin (Keflex) Caps250mg, 500mg Sulfonamides AntiviralCephalexin (Keflex) Susp250mg / 5mL Sulfamethoxazole 800mg / Amantadine (Symmetrel) Trimethoprim 160mg Caps 100mgFluoroquinolones (Bactrim DS) Tabs Acyclovir (Zovirax) Caps Sulfamethoxazole 200mg/ 200mg, Tabs 800mg,Ciprofloxacin (Cipro) Tabs Trimethoprim 40mg Sus 200mg/5ml 100mg, 250mg, 500 (Bactrim Pediatric) Hydroxychloroquine mg, Susp 250mg/5ml Susp (Plaquenil) TabsLevofloxacin (Levaquin) 200mg Tabs 250mg, 500mg, Tetracyclines Metronidazole (Flagyl) 750mg, Sol 25mg/ml Tabs 250mg Doxycycline (Vibramycin) Oseltamivir (Tamiflu) TabsMacrolides Tabs 100mg 75mg, Sol 6mg/ml Tetracycline (Achromycin) Valcyclovir (Valtrex) Tabs Azithromycin (Zithromax) Caps 250mg 500mg Susp 200mg / 5mL Minocycline (Minocin) Azithromycin (Zithromax) Caps 100mg Antitubercular Agents Susp 100 mg / 5 mL Azithromycin (Zithromax) Ethambutol (Myambutol) Other Z-pak Tabs 250mg, Tabs 100mg, 400mg Tri-Pak 500mg, 1gm Isoniazid (INH) Tabs packets Clindamycin (Cleocin) 100mg, 300mg Clarithromycin (Biaxin) Caps 150mg, 300 mg Isoniazid (INH) Syrup Tabs 250mg, 500mg Clindamycin (Cleocin) 50mg / 5mL Erythromycin (Ery-Tab) Liquid 75mg/5ml Pyrazinamide Tabs 500 Tabs 250mg, 333mg, Nitrofurantoin mg 400mg (Macrodantin) Caps Rifampin (Rifadin) Caps Erythromycin (EryPed) 50mg, 100mg 300mg Susp 200mg/5mL, Nitrofurantoin (Macrobid) 400mg / 5mL Caps 100mg Antihelmintic AgentPenicillins Antifungals Mebendazole (Vermox) Chew Tab 100mgAmoxicillin (Trimox) Susp Fluconazole (Diflucan) 250mg/5ml; Tabs 150mg, Susp 400mg/5mL 10mg/ml II. CardiovascularAmoxicillin (Trimox) Caps Agents 250, 500mg2
  3. 3. Antianginals/Vasodilator MISC 80mg/12.5mg, 160mg/12.5mg, Ezetimibe (Zetia) 160mg/25mg,Nitroglycerin sl Tabs Tabs10mg 320mg/12.5mg, 0.3mg, 0.4mg, Pump Niacin (Niaspan Extended- 320mg/25mg Spray, Oint 2%, Release) Tabs 500mg, Patches 0.1mg/hr, 750mg, and 1,000mg BETA BLOCKERS 0.2mg/hr, 0.3mg/hr, Nicotinic Acid (Niacin) Tab 0.4mg/hr, 0.6mg/hr, 500mg Atenolol (Tenormin) Tabs 0.8mg/hr 25mg, 50mg, 100mgIsosorbide Dinitrate Tabs Antihypertensives Carvedilol (Coreg) Tabs 5mg, 10mg, 40mg SR 3.125mg, 6.25mg, caps ACE 12.5mg, and 25mgIsosorbide Mononitrate INHIBITORS/COMBIN Labetalol (Trandate) Tabs (Imdur) Tabs 30mg, ATION PRODUCTS 200mg 60mg, and 120mg Metoprolol (Lopressor) Amlodipine/Benazepril Tabs 25 mg, 50mg, (Lotrel) Caps 2.5/10, and 100mgAntihyperlipemics 5/10, 5/20, 10/20, Metoprolol XL (Toprol XL) 5/40, 10/40 mg Tabs 25mg, 50mg, Captopril (Capoten) Tabs BILE ACID 100mg, and 200mg 25mg, 50mg, and SEQUESTRANT 100mg Propranolol (Inderal) Tabs Lisinopril (Prinivil, Zestril) 10mg, 40mgColestipol (Colestid) Tabs 2.5mg, 5mg, granules 300gm/box Propranolol (Inderal LA) 10mg, 20mg, 30mg,Colestipol (Colestid) Tabs Caps 60mg, 80mg, and 40mg 1gram and 120mg Lisinopril-HCTZ (Zestoretic) Tabs 10- FIBRIC ACID 12.5mg, 20-25mg, 20- DERIVATIVES 12.5mg Ramipril (Altace) Caps CALCIUM CHANNELFenofibrate (TriCor) Tabs BLOCKERS 2.5mg, 5mg, 10mg 48mg, 145mgGemfibrozil (Lopid) Tabs Amlodipine (Norvasc) ANGIOTENSIN II 600mg Tabs 2.5mg, 5mg, BLOCKERS/COMBIN ATION DIURETIC 10mg HMG-CoA REDUCTASE Diltiazem (Tiazac) Tabs INHIBITOR 60mg Losartan (Cozaar) Tabs 25mg, 50mg, and Diltiazem (Tiazac SR)Atorvastatin (Lipitor) Tabs Caps 120mg, 180mg, 100mg 10mg, 20mg, 40mg, 240mg, 300mg, Losartan/HCTZ (Hyzaar) 80mg 360mg, and 420mg Tabs 50/12.5mg,Pravastatin (Pravachol) Felodipine (Plendil) Tabs 100/25mg Tabs 10mg, 20mg, 2.5mg, 5mg, 10mg Telmisartan (Micardis) 40mg, and 80mg Nifedipine SR (Adalat CC) Tabs 20mg, 40mg,Rosuvastatin(Crestor) Tabs 30g, 60mg, and and 80mgTabs 5mg, 10mg, 20mg, 90mg Telmisartan/Hctz (Micardis40mg Verapamil (Calan) Tabs HCT) 80mg/12.5mg,Simvastatin (Zocor) Tabs 80mg 80mg/25mg,5mg, 10mg, 20mg, 40mg, Verapamil (Calan SR) 40mg/12.5MGand 80mg Tabs 120mg,180mg, Valsartan (Diovan) TabsEzetimibe/Simvastatin 240mg 40mg, 80mg, 160mg,(Vytorin) Tabs 10/10, 320mg10/20, 10/40, 10/80 mg Valsartan/HCTZ (Diovan HCT) Tabs 3
  4. 4. HOLLOMAN AFB FORMULARY ALPHA-ADRENERGIC Primidone (Mysoline) Tabs BLOCKERS LOOP 50mg, 250mgDoxazosin (Cardura) Furosemide (Lasix) Tabs BENZODIAZEPINE Tabs 2mg, 4mg, and 20mg, 40mg, sol 8mg 10mg/ml **Clonazepam (Klonopin)Prazosin (Minipress) Tabs 0.5mg Caps 1mg, 2mg, 5mg THIAZIDE/COMBINATION **Diazepam (Valium) TabsTerazosin (Hytrin) Caps POTASSIUM_ 5mg 1mg, 2mg, 5mg, 10mg SPARING MISC MISC. Chlorthalidone (Hygroton) ANTIHYPERTENSIVES Tabs 25mg, 50mg Carbamazepine (Tegretol) Hydrochlorothiazide Chewtabs 100mg;Clonidine (Catapress TT (HCTZ) Caps 12.5mg Tabs 200mg, Sus Patches) 0.1 mg, 0.2 Hydrochlorothiazide 100mg/5ml mg, 0.3 mg (HCTZ) Tabs 25mg, Carbamazepine ExtendedClonidine (Catapres) 50mg Release (Tegretol XR) Tabs 0.1mg Hydrochlorothiazide 25mg Tabs 400mgHydralazine (Apresoline) / Triamterene 37.5mg Divalproex Sodium Tabs 10mg, 25mg (Maxzide-25) Tabs (Depakote) TabsMethyldopa (Aldomet) Indapamide (Lozol) Tabs 125mg, 250mg, Caps Tabs 250mg 2.5mg Sprk 125mg Metazolone (Zaroxolyn) Divalproex SodiumAntiplatelets / Tabs 5mg (Depakote ER) Tabs Anticoagulants 250mg, 500mg POTASSIUM-SPARING Gabapentin (Neurontin)Aspirin / Dipyridamole Caps100mg 300mg, Spironolactone 400mg, 600mg, (Aggrenox) caps (Aldactone) Tabs 5/200mg 800mg 25mg Phenytoin (Dilantin) CapsAspirin 81 mg Chewable Tabs, 325mg Tabs 100mgAspirin (Ecotrin) EC Tabs Phenytoin (Dilantin Antiarrhythmics Infatabs) Chewtabs 325mgDipyridamole 50mg (Persantine) Tabs Amiodarone (Pacerone) Phenytoin (Dilantin) Oral 25mg Tabs 200mg susp 125mg / 5mLClopidogrel (Plavix) Tabs Digoxin (Lanoxin) Tabs Topiramate (Topamax) 75mg 0.125mg, 0.25mg, Caps 15mg, TabsPrasugrel (Effient) Tabs Sol 0.05/ml 25mg, 50mg. 100mg, 5mg,10mg Mexiletine (Mexitil) Caps 200mgWarfarin (Coumadin) 250mg Tabs 1mg, 2mg, Antidepressants 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, and ALPHA-2 ANTAGONISTS 10mg III. Central Nervous Mirtazapine (Remeron) System Agents Tabs 15mgDiuretics Anticonvulsants CARBONIC ANHYDRASE INHIBITOR BARBITURATEAcetazolamide (Diamox) **Phenobarbital (Luminal) Tabs 250mg, Tabs 30mg; Syrup 500mgCaps 20mg/5ml4
  5. 5. DOPAMINE-REUPTAKE Mood Stabilizer / BENZODIAZEPINE INHIBITOR Antipyscotics Alprazolam (Xanax) TabsBupropion (Wellbutrin) 0.5mg Aripiprazole (Abilify) Tabs Tabs SR 100mg, Clonazepam (Klonopin) 2mg,5mg,10mg,15mg, 150mg Tabs 0.5mg 20mg Diazepam (Valium) Tabs Lithium Carbonate CapsSELECTIVE SEROTONIN 5mg 150mg, Tabs 300 mg, REUPTAKE Lorazepam (Ativan) Tabs syp 8meq/5ml INHIBITOR (SSRI) 1mg Olanzapine (Zyprexa) Temazepam (Restoril) Tabs 2.5mg, 5 mg,Citalopram (Celexa) Tabs Caps 15mg, 30mg and 10mg 20mg, 40mg Quetiapine (Seroquel)Fluoxetine (Prozac) Caps Tabs 25mg, 100mg, 10mg, 20mg, Sol 200mg, and 300mg 20mg/5ml MISC Quetiapine ExtendedParoxetine (Paxil) Tabs Release (Seroquel 20mg, 40mg Buspirone (Buspar) Tabs XR) Tabs 150mg,Sertraline (Zoloft) Tabs 5mg, 10mg 200mg, and 50mg 50mg, 100 mg, sol Zolpidem (Ambien) Tabs Risperidone (Risperdal) 20mg/ml 5mg, 10mg Tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg, SolSEROTONIN/NOREPINE Central Nervous System 1mg/ml PHRINE INHIBITOR Stimulants/ADHD Thioridazine (Mellaril) (SNRI) Medications Tabs 25mg, 100mgVenlafaxine (Effexor) Tabs Atomoxetine (Strattera) Anti- Parkinson’s Agents 75mg, 100mg; 10mg, 18mg, 25mg,XR Caps 37.5mg, 75mg, 40mg, 60mg Caps 150mg ANTICHOLINERGIC **Dextroamphetamine (Dexedrine) TabsSEROTONIN REUPTAKE Benztropine (Cogentin) 5mg; 10mg, 15mg SR INHIBITOR/ANTAGO Tabs 0.5mg, 2mg Caps NIST (SNIA) **Methylphenidate (Ritalin) DOPAMINE AGONIST Tabs 5mg, 10mgTrazodone (Desyrel) Tabs **Methylphenidate LA 50mg, 100mg Pramipexole (Mirapex) (Ritalin LA) Caps Tabs .025mg, 0.75mg 10mg, 20mg, 30mg, TRICYCLIC-(Limit of 30 Ropinirole (Requip) Tabs 40mg day supply) 0.25mg,0.5mg,1mg, **Methylphenidate SR 5mg (Ritalin SR) Tabs SRAmitriptyline (Elavil) Tabs Amantadine (Symmetrel) 20mg 10mg, 25mg, 100mg Caps 100mg **MethylphenidateDoxepin (Sinequan) Caps Carbidopa / Levodopa (Concerta) Tabs Ext. 25mg, 100mg, 150mg, (Sinemet) Tabs 25/250 Release 18 mg, 27mg, sol 10mg/ml mg, 25/100mg, 36mg, and 54mgImipramine (Tofranil) Tabs 10/100mg **D, L-amphetamine 10mg, 25mg Trihexyphenidyl (Artane) (Adderall) Tabs 5mg,Nortriptyline (Pamelor) Tabs 2mg, 5mg; Elixir 10mg, 20mg Caps 10mg, 25mg, sol 2mg/5ml **D, L-amphetamine 10mg/5ml (Adderall-XR) Caps Anxiolytics / Sedatives / 5mg, 10mg, 15mg, Hypnotics 20mg, 25mg, 30mg 5
  6. 6. HOLLOMAN AFB FORMULARY Antibiotics – Topicals Fluocinonide (Lidex) Cream, Ointment 0.05% Bacitracin ointMigraine Agents Fluocinolone (Derma- Clindamycin (Cleocin) 1% Smooth/FS) Oil 0.01% SolnSEROTONIN 5-HT1D Flurandrenolide (Cordran) Erythromycin 2% Soln, Gel AGONIST- (Limit Tape Metronidazole (Metrogel) Quantities) Hydrocortisone Cream 1% Gel 1%, 2.5% Mupiricin (Bactroban) 2%Sumatriptan (Imitrex) Hydrocortisone Valerate Oint Injection 6mg (Westcort) Cream0.2% Silver sulfadiazineSumatriptan (Imitrex) Tabs Triamcinolone (Kenalog) (Silvadene) Cream 1% 25mg, 50mg, and 0.1%; Cream, Spray 100mg Antifungals – TopicalsSumatriptan (Imitrex) Nasal spray 5mg, ANESTHETIC/CORTICOS 20mg Clotrimazole (Lotrimin) TEROIDZolmitriptan (Zomig) Tabs Topical sol 1%, Cream COMBINATION 2.5mg, 5mg 1% Ketoconazole (Nizoral) 2% Pramozine/Hydrocortisone MISC Cream, 2%Shampoo (Proctofoam HC) Miconazole (Monistat Foam 1%/1%**Acetaminophen 325 mg / Derm) Cream 2% Butalbital 50 mg / Nystatin/Triamcinolone Local Anesthetics- Caffeine 40mg (Mycolog) Cream topical (Fiorcet) Tabs 100,000 units/0.1%**Aspirin 325mg / Nystatin (Mycostatin) Cepacol lozenges Reg Butalbital 50mg / 100,000 units/gm Lidocaine (Xylocaine) Oint Caffeine 40mg Cream, Oint. Powder 5%; Jelly 2%; Visc (Fiorinal) Tabs Terbinafine (Lamisil) soln 2%Divalproex Sodium Cream 1% Lidoderm 5% Patches (Depakote ER) Tabs 250mg, 500mg Antiparasitic – Topical Misc-Topical Permethrin (NIX) 1%IV. Dermatologic Agents Aluminum chloride Cream Rinse (Drysol) Soln 20% Permethrin (Elimite)Acne Products Amlexanox (Aphthasol) Cream 5% Oral Paste 5%Adapalene (Differin) Ammonium lactate (Lac- Antiseborrheic Agent- Cream & Gel 0.1% Hydrin) Lotion12% TopicalBenzoyl Peroxide Gel Fluorouracil (Efudex) 2.5% Cream 5%Clindamycin/Benzoyl Selenium sulfide (Selsun) Pimecrolimus (Elidel) Peroxide (Benzaclin) Shampoo 2.5% Cream 1% Gel Podofilox (Condylox) SolnTretinoin (Retin A) Cream Corticosteroids-Topical 0.5% 0.025%, 0.05%, 0.1%; Salicylic acid (Duofilm) Gel 0.01%, 0.025% soln 17% Betamethasone Valerate (Age limit of 35 or Zinc Oxide Oint. 20% (Valisone) Cream younger) Diclofenac 1% Gel 0.1%Isotretinoin (Accutane) (Voltaren Gel) Clobetasol Propionate Caps 10mg, 20mg, Clotrimazole- (Temovate) Cream, 40mg Betamthasone Cream Oint, Soln 0.05% (Lotrisone)6
  7. 7. Docusate sodium (Colace) Ondansetron (Zofran Caps 100mg; ODT) 4mg, 8mg 150mg/15ml Syrup Ondansetron (Zofran) 2 Fleets Enema mg / mL liquid Fleets Oral Saline Laxative (PhosphaSoda) GoLytely/CoLytely VI. Genitourinary Agents Lactulose (Cephulac) V. Gastrointestinal Syrup 10mg / 15ml Urinary Tract Agents Agents MoviPrep OVERACTIVE BLADDER H2-ANTAGONIST ANTIDIARRHEALS AGENTSCimetidine (Tagamet) Bismuth subsalicylate Oxybutynin (Ditropan) Tabs 400mg; (Pepto-Bismol) Tabs 5mg; 5mg/5ml 300mg/5ml Syrup Chewtabs 262mg SyrupRanitidine (Zantac) Tabs **Diphenoxylate/Atropine Oxybutynin ER (Ditropan 150mg; Syrup (Lomotil) Tabs XL) Tabs 5mg, 15mg/mL 2.5mg/0.025mg 10mg,15mg Loperamide (Imodium) Solifenacin (Vesicare) Caps 2mg Caps 5mg,10mg PROTON PUMP INHIBITORS MISC Tolterodine (Detrol LA)Esomeprazole (Nexium) Pancreatic Enzymes Caps 2mg, 4mg Caps 20mg, 40mg (Pancreaze)Omeprazole (Prilosec) Simethicone (Mylicon) URINARY ANALGESIC Caps 10mg, 20mg Tabs 80mg Sucralfate (Carafate) Tabs Phenazopyridine ANTISPASMODIC 1gm (Pyridium) Tabs AGENTS Sulfasalazine (Azulfidine) 100mgHyoscyamine / Atropine / Tabs 500mg; Entabs Phenobarbital/ 500mg BPH AGENTS Scopalamine Mesalamine (Asacol) Tabs (Donnatal) Tabs 400 mg Alfuzosin (Uroxatral) Tabs 0.1037 mg/0.0194 10mg mg/16.2mg/0.0065mg, Doxazosin (Cardura) Tabs Elixir 16.2mg/5ml Antiemetics 2mg, 4mg, and 8mgBelladonna 0.2 Terazosin (Hytrin) Caps mg/Phenobarbital 40 Meclizine (Antivert) Tabs 1mg, 2mg, 5mg, mg/Ergotamine 0.6mg 25mg 10mg (Bellergal-S) Tabs Metoclopramide (Reglan) Finasteride (Proscar) TabsDicyclomine (Bentyl) Tabs Tabs 10mg; 5mg 20mg, Caps 10mg sol Syrup 5mg/5ml Tamsulosin (Flomax) Cap 10mg/5ml Prochlorperazine 0.4mgChlordiazepoxide (Compazine) Tabs /Clindinium (Librax) 5mg Caps Prochlorperazine VII. Metabolic / (Compazine) Supps Endocrine Agents 25mg LAXATIVE Promethazine Androgens (Phenergan) TabsBisacodyl (Dulcolax) Tabs 25mg, Syp 5mg; Supps 10mg 6.25mg/5ml: **Testosterone Cypionate Suppositories 12.5mg, Inj 200mg /mL 25mg **Fortesta 2% Gel 7
  8. 8. HOLLOMAN AFB FORMULARY SULFONYLUREACorticosteroids AGENTS Gout AgentsBudesonide EC (Entocort) Glipizide (Glucotrol) Tabs Allopurinol (Zyloprim) Tabs Cap 3mg 5mg 100mg, 300mgDexamethasone Glyburide (Diabeta, Probenecid (Benemid) (Decadron) Tabs 1mg, Micronase) Tabs 5mg Tabs 500mg 4mg Glyburide micronizedFludrocortisone (Florinef) (Glynase) Tabs 1.5mg, Tabs 0.1mg 3mg, and 6mg Hormone ReplacementHydrocortisone (Cortef) Glyburide Tabs 1.25mg, Therapy Tabs 20mg 2.5mgMethylprednisolone Estradiol (Estrace) Tabs (Medrol-Dose Pak) BIGUANIDE 0.5mg, 1mg, 2mg Tabs 4mg 21’S Estradiol Trans (Climara)Prednisolone Oral Metformin (Glucophage) 0.05mg/day, (Prelone) liquid 15mg / Tabs 500mg, 850mg. 0.1mg)/day 5mL 1000mg Estrogen Conj (Premarin)Prednisone (Deltasone) Metformin XR Tabs 0.3mg, 0.45mg, Tabs 1mg, 5mg, (Glucophage XR) 0.625mg, 0.9mg, 20mg, sol 5mg/5ml Tabs 500mg, 750mg 1.25mgPrednisolone Sodium Estrogen ConjugatedPhosphate (Orapred) (Premarin) vaginal15mg/5ml cream 0.625mg/g THIAZOLIDINEDIONE/ Estrogen COMBINATION Conj/Medroxyprogeste rone (PremPro) TabsDiabetic Agents Pioglitazone (Actos) Tabs 0.3mg/ 1.5mg 15mg, 30mg, 45mg Estrogen INSULIN Conj/Medroxyprogeste MISC rone (PremPro) TabsInsulin NPH (Novolin N) 0.45mg/1.5mg 100units/ml 10ml Estrogen Nateglinide (Starlix) TabsInsulin NPH / Regular Conj/Medroxyprogeste 60mg, 120mg 70/30 (Novolin 70/30) rone (PremPro) Tabs 100units/ml 10ml Sitagliptin (Januvia) Tabs 0.625mg /2.5mgInsulin Regular (Novolin R) 50 mg, 100 mg Estrogen 100units/ml 10ml Conj/Medroxyprogeste Sitagliptin / MetforminInsulin Glargine (Lantus) rone (PremPro) Tabs (Janumet) Tabs 100units/ml 10ml 0.625mg/5mg 50/500, 50/1000Insulin Aspart (Novolog) Estropipate (Ogen) Tabs 100units/ml 10ml Sitagliptin/Metformin XR 0.625mg, 1.25mgInsulin Glargine Pen Medroxyprogesterone (Lantus Solostar) 15ml (Janumet XR) Tabs 50- 500, 50-1000, 100-1000 (Provera) Tabs 2.5mg, per box 10mgInsulin Aspart Pen Raloxifene (Evista) Tabs (Novolog Flex Pen) Diabetic Supplies 60mg 15ml per boxInusulin Aspart 70/30 Pen Glucose Test Strips Contraceptives (Novolog 70/30 Flex (Precision XTRA) Pen) Lancets AlesseInsulin Lispro (Humalog) Syringes, insulin 0.5mL Depo-Provera 150mg/ml 10ml vial (Lo-Dose) 100s; 1mL Demulen 1/35-28Insulin Lispro(Humalog 100s Jolessa (generic Kwikpen) BD Pen Needles Original Seasonale) and Short8
  9. 9. Levlin Celecoxib (Celebrex) **Morphine sulfate SR (MSLoestrin Fe 1/20, 1.5/30 100mg & 200mg Contin) Tabs 15mg,Lo-Ovral Ibuprofen (Motrin) Tabs 30mgNor QD 400mg, 600mg, **Morphine sulfate IROrtho Cyclen(Mononessa) 800mg (MSIR) 15mg, 30mgOrtho-Evra Transdermal Ibuprofen (Motrin) Susp **Oxycodone SR patches 100mg / 5mL (Oxycontin) 5mg,Ortho Tri-cyclen, Ortho Tri- Indomethacin (Indocin) 10mg,15mg, 20mg, cyclen LO Caps 25mg 30mgOrtho Novum 1/35, 1/50 Ketorolac (Toradool) TabsOrtho Novum 7-7-7 10mg (max 20/month) Antirheumatic AgentsOvral Meloxicam (Mobic) TabsTriphasil / Trilevlen 7.5mg, 15mg Azathioprine (Imuran)Desogen/Apri/Ortho-Cept Naproxen (Naprosyn) Tabs 50mgNuvaring Tabs 250mg, 275mg, HydroxychloroquineYasmin 500mg, 550mg, (Plaquenil) TabsYaz 125/5mlsusp 200mgPlan B/ Next Choice Oxaprozin (Daypro) Tabs Methotrexate (Rhematrex) 600mg Tabs 2.5mgThyroid Agents Piroxicam (Feldene) Caps Sulfasalazine (Azulfidine) 20mg Tabs 500mg; ENtabsLevothyroxine (Synthroid) Salsalate (Disalcid) Tabs 500mg Tabs 0.025, 0.05, 500mg, 750mg 0.075, 0.088, 0.1, Sulindac (Clinoril) Tabs 0.112, 0.125, 0.15, 200mg 0.175mg OsteoporosisMethimazole (Tapazole) Analgesics Opioids Agents/Bisphosphon Tabs 10 mg atePropylthiouracil (PTU) **Acetaminophen 300mg / Tabs 50 mg Codeine 30mg Alendronate (Fosamax) (Tylenol #3) Tabs Tabs 5mg, 10mg, **Acetaminophen 120mg / 35mg, 70mg Codeine 10mg / 5mL Alendronate PlusDLHRH Agonists Elixir 70mg/2800IU **Acetaminophen Ibandronate (Boniva) TabsGoserelin (Zoladex) Hydrocodone 2.5mg, 150mg 3.6mg, 10.8mg (Lortab/Vicodin) Tabs: Raloxifene (Evista) Tabs implants 325mg/5mg; 60mg 325mg/7.5mg; Risedronate (Actonel) 325mg/10mg; Tabs 35mg VIII. Musculoskeletal 500mg/5mg Agents **Acetaminophen Skeletal Muscle Oxycodone RelaxantAnalgesics (Percocet) Tabs 325mg/5mg Baclofen (Lioresal) TabsAcetaminophen (Tylenol) 325mg/7.5mg 10mg Tabs 325mg 325mg/10mg Cyclobenzaprine (Flexeril)Acetaminophen (Tylenol) **Acetaminophen 500mg / Tabs 5mg, 10mg Elixir 160mg/5mL Oxycodone 5mg Metaxalone (Skelaxin)**Tramadol (Ultram) Tabs (Tylox) Caps Tabs 800mg (limit of 50mg **Codeine Tabs 30mg 30 day supply) **Meperidine (Demerol) Methocarbamol (Robaxin) Tabs 50mg, Inj. 50mg, Tabs 500mg NSAIDS 100mg Orphenadrine (Norflex) **Methadone Tabs 10mg- Tabs 100mg (For pain only) 9
  10. 10. HOLLOMAN AFB FORMULARYTizanidine (Zanaflex) Tabs Prednisolone (Pred Mild) 4mg Soln 0.125% Acetic Acid (Domeboro) Soln 2% Glaucoma Antipyrine/Benzocaine (Auralgan) SolnMisc BETA_BLOCKERS Bacitracin / Neomycin/ PolymyxinPyridostigmine (Mestinon) Betaxolol S (Betoptic S) B/Hydrocortisone Tabs 60mg Susp 0.25% (Cortisporin) Susp Carteolol (Ocupress) Soln Carbamide(Debrox) Soln 1% 6.5% IX. Ophthalmic Agents Timolol (Timoptic) Soln Ciprofloxacin / 0.25%, 0.5% DexamethazoneAnti-Infectives Timolol (Timocptic-XE) Gel (Ciprodex) 0.25% 0.5%Bacitracin ointCiprofloxacin (Ciloxin) ALPHA2-ADRENERGIC XI. Respiratory Agents 0.3% Soln; Oint 0.3% AGONISTErythromycin Oint 5mg/gm Antihistamines /Gentamicin (Garamycin) Brimonidine (Alphagan-P) Decongestants / Soln 0.3%; Oint 0.3% Drops 0.15% Cough / Cold /Moxifloxacin (Vigamox) Brimonidine (Alphagan) Allergy 0.5% Soln Drops 0.2%Neomycin / Polymyxin B / Dipivefrin (Propine) Soln ANTIHISTAMINES/ANTIHI Gramicidin 0.1% STAMINE & (Neosporin) Soln DECONGESTANTNeomycin / Polymyxin B / PROSTAGLANDIN COMBO Bacitracin (Neosporin) Oint Latanoprost (Xalatan) Soln Brompheniramine/PseudoPolymyxin B / 0.05% ephedrine (Dimetapp) Trimethoprim & (Dimetapp DM) Elixir (Polytrim) Soln CHOLINERGIC AGENT Cetirizine (Zyrtec) Tabs 10Sulfacetamide (Bleph-10) mg; Syrup 5mg/5mL 10% Soln, Oint Pilocarpine (Isoptocarpine) Chlorpheniramine (CTM)Tobramycin/Dexamethaso Soln 0.5%, 1%, 2%, Tabs 4mg ne (TobraDex) Susp, 4% Cyproheptadine (Periactin) Oint Pilocarpine (Pilopine HS) Tabs 4mgTobramycin (Tobrex) Gel 4% Diphenhydramine 0.03% soln (Benadryl) Caps NSAID 25mg, Tabs 25mg DiphenhydramineAnti-Inflammatory / Ketorolac (Acular LS) (Benadryl) Elixir Allergy 0.4% Soln 12.5mg / 5mL Fexofenadine (Allegra) Misc Tabs 60mg, 180mgFluorometholone(FML) Susp 0.1% Hydroxyzine HCl (Atarax)Flurbiprofen (Ocufen) Soln Artificial Tears Tabs 10mg, 25mg,Lodoxamide (Alomide) Celluvisc Drops Syrup 10mg/5ml Soln 0.1% GenTeal 0.3% Soln Loratadine (Claritin) TabsLoteprednol (Lotemax) Sodium Chloride 5% 10mg, Syrup 5mg/5ml Susp 0.5% (Muro) Ointment Meclizine (Antivert) TabsOlopatadine(Patanol) Soln Cyclosporine0.5% 25mg 0.1% (Restasis) Soln **Pseudoephedrine /Prednisolone (Pred-Forte) Triprolidine tabs Soln 1% (Actifed) Tabs X. Otic Agents10
  11. 11. ANTITUSSIVE Theophylline (Elixophyllin CORTICOSTEROID, 80mg/15mLBenzonatate (Tessalon) INHALED/COMBINATION Perles 100mg PRODUCTS Budesonide (Pulmicort Respules) inhalation Susp 0.25mg/2ml, Nasal PreparationsEXPECTORANT/COMBIN 0.5mg/2ml ATION Flunisolide (Aerobid) ANTICHOLINERGIC Inhaler 250mcg / puff AGENT**Guaifenesin / Codeine Fluticasone (Flovent HFA) 30mg (Robitussin AC) Inhaler 44, 110, 220 Ipratropium (Atrovent) Syrup mcg / puff Spray 0.3%, 0.6%Guaifenesin / Fluticasone/Salmeterol Dextromethorphan (Advair Diskus) ANTIHISTAMINE (Robitussin DM) Syrup 100/50, 250/50, 500/50mcg Azelastine (Astelin Nasal) Mometasone Furoate Spray 137mcg/spray DECONGESTANT (Asmanex Twisthaler) 110mcg, 220mcg CORTICOSTEROID,**Pseudoephedrine Budesonide/Formoterol INTRANASAL (Sudafed) Tabs 30mg; (Symbicort) Inhaler Syrup 30mg / 5mL 80/4.5, 160/4.5 Flunisolide (Nasarel) Spray 25mcgAsthma Medications MAST CELL STABILIZER Fluticasone (Flonase) Spray ANTICHOLINERGIC Cromolyn Sodium (Intal) Mometasone (Nasonex) AGENTS Inhalant Soln 10 mg/ Spray mLIpratropium Bromide SEROTONIN 5-HT1D (Atrovent HFA) Inhaler LEUKOTRIENE AGONIST 17 mcg / puff RECEPTOR Sumatriptan (Imitrex)Ipratropium Bromide ANTAGONIST Spray 5mg, 20mg (Atrovent) Neb Soln for inhalation 0.03% Montelukast (Singulair) VASOCONSTRICTORTiotropium Bromide Tabs 4mg, 5mg, (Spiriva) HandiHaler 10mg; Granules 4mg Oxymetazoline (Afrin) Spray 0.05% BETA2- MISC AGONISTS/COMBINA MISC TION PRODUCTS Inspirase (drug delivery system for MDI’s) Desmopressin (DDAVP)Albuterol HFA (Ventolin) Aerochamber (drug Spray 0.1% Inhaler delivery system for Sodium chloride (Ocean)Albuterol (Proventil) Soln MDI’s) Drops / Spray 0.65% 0.5% Sodium Chloride 5ml NebAlbuterol (Proventil) Soln Soln 0.083% Theophylline (Theodur) XII. Vaginal PreparationsAlbuterol (Proventil) Syrup Tabs 200mg, 300mg 2mg /5ml Theophylline Anhydrous Clotrimazole (Gyne-Ipratropium / Albuterol (Theo-24) Caps Lotrimin) Cream 1% (Combivent) Inhaler 300mg, Clindamycin (Cleocin)Salmeterol Theophylline Anhydrous Cream 2% Xinafoate(Serevent (Theophylline ER) Diskus) Tabs 400mg 11
  12. 12. HOLLOMAN AFB FORMULARYEstrogen Conjugated Pyridoxine (Vitamin B6) (Premarin) Cream Tabs 50mg Hemorrhoidal HC Supps 0.625 mg / gm Thiamine (Vitamin B1) (Anusol HC)Metronidazole (Metrogel) Tabs 50mg Hemorrhoidal Supps Gel 0.75% (Anusol)Terconazole (Terazol 3) Hydrocortisone Cream Supps 2.5% I. Misc Agents Pramozine/Hydrocortisone (Proctofoam HC) Antineoplastic Agents Foam 1%/1% XIII. Vitamin / Mineral / Electrolyte Agents Azathioprine (Imuran) Tabs 50mgCalcium 500mg with Vit D Fluorouracil (Efudex) Smoking Deterrents (OsCal) Tabs Cream 5%Cyanocobalamin (Vit B 12) Methotrexate Bupropion SR 150 mg 1,000mcg Tabs and (Rheumatrex) Tabs Nicotine Patch (Nicoderm) 1mg/ml injection 2.5mg 7mg / day, 14mg/day,Ergocalciferol (Vitamin D2) Tamoxifen (Nolvadex) 21mg / day caps 50,000IU Tabs 10mg Nicotine Gum 2mg, 4mgFerrous Sulfate Tabs 325mg Dental Preparations OtherFerrous Sulfate Oral sol 15mg /0.6mL Chlorhexidine (Peridex /Folic Acid Tabs 1mg Clomiphene (Clomid) Tabs Periogard) Oral soln 50mgFolic Acid, 0.12% Cyanocobalamin, Donepezil (Aricept) Tabs 5 Sodium Fluoride (Luride) mg, 10mg Pyridoxine (Foltx) Tabs 1.1mg (0.5mg Fl) 2.5mg/1mg/25mg Disulfiram (Antabuse) Sodium Fluoride Oral soln Tabs 250mgMagnesium Gluconate 0.5mg /mL Tabs 500mg Epinephrine (Epipen Jr, Sodium Fluoride Epipen) AutoinjectorPoly-Vi Sol Fe (multi- (PreviDent) 1.1% gel vitamin for breastfed 0.15mg, 0.3mg Sodium Flouride Methylergonovine babies) (PreviDent Plus) 1.1%Potassium Chloride Tabs (Methergine) Tabs 0.2mg paste Memantine (Namenda) 10mEq, 20mEq; Stannous Fluoride 20mEq packets, Liq 10mg (GelKam) 0.4% gel Sodium citrate with citric 10% Triamcinolone (Kenalog)Prenatal Vitamins / acid 480ml (Bicitra) Dental Paste 0.1% **Sildenafil HCL (Viagra) Minerals Tabs (Age ClinPro 1.1% Paste limit of 45 or younger.) Tabs 25mg, 50mg, 100mg Vitamin D Caps 50,000 IU Hemorrhoid Agents12