Contenu connexe Similaire à Holloman AFB Formulary Similaire à Holloman AFB Formulary (20) Holloman AFB Formulary1. HOLLOMAN AFB FORMULARY
DISPENSING POLICIES / from the date they were written with up to 5
PROCEDURES refills. Prescriptions for Schedule 2
medications will be honored for 7 days from
MAIN Pharmacy the date they were written with no refills.
280 First St, Bldg 15 Providers are reminded to include their DEA
Holloman AFB, NM 88330 number on all controlled prescriptions.
Open: 0730 – 1630, M-F
TEL. NO: (575) 572-2778 - REFILL POLICY: Refills MUST be called
FAX No: (575) 572-5781 in through the automated refill system at
REFILL Pharmacy 572-7045. They may be called in 7 days
TEL. NO: (575) 572-7045 / 1-800-843-4682 before the Rx should run out. Please allow
for 2 duty days for refills to be ready.
The Pharmacy is closed: Saturday, Sunday,
all federal holidays and specially designated - Although medications are provided at no
‘down’ days cost to our patients, this service is not free—
the American taxpayer pays the bill. Please
-The pharmacy must use generic consider less expensive alternatives
medication whenever possible so please whenever possible when prescribing.
write all medications generically.
TRICARE MAIL ORDER PHARMACY
-A prescription written as “Dispense as (EXPRESS SCRIPTS): Contact
Written” may not be accepted. 1-866-363-8667 or www.express-
scripts.com/TRICARE for more information.
-Drugs with narrow therapeutic margins will 30 or 90 day supply:
not be generically substituted. Active duty: No cost
All Other Beneficiaries: Generic $0,
- TELEPHONE PRESCRIPTIONS: Per Air Formulary Brand-Name: $9; Non-Formulary
Force directives, no pharmacy staff member Brand-Name: $25
may receive a prescription called in from a Copayments at retail pharmacies are $5 for
provider. This also includes prescription generic drugs, $12 for brand name and $25
renewals. 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 for
prescription is located within the pharmacy. reference only and do not signify the
product dispensed**
-Fax’s: New prescriptions for non-
controlled substances and controlled
substances in schedules III-V from providers
offices, hospitals, or nursing homes may be
faxed.
- NON-CONTROLLED PRESCRIPTIONS:
Are honored up to 1 year from the date the
prescription was written. Antibiotic
prescriptions over 10 days old will be filled
at the discretion of the pharmacy.
Prescriptions for maintenance medications
may be written for up to a 90 day supply
with a maximum of 3 refills when requested
by prescriber. All other non-controlled
prescriptions may be written for up to 30
days supply with a maximum of 11 refills.
- CONTROLLED PRESCRIPTIONS(**):
Prescriptions for Schedule 3, 4 or 5
medications will be honored for 6 months
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 125mg
Cefdinir (Omnicef) Caps 400mg/5ml, Ketoconazole (Nizoral)
300 mg 600mg/5ml Tabs 200mg
Cefdinir (Omnicef) Susp Dicloxacillin (Dynapen) Ketoconazole (Nizoral) 2%
125mg/5ml, 250mg/5ml Caps 250mg Shampoo
Cefpodoxime (Vantin) Penicillin V Pot (Pen VK) Nystatin (Mycostatin) Tabs
Tabs 100mg, 200 mg Tabs 250mg, 500mg 500,000 units
Cefpodoxime (Vantin) Penicillin V Pot (Pen VK) Terbinafine (Lamisil) Tabs
Susp 100mg / 5mL Oral Susp 250mg /5mL 250mg
Cephalexin (Keflex) Caps
250mg, 500mg Sulfonamides Antiviral
Cephalexin (Keflex) Susp
250mg / 5mL Sulfamethoxazole 800mg / Amantadine (Symmetrel)
Trimethoprim 160mg Caps 100mg
Fluoroquinolones (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) Tabs
Levofloxacin (Levaquin) 200mg
Tabs 250mg, 500mg, Tetracyclines Metronidazole (Flagyl)
750mg, Sol 25mg/ml Tabs 250mg
Doxycycline (Vibramycin) Valcyclovir (Valtrex) Tabs
Macrolides Tabs 100mg 500mg
Tetracycline (Achromycin)
Azithromycin (Zithromax) Caps 250mg Antitubercular Agents
Susp 200mg / 5mL Minocycline (Minocin)
Azithromycin (Zithromax) Caps 100mg Ethambutol (Myambutol)
Susp 100 mg / 5 mL Tabs 100mg, 400mg
Azithromycin (Zithromax) Isoniazid (INH) Tabs
Other
Z-pak Tabs 250mg, 100mg, 300mg
Tri-Pak 500mg, 1gm Isoniazid (INH) Syrup
packets Clindamycin (Cleocin) 50mg / 5mL
Clarithromycin (Biaxin) Caps 150mg, 300 mg Pyrazinamide Tabs 500
Tabs 250mg, 500mg Clindamycin (Cleocin) mg
Erythromycin (Ery-Tab) Liquid 75mg/5ml Rifampin (Rifadin) Caps
Tabs 250mg, 333mg, Nitrofurantoin 300mg
400mg (Macrodantin) Caps
Erythromycin (EryPed) 50mg, 100mg Antihelmintic Agent
Susp 200mg/5mL, Nitrofurantoin (Macrobid)
400mg / 5mL Caps 100mg Mebendazole (Vermox)
Chew Tab 100mg
Penicillins Antifungals
Amoxicillin (Trimox) Susp Fluconazole (Diflucan) II. Cardiovascular
250mg/5ml; Tabs 150mg, Susp Agents
400mg/5mL 10mg/ml
Amoxicillin (Trimox) Caps Antianginals/Vasodilator
250, 500mg
2
3. Nitroglycerin sl Tabs Ezetimibe (Zetia) 320mg/12.5mg,
0.3mg, 0.4mg, Pump Tabs10mg 320mg/25mg
Spray, Oint 2%, Niacin (Niaspan Extended-
Patches 0.1mg/hr, Release) Tabs 500mg, BETA BLOCKERS
0.2mg/hr, 0.3mg/hr, 750mg, and 1,000mg
0.4mg/hr, 0.6mg/hr, Nicotinic Acid (Niacin) Tab Atenolol (Tenormin) Tabs
0.8mg/hr 500mg 25mg, 50mg, 100mg
Isosorbide Dinitrate Tabs Carvedilol (Coreg) Tabs
5mg, 10mg, 40mg SR Antihypertensives 3.125mg, 6.25mg,
caps 12.5mg, and 25mg
Isosorbide Mononitrate ACE Labetalol (Trandate) Tabs
(Imdur) Tabs 30mg, INHIBITORS/COMBIN 200mg
60mg, and 120mg ATION PRODUCTS Metoprolol (Lopressor)
Tabs 25 mg, 50mg,
Amlodipine/Benazepril and 100mg
Antihyperlipemics (Lotrel) Caps 2.5/10,
Metoprolol XL (Toprol XL)
5/10, 5/20, 10/20,
Tabs 25mg, 50mg,
5/40, 10/40 mg
100mg, and 200mg
BILE ACID Captopril (Capoten) Tabs
SEQUESTRANT 25mg, 50mg, and Propranolol (Inderal) Tabs
100mg 10mg, 40mg
Colestipol (Colestid) Lisinopril (Prinivil, Zestril)
Propranolol (Inderal LA)
granules 300gm/box Tabs 2.5mg, 5mg,
Caps 60mg, 80mg,
Colestipol (Colestid) Tabs 10mg, 20mg, 30mg,
and 120mg
1gram and 40mg
Lisinopril-HCTZ
FIBRIC ACID (Zestoretic) Tabs
DERIVATIVES 10-12.5mg, 20-25mg,
CALCIUM CHANNEL
20-12.5mg
BLOCKERS
Fenofibrate (TriCor) Tabs Ramipril (Altace) Caps
48mg, 145mg 2.5mg, 5mg, 10mg
Amlodipine (Norvasc)
Gemfibrozil (Lopid) Tabs
Tabs 2.5mg, 5mg,
600mg ANGIOTENSIN II
10mg
BLOCKERS/COMBIN
Diltiazem (Tiazac) Tabs
HMG-CoA REDUCTASE ATION DIURETIC
60mg
INHIBITOR
Diltiazem (Tiazac SR)
Losartan (Cozaar) Tabs
Caps 120mg, 180mg,
Atorvastatin (Lipitor) Tabs 25mg, 50mg, and
240mg, 300mg,
10mg, 20mg, 40mg, 100mg
360mg, and 420mg
80mg Losartan/HCTZ (Hyzaar)
Felodipine (Plendil) Tabs
Pravastatin (Pravachol) Tabs 50/12.5mg,
2.5mg, 5mg, 10mg
Tabs 10mg, 20mg, 100/25mg
Nifedipine SR (Adalat CC)
40mg, and 80mg Telmisartan (Micardis)
Tabs 30g, 60mg, and
Rosuvastatin(Crestor) Tabs 20mg, 40mg,
90mg
Tabs 5mg, 10mg, 20mg, and 80mg
Verapamil (Calan) Tabs
40mg Telmisartan/Hctz (Micardis
80mg
Simvastatin (Zocor) Tabs HCT) 80mg/12.5mg,
Verapamil (Calan SR)
5mg, 10mg, 20mg, 40mg, 80mg/25mg,
Tabs 120mg,180mg,
and 80mg 40mg/12.5MG
240mg
Ezetimibe/Simvastatin Valsartan (Diovan) Tabs
(Vytorin) Tabs 10/10, 40mg, 80mg, 160mg,
ALPHA-ADRENERGIC
10/20, 10/40, 10/80 mg 320mg
BLOCKERS
Valsartan/HCTZ (Diovan
MISC HCT) Tabs
80mg/12.5mg, 160mg/
12.5mg, 160mg/25mg,
3
4. HOLLOMAN AFB FORMULARY
Doxazosin (Cardura) Furosemide (Lasix) Tabs Primidone (Mysoline) Tabs
Tabs 2mg, 4mg, and 20mg, 40mg, sol 50mg, 250mg
8mg 10mg/ml
Prazosin (Minipress) BENZODIAZEPINE
Caps 1mg, 2mg, 5mg THIAZIDE/COMBINATIO
Terazosin (Hytrin) Caps N **Clonazepam (Klonopin)
1mg, 2mg, 5mg, 10mg POTASSIUM_SPARIN Tabs 0.5mg
G **Diazepam (Valium) Tabs
MISC. 5mg
ANTIHYPERTENSIVE Chlorthalidone (Hygroton)
S Tabs 25mg, 50mg MISC
Hydrochlorothiazide
Clonidine (Catapress TT (HCTZ) Caps 12.5mg Carbamazepine (Tegretol)
Patches) 0.1 mg, 0.2 Hydrochlorothiazide Chewtabs 100mg;
mg, 0.3 mg (HCTZ) Tabs 25mg, Tabs 200mg, Sus
Clonidine (Catapres) 50mg 100mg/5ml
Tabs 0.1mg Hydrochlorothiazide Carbamazepine Extended
Hydralazine (Apresoline) 25mg / Triamterene Release (Tegretol XR)
Tabs 10mg, 25mg 37.5mg (Maxzide-25) Tabs 400mg
Methyldopa (Aldomet) Tabs Divalproex Sodium
Tabs 250mg Indapamide (Lozol) Tabs (Depakote) Tabs
2.5mg 125mg, 250mg, Caps
Antiplatelets / Metazolone (Zaroxolyn) Sprk 125mg
Anticoagulants Tabs 5mg Divalproex Sodium
(Depakote ER) Tabs
POTASSIUM-SPARING 250mg, 500mg
Aspirin / Dipyridamole
Gabapentin (Neurontin)
(Aggrenox) caps
Spironolactone Caps100mg 300mg,
5/200mg
(Aldactone) Tabs 400mg, 600mg,
Aspirin 81 mg Chewable
25mg 800mg
Tabs, 325mg Tabs
Phenytoin (Dilantin) Caps
Aspirin (Ecotrin) EC Tabs
100mg
325mg
Antiarrhythmics Phenytoin (Dilantin
Dipyridamole
Infatabs) Chewtabs
(Persantine) Tabs
50mg
25mg Amiodarone (Pacerone)
Phenytoin (Dilantin) Oral
Clopidogrel (Plavix) Tabs Tabs 200mg
susp 125mg / 5mL
75mg Digoxin (Lanoxin) Tabs
Warfarin (Coumadin) 0.125mg, 0.25mg,
Antidepressants
Tabs 1mg, 2mg, Sol 0.05/ml
2.5mg, 3mg, 4mg, Mexiletine (Mexitil) Caps
ALPHA-2 ANTAGONISTS
5mg, 6mg, 7.5mg, and 250mg
10mg
Mirtazapine (Remeron)
Tabs 15mg
Diuretics
III. Central Nervous DOPAMINE-REUPTAKE
CARBONIC
ANHYDRASE
System Agents INHIBITOR
INHIBITOR
Anticonvulsants Bupropion (Wellbutrin)
Tabs SR 100mg,
Acetazolamide (Diamox)
BARBITURATE 150mg
Tabs 250mg,
500mgCaps
**Phenobarbital (Luminal) SELECTIVE SEROTONIN
Tabs 30mg; Syrup REUPTAKE
LOOP
20mg/5ml INHIBITOR (SSRI)
4
5. Citalopram (Celexa) Tabs XR) Tabs 150mg, Buspirone (Buspar) Tabs
20mg, 40mg 200mg, and 50mg 5mg, 10mg
Fluoxetine (Prozac) Caps Risperidone (Risperdal) Zolpidem (Ambien) Tabs
10mg, 20mg, Sol Tabs 0.25mg, 0.5mg, 5mg, 10mg
20mg/5ml 1mg, 2mg, 3mg, Sol
Paroxetine (Paxil) Tabs 1mg/ml Central Nervous System
20mg, 40mg Thioridazine (Mellaril) Stimulants/ADHD
Sertraline (Zoloft) Tabs Tabs 25mg, 100mg Medications
50mg, 100 mg, sol
20mg/ml Atomoxetine (Strattera)
10mg, 18mg, 25mg,
SEROTONIN/NOREPINE 40mg, 60mg Caps
PHRINE INHIBITOR **Dextroamphetamine
(SNRI) Anti- Parkinson’s Agents (Dexedrine) Tabs
5mg; 10mg, 15mg SR
Venlafaxine (Effexor) Tabs ANTICHOLINERGIC Caps
75mg, 100mg; **Methylphenidate (Ritalin)
XR Caps 37.5mg, 75mg, Benztropine (Cogentin) Tabs 5mg, 10mg
150mg Tabs 0.5mg, 2mg **Methylphenidate LA
(Ritalin LA) Caps
SEROTONIN REUPTAKE DOPAMINE AGONIST 10mg, 20mg, 30mg,
INHIBITOR/ANTAGO 40mg
NIST (SNIA) Amantadine (Symmetrel) **Methylphenidate SR
Caps 100mg (Ritalin SR) Tabs SR
Trazodone (Desyrel) Tabs Carbidopa / Levodopa 20mg
50mg, 100mg (Sinemet) Tabs 25/250 **Methylphenidate
mg, 25/100mg, (Concerta) Tabs Ext.
TRICYCLIC-(Limit of 30 10/100mg Release 18 mg, 27mg,
day supply) Trihexyphenidyl (Artane) 36mg, and 54mg
Tabs 2mg, 5mg; Elixir **D, L-amphetamine
Amitriptyline (Elavil) Tabs 2mg/5ml (Adderall) Tabs 5mg,
10mg, 25mg, 100mg 10mg, 20mg
Doxepin (Sinequan) Caps **D, L-amphetamine
25mg, 100mg, 150mg, (Adderall-XR) Caps
sol 10mg/ml 5mg, 10mg, 15mg,
Anxiolytics / Sedatives /
Imipramine (Tofranil) Tabs 20mg, 25mg, 30mg
Hypnotics
10mg, 25mg
Nortriptyline (Pamelor) Migraine Agents
Caps 10mg, 25mg, sol BENZODIAZEPINE
10mg/5ml SEROTONIN 5-HT1D
Alprazolam (Xanax) Tabs AGONIST- (Limit
Mood Stabilizer / 0.5mg Quantities)
Antipyscotics Clonazepam (Klonopin)
Tabs 0.5mg Sumatriptan (Imitrex)
Diazepam (Valium) Tabs Injection 6mg
Lithium Carbonate Caps 5mg Sumatriptan (Imitrex) Tabs
150mg, Tabs 300 mg, Lorazepam (Ativan) Tabs 25mg, 50mg, and
syp 8meq/5ml 1mg 100mg
Olanzapine (Zyprexa) Temazepam (Restoril) Sumatriptan (Imitrex)
Tabs 2.5mg, 5 mg, Caps 15mg, 30mg Nasal spray 5mg,
and 10mg
20mg
Quetiapine (Seroquel)
Zolmitriptan (Zomig) Tabs
Tabs 25mg, 100mg,
2.5mg, 5mg
200mg, and 300mg
Quetiapine Extended MISC MISC
Release (Seroquel
5
6. HOLLOMAN AFB FORMULARY
**Acetaminophen 325 mg / Nystatin/Triamcinolone
Butalbital 50 mg / (Mycolog) Cream Cepacol lozenges Reg
Caffeine 40mg 100,000 units/0.1% Lidocaine (Xylocaine) Oint
(Fiorcet) Tabs Nystatin (Mycostatin) 5%; Jelly 2%; Visc
**Aspirin 325mg / 100,000 units/gm soln 2%
Butalbital 50mg / Cream, Oint. Powder
Caffeine 40mg Terbinafine (Lamisil)
(Fiorinal) Tabs Cream 1%
Divalproex Sodium
(Depakote ER) Tabs Antiparasitic – Topical
250mg, 500mg Misc-Topical
Permethrin (NIX) 1%
Cream Rinse Aluminum chloride
IV. Dermatologic Agents
Permethrin (Elimite) (Drysol) Soln 20%
Cream 5% Amlexanox (Aphthasol)
Acne Products
Oral Paste 5%
Antiseborrheic Agent- Ammonium lactate (Lac-
Adapalene (Differin)
Topical Hydrin) Lotion12%
Cream & Gel 0.1%
Benzoyl Peroxide Gel
2.5% Selenium sulfide (Selsun) Fluorouracil (Efudex)
Clindamycin/Benzoyl Shampoo 2.5% Cream 5%
Peroxide (Benzaclin) Pimecrolimus (Elidel)
Gel Corticosteroids-Topical Cream 1%
Tretinoin (Retin A) Cream Podofilox (Condylox) Soln
0.025%, 0.05%, 0.1%; 0.5%
Betamethasone Valerate Salicylic acid (Duofilm)
Gel 0.01%, 0.025%
(Valisone) Cream soln 17%
(Age limit of 35 or
0.1% Zinc Oxide Oint. 20%
younger)
Clobetasol Propionate
Isotretinoin (Accutane)
(Temovate) Cream,
Caps 10mg, 20mg,
Oint, Soln 0.05%
40mg
Fluocinonide (Lidex)
Cream, Ointment V. Gastrointestinal
Antibiotics – Topicals
0.05% Agents
Fluocinolone (Derma-
Bacitracin oint Smooth/FS) Oil 0.01% H2-ANTAGONIST
Clindamycin (Cleocin) 1% Flurandrenolide (Cordran)
Soln Tape Cimetidine (Tagamet)
Erythromycin 2% Soln, Gel Hydrocortisone Cream Tabs 400mg;
Metronidazole (Metrogel) 1%, 2.5% 300mg/5ml Syrup
1% Gel Hydrocortisone Valerate Ranitidine (Zantac) Tabs
Mupiricin (Bactroban) 2% (Westcort) Cream0.2% 150mg; Syrup
Oint Triamcinolone (Kenalog) 15mg/mL
Silver sulfadiazine 0.1%; Cream, Spray
(Silvadene) Cream 1% PROTON PUMP
ANESTHETIC/CORTICOS INHIBITORS
Antifungals – Topicals TEROID
COMBINATION Esomeprazole (Nexium)
Clotrimazole (Lotrimin) Caps 20mg, 40mg
Pramozine/Hydrocortisone Omeprazole (Prilosec)
Topical sol 1%, Cream
(Proctofoam HC) Caps 10mg, 20mg
1%
Foam 1%/1%
Ketoconazole (Nizoral) 2%
Cream, 2%Shampoo ANTISPASMODIC
Local Anesthetics- AGENTS
Miconazole (Monistat
topical
Derm) Cream 2%
6
7. Hyoscyamine / Atropine / Mesalamine (Asacol) Tabs Doxazosin (Cardura) Tabs
Phenobarbital/ 400 mg 2mg, 4mg, and 8mg
Scopalamine Terazosin (Hytrin) Caps
(Donnatal) Tabs 1mg, 2mg, 5mg,
0.1037 mg/0.0194 mg/ Antiemetics 10mg
16.2mg/0.0065mg, Finasteride (Proscar) Tabs
Elixir 16.2mg/5ml Meclizine (Antivert) Tabs 5mg
Belladonna 0.2 25mg Tamsulosin (Flomax) Cap
mg/Phenobarbital 40 Metoclopramide (Reglan) 0.4mg
mg/Ergotamine 0.6mg Tabs 10mg;
(Bellergal-S) Tabs Syrup 5mg/5ml
Dicyclomine (Bentyl) Tabs Prochlorperazine VII. Metabolic /
20mg, Caps 10mg sol (Compazine) Tabs Endocrine Agents
10mg/5ml 5mg
Chlordiazepoxide Prochlorperazine Androgens
/Clindinium (Librax) (Compazine) Supps
Caps 25mg
**Testosterone Cypionate
Promethazine
Inj 200mg /mL
(Phenergan) Tabs
LAXATIVE 25mg, Syp
Corticosteroids
6.25mg/5ml:
Bisacodyl (Dulcolax) Tabs Suppositories 12.5mg,
Dexamethasone
5mg; Supps 10mg 25mg
(Decadron) Tabs 1mg,
Docusate sodium (Colace) Ondansetron (Zofran
4mg
Caps 100mg; ODT) 4mg, 8mg
Fludrocortisone (Florinef)
150mg/15ml Syrup Ondansetron (Zofran) 2
Tabs 0.1mg
Fleets Enema mg / mL liquid
Hydrocortisone (Cortef)
Fleets Oral Saline Laxative
Tabs 20mg
(PhosphaSoda)
Methylprednisolone
GoLytely/CoLytely VI. Genitourinary Agents
(Medrol-Dose Pak)
Lactulose (Cephulac)
Tabs 4mg 21’S
Syrup 10mg / 15ml Urinary Tract Agents
Prednisolone Oral
(Prelone) liquid 15mg /
ANTIDIARRHEALS OVERACTIVE BLADDER 5mL
AGENTS Prednisone (Deltasone)
Bismuth subsalicylate
Tabs 1mg, 5mg,
(Pepto-Bismol) Oxybutynin (Ditropan) 20mg, sol 5mg/5ml
Chewtabs 262mg Tabs 5mg; 5mg/5ml
**Diphenoxylate/Atropine Syrup
(Lomotil) Tabs 2.5mg/ Oxybutynin ER (Ditropan Diabetic Agents
0.025mg XL) Tabs 5mg,
Loperamide (Imodium) 10mg,15mg INSULIN
Caps 2mg Tolterodine (Detrol LA)
Caps 2mg, 4mg Insulin NPH (Novolin N)
MISC 100units/ml 10ml
URINARY ANALGESIC Insulin NPH / Regular
Pancreatic Enzymes 70/30 (Novolin 70/30)
(Pancreaze) Phenazopyridine 100units/ml 10ml
Simethicone (Mylicon) (Pyridium) Tabs Insulin Regular (Novolin R)
Tabs 80mg 100mg 100units/ml 10ml
Sucralfate (Carafate) Tabs Insulin Glargine (Lantus)
1gm BPH AGENTS 100units/ml 10ml
Sulfasalazine (Azulfidine) Insulin Aspart (Novolog)
Tabs 500mg; Entabs Alfuzosin (Uroxatral) Tabs 100units/ml 10ml
500mg 10mg
7
8. HOLLOMAN AFB FORMULARY
Insulin Glargine Pen Syringes, insulin 0.5mL Depo-Provera 150mg/ml
(Lantus Solostar) 15ml (Lo-Dose) 100s; 1mL Demulen 1/35-28
per box 100s Jolessa (generic
Insulin Aspart Pen BD Pen Needles Original Seasonale)
(Novolog Flex Pen) and Short Levlin
15ml per box Loestrin Fe 1/20, 1.5/30
Inusulin Aspart 70/30 Pen Gout Agents Lo-Ovral
(Novolog 70/30 Flex Nor QD
Pen) Allopurinol (Zyloprim) Tabs Ortho Cyclen(Mononessa)
100mg, 300mg Ortho-Evra Transdermal
SULFONYLUREA Probenecid (Benemid) patches
AGENTS Tabs 500mg Ortho Tri-cyclen, Ortho Tri-
cyclen LO
Glipizide (Glucotrol) Tabs Hormone Replacement Ortho Novum 1/35, 1/50
5mg Therapy Ortho Novum 7-7-7
Glyburide (Diabeta, Ovral
Micronase) Tabs 5mg Estradiol (Estrace) Tabs Triphasil / Trilevlen
Glyburide micronized 0.5mg, 1mg, 2mg Desogen/Apri/Ortho-Cept
(Glynase) Tabs 1.5mg, Estradiol Trans (Climara) Nuvaring
3mg, and 6mg 0.05mg/day, Yasmin
Glyburide Tabs 1.25mg, 0.1mg)/day Yaz
2.5mg Estrogen Conj (Premarin) Plan B/ Next Choice
Tabs 0.3mg, 0.45mg,
BIGUANIDE 0.625mg, 0.9mg, Thyroid Agents
1.25mg
Metformin (Glucophage) Estrogen Conjugated Levothyroxine (Synthroid)
Tabs 500mg, 850mg. (Premarin) vaginal Tabs 0.025, 0.05,
1000mg cream 0.625mg/g 0.075, 0.088, 0.1,
Metformin XR Estrogen 0.112, 0.125, 0.15,
(Glucophage XR) Conj/Medroxyprogeste 0.175mg
Tabs 500mg, 750mg rone (PremPro) Tabs Methimazole (Tapazole)
0.3mg/ 1.5mg Tabs 10 mg
Estrogen Propylthiouracil (PTU)
Conj/Medroxyprogeste Tabs 50 mg
THIAZOLIDINEDIONE/CO rone (PremPro) Tabs
MBINATION 0.45mg/1.5mg
Estrogen
Pioglitazone (Actos) Tabs Conj/Medroxyprogeste LHRH Agonists
15mg, 30mg, 45mg rone (PremPro) Tabs
0.625mg /2.5mg Goserelin (Zoladex)
MISC Estrogen 3.6mg, 10.8mg
Conj/Medroxyprogeste implants
Nateglinide (Starlix) Tabs rone (PremPro) Tabs
60mg, 120mg 0.625mg/5mg
Estropipate (Ogen) Tabs VIII. Musculoskeletal
Sitagliptin (Januvia) Tabs 0.625mg, 1.25mg Agents
50 mg, 100 mg Medroxyprogesterone
Sitagliptin / Metformin (Provera) Tabs 2.5mg, Analgesics
(Janumet) Tabs 10mg
50/500, 50/1000 Raloxifene (Evista) Tabs Acetaminophen (Tylenol)
60mg Tabs 325mg
Diabetic Supplies Acetaminophen (Tylenol)
Contraceptives Elixir 160mg/5mL
Glucose Test Strips **Tramadol (Ultram) Tabs
(Precision XTRA) Alesse 50mg
Lancets
8
9. **Morphine sulfate IR
(MSIR) 15mg, 30mg
NSAIDS IX. Ophthalmic Agents
Antirheumatic Agents
Celecoxib (Celebrex) Anti-Infectives
100mg & 200mg Azathioprine (Imuran)
Ibuprofen (Motrin) Tabs Tabs 50mg Bacitracin oint
400mg, 600mg, Hydroxychloroquine Ciprofloxacin (Ciloxin)
800mg (Plaquenil) Tabs 0.3% Soln; Oint 0.3%
Ibuprofen (Motrin) Susp 200mg Erythromycin Oint 5mg/gm
100mg / 5mL Methotrexate (Rhematrex) Gentamicin (Garamycin)
Indomethacin (Indocin) Tabs 2.5mg Soln 0.3%; Oint 0.3%
Caps 25mg Sulfasalazine (Azulfidine) Moxifloxacin (Vigamox)
Ketorolac (Toradool) Tabs Tabs 500mg; ENtabs 0.5% Soln
10mg (max 20/month) 500mg Neomycin / Polymyxin B /
Meloxicam (Mobic) Tabs Gramicidin
7.5mg, 15mg (Neosporin) Soln
Naproxen (Naprosyn) Neomycin / Polymyxin B /
Tabs 250mg, 275mg, Osteoporosis Bacitracin (Neosporin)
500mg, 550mg, Agents/Bisphosphon Oint
125/5mlsusp ate Polymyxin B /
Oxaprozin (Daypro) Tabs Trimethoprim
600mg Alendronate (Fosamax) (Polytrim) Soln
Piroxicam (Feldene) Caps Tabs 5mg, 10mg, Sulfacetamide (Bleph-10)
20mg 35mg, 70mg 10% Soln, Oint
Salsalate (Disalcid) Tabs Alendronate PlusD Tobramycin/Dexamethaso
500mg, 750mg 70mg/2800IU ne (TobraDex) Susp,
Sulindac (Clinoril) Tabs Ibandronate (Boniva) Tabs Oint
200mg 2.5mg, 150mg Tobramycin (Tobrex)
Raloxifene (Evista) Tabs 0.03% soln
Analgesics Opioids 60mg
Risedronate (Actonel) Anti-Inflammatory /
**Acetaminophen 300mg / Tabs 35mg Allergy
Codeine 30mg
(Tylenol #3) Tabs Skeletal Muscle Fluorometholone(FML)
**Acetaminophen 120mg / Relaxant Susp 0.1%
Codeine 10mg / 5mL Flurbiprofen (Ocufen) Soln
Elixir Baclofen (Lioresal) Tabs Lodoxamide (Alomide)
**Acetaminophen 500mg / 10mg Soln 0.1%
Hydrocodone 5mg Cyclobenzaprine (Flexeril) Loteprednol (Lotemax)
(Lortab/Vicodin) Tabs Tabs 5mg, 10mg Susp 0.5%
**Acetaminophen 325mg / Metaxalone (Skelaxin) Olopatadine(Patanol) Soln
Oxycodone 5mg Tabs 800mg (limit of 0.1%
(Percocet) Tabs 30 day supply) Prednisolone (Pred-Forte)
**Acetaminophen 500mg / Methocarbamol (Robaxin) Soln 1%
Oxycodone 5mg Tabs 500mg Prednisolone (Pred Mild)
(Tylox) Caps Orphenadrine (Norflex) Soln 0.125%
**Codeine Tabs 30mg Tabs 100mg
**Meperidine (Demerol) Glaucoma
Tabs 50mg, Inj. 50mg,
100mg
**Methadone Tabs 10mg- BETA_BLOCKERS
Misc
(For pain only)
**Morphine sulfate SR (MS Betaxolol S (Betoptic S)
Contin) Tabs 15mg, Pyridostigmine (Mestinon) Susp 0.25%
30mg Tabs 60mg
9
10. HOLLOMAN AFB FORMULARY
Carteolol (Ocupress) Soln Ciprofloxacin / Guaifenesin /
1% Dexamethazone Dextromethorphan
Timolol (Timoptic) Soln (Ciprodex) (Robitussin DM) Syrup
0.25%, 0.5%
Timolol (Timocptic-XE) Gel
0.25% 0.5% XI. Respiratory Agents
ALPHA2-ADRENERGIC Antihistamines / DECONGESTANT
AGONIST Decongestants /
Cough / Cold / **Pseudoephedrine
Brimonidine (Alphagan-P) Allergy (Sudafed) Tabs 30mg;
Drops 0.15% Syrup 30mg / 5mL
Brimonidine (Alphagan) ANTIHISTAMINES/ANTIHI
Drops 0.2% STAMINE & Asthma Medications
Dipivefrin (Propine) Soln DECONGESTANT
0.1% COMBO ANTICHOLINERGIC
AGENTS
PROSTAGLANDIN Brompheniramine/Pseudo
ephedrine (Dimetapp) Ipratropium Bromide
Latanoprost (Xalatan) Soln & (Dimetapp DM) Elixir (Atrovent HFA) Inhaler
0.05% Cetirizine (Zyrtec) Tabs 10 17 mcg / puff
mg; Syrup 5mg/5mL Ipratropium Bromide
CHOLINERGIC AGENT Chlorpheniramine (CTM) (Atrovent) Neb Soln
Tabs 4mg for inhalation 0.03%
Pilocarpine (Isoptocarpine) Cyproheptadine (Periactin) Tiotropium Bromide
Soln 0.5%, 1%, 2%, Tabs 4mg (Spiriva) HandiHaler
4% Diphenhydramine
Pilocarpine (Pilopine HS) (Benadryl) Caps BETA2-
Gel 4% 25mg, Tabs 25mg AGONISTS/COMBINA
Diphenhydramine TION PRODUCTS
NSAID (Benadryl) Elixir
12.5mg / 5mL Albuterol HFA (Ventolin)
Ketorolac (Acular LS) Fexofenadine (Allegra) Inhaler
0.4% Soln Tabs 60mg, 180mg Albuterol (Proventil) Soln
Hydroxyzine HCl (Atarax) 0.5%
Misc Tabs 10mg, 25mg, Albuterol (Proventil) Soln
Syrup 10mg/5ml 0.083%
Artificial Tears Loratadine (Claritin) Tabs Albuterol (Proventil) Syrup
Celluvisc Drops 10mg, Syrup 5mg/5ml 2mg /5ml
GenTeal 0.3% Soln Meclizine (Antivert) Tabs Ipratropium / Albuterol
Sodium Chloride 5% 25mg (Combivent) Inhaler
(Muro) Ointment **Pseudoephedrine / Salmeterol
Triprolidine tabs Xinafoate(Serevent
(Actifed) Tabs Diskus)
X. Otic Agents
ANTITUSSIVE
Acetic Acid (Domeboro)
Soln 2% Benzonatate (Tessalon) CORTICOSTEROID,
Antipyrine/Benzocaine Perles 100mg INHALED/COMBINATI
(Auralgan) Soln ON PRODUCTS
Bacitracin / Neomycin/ EXPECTORANT/COMBIN
Polymyxin ATION Budesonide (Pulmicort
B/Hydrocortisone Respules) inhalation
(Cortisporin) Susp **Guaifenesin / Codeine Susp 0.25mg/2ml,
Carbamide(Debrox) Soln 30mg (Robitussin AC) 0.5mg/2ml
6.5% Syrup
10
11. Flunisolide (Aerobid) Ipratropium (Atrovent) Cyanocobalamin (Vit B 12)
Inhaler 250mcg / puff Spray 0.3%, 0.6% 1,000mcg Tabs and
Fluticasone (Flovent HFA) 1mg/ml injection
Inhaler 44, 110, 220 ANTIHISTAMINE Ergocalciferol (Vitamin D2)
mcg / puff caps 50,000IU
Fluticasone/Salmeterol Azelastine (Astelin Nasal) Ferrous Sulfate Tabs
(Advair Diskus) Spray 137mcg/spray 325mg
100/50, 250/50, Ferrous Sulfate Oral sol
500/50mcg CORTICOSTEROID, 15mg /0.6mL
Mometasone Furoate INTRANASAL Folic Acid Tabs 1mg
(Asmanex Twisthaler) Folic Acid,
110mcg, 220mcg Flunisolide (Nasarel) Cyanocobalamin,
Budesonide/Formoterol Spray 25mcg Pyridoxine (Foltx)
(Symbicort) Inhaler Fluticasone (Flonase) 2.5mg/1mg/25mg
80/4.5, 160/4.5 Spray Magnesium Gluconate
Tabs 500mg
MAST CELL STABILIZER SEROTONIN 5-HT1D Poly-Vi Sol Fe (multi-
AGONIST vitamin for breastfed
Cromolyn Sodium (Intal) Sumatriptan (Imitrex) babies)
Inhalant Soln 10 mg/ Spray 5mg, 20mg Potassium Chloride Tabs
mL 10mEq, 20mEq;
VASOCONSTRICTOR 20mEq packets, Liq
LEUKOTRIENE 10%
RECEPTOR Oxymetazoline (Afrin) Prenatal Vitamins /
ANTAGONIST Spray 0.05% Minerals Tabs (Age
limit of 45 or younger.)
Montelukast (Singulair) MISC Pyridoxine (Vitamin B6)
Tabs 4mg, 5mg, Tabs 50mg
10mg; Granules 4mg Desmopressin (DDAVP) Thiamine (Vitamin B1)
Spray 0.1% Tabs 50mg
MISC Sodium chloride (Ocean)
Drops / Spray 0.65% I. Misc Agents
Inspirase (drug delivery
system for MDI’s) Antineoplastic Agents
Aerochamber (drug XII. Vaginal Preparations
delivery system for Azathioprine (Imuran)
MDI’s) Clotrimazole (Gyne- Tabs 50mg
Sodium Chloride 5ml Neb Lotrimin) Cream 1% Fluorouracil (Efudex)
Soln Clindamycin (Cleocin) Cream 5%
Theophylline (Theodur) Cream 2% Methotrexate
Tabs 200mg, 300mg Estrogen Conjugated (Rheumatrex) Tabs
Theophylline Anhydrous (Premarin) Cream 2.5mg
(Theo-24) Caps 0.625 mg / gm Tamoxifen (Nolvadex)
300mg, Metronidazole (Metrogel) Tabs 10mg
Theophylline Anhydrous Gel 0.75%
(Theophylline ER) Terconazole (Terazol 3) Dental Preparations
Tabs 400mg Supps
Theophylline (Elixophyllin Chlorhexidine (Peridex /
80mg/15mL Periogard) Oral soln
0.12%
Nasal Preparations XIII. Vitamin / Mineral / Sodium Fluoride (Luride)
Electrolyte Agents Tabs 1.1mg (0.5mg Fl)
ANTICHOLINERGIC Sodium Fluoride Oral soln
AGENT Calcium 500mg with Vit D 0.5mg /mL
(OsCal) Tabs
11
12. HOLLOMAN AFB FORMULARY
Sodium Fluoride Pramozine/Hydrocortisone
(PreviDent) 1.1% gel (Proctofoam HC) Clomiphene (Clomid) Tabs
Sodium Flouride Foam 1%/1% 50mg
(PreviDent Plus) 1.1% Donepezil (Aricept) Tabs 5
paste mg, 10mg
Stannous Fluoride Disulfiram (Antabuse)
(GelKam) 0.4% gel Tabs 250mg
Triamcinolone (Kenalog) Epinephrine (Epipen Jr,
Dental Paste 0.1% Epipen) Autoinjector
Smoking Deterrents 0.15mg, 0.3mg
Hemorrhoid Agents Methylergonovine
Bupropion SR 150 mg (Methergine) Tabs 0.2mg
Hemorrhoidal HC Supps Nicotine Patch (Nicoderm) Sodium citrate with citric
(Anusol HC) 7mg / day, 14mg/day, acid 480ml (Bicitra)
Hemorrhoidal Supps 21mg / day Sildenafil HCL (Viagra)
(Anusol) Tabs 25mg, 50mg, 100mg
Hydrocortisone Cream Other Vitamin D Caps 50,000 IU
2.5%
12