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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
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
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
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
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
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
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
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
**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
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
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
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

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Holloman AFB Formulary

  • 1. 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