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Edwards Air Force Base
     Pharmacy




       Formulary
       Current as of 1 Oct 2011
Table of Contents

Welcome Letter from Flight Commander                       4

General Pharmacy Information                               5

How do I get my Refills?                                   6

Pharmacy Benefits                                          7

New to our Formulary                                       9

Formulary Listing by alphabetical order (generic names)   10

Listing by Common Use (not a complete listing)            21

Quick Reference Phone Guide                               22




                                                               2
Welcome to Edwards AFB and the 95th Medical Group!

We, the military and civilian pharmacy staff at the 95th Medical Group, are always striving to
provide you and your family the best pharmaceutical care available. All of us are committed to
providing quality services, and to ensure that the care you receive is and continues to be the best
you’ve ever experienced.

The pharmacy handbook/frequently asked questions has been created to hopefully make
accessing pharmacy services easier and less confusing for beneficiaries. While it does not
answer every question, it does provide guidance on most of our services.

I would like to extend on behalf of my staff and self, a special thank you to all of you in
uniform who are defending our country and to all the veterans who have made major
contributions to our nation. We also thank the families who have and continue to support all of
you.



                                           Vanthy Pham
                                           Vanthy B. Pham, Maj, USAF, BSC, PharmD
                                           Diagnostics and Therapeutics Flight Commander




                                                                                                  3
Pharmacy General Information


What are the hours for the Pharmacy?
Pharmacy hours are below.

Monday       0730-1630
Tuesday      0730-1630
Wednesday    0730-1630
Thursday     0730-1630
Friday       0730-1630
Closed the first Monday of each month, weekends, federal holidays, AFMC approved
family days and Military down days.


Where is the Pharmacy?
The Pharmacy is located in the main clinic on 30 Nightingale Rd in building 5525.
It is located in the south end of the first floor.

Eligible beneficiaries include:

      Active duty service members and their families
      Activated National Guard and Reserve Members and their families (on Title 10 or Title
      32 [federal] orders)
      Retired service members and their families
      Survivors, widows/widowers and certain former spouses
      Medal of Honor recipients and their families
      Beneficiaries enrolled in TRICARE Reserve Select or the Continued Health Care Benefit
      Program
      Other beneficiaries listed in DEERS as eligible for TRICARE, including foreign force
      members and their families

When updating DEERS with your personal information, be sure to update your address with a
physical address.




                                                                                            4
How do I get medication refills?
       If you have an existing prescription that is still active with refills left, call the Pharmacy
at 661-277-9896. Prescriptions called into the refill line will be available for pickup within
two duty days at the main pharmacy or at the APM located in BX lobby (*certain medications
only*). If you present to the pharmacy window for a refill you may be asked to come back later
or the next duty day. Please make every effort to call in prescription refills to avoid delays.

Typically, if you’re running out of a medication (down to last refill or last set of doses), it
means your provider is expecting you to follow-up for a re-evaluation. Please make a follow-up
appointment prior to running out so your provider can see how you are doing.

If your prescription has expired or you have no refills left and you see a provider on base,
please call PCC at 661-277-7118 at least one week prior to running out of your medication.
Ask to leave a telephone consult for your provider’s nurse. Please have the name and dosage of
the medication ready to provide to the phone clerk, as it makes renewing your prescription
easier. As long as the provider determines that you do not need a follow-up appointment prior
to prescription renewal, your refill request will typically be taken care of within 72 business
hours.

If you see a civilian provider off base you will have to contact your provider for a new
prescription. The pharmacy does NOT accept fax or phone-in prescription orders or refills.

Any questions regarding your medications that can be handled by the pharmacy should be
directed to their staff at 661-277-9896 (option 1 clinic pharmacy, option 5 speak to pharmacy
personnel)




Can’t make it to the pharmacy during normal duty hours? Sign up today to use our
Automated Prescription Machine (APM) located in the BX food lobby to pick up your
prescription refills. The APM is available during BX hours including weekends.




                                                                                                    5
YOUR PHARMACY Benefits




All formulary medication at EDWARDS Pharmacy:

$0 cost for up to a 90 day Supply

Other Military Treatment Facility (MTF) Pharmacies
An MTF pharmacy provides those medications listed on its local formulary (drug listing). Most
MTF pharmacies accept prescriptions written by both civilian and military providers.
To check the availability of a particular drug, contact you’re nearest MTF if not stationed at
Edwards AFB in person or by phone.

TRICARE Mail Order Pharmacy (TMOP)
You can receive up to a 90-day supply* for most medications you take regularly (for instance,
drugs for high blood-pressure, asthma or oral contraceptives) using TMOP.

When you use the TMOP service you get:
• Savings: You can save up to 66% of retail costs, because your
co-payment for a 90-day supply is the same as for a 30-day supply at a retail pharmacy.
• Convenience and safety: Your medication is mailed to your home in a weather-resistant
pouch for your privacy and protection and there is no charge for postage.

To use the TMOP service, just follow these steps:

1) Ask your doctor for a prescription (for up to a 90-day supply*,plus refills for up to one year,
if appropriate).

2) Complete the TMOP registration/order form which can be downloaded from their website at:
http://www.express-scripts.com/TRICARE/

3) Insert your prescription, completed TMOP registration form, and co-payment, if needed, into
the pre-addressed, postage paid envelope (attached to the registration form — use this envelope
only for your TMOP registration) and mail them. Your prescriptions will be mailed to you
within 14 days.

• For more details on TMOP, please visit www.express-scripts.com/TRICARE or call 1-
877-363-1303.




                                                                                                     6
DoD TRICARE Retail Pharmacy (TRRx) Network
Another option for filling your prescription is to use a DoD TRRx network retail pharmacy.
Simply give the network pharmacist your written prescription and your uniformed services
identification (ID) card.


You will pay a co-payment of:
$0 for formulary generic for 30-day supply
$9 for formulary brand-name for 30-day supply
$25 for non-formulary drugs for 30-day supply.



To find a DoD TRICARE Retail Pharmacy near you:
• Visit www.express-scripts.com/TRICARE.
The online pharmacy locator is updated on the first day of each month. If a pharmacy joined
after the first day of the month, it might not appear on the locator until the following month.
• Call 1.877.363.1303).



Non-Network Retail Pharmacy
Your medications will cost the most at non-network retail pharmacies because they do not
belong to the DoD TRRx network. At non-network pharmacies you will pay full price for your
medication. To be reimbursed for non-network pharmacy claims, you must fill out the enclosed
claim form (DD 2642),attach the required paperwork as described on the DD2642,and mail it
to:

Express Scripts
P.O. Box 66518
St. Louis, MO 63166-6518
You can download additional claim forms (DD 2642) at www.express-scripts.com/TRICARE
or www.tricare.osd.mil/ pharmacy/claims.cfm. Claim forms may also be obtained at
TRICARE Service Centers and MTFs.




                                                                                                  7
New to our formulary!



Budesonide/formoterol (Symbicort) for Asthma or COPD

Cetirizine (Zyrtec) chewable tablets for allergies

Cetirizine/pseudoephedrine (Zyrtec-D) for allergies

Insulin glargine pen (Lantus SoloStar Pen) for diabetes mellitus

Scopalamine patches (Transderm Scop) for motion sickness

Tamsulosin (Flomax) for enlarged prostate or BPH

Valsartan (Diovan) for hypertension

Valsartan/HCTZ (DiovanHCT) for hypertension

Ciprofloxacin/Dexamethasone (Ciprodex) for ear infection

Famotidine (Pepcid) for heartburn, GERD

Fenofibrate 54mg and 160mg for hyperlipidemia (replacing Fenoglide)

Fenofibrate (Tricor) 48mg and 145mg for hyperlipidemia

Rovustatin (Crestor) for hyperlipidemia *DoD requires Prior Authorization

Mometasone/Formoterol (Dulera) Inhaler for asthma or COPD

Ergocalciferol (Vitamin D) 50,000 units for Vit D supplements

Calcium Carbonate + Vit D 500mg (Oscal+D) for calcium supplements
                                                                            8
Diclofenac (Voltaren) 1% topical gel for pain

Lidocaine (Lidoderm) 5% patch-for pain

Detemir (Levemir) Insulin-for diabetes

Pantoprazole (Protonix)-for GERD

Clindamycin (Cleocin T) 1% Pads-for acne

Aspart (Novolog FlexPen) Insulin Pen-for diabetes


                  No longer on formulary!

Rosiglitazone (Avandia) for diabetes

Rosiglitazone/Metformin (Avandamet) for diabetes

Ciprofloxacin/Hydrocortisone (CiproHC) for ear infection




                                                           9
Edwards AFB Pharmacy Formulary
                   Alphabetically Listed by Generic Name
Generic Name                Brand Name                 How Supplied
ACETAMINOPHEN               Tylenol                   Tabs: 325 mg, 650mg
                                                      Infant Drops: 80 mg/0.8 ml
                                                      Soln: 160 mg/5 ml.
                                                      Supps: 120mg, 650 mg
ACETAMINOPHEN/BUTALBITAL/   Fioricet                  Tabs: 325mg/50mg/40mg
CAFFEINE
ACETAMINOPHEN/CODEINE       Tylenol w/Codeine C-III   Tabs: 30mg/300mg
PHOSPHATE                                             Elixir: 12mg/120 mg/5 ml
ACETAZOLAMIDE               Diamox                    Tabs: 250 mg, 500mg
ACETIC ACID                 Domeboro                  Powder Packets
ACYCLOVIR                   Zovirax                   Caps: 200mg Tabs: 400mg, 800mg
                                                      Susp: 200mg/5ml
                                                      Oint: 15 g
ADAPALENE GEL               Differin                  0.1% Gel: 45g
ALBUTEROL HFA               Ventolin HFA              Inhaler: 90mcg, 200 sprays/unit
                                                      Neb Soln: 0.5%, 0.083%
                                                      Oral Liq: 5mg/5ml.
ALBUTEROL/ IPRATROPIUM      Combivent                 Inhaler: 200 sprays/unit
ALENDRONATE                 Fosamax                   Tabs: 5mg, 10 mg, 35 mg, 70 mg
                                                      Soln: 70mg/75ml
ALENDRONATE/VITAMIN D       Fosamax Plus D            Tabs: 70mg/2800 IU, 70mg/5600 IU
ALFUZOSIN                   Uroxatral                 Tabs: 10mg
ALLOPURINOL                 Zyloprim                  Tabs: 100mg, 300mg
ALPRAZOLAM                  Xanax C-IV                Tabs: 0.25mg, 0.5mg, 1mg, 2mg
ALUMINUM CHLORIDE           Drysol                    Liq: 37.5ml
HEXAHYDRATE
AMANTADINE                  Symmetrel                 Tabs: 100mg
                                                      Syrup: 50mg/5 ml
AMIODARONE                  Cordarone/Pacerone        Tabs: 200mg, 400mg
AMITRIPTYLINE               Elavil                    Tabs: all strengths
AMLODIPINE                  Norvasc                   Tabs: all strengths
AMLODIPINE/BENAZEPRIL       Lotrel                    Caps: all strengths
AMMONIUM LACTATE            Lac-Hydrin                Lotion: 12%
AMOXICILLIN                 Amoxil                    Susp:125mg/5ml, 250 mg/5ml, 400 mg/5 ml
                                                      Caps: 250mg, 500mg
AMOXICILLIN/ CLAVULANATE    Augmentin                 Susp: 200mg/5ml, 250mg/5ml, 400mg/5ml
                                                      ES Susp: 600 mg/5 ml
                                                      Tabs: 250mg/125mg, 500mg/125mg,
                                                      875mg/125mg
                                                      Chew Tabs: 250/62.5mg
                                                      XR: 1000 mg
AMPHETAMINE/                Adderall C-II             Tabs: 5, 10, 30 mg
DEXTROAMPHETAMINE           Adderall XR C-II          XR Caps: all strengths
AMPICILLIN                  Ampicillin                Caps: 500 mg
ANTIPYRINE/                 Auralgan                  Otic soln: 15 ml
BENZOCAINE/GLYCERIN
ASPIRIN ENTERIC COATED      Ecotrin                   Tabs: 81mg, 325mg
ATENOLOL                    Tenormin                  Tabs: all strengths
ATOMOXETINE                 Strattera                 Caps: all strengths
ATORVASTATIN                Lipitor                   Tabs: all strengths
AZELASTINE                  Astelin                   Nasal spray: 137mcg/spray
                                                      **DoD Quantity limit 2 per 30 days**
AZITHROMYCIN                Zithromax                 Tabs: 250mg, 500mg Packet: 1g
                                                      Susp: 100mg/5ml, 200mg/5ml
                                                                                                10
BACITRACIN                    Bacitracin           Oph oint
                                                   Topical oint
BACITRACIN/NEOMYCIN/          Polysporin           Oph oint
POLYMYXIN
BACLOFEN                      Lioresal             Tabs: all strenghts
BELLADONNA ALKALOIDS          Donnatal             Tabs: 16.2mg
                                                   Liq: 16.2mg/5ml
BENAZEPRIL                    Lotensin             Tabs: all strengths
BENZONATATE                   Tessalon Perles      Caps: all strengths
BENZOYL PEROXIDE GEL,         Benzac               Gel: 42.5g (10%)
BENZOYL PEROXIDE WASH                              Sol: 227g (10%)
BENZOYL PEROXIDE/             Benzaclin            Gel: 25 g (1-5%)
CLINDAMYCIN
BENZTROPINE                   Cogentin             Tabs: all strengths
BETAMETHASONE                 Diprosone            Cream: 0.05%, 45 g
DIPROPRIONATE                                      Oint: 0.05%, 15 g
BETAMETHASONE VALERATE        Valisone             Cream: 0.1%, 15 g, 45 g
BETAXOLOL                     Betoptic S           Oph susp: 0.5%, 5 ml.
BISACODYL                     Dulcolax             Tabs: 5 mg
BRIMONIDE                     Alphagan P           Oph soln: 0.15%, 0.2%
BROMOCRIPTINE                 Parlodel             Tabs: all strengths
BUDESONIDE                    Pulmicort Respules   Neb Sol: all strengths
BUDESONIDE/FORMOTEROL         Symbicort            Inhaler: 160/4.5, 80/4.5 mcg
BUPROPRION                    Wellbutrin           Tabs: 75, 100mg
BUPROPRION                    Wellbutrin SR        SR Tabs: 100mg, 150mg
BUPROPRION                    Zyban                SR Tabs: 150 mg
BUSPIRONE HCL                 Buspar               Tabs: all strengths
CALCIUM CARB+VIT D            OSCAL+D              Tabs: 500mg
CANDESARTAN                   Atacand              Tabs: all strenghts
CANDESATAN/HCTZ               Atacand HCT          Tabs: 16/12.5, 32/12.5mg
CAPTOPRIL                     Capoten              Tabs: all strengths
CARBAMAZEPINE                 Tegretol             Chewable tabs: 100mg Tabs: 200mg
                              Tegretol XR          XR tabs: all strengths
                                                   Liq: 100mg/5ml
CARBIDOPA/LEVODOPA            Sinemet              Tabs: 10/100, 25/100, 25/250 mg
                              Sinemet CR           CR: 25/100 mg
CARBOXYMETHYLCELLULOSE        Celluvisc            Boxes of 30
CARISOPRODOL                  Soma                 Tabs: 350 mg
CARVEDILOL                    Coreg                Tabs: all strengths
CEFADROXIL                    Duricef              Susp: 250 mg/5 ml
CEFDINIR                      Omnicef              Susp: 125 mg/5 ml & 250 mg/5 ml
CEFPODOXIME                   Vantin               Susp: 100 mg/5 ml
CEFUROXIME                    Ceftin               Susp: 250 mg/5 ml
                                                   Tabs: 250, 500 mg
CELECOXIB                     Celebrex             Caps: all strengths
CEPHALEXIN                    Keflex               Caps: all strengths
                                                   Susp: 250mg/5ml
CETIRIZINE                    Zyrtec               Tabs: 10 mg Liquid: 5 mg/5 ml Chewable: 5mg
CETIRIZINE/PSEUDOEPHEDRINE    Zyrtec-D             Tabs: 5/120 mg
CHLORAL HYDRATE               Noctec               Syrup: 500 mg/5 ml
CHLORHEXIDINE RINSE           Peridex              Rinse: 0.12%
CHLOROQUINE                   Aralen               Tabs: 250, 500 mg
CHLORTHALIDONE                Hygroton             Tabs: all strengths
CIMETIDINE                    Tagamet              Tabs: all strengths
CIPROFLOXACIN                 Cipro                Tabs: all strengths
                                                   Susp: 5gm/100ml
CIPROFLOXACIN                 Ciloxan              Opth: 0.3%/2.5 ml
CIPROFLOXACIN/DEXAMETHASONE   CiproDex             Soln: 7.5 ml


                                                                                            11
CITALOPRAM                      Celexa              Tabs: all strengths
                                                    Soln: 10mg/5ml
CLARITHROMYCIN                  Biaxin              Tabs: 250, 500 mg
CLINDAMYCIN                     Cleocin             Caps: all strengths
                                                    Susp: 75 mg/5 ml
                                                    Top Soln: 1%, 60 ml
                                                    Top Pads: 1%
                                                    Vaginal Cream: 2%(40 gm)
CLINDINIUM/                     Librax              Caps: 2.5 mg/5 mg
CHLORDIAZEPOXIDE
CLOBETASOL PROPRIONATE          Temovate            0.05% Cream: 15g, 45g
                                                    0.05% Oint, 0.05% Soln
CLOMIPHENE                      Clomid              Tabs: 50 mg
CLONAZEPAM                      Klonopin C-IV       Tabs: all strengths
CLONIDINE                       Catapres            Tabs: all strengths
CLOPIDOGREL                     Plavix              Tabs: 75 mg
CLOTRIMAZOLE                    Lotrimin            1% Cream: 30 g
                                                    1% Topical soln
CLOTRIMAZOLE / BETAMETHASONE    Lotrisone           Cream: 15, 45 g
DIP
CODEINE SULFATE                 Codeine C-III       Tabs: 30 mg
CODEINE/ GUAIFENESIN            Robitussin AC C-V   Liq: 10/100 mg per 5 ml (120 ml)
                                                    **Qty must be in equivalents of 120 ml**
COLESTIPOL                      Colestid            Tabs: 1 g Powder Packets: Box of 90
COLOCHICINE                     Colchicine          Tabs: 0.6 mg
CONJUGATED ESTROGENS            Premarin            Tabs: all strengths
                                                    Vaginal cream 0.625mg/gm
CONJUGATED ESTROGEN/            Prempro             Tabs: all strengths
MEDROXYPROGESTERONE
CROMOLYN SODIUM                 Crolom              Oph Soln: 4%, 15 ml
CYCLOBENZAPRINE                 Flexeril            Tabs: all strengths
CYCLOPENTOLATE                  Cyclogel            Oph Soln: 0.1%, 5 ml
CYPROHEPTADINE                  Periactin           Tabs: 4 mg
                                                    Syrp: 2mg/5ml
DESIPRAMINE                     Norpramin           Tabs: all strengths
DESMOPRESSIN                    DDAVP               Tabs: 0.2 mg
DESOGESTREL/ETHINYL             Mircette            28 day packs
ESTRADIOL (Biphasic)
DESOGESTREL/ETHINYL ESTRADIOL   Desogen             28 day packs
DETEMIR                         Levemir             Insulin vial
DEXAMETHASONE                   Decadron            Tabs: 0.5 mg, 4 mg
DEXTROAMPHETAMINE               Dexedrine C-II      Tabs: 5, 10 mg
                                                    SR Caps: 5 mg, 15mg
DIAGNOSTIC STRIPS               Precision Xtra      Boxes of 50
                                AccuChek Aviva
DIAZEPAM                        Valium C-IV         Tabs: all strengths
DICLOFENAC SODIUM               Voltaren            Tabs: 50, 75 mg
                                                    Oph soln: 0.1%
                                                    Top Gel: 1%
DICLOXACILLIN                   Dynapen             Caps: all strengths
DICYCLOMINE                     Bentyl              Tabs: all strengths
                                                    Soln: 10mg/5ml
DIGOXIN                         Lanoxin             Tabs: all strengths
                                                    Soln: 0.05mg/ml
DILTIAZEM                       Tiazac              Tabs: 60 mg
                                                    ER Caps: all strengths
DIPHENOXYLATE W/ATROPINE        Lomotil C-V         Tabs: 2.5/0.025 mg
DIPHENYDRAMINE                  Benadryl            Caps: 25 mg, 50 mg Liq: 12.5 mg/5 ml
DISOPYRAMINE                    Norpace             Caps: 100 mg

                                                                                               12
DIVALPROEX                        Depakote                      Tabs: all strengths
                                  Depakote Sprinkles            Caps: 125 mg
                                  Depakote ER                   ER tabs: all strengths
DOCUSATE SODIUM                   Colace                        Caps: 100 mg
DONEPEZIL                         Aricept                       Tabs: all strengths
DORZOLAMIDE                       Trusopt                       2% Oph soln: 10 ml
DORZOLAMIDE / TIMOLOL             Cosopt                        Oph soln: 2%-0.05%
DOXAZOSIN                         Cardura                       Tabs: all strengths
DOXEPIN                           Adapin                        Caps: all strengths
                                                                Soln: 10mg/ml
DOXYCYCLINE HYCLATE               Vibramycin                    Tabs: 100 mg
                                                                Caps: 50, 100mg
EPINEPHRINE                       Epi-Pen/Epi-Pen Jr            Auto-injector 0.15mg/dose, 0.3mg/dose
                                  Twinject
EPINEPHRINE                       Ephfrin                       2% Oph soln: 15 ml
ERGOTAMINE TARTRATE               Cafergot                      Tabs: 100 mg/1 mg
W/CAFFEINE
ERYTHROMYCIN                      Erythrocin                    Tabs: all strengths
                                                                Susp: 200 mg/5 ml
                                  Romycin                       Oph oint: 0.5% 5 mg/gm
                                                                2% Topical soln: 60 ml
                                                                2% gel
ERGOCALCIFEROL                    Vitamin D                     Gel Caps: 50,000 units
ESOMEPERZOLE                      Nexium                        Caps: all strengths
ESTRADIOL                         Estrace                       Tabs: all strengths
                                  Estraderm                     Patch: all strengths
                                  Vivelle Dot
                                  Esclim
ESTROGEN/                         Estratest HS                  Tabs: 0.625/1.25 mg
METHYLTESTOSTERONE
ETHAMBUTOL                     Myambutol                        Tabs: all strengths
ETHINYL ESTRADIOL/ DESOGESTREL Orthocept (Reclipsen)            0.03 mg EE/.015 mg D
                                                                28 day packs
ETHINYL ESTRADIOL/                Yasmin                        Tabs: 30 mcg/3 mg; 28 day packs
DROSPIRENONE                      Yaz                           Tabs: 20 mcg/3 mg; 28 day packs
ETHINYL ESTRADIOL/                Nuvaring                      Vaginal ring
ETONOGESTREL
ETHINYL ESTRADIOL                 TriLevlen, TriPhasil, Alesse, Tabs:
LEVONORGESTREL                    Lutera                        28 day packs
ETHINYL ESTRADIOL/                Nordette, Mircette            28 day packs
LEVONORGESTREL
ETHINYL ESTRADIOL/                Ortho Evra                    Transdermal patch
NORELGESTROMIL
ETHINYL ESTRADIOL/                Ortho-Novum                   28 day packs
NORETHINDRONE                     Loestrin 1/20 FE
                                  Necon 1/35
ETHINYL ESTRADIOL/                Ortho-Cyclen                  28 day packs
NORGESTIMATE                      Ortho Tri-cyclen
                                  Ortho Tri-cyclen LO
ETHINYL ESTRADIOL/ NORGESTREL     Ovral, LoOvral                28 day packs

ETONORGESTREL                     Implanon                      IM device
EZETMIBE                          Zetia                         Tabs: 10 mg
FAMOTIDINE                        Pepcid                        Tabs: 20mg and 40mg
FELODIPINE                        Plendil                       Tabs: all strengths
FENOFIBRATE                       Lofibra, Tricor               Tabs: 48mg, 54mg, 145mg, and 160 mg
FERROUS SULFATE                   FeoSol                        Soln: 25 mg/ml, 50ml.
                                                                Tabs: 325 mg
FEXOFENADINE                      Allegra                       Tabs: 60, 180 mg
FINASTERIDE                       Proscar                       Tabs: 5 mg
                                                                                                        13
FLUCONAZOLE                     Diflucan                  Tabs: all strengths
FLUDROCORTISONE                 Florinef                  Tabs: 0.1 mg
FLUNISOLIDE                     Nasarel                   Nasal spray: 25 mcg. 200 sprays/unit
FLUOCINOLONE                    Synalar                   Soln: 1%, 60 ml
FLUOCINONIDE                    Lidex                     *Cream: 0.05%, 15 g, 60 g
                                                          Gel: 0.05%, 60 g
                                                          Oint: 0.05%, 60 g
FLUORIDE                        Prevident 5000+, Luride   Gel: 1.1%, 2oz
                                                          Drops: 1.1 mg/ml
                                                          Tabs: 1.1 mg
FLUOROMETHOLONE                 Fluor-Op, FML             Susp: 0.1%, 15 ml
FLUOXETINE                      Prozac                    Caps: 10, 20, 40 mg
                                                          Soln: 20mg/5ml
FLUTICASONE                     Flonase                   Nasal spray: 50 mcg, 120 sprays/unit
FLUTICASONE HFA                 Flovent HFA               Inhaler: 44, 110, 220 mcg
                                                          **Qty limit 2 per 30 days**
FLUTICASONE Diskus              Flovent Diskus            Inhaler
FLUTICASONE/ SALMETEROL         Advair                    Inhaler: 100/50 mcg, 250/50mcg, 500/50 mcg
                                Advair HFA                Inhaler: 45/21 mcg, 115/21 mcg, 230/21 mcg
FOLIC ACID                      Folic Acid                Tabs: 1 mg
FUROSEMIDE                      Lasix                     Tabs: all strengths
                                                          Soln: 10mg/ml
GABAPENTIN                      Neurontin                 Caps: all strengths
GEMFIBROZIL                     Lopid                     Tabs: 600 mg
GENTAMICIN SULFATE              Geramicin                 Oph soln: 0.3%, 5 ml
                                                          Oph oint: 3.5 g
GLIPIZIDE                       Glucotrol                 *Tabs: all strengths
                                Glucotrol XL              XL Tabs: all strengths
GLYBURIDE                       Micronase                 Tabs: all strengths
GLYBURIDE MICRONIZED                                      Micronized: all strengths
GLYBURIDE/ METFORMIN            Glucovance                Tabs: all strengths
GLYCOPYRROLATE                  Robinul                   Tabs: 1 mg
GOSERELIN                       Zoladex                   Implants: 3.6 mg, 10.8 mg
GRAMICIDIN/NEOMYCIN/POLYMYXIN                             Soln: 0.025mg/2.5mg/10000unit/ml
B
GRISEOFULVIN                    Grispeg, Grifulvin V      Tabs: 125, 250 mg Susp: 125 mg/5 ml
GUAIFENESIN                     Mucinex                   Tabs: 600 mg
GUAIFENESIN/PSE                 MucinexD                  Tabs: 600/60 mg,
GUAIFENSIN/DEXTROMETHORPHAN     Robitussin DM             Liq: 100/10 mg per 5 ml
HALOPERIDOL                     Haldol                    Caps: 1 mg, 10 mg
HOMATROPINE                     Isopto Homatropine        Liq: 5%, 5 ml
HYALURONIC ACID                 Atopiclair                Topical cream
HYDRALAZINE                     Apresoline                Tabs: 10, 25, 50 mg
HYDROCHLOROTHIAZIDE             HCTZ                      Caps 12.5 mg Tabs 25, 50 mg
HYDROCODONE/                    Vicodin                   *Tabs: 5/500 mg
ACETAMINOPHEN                   Vicodin ES                ES Tabs: 7.5/750 mg
HYDROCORTISONE                  Anusol HC                 Cream: 2.5%
                                                          Supps: 25 mg
HYDROCORTISONE ACETATE/         Proctofoam                Foam: 1%, 10 g
PRAMOXINE                                                 Cream: 30 g
HYDROCORTISONE VALERATE         Westcort                  0.2% Cream: 15 g, 60 g
                                                          0.2% Oint: 45 g
HYDROCORTISONE/                 Vosol HC                  Susp: 10 ml
ACETIC ACID
HYDROXYAMPHETAMINE/             Paremyd                   Soln: 1%/0.25%
TROPICAMIDE
HYDROXYCHLOROQUINE              Plaquenil                 Tabs: 200 mg
HYDROXYZINE                     Atarax                    Tabs: all strengths Liq: 10 mg/5 ml
IBANDRONATE                     Boniva                    Tabs: all strengths

                                                                                                       14
IBUPROFEN                   Motrin                      Tabs: all strengths
                                                        Susp: 100 mg/5 ml
IMIPRAMINE                  Tofranil                    Tabs: all strengths
INDOMETHACIN                Indocin                     *Caps: all strengths
                                                        ER Cap: 75 mg
INSULIN ASPART              Novolog, Novolog Flexpen    100 units/ml, 10 ml vial
INSULIN GLARGINE            Lantus, Lantus SoloStar Pen 100 units/ml, 10 ml vial
                                                        100 units/ml, pen
INSULIN NPH/REGULAR 70/30   Novolin 70/30               100 units/ml, 10 ml vial
INSULIN HUMAN NPH           Novolin N                   100 units/ml, 10 ml vial
INSULIN HUMAN 70/30         Novolog Mix 70/30           100 units/ml, 10 ml vial
INSULIN HUMAN REGULAR       Novolin R                   100 units/ml, 10 ml vial
INSULIN SYRINGES                                        Boxes of 100: 0.5 ml, 1 ml 29 G,½”
INSULIN PEN NEEDLES                                     **Limit 300 syringes/90 days**
IPATROPIUM BROMIDE          Atrovent                    Neb Soln, Nasal spray
                            Atrovent HFA                Inhaler
ISONIAZID                   INH                         Tabs: all strengths Syrup: 50 mg/5 ml
ISOSORBIDE DINITRATE        Isordil                     SR Caps: 40 mg
                                                        Tabs: all strengths
ISOSORBIDE MONONITRATE      Imdur                       Tabs: all strengths
ISOTRETINOIN                Accutane                    Caps: all strengths
KETOCONAZOLE                Nizoral                     Cream: 30 g
                                                        Shampoo: 4 oz
KETOROLAC TROMETHAMINE      Acular                      Oph soln: 0.5%, 5ml
KETOTIFEN                   Zaditor                     Oph soln: 0.025 % 5 ml
LACTULOSE                   Cepulac                     Syrup: 10 g/15 ml
LAMOTRIGINE                 Lamictal                    Tabs: all strengths
LANCETS                     Soft-Touch                  Boxes of 200
                            Accu-chek Soft Clix
LANCET DEVICE               Soft-Touch                  Device
LATANOPROST                 Xalatan                     Oph soln: 0.005%, 2.5 ml
LEUCOVORIN                  Leucovorin                  Tabs: 5 mg
LEVALBUTEROL                Xopenex                     Inhaler: 200 sprays/unit
LEVOBUNOLOL                 Betagan                     Oph Soln: 0.5%, 5ml
LEVOCABASTINE               Livostin                    Oph soln: 0.025%, 5 ml
LEVOFLOXACIN                Levaquin                    Tabs: all strengths
                                                        Soln: 25mg/ml
LEVONORGESTREL              Plan B One-Step             Tabs: 1.5mg
                            Next Choice                 Tabs: 0.75mg
LEVONORGESTREL IUD          Mirena                      IUD *Must have scheduled appt*
LEVOTHYROXINE               Synthroid                   Tabs: all strengths
LIDOCAINE HCL               Xylocaine                   Gel: 2%, 30 ml
                                                        Soln: 2%, 100 ml
                            Lidoderm                    Top Patch: 5%
LISINOPRIL                  Zestril                     Tabs: all strengths
LISINOPRIL/HCTZ             Zestoretic                  Tabs: all strengths
LITHIUM CARBONATE           Lithium                     Tabs: all strengths
                            Lithium citrate             Syrp: 8mEq/5ml
LOPERAMIDE                  Imodium                     Caps: 2 mg
LORATADINE                  Claritin                    Tabs: 10 mg
                                                        Syrup: 1 mg/ml
LORAZEPAM                   Ativan                      Tabs: all strengths
LOSARTAN                    Cozaar                      Tabs: all strengths
LOSARTAN/HCTZ               Hyzaar                      Tabs: all strengths
LOTEPREDNOL                 Alrex                       Susp: 0.2%, 5 ml
LUBRICANT                   Lacrilube                   Opth oint: 3.5 g
LUVOXAMINE                  Luvox                       Tabs: 100 mg
MEBENDAZOLE                 Vermox                      Chew Tabs: 100 mg
MECLIZINE                   Antivert                    Tabs: all strengths
                                                                                                15
MEDROXYPROGESTERONE        Depo Provera                 Injection: 150 mg
                                                        **Must have appt for administration**
MEDROXYPROGESTERONE        Provera                      Tabs: all strengths
MEFLOQUINE                 Lariam                       Tabs: 250 mg
MELOXICAM                  Mobic                        Tabs: 7.5, 15 mg
METAXOLONE                 Skelaxin                     Tabs: 800 mg
METFORMIN HCL              Glucophage                   Tabs: all strengths
                           Glucophage XR                XR Tabs: all strengths
METHOCARBAMOL              Robaxin                      Tabs: all strengths
METHOTREXATE               Rhemstrex                    Tabs: 2.5 mg
METHYLDOPA                 Aldomet                      Tabs: all strengths
METHYLPHENIDATE            Ritalin C-II                 *Tabs: all strengths
                                                        SR Tabs: 20 mg
METHYLPHENIDATE XR         Concerta C-II                Tabs: all strengths
METHYLPREDNISOLONE         Medrol                       Tabs: 4 mg, dosepack
METOCLOPRAMIDE HCL         Reglan                       Tabs: all strengths Liq: 5 mg/5 ml
METOPROLOL                 Lopressor                    Tabs: all strengths
                           Toprol XL                    Tabs: all strengths
METRONIDAZOLE              Flagyl                       Tabs: all strengths
METRONIDAZOLE              Metrogel-Vaginal             Gel: 0.75%, 70 g
MINOCYCLINE                Minocin                      Caps: all strengths
MI PASTE PLUS              MI Paste                     Dental paste
MOISTURIZING CREAM         Eucerin cream                Cream
MOMETASONE                 Elocon                       Cream: 15g, 30g
MOMETASONE                 Nasonex                      Nasal spray
                           Asmanex                      Twisthaler
MOMETASONE/FORMOTEROL      Dulera                       Inhaler
MONITOR, BLOODGLUCOSE      Precision Xtra               Kit
                           AccuCheck Aviva
MONTELUKAST                Singulair                    Tabs: all strengths
                                                        Oral granules: 4 mg
MORPHINE SULFATE IR        Morphine C-II                Tabs: all strengths
MORPHINE SULFATE ER        MS Contin C-II               ER Tabs: all strengths
MOXIFLOXACIN               Vigamox                      Oph Soln: 0.5%, 5ml
MULTIVITAMIN PEDIATRIC     Poly Vi Sol w/Iron           Soln: 50 ml
SOLUTION W/IRON
MULTIVITAMIN W/ FLUORIDE   Poly Vi Flor                 Soln: 50 ml
                                                        Chew Tab: 0.25mg, 0.5 mg
MUPIROCIN                  Bactroban                    Oint: 15 g
NAPROXEN                   Naprosyn                     Tabs: all strengths
                           Naproxen sodium              Tabs: all strengths
                                                        Susp: 125mg/ 5ml
NEFAZODONE                 Serzone                      Tabs: 150 mg
NEOMYCIN/POLYMYXIN/HC      Cortisporin HC               Soln, Susp: 10 ml
NEOMYCIN/POLYMYXIN/        Neosporin                    Ophth oint
BACITRACIN
NEOMYCIN/POLYMYXIN/        Neosporin                    Oph soln 10 ml
GRAMICIDIN
NIACIN                     Niaspan                      *CR Tabs: all strengths
NICOTINE                   Nicoderm                     Patches: all strengths
NIFEDIPINE                 Adalat CC                    *SR Tabs: all strengths
                           Procardia                    Caps: 10 mg
NITROFURANTOIN             Macrobid                     Caps: 100 mg
                           Macrodantin                  Caps: all strengths
NITROGLYCERIN              Nitrostat, Nitrobid, Nitro   SL Tabs: 0.4 mg
                           Dur                          SL Spray: 0.4 mg
                                                        SR Caps: all strengths
                                                        Patches: all strengths
NORETHINDRONE              Micronor                     28 day packs

                                                                                                16
NORTRIPTYLINE                    Pamelor              Caps: all strengths
                                                      Soln: 10mg/5ml
NYSTATIN                         Niastat              Cream: 15 g
                                                      Oint: 15 g
                                                      Powder 100,000 unit
                                                      Susp: 100,000 units/60 ml
OFLOXACIN                        Ocuflox              Oph Soln: 0.3% 5 ml
OFLOXACIN                        Floxin Otic          Soln: 5 mL
OLANZAPINE                       Zyprexa              Tabs: all strengths
OLOPATADINE                      Patanol              Oph soln: 0.1 % 5 ml
OMEPRAZOLE                       Priolosec            Caps: all strengths
OXYBUTYNIN                       Ditropan             Tabs: 5mg
OXYBUTYNIN ER                    Ditropan XL          Tabs: all strengths
OXYCODONE/                       Percocet             Tabs: 5/325 mg
ACETAMINOPHEN
OXYMETAZOLINE                    Afrin nasal spray    Soln: 0.05% (15 ml)
PANTOPRAZOLE                     Protonix             Tabs: 40mg
PAROXETINE                       Paxil                Tabs: all strengths
PENICILLIN VK                    PenV K, Veetids      Susp: 125mg/5ml, 250 mg/5 ml
                                                      Tabs: all strengths
PERMETHRIN                       Elimite, Nix         Cream: 5%, 60 g Cream: 1%, twinpack 60 ml
PHENAZOPYRIDINE                  Pyridium             Tabs: all strengths
PHENOBARBITAL                    Phenobarbital        Tabs: 15, 30, 60, 100 mg Liq: 20 mg/5 ml
PHENYLEPHRINE                    Mycifrin             Oph soln: 2.5%, 15 ml
PHENYTOIN                        Dilantin             Caps: 100 mg Tabs Chew: 50 mg
                                                      Susp: 125mg/5ml
PILOCARPINE                      Pilocar              Oph Soln: all strengths
                                                      Oph Gel 4%
PIMECROLIMUS                     Elidel               Tube: 15 g, 30 g
PIOGLITAZONE                     Actos                Tabs: all strengths
PIOGLITAZONE/                    Actoplus met         Tabs: 15/850, 15/500 mg
METFORMIN
POLYETHYLENE GLYCOL              Trilyte              Pwd for Reconst: 4 L
POLYETHYLENE GLYCOL 3350         Miralax              Powder: 527, 255 g
POLYMYXIN B/TRIMETHOPRIM         Polytrim             Oph soln: 5 ml
POTASSIUM BICARBONATE/POT        Klorvess             Packets: 20 mEq
CHLORIDE                                              Box of 30
POTASSIUM CHLORIDE               Klor-con             ER Tabs: all strengths
                                                      Powder packet: 20 mEq
                                                      Soln: 20 mEq/15 ml
                                 Micro K              CR Caps: 10 mEq
PRAVASTATIN                      Pravachol            Tabs: all strengths
PRAZOSIN                         Minipress            Caps: all strengths
PREDNISOLONE                     Prelone/Orapred      Liq: 15 mg/5 ml
PREDNISOLONE ACETATE             Pred Forte           Oph Susp: 1%, 5 ml
                                 Pred Mild            Oph Susp: 0.12%
PREDNISOLONE ACETATE/            AKCide               Oph oint
SULFACETAMIDE
PREDNISONE                       Orasone, Deltasone   Tabs: all strengths
                                                      Syrup: 5mg/5ml
PRENATAL VITAMINS + FOLIC ACID   Natalins             Tabs : PNV with 1mg folic acid
                                                      **Limited to women age 45 and younger**
PRENISOLONE SODIUM PHOSPHATE     Inflamase            Susp: 1/8%, 1%, 5 ml
PRIMAQUINE                       Primaquine           Tabs: 23.6 mg
PRIMIDONE                        Mysoline             Tabs: all strengths
PROBENECID                       Benemid              Tabs: 500 mg
PROCHLORPERAZINE                 Compazine            Tabs: all strengths Supps: 25 mg
PROGESTERONE                     Prometrium           Caps: 100, 200 mg


                                                                                                  17
PROMETHAZINE                  Phenergan            Tabs: all strengths Supps: all strengths
                                                   Syrp: 6.25mg/5ml
PROMETHAZINE/DEXTROMETHORPH   Phenergan DM         Syrp: 120 ml
AN
PROPARACAINE                  Ophthaine            Soln: 0.5%, 15 ml
PROPOXYPHENE/                 Darvocet-N 100       Tabs: 100/650 mg
ACETAMINOPHEN
PROPRANOLOL                   Inderal              Tabs: 10, 40 mg
                              Inderal LA           LA Caps: 80 mg
PROPYLTHIOURACIL              PTU                  Tabs: 50 mg
PSEUDOEPHEDRINE               Sudafed              Tabs: 30, 120 mg
                                                   Liq: 30 mg/5 ml
PYRAZINAMIDE                  PZA                  Tabs: 500 mg
PYRIDOSTIGMINE                Mestinon             Tabs: 60 mg
PYRIDOXINE                    Vitamin B6           Tabs: all strengths
QUETIAPINE                    Seroquel             Tabs: all strengths
                              Seroquel XR          XR: all strengths
RALOXIFENE                    Evista               Tabs: 90 mg
RANITIDINE                    Zantac               Tabs: all strengths
                                                   Syrup: 15 mg/ml
RIFAMPIN                      Rifadin              Caps: 300 mg
RIMEXOLONE                    Vexol                Oph Susp: 1%
RISPERIDONE                   Risperdal            Tabs: all strengths
                                                   Soln 1mg/ml
RIZATRIPTAN                   Maxalt               Tabs: all strengths
                              Maxalt MLT           MLT tabs: all strengths
                                                   **DoD Quantity limit 36 tablets/90 days**
ROVUSTATIN                    Crestor              Tabs: all strengths
                                                   **DoD requires Prior Authorization from MD
SALICYLIC ACID                Clear Away           Plasters: 40%
SALINE NASAL SPRAY            Sea-mist             Soln: 0.65%
SALMETEROL                    Serevent Diskus      *Inhaler: 18 mcg, 200 sprays/unit
                              Serevent             Neb Soln: 0.02%/2.5 ml, 30 unit
SALISALATE                    Disalcid             Tabs: 500, 750 mg
SCOPOLAMINE                   Transderm Scop       Patch: 1.5 mg
SELENIUM SULFIDE              Selsun               Shampoo: 2.5% 120 ml
SERTRALINE                    Zoloft               Tabs: all strengths
                                                   Liq: 20mg/ml
SILVER SULFADIAZINE           Silvadene            1% cream
SIMVASTATIN                   Zocor                Tabs: all strengths
SIMVASTATIN/EZETIMIBE         Vytorin              Tabs: all strengths
SODIUM CHLORIDE 0.9%          Normal saline        3ml vials for Nebulization
SPACER                        Optichamber          Device
                              Optichamber w/mask
                              Aerochamber w/mask
SPIRONOLACTONE                Aldactone            Tabs: all strengths
SUCRALFATE                    Carafate             Tabs: 1 g
                                                   Liq: 1 g/10 ml
SULFACETAMIDE                 Sulamyd, Bleph-10    Oph soln: 10%, 15 ml
                                                   Opth oint: 3.5 g
SULFACETAMIDE SODIUM/         Vasocine             Opth oint: 10%/0.5%
PREDNISOLONE ACETATE
SULFACETAMIDE SODIUM/         Isopto Catapred      Susp: 10%/0.25%, 15ml.
PREDNISOLONE ACETATE
SULFACETAMIDE/                Plexion              Cleanser: 6oz
SULFUR CLEANSER
SULFAMETHOXAZOLE/             Pediazole            Susp:600/200 mg/5 ml
ERYTHROMYCIN


                                                                                              18
SULFAMETHOXISOLE/          Bactrim, Septra, Bactrim DS Tabs: all strengths
 TRIMETHOPRIM               Sulfatrim                   Susp:40/200 mg /5 ml
 SULFASALAZINE              Azulfidine                  Tabs: 500 mg
                                                        EC Tabs: 500mg
 SUMATRIPTAN                Imitrex                     Tabs: 25, 50 mg
                                                        **DoD Quantity limit 54 tablets/90 days**
                                                        Tabs: 100 mg
                                                        **DoD Quantity limit 27 tablets/90 days**
 SUMATRIPTAN                Imitrex Stat Dose           Kit all strengths
 TAMOXIFEN                  Nolvadex                    Tabs: all strengths
 TAMSULOSIN                 Flomax                      Caps: 0.4mg
 TELMISARTAN                Micardis,                   Tabs: all strengths
 TELMISARTAN/HCTZ           Micardis HCT                Tabs: all strengths
 TEMAZEPAM                  Restoril C-IV               Caps: all strengths
 TERAZOSIN                  Hytrin                      Caps: all strengths
 TERBUTALINE                Brethine                    Tabs: 5 mg
 TERCONAZOLE                Terazol 7                   Cream: 0.4%, 20 g
 TETRACYCLINE               Achromycin                  Caps: all strengths
 THEOPHYLLINE               Theo-24                     24 hr Caps: all strengths
                            Theodur                     *12 hr Tabs: all strengths *Liq: 80 mg/15 ml
                            Uniphyl                     *24 hr Tabs: 400mg
 THIAMINE                   Vitamin B1                  Tabs: all strengths
 TIMOLOL MALEATE            Timolol                     Oph soln: all strengths
                            Timoptic XE                 Gel: all strengths
 TIOTROPIUM                 Spiriva                     Inh w/ device: 18 mcg
 TOBRAMYCIN                 Tobrex                      Soln: 0.3%, 5 ml
 TOBRAMYCIN/DEXAMETHASONE   Tobradex                    Susp: 0.3%/0.1%, 2.5 ml
                                                        Opth Oint: 3.5 g
 TOLNAFTATE                 Tinactin                    Soln: 1%, 10 ml
 TOLTERODINE                Detrol LA                   SR Caps: all strengths
 TOPIRAMATE                  Topamax                    Tabs: all strengths
 TRAMADOL                   Ultram                      Tabs: all strengths
                                                        **DoD Quantity Limit 240 tabs per 30 days**
 TRAZADONE                  Desyrel                      Tabs: 50, 100, 150, 300 mg
 TRETINOIN                  Retin A, Avita              Cream: all strengths
                                                        **Limited to persons <36 yrs of age**
  TRIAMCINOLONE             Kenalog in Orabase          Paste: 0.1% 5 g
T TRIAMCINOLONE             Kenalog                     *Cream: 1%, 5%
                                                         Spray: 15 mcg/spray. 63g
                                                        Ointment: 1%
 TRIAMTERENE/HCTZ           Maxzide                     Tabs: 37.5/25, 75/50 mg
 TRIHEXYPHENIDYL            Artane                      Tabs: all strengths *Elixir: 0.4mg/ml
 TRIMETHOBENZAMIDE          Tigan                       Caps: 300 mg
 TRIMETHOPRIM/POLYMYXIN B   Polytrim                    Soln: 10 ml
 TROPICAMIDE                Mydriacyl                   Soln: 1%, 15 ml
 VALACYCLOVIR               Valtrex                     Tabs: all strengths
 VALPROIC ACID              Depakene                    Liq: 250 mg/5ml
 VALSARTAN                  Diovan                      Tabs: all strengths
 VALSARTAN/HCTZ             DiovanHCT                   Tabs: all strengths
 VARDENAFIL                 Levitra                     Tabs: all strengths
                                                        Under 40? Need prior authorization form
                                                        **DoD Quantity limit 18 tablets/90 days**
 VARENECLINE                Chantix                     Tabs: Starter pack, continuing treatment pack
                                                        (0.5, 1 mg tabs)
                                                        **Must be enrolled in Smoking Cessation
                                                        class**
 VENLAFAXINE                Effexor, Effexor XR         XR Caps: all strengths
 VERAPAMIL                  Calan                       Tabs: 80 mg
                                                        SR Tabs: all strengths

                                                                                                        19
WARFARIN      Coumadin          Tabs: all strengths
XYLITOL       Spry Gum          Dental chewing gum
ZIPRASIDONE   Geodon            Caps: all strengths
ZOLPIDEM      Ambien C-IV       Tabs: all strengths
ZOMITRIPTAN   Zomig/Zomig ZMT   Tabs: all strengths/Oral disintegrating tabs
                                **DoD Quantity limit 36 tablets/90 days**




                                                                               20
Quick List for Common Uses
        For Asthma/Allergies                         For Blood pressure                           For Cholesterol
Inhalers: Albuterol (Ventolin/Proventil      ACEs: benazepril (Lotensin), captopril   Statins: atorvastatin (Lipitor),
HFA), levalbuterol (Xopenex) MDI,            (Capoten), lisinopril (Zestril)          pravastatin (Pravachol), simvastatin
salmeterol (Serevent Diskus)                                                          (Zocor)
                                             ARBs: candesartan (Atacand), losartan
Nebulizer solutions: albuterol,              (Cozaar), telmisartan (Micardis),        Other: Ezetimibe (Zetia), fenofibrate
budesonide (Pulmicort), ipratropium          valsartan (Diovan)                       (Lofibra), niacin (Niaspan), gemfibrozil
                                                                                      (Lopid)
Other: montelukast (Singulair)               BBs: atenolol (Tenormin), carvedilol
                                             (Coreg), metoprolol succinate (Toprol    Combo: ezetimibe/simvastatin
Steroids: fluticasone (Flovent HFA)          XL), metoprolol tartrate (Lopressor)     (Vytorin)
mometasone (Asmanex)
                                             CCBs: amlodipine (Norvasc), diltiazem
Combo: albuterol/salmeterol (Advair &        ER (Tiazac), felodipine (Plendil),
Advair HFA), budesonide/formoterol           nifedipine SR (Adalat CC), verapamil
(Symbicort)                                  (Calan SR)

Allergies: cetirizine (Zyrtec), loratadine   Diuretics: furosemide (Lasix), HCTZ,
(Claritin), fexofenadine (Allegra),          spironolactone, triamterene/HCTZ
cetirizine/pseudoephedrine (Zyrtec-D)        (Maxzide)

Nasal: azelastine (Astelin), fluticasone     Combos: benazepril/amlodipine
(Flonase), mometasone (Nasonex),             (Lotrel), lisinopril/HCTZ (Zestoretic)
fluocinonide (Nasarel)                       losartan/HCTZ (Hyzaar),
                                             telmisartan/HCTZ (Micardis HCT),
                                             valsartan/HCTZ (Diovan HCT)
             For Diabetes                                  For Migraines                    Controlled Substances
Oral Agents: Glipizide (Glucotrol &          Triptans: rizatriptan (Maxalt & Maxalt   The state of California requires
Glucotrol XL), Glyburide (Micronase),        MLT), sumatriptan (Imitrex),             that controlled substances MUST
Metformin (Glucophage & Glucophage           zolmitriptan (Zomig & Zomig ZMT)         be written on a California Security
XR), pioglitazone (Actos),                   [Please note DoD quantity limitations]   Prescription pad.
pioglitazone/metformin (Actoplusmet)
                                             Acetaminophen/butalbital/caffeine        C-II: Adderall and Adderall XR, Ritalin,
Insulin: Novolog (aspart), Novolin N         (Fioricet)                               Concerta, Morphine IR, MS Contin,
(NPH), Novolin R (regular), Novolin                                                   Percocet
70/30 (NPH/Reg), Novolog Mix 70/30
(NPH/Reg), Lantus (glargine)                                                          C-III: Tylenol w/ codeine #3, Codeine
                                                                                      sulfate, Vicodin, and Vicodin ES
Syringes: 0.5 ml, 1ml. BD Sharps
container for disposal. Insulin Pen                                                   C-IV: Alprazolam (Xanax), Clonazepam
needles                                                                               (Klonapin), diazepam (Valium),
                                                                                      lorazepam (Ativan), temazepam
Blood glucose monitors/test strips:                                                   (Restoril), zolpidem (Ambien).
Accu-chek Aviva, Precision Xtra (box of
50 test strips)                                                                       C-V: Robitussin AC (qty of 120ml),
                                                                                      Lomotil
Lancets (box of 200): Accu-chek
Softclix for Aviva Accu-check Soft                                                    NOTE: C-II: no refills allowed C-III-V:
touch plus lancet device for Precision                                                prescription only valid for 6 months.
Xtra.                                                                                 Refills are allowed but may not exceed
                                                                                      6 months




                                                                                                                             21
Quick Reference Telephone List

Emergencies............................................................ 911
Emergencies from cell phone on base................... 661- 277- 4541
Poison Control ...................................................... 800-222-1222

Appointments:
Family practice ...................................................... 661-277-7118, option 1, then 1
Pediatrics................................................................ 661-277-7118, option 1, then 2
Flight Surgeon’s Office.......................................... 661-277-7118, option 1, then 3
Optometry.............................................................. 661-277-7118, option 1, then 4
Physical Therapy.................................................... 661-277-7118, option 1, then 5
Dental Clinic.......................................................... 661-277-2872
Family Advocacy................................................... 661-277-5292
Flight Surgeon’s Office.......................................... 661-277-7118 option 3
Health and Wellness Center.................................... 661-277-8480
Immunizations.........................................................661-277-3427
Laboratory............................................................... 661-277-2306
Mental Health..........................................................661-277-5291
Managed Care......................................................... 661-277-6969
NurseLine................................................................ 661- 275-6877, or
                                                                           888-762-3842
Patient Administration........................................... 661-275-2668
Pharmacy................................................................ 661-277-9896
Physical Therapy.................................................... 661-277-3891
Primary Care Clinic............................................... 661-277-7118
Public Health.......................................................... 661-275-2694
Radiology................................................................ 661-277-2681
TriWest/TRICARE................................................. 888-874-9378
                 Base Exchange: Main Store                         258-1078
                 Commissary                                        277-4589
                 Family Child Care Program                         275-4FCC/275-4322
                 Golf Course                                       275-PUTT/275-7888
                 Information, Tickets and Travel (leisure)         275-TRIP/275-8747
                 Base Schools Switchboard                          258-4411
                 Security Forces                                   277-3340
                 Retiree Activity Office                           277-4931


                                                                                                            22

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Formulary (updated jul 11)

  • 1. Edwards Air Force Base Pharmacy Formulary Current as of 1 Oct 2011
  • 2. Table of Contents Welcome Letter from Flight Commander 4 General Pharmacy Information 5 How do I get my Refills? 6 Pharmacy Benefits 7 New to our Formulary 9 Formulary Listing by alphabetical order (generic names) 10 Listing by Common Use (not a complete listing) 21 Quick Reference Phone Guide 22 2
  • 3. Welcome to Edwards AFB and the 95th Medical Group! We, the military and civilian pharmacy staff at the 95th Medical Group, are always striving to provide you and your family the best pharmaceutical care available. All of us are committed to providing quality services, and to ensure that the care you receive is and continues to be the best you’ve ever experienced. The pharmacy handbook/frequently asked questions has been created to hopefully make accessing pharmacy services easier and less confusing for beneficiaries. While it does not answer every question, it does provide guidance on most of our services. I would like to extend on behalf of my staff and self, a special thank you to all of you in uniform who are defending our country and to all the veterans who have made major contributions to our nation. We also thank the families who have and continue to support all of you. Vanthy Pham Vanthy B. Pham, Maj, USAF, BSC, PharmD Diagnostics and Therapeutics Flight Commander 3
  • 4. Pharmacy General Information What are the hours for the Pharmacy? Pharmacy hours are below. Monday 0730-1630 Tuesday 0730-1630 Wednesday 0730-1630 Thursday 0730-1630 Friday 0730-1630 Closed the first Monday of each month, weekends, federal holidays, AFMC approved family days and Military down days. Where is the Pharmacy? The Pharmacy is located in the main clinic on 30 Nightingale Rd in building 5525. It is located in the south end of the first floor. Eligible beneficiaries include: Active duty service members and their families Activated National Guard and Reserve Members and their families (on Title 10 or Title 32 [federal] orders) Retired service members and their families Survivors, widows/widowers and certain former spouses Medal of Honor recipients and their families Beneficiaries enrolled in TRICARE Reserve Select or the Continued Health Care Benefit Program Other beneficiaries listed in DEERS as eligible for TRICARE, including foreign force members and their families When updating DEERS with your personal information, be sure to update your address with a physical address. 4
  • 5. How do I get medication refills? If you have an existing prescription that is still active with refills left, call the Pharmacy at 661-277-9896. Prescriptions called into the refill line will be available for pickup within two duty days at the main pharmacy or at the APM located in BX lobby (*certain medications only*). If you present to the pharmacy window for a refill you may be asked to come back later or the next duty day. Please make every effort to call in prescription refills to avoid delays. Typically, if you’re running out of a medication (down to last refill or last set of doses), it means your provider is expecting you to follow-up for a re-evaluation. Please make a follow-up appointment prior to running out so your provider can see how you are doing. If your prescription has expired or you have no refills left and you see a provider on base, please call PCC at 661-277-7118 at least one week prior to running out of your medication. Ask to leave a telephone consult for your provider’s nurse. Please have the name and dosage of the medication ready to provide to the phone clerk, as it makes renewing your prescription easier. As long as the provider determines that you do not need a follow-up appointment prior to prescription renewal, your refill request will typically be taken care of within 72 business hours. If you see a civilian provider off base you will have to contact your provider for a new prescription. The pharmacy does NOT accept fax or phone-in prescription orders or refills. Any questions regarding your medications that can be handled by the pharmacy should be directed to their staff at 661-277-9896 (option 1 clinic pharmacy, option 5 speak to pharmacy personnel) Can’t make it to the pharmacy during normal duty hours? Sign up today to use our Automated Prescription Machine (APM) located in the BX food lobby to pick up your prescription refills. The APM is available during BX hours including weekends. 5
  • 6. YOUR PHARMACY Benefits All formulary medication at EDWARDS Pharmacy: $0 cost for up to a 90 day Supply Other Military Treatment Facility (MTF) Pharmacies An MTF pharmacy provides those medications listed on its local formulary (drug listing). Most MTF pharmacies accept prescriptions written by both civilian and military providers. To check the availability of a particular drug, contact you’re nearest MTF if not stationed at Edwards AFB in person or by phone. TRICARE Mail Order Pharmacy (TMOP) You can receive up to a 90-day supply* for most medications you take regularly (for instance, drugs for high blood-pressure, asthma or oral contraceptives) using TMOP. When you use the TMOP service you get: • Savings: You can save up to 66% of retail costs, because your co-payment for a 90-day supply is the same as for a 30-day supply at a retail pharmacy. • Convenience and safety: Your medication is mailed to your home in a weather-resistant pouch for your privacy and protection and there is no charge for postage. To use the TMOP service, just follow these steps: 1) Ask your doctor for a prescription (for up to a 90-day supply*,plus refills for up to one year, if appropriate). 2) Complete the TMOP registration/order form which can be downloaded from their website at: http://www.express-scripts.com/TRICARE/ 3) Insert your prescription, completed TMOP registration form, and co-payment, if needed, into the pre-addressed, postage paid envelope (attached to the registration form — use this envelope only for your TMOP registration) and mail them. Your prescriptions will be mailed to you within 14 days. • For more details on TMOP, please visit www.express-scripts.com/TRICARE or call 1- 877-363-1303. 6
  • 7. DoD TRICARE Retail Pharmacy (TRRx) Network Another option for filling your prescription is to use a DoD TRRx network retail pharmacy. Simply give the network pharmacist your written prescription and your uniformed services identification (ID) card. You will pay a co-payment of: $0 for formulary generic for 30-day supply $9 for formulary brand-name for 30-day supply $25 for non-formulary drugs for 30-day supply. To find a DoD TRICARE Retail Pharmacy near you: • Visit www.express-scripts.com/TRICARE. The online pharmacy locator is updated on the first day of each month. If a pharmacy joined after the first day of the month, it might not appear on the locator until the following month. • Call 1.877.363.1303). Non-Network Retail Pharmacy Your medications will cost the most at non-network retail pharmacies because they do not belong to the DoD TRRx network. At non-network pharmacies you will pay full price for your medication. To be reimbursed for non-network pharmacy claims, you must fill out the enclosed claim form (DD 2642),attach the required paperwork as described on the DD2642,and mail it to: Express Scripts P.O. Box 66518 St. Louis, MO 63166-6518 You can download additional claim forms (DD 2642) at www.express-scripts.com/TRICARE or www.tricare.osd.mil/ pharmacy/claims.cfm. Claim forms may also be obtained at TRICARE Service Centers and MTFs. 7
  • 8. New to our formulary! Budesonide/formoterol (Symbicort) for Asthma or COPD Cetirizine (Zyrtec) chewable tablets for allergies Cetirizine/pseudoephedrine (Zyrtec-D) for allergies Insulin glargine pen (Lantus SoloStar Pen) for diabetes mellitus Scopalamine patches (Transderm Scop) for motion sickness Tamsulosin (Flomax) for enlarged prostate or BPH Valsartan (Diovan) for hypertension Valsartan/HCTZ (DiovanHCT) for hypertension Ciprofloxacin/Dexamethasone (Ciprodex) for ear infection Famotidine (Pepcid) for heartburn, GERD Fenofibrate 54mg and 160mg for hyperlipidemia (replacing Fenoglide) Fenofibrate (Tricor) 48mg and 145mg for hyperlipidemia Rovustatin (Crestor) for hyperlipidemia *DoD requires Prior Authorization Mometasone/Formoterol (Dulera) Inhaler for asthma or COPD Ergocalciferol (Vitamin D) 50,000 units for Vit D supplements Calcium Carbonate + Vit D 500mg (Oscal+D) for calcium supplements 8
  • 9. Diclofenac (Voltaren) 1% topical gel for pain Lidocaine (Lidoderm) 5% patch-for pain Detemir (Levemir) Insulin-for diabetes Pantoprazole (Protonix)-for GERD Clindamycin (Cleocin T) 1% Pads-for acne Aspart (Novolog FlexPen) Insulin Pen-for diabetes No longer on formulary! Rosiglitazone (Avandia) for diabetes Rosiglitazone/Metformin (Avandamet) for diabetes Ciprofloxacin/Hydrocortisone (CiproHC) for ear infection 9
  • 10. Edwards AFB Pharmacy Formulary Alphabetically Listed by Generic Name Generic Name Brand Name How Supplied ACETAMINOPHEN Tylenol Tabs: 325 mg, 650mg Infant Drops: 80 mg/0.8 ml Soln: 160 mg/5 ml. Supps: 120mg, 650 mg ACETAMINOPHEN/BUTALBITAL/ Fioricet Tabs: 325mg/50mg/40mg CAFFEINE ACETAMINOPHEN/CODEINE Tylenol w/Codeine C-III Tabs: 30mg/300mg PHOSPHATE Elixir: 12mg/120 mg/5 ml ACETAZOLAMIDE Diamox Tabs: 250 mg, 500mg ACETIC ACID Domeboro Powder Packets ACYCLOVIR Zovirax Caps: 200mg Tabs: 400mg, 800mg Susp: 200mg/5ml Oint: 15 g ADAPALENE GEL Differin 0.1% Gel: 45g ALBUTEROL HFA Ventolin HFA Inhaler: 90mcg, 200 sprays/unit Neb Soln: 0.5%, 0.083% Oral Liq: 5mg/5ml. ALBUTEROL/ IPRATROPIUM Combivent Inhaler: 200 sprays/unit ALENDRONATE Fosamax Tabs: 5mg, 10 mg, 35 mg, 70 mg Soln: 70mg/75ml ALENDRONATE/VITAMIN D Fosamax Plus D Tabs: 70mg/2800 IU, 70mg/5600 IU ALFUZOSIN Uroxatral Tabs: 10mg ALLOPURINOL Zyloprim Tabs: 100mg, 300mg ALPRAZOLAM Xanax C-IV Tabs: 0.25mg, 0.5mg, 1mg, 2mg ALUMINUM CHLORIDE Drysol Liq: 37.5ml HEXAHYDRATE AMANTADINE Symmetrel Tabs: 100mg Syrup: 50mg/5 ml AMIODARONE Cordarone/Pacerone Tabs: 200mg, 400mg AMITRIPTYLINE Elavil Tabs: all strengths AMLODIPINE Norvasc Tabs: all strengths AMLODIPINE/BENAZEPRIL Lotrel Caps: all strengths AMMONIUM LACTATE Lac-Hydrin Lotion: 12% AMOXICILLIN Amoxil Susp:125mg/5ml, 250 mg/5ml, 400 mg/5 ml Caps: 250mg, 500mg AMOXICILLIN/ CLAVULANATE Augmentin Susp: 200mg/5ml, 250mg/5ml, 400mg/5ml ES Susp: 600 mg/5 ml Tabs: 250mg/125mg, 500mg/125mg, 875mg/125mg Chew Tabs: 250/62.5mg XR: 1000 mg AMPHETAMINE/ Adderall C-II Tabs: 5, 10, 30 mg DEXTROAMPHETAMINE Adderall XR C-II XR Caps: all strengths AMPICILLIN Ampicillin Caps: 500 mg ANTIPYRINE/ Auralgan Otic soln: 15 ml BENZOCAINE/GLYCERIN ASPIRIN ENTERIC COATED Ecotrin Tabs: 81mg, 325mg ATENOLOL Tenormin Tabs: all strengths ATOMOXETINE Strattera Caps: all strengths ATORVASTATIN Lipitor Tabs: all strengths AZELASTINE Astelin Nasal spray: 137mcg/spray **DoD Quantity limit 2 per 30 days** AZITHROMYCIN Zithromax Tabs: 250mg, 500mg Packet: 1g Susp: 100mg/5ml, 200mg/5ml 10
  • 11. BACITRACIN Bacitracin Oph oint Topical oint BACITRACIN/NEOMYCIN/ Polysporin Oph oint POLYMYXIN BACLOFEN Lioresal Tabs: all strenghts BELLADONNA ALKALOIDS Donnatal Tabs: 16.2mg Liq: 16.2mg/5ml BENAZEPRIL Lotensin Tabs: all strengths BENZONATATE Tessalon Perles Caps: all strengths BENZOYL PEROXIDE GEL, Benzac Gel: 42.5g (10%) BENZOYL PEROXIDE WASH Sol: 227g (10%) BENZOYL PEROXIDE/ Benzaclin Gel: 25 g (1-5%) CLINDAMYCIN BENZTROPINE Cogentin Tabs: all strengths BETAMETHASONE Diprosone Cream: 0.05%, 45 g DIPROPRIONATE Oint: 0.05%, 15 g BETAMETHASONE VALERATE Valisone Cream: 0.1%, 15 g, 45 g BETAXOLOL Betoptic S Oph susp: 0.5%, 5 ml. BISACODYL Dulcolax Tabs: 5 mg BRIMONIDE Alphagan P Oph soln: 0.15%, 0.2% BROMOCRIPTINE Parlodel Tabs: all strengths BUDESONIDE Pulmicort Respules Neb Sol: all strengths BUDESONIDE/FORMOTEROL Symbicort Inhaler: 160/4.5, 80/4.5 mcg BUPROPRION Wellbutrin Tabs: 75, 100mg BUPROPRION Wellbutrin SR SR Tabs: 100mg, 150mg BUPROPRION Zyban SR Tabs: 150 mg BUSPIRONE HCL Buspar Tabs: all strengths CALCIUM CARB+VIT D OSCAL+D Tabs: 500mg CANDESARTAN Atacand Tabs: all strenghts CANDESATAN/HCTZ Atacand HCT Tabs: 16/12.5, 32/12.5mg CAPTOPRIL Capoten Tabs: all strengths CARBAMAZEPINE Tegretol Chewable tabs: 100mg Tabs: 200mg Tegretol XR XR tabs: all strengths Liq: 100mg/5ml CARBIDOPA/LEVODOPA Sinemet Tabs: 10/100, 25/100, 25/250 mg Sinemet CR CR: 25/100 mg CARBOXYMETHYLCELLULOSE Celluvisc Boxes of 30 CARISOPRODOL Soma Tabs: 350 mg CARVEDILOL Coreg Tabs: all strengths CEFADROXIL Duricef Susp: 250 mg/5 ml CEFDINIR Omnicef Susp: 125 mg/5 ml & 250 mg/5 ml CEFPODOXIME Vantin Susp: 100 mg/5 ml CEFUROXIME Ceftin Susp: 250 mg/5 ml Tabs: 250, 500 mg CELECOXIB Celebrex Caps: all strengths CEPHALEXIN Keflex Caps: all strengths Susp: 250mg/5ml CETIRIZINE Zyrtec Tabs: 10 mg Liquid: 5 mg/5 ml Chewable: 5mg CETIRIZINE/PSEUDOEPHEDRINE Zyrtec-D Tabs: 5/120 mg CHLORAL HYDRATE Noctec Syrup: 500 mg/5 ml CHLORHEXIDINE RINSE Peridex Rinse: 0.12% CHLOROQUINE Aralen Tabs: 250, 500 mg CHLORTHALIDONE Hygroton Tabs: all strengths CIMETIDINE Tagamet Tabs: all strengths CIPROFLOXACIN Cipro Tabs: all strengths Susp: 5gm/100ml CIPROFLOXACIN Ciloxan Opth: 0.3%/2.5 ml CIPROFLOXACIN/DEXAMETHASONE CiproDex Soln: 7.5 ml 11
  • 12. CITALOPRAM Celexa Tabs: all strengths Soln: 10mg/5ml CLARITHROMYCIN Biaxin Tabs: 250, 500 mg CLINDAMYCIN Cleocin Caps: all strengths Susp: 75 mg/5 ml Top Soln: 1%, 60 ml Top Pads: 1% Vaginal Cream: 2%(40 gm) CLINDINIUM/ Librax Caps: 2.5 mg/5 mg CHLORDIAZEPOXIDE CLOBETASOL PROPRIONATE Temovate 0.05% Cream: 15g, 45g 0.05% Oint, 0.05% Soln CLOMIPHENE Clomid Tabs: 50 mg CLONAZEPAM Klonopin C-IV Tabs: all strengths CLONIDINE Catapres Tabs: all strengths CLOPIDOGREL Plavix Tabs: 75 mg CLOTRIMAZOLE Lotrimin 1% Cream: 30 g 1% Topical soln CLOTRIMAZOLE / BETAMETHASONE Lotrisone Cream: 15, 45 g DIP CODEINE SULFATE Codeine C-III Tabs: 30 mg CODEINE/ GUAIFENESIN Robitussin AC C-V Liq: 10/100 mg per 5 ml (120 ml) **Qty must be in equivalents of 120 ml** COLESTIPOL Colestid Tabs: 1 g Powder Packets: Box of 90 COLOCHICINE Colchicine Tabs: 0.6 mg CONJUGATED ESTROGENS Premarin Tabs: all strengths Vaginal cream 0.625mg/gm CONJUGATED ESTROGEN/ Prempro Tabs: all strengths MEDROXYPROGESTERONE CROMOLYN SODIUM Crolom Oph Soln: 4%, 15 ml CYCLOBENZAPRINE Flexeril Tabs: all strengths CYCLOPENTOLATE Cyclogel Oph Soln: 0.1%, 5 ml CYPROHEPTADINE Periactin Tabs: 4 mg Syrp: 2mg/5ml DESIPRAMINE Norpramin Tabs: all strengths DESMOPRESSIN DDAVP Tabs: 0.2 mg DESOGESTREL/ETHINYL Mircette 28 day packs ESTRADIOL (Biphasic) DESOGESTREL/ETHINYL ESTRADIOL Desogen 28 day packs DETEMIR Levemir Insulin vial DEXAMETHASONE Decadron Tabs: 0.5 mg, 4 mg DEXTROAMPHETAMINE Dexedrine C-II Tabs: 5, 10 mg SR Caps: 5 mg, 15mg DIAGNOSTIC STRIPS Precision Xtra Boxes of 50 AccuChek Aviva DIAZEPAM Valium C-IV Tabs: all strengths DICLOFENAC SODIUM Voltaren Tabs: 50, 75 mg Oph soln: 0.1% Top Gel: 1% DICLOXACILLIN Dynapen Caps: all strengths DICYCLOMINE Bentyl Tabs: all strengths Soln: 10mg/5ml DIGOXIN Lanoxin Tabs: all strengths Soln: 0.05mg/ml DILTIAZEM Tiazac Tabs: 60 mg ER Caps: all strengths DIPHENOXYLATE W/ATROPINE Lomotil C-V Tabs: 2.5/0.025 mg DIPHENYDRAMINE Benadryl Caps: 25 mg, 50 mg Liq: 12.5 mg/5 ml DISOPYRAMINE Norpace Caps: 100 mg 12
  • 13. DIVALPROEX Depakote Tabs: all strengths Depakote Sprinkles Caps: 125 mg Depakote ER ER tabs: all strengths DOCUSATE SODIUM Colace Caps: 100 mg DONEPEZIL Aricept Tabs: all strengths DORZOLAMIDE Trusopt 2% Oph soln: 10 ml DORZOLAMIDE / TIMOLOL Cosopt Oph soln: 2%-0.05% DOXAZOSIN Cardura Tabs: all strengths DOXEPIN Adapin Caps: all strengths Soln: 10mg/ml DOXYCYCLINE HYCLATE Vibramycin Tabs: 100 mg Caps: 50, 100mg EPINEPHRINE Epi-Pen/Epi-Pen Jr Auto-injector 0.15mg/dose, 0.3mg/dose Twinject EPINEPHRINE Ephfrin 2% Oph soln: 15 ml ERGOTAMINE TARTRATE Cafergot Tabs: 100 mg/1 mg W/CAFFEINE ERYTHROMYCIN Erythrocin Tabs: all strengths Susp: 200 mg/5 ml Romycin Oph oint: 0.5% 5 mg/gm 2% Topical soln: 60 ml 2% gel ERGOCALCIFEROL Vitamin D Gel Caps: 50,000 units ESOMEPERZOLE Nexium Caps: all strengths ESTRADIOL Estrace Tabs: all strengths Estraderm Patch: all strengths Vivelle Dot Esclim ESTROGEN/ Estratest HS Tabs: 0.625/1.25 mg METHYLTESTOSTERONE ETHAMBUTOL Myambutol Tabs: all strengths ETHINYL ESTRADIOL/ DESOGESTREL Orthocept (Reclipsen) 0.03 mg EE/.015 mg D 28 day packs ETHINYL ESTRADIOL/ Yasmin Tabs: 30 mcg/3 mg; 28 day packs DROSPIRENONE Yaz Tabs: 20 mcg/3 mg; 28 day packs ETHINYL ESTRADIOL/ Nuvaring Vaginal ring ETONOGESTREL ETHINYL ESTRADIOL TriLevlen, TriPhasil, Alesse, Tabs: LEVONORGESTREL Lutera 28 day packs ETHINYL ESTRADIOL/ Nordette, Mircette 28 day packs LEVONORGESTREL ETHINYL ESTRADIOL/ Ortho Evra Transdermal patch NORELGESTROMIL ETHINYL ESTRADIOL/ Ortho-Novum 28 day packs NORETHINDRONE Loestrin 1/20 FE Necon 1/35 ETHINYL ESTRADIOL/ Ortho-Cyclen 28 day packs NORGESTIMATE Ortho Tri-cyclen Ortho Tri-cyclen LO ETHINYL ESTRADIOL/ NORGESTREL Ovral, LoOvral 28 day packs ETONORGESTREL Implanon IM device EZETMIBE Zetia Tabs: 10 mg FAMOTIDINE Pepcid Tabs: 20mg and 40mg FELODIPINE Plendil Tabs: all strengths FENOFIBRATE Lofibra, Tricor Tabs: 48mg, 54mg, 145mg, and 160 mg FERROUS SULFATE FeoSol Soln: 25 mg/ml, 50ml. Tabs: 325 mg FEXOFENADINE Allegra Tabs: 60, 180 mg FINASTERIDE Proscar Tabs: 5 mg 13
  • 14. FLUCONAZOLE Diflucan Tabs: all strengths FLUDROCORTISONE Florinef Tabs: 0.1 mg FLUNISOLIDE Nasarel Nasal spray: 25 mcg. 200 sprays/unit FLUOCINOLONE Synalar Soln: 1%, 60 ml FLUOCINONIDE Lidex *Cream: 0.05%, 15 g, 60 g Gel: 0.05%, 60 g Oint: 0.05%, 60 g FLUORIDE Prevident 5000+, Luride Gel: 1.1%, 2oz Drops: 1.1 mg/ml Tabs: 1.1 mg FLUOROMETHOLONE Fluor-Op, FML Susp: 0.1%, 15 ml FLUOXETINE Prozac Caps: 10, 20, 40 mg Soln: 20mg/5ml FLUTICASONE Flonase Nasal spray: 50 mcg, 120 sprays/unit FLUTICASONE HFA Flovent HFA Inhaler: 44, 110, 220 mcg **Qty limit 2 per 30 days** FLUTICASONE Diskus Flovent Diskus Inhaler FLUTICASONE/ SALMETEROL Advair Inhaler: 100/50 mcg, 250/50mcg, 500/50 mcg Advair HFA Inhaler: 45/21 mcg, 115/21 mcg, 230/21 mcg FOLIC ACID Folic Acid Tabs: 1 mg FUROSEMIDE Lasix Tabs: all strengths Soln: 10mg/ml GABAPENTIN Neurontin Caps: all strengths GEMFIBROZIL Lopid Tabs: 600 mg GENTAMICIN SULFATE Geramicin Oph soln: 0.3%, 5 ml Oph oint: 3.5 g GLIPIZIDE Glucotrol *Tabs: all strengths Glucotrol XL XL Tabs: all strengths GLYBURIDE Micronase Tabs: all strengths GLYBURIDE MICRONIZED Micronized: all strengths GLYBURIDE/ METFORMIN Glucovance Tabs: all strengths GLYCOPYRROLATE Robinul Tabs: 1 mg GOSERELIN Zoladex Implants: 3.6 mg, 10.8 mg GRAMICIDIN/NEOMYCIN/POLYMYXIN Soln: 0.025mg/2.5mg/10000unit/ml B GRISEOFULVIN Grispeg, Grifulvin V Tabs: 125, 250 mg Susp: 125 mg/5 ml GUAIFENESIN Mucinex Tabs: 600 mg GUAIFENESIN/PSE MucinexD Tabs: 600/60 mg, GUAIFENSIN/DEXTROMETHORPHAN Robitussin DM Liq: 100/10 mg per 5 ml HALOPERIDOL Haldol Caps: 1 mg, 10 mg HOMATROPINE Isopto Homatropine Liq: 5%, 5 ml HYALURONIC ACID Atopiclair Topical cream HYDRALAZINE Apresoline Tabs: 10, 25, 50 mg HYDROCHLOROTHIAZIDE HCTZ Caps 12.5 mg Tabs 25, 50 mg HYDROCODONE/ Vicodin *Tabs: 5/500 mg ACETAMINOPHEN Vicodin ES ES Tabs: 7.5/750 mg HYDROCORTISONE Anusol HC Cream: 2.5% Supps: 25 mg HYDROCORTISONE ACETATE/ Proctofoam Foam: 1%, 10 g PRAMOXINE Cream: 30 g HYDROCORTISONE VALERATE Westcort 0.2% Cream: 15 g, 60 g 0.2% Oint: 45 g HYDROCORTISONE/ Vosol HC Susp: 10 ml ACETIC ACID HYDROXYAMPHETAMINE/ Paremyd Soln: 1%/0.25% TROPICAMIDE HYDROXYCHLOROQUINE Plaquenil Tabs: 200 mg HYDROXYZINE Atarax Tabs: all strengths Liq: 10 mg/5 ml IBANDRONATE Boniva Tabs: all strengths 14
  • 15. IBUPROFEN Motrin Tabs: all strengths Susp: 100 mg/5 ml IMIPRAMINE Tofranil Tabs: all strengths INDOMETHACIN Indocin *Caps: all strengths ER Cap: 75 mg INSULIN ASPART Novolog, Novolog Flexpen 100 units/ml, 10 ml vial INSULIN GLARGINE Lantus, Lantus SoloStar Pen 100 units/ml, 10 ml vial 100 units/ml, pen INSULIN NPH/REGULAR 70/30 Novolin 70/30 100 units/ml, 10 ml vial INSULIN HUMAN NPH Novolin N 100 units/ml, 10 ml vial INSULIN HUMAN 70/30 Novolog Mix 70/30 100 units/ml, 10 ml vial INSULIN HUMAN REGULAR Novolin R 100 units/ml, 10 ml vial INSULIN SYRINGES Boxes of 100: 0.5 ml, 1 ml 29 G,½” INSULIN PEN NEEDLES **Limit 300 syringes/90 days** IPATROPIUM BROMIDE Atrovent Neb Soln, Nasal spray Atrovent HFA Inhaler ISONIAZID INH Tabs: all strengths Syrup: 50 mg/5 ml ISOSORBIDE DINITRATE Isordil SR Caps: 40 mg Tabs: all strengths ISOSORBIDE MONONITRATE Imdur Tabs: all strengths ISOTRETINOIN Accutane Caps: all strengths KETOCONAZOLE Nizoral Cream: 30 g Shampoo: 4 oz KETOROLAC TROMETHAMINE Acular Oph soln: 0.5%, 5ml KETOTIFEN Zaditor Oph soln: 0.025 % 5 ml LACTULOSE Cepulac Syrup: 10 g/15 ml LAMOTRIGINE Lamictal Tabs: all strengths LANCETS Soft-Touch Boxes of 200 Accu-chek Soft Clix LANCET DEVICE Soft-Touch Device LATANOPROST Xalatan Oph soln: 0.005%, 2.5 ml LEUCOVORIN Leucovorin Tabs: 5 mg LEVALBUTEROL Xopenex Inhaler: 200 sprays/unit LEVOBUNOLOL Betagan Oph Soln: 0.5%, 5ml LEVOCABASTINE Livostin Oph soln: 0.025%, 5 ml LEVOFLOXACIN Levaquin Tabs: all strengths Soln: 25mg/ml LEVONORGESTREL Plan B One-Step Tabs: 1.5mg Next Choice Tabs: 0.75mg LEVONORGESTREL IUD Mirena IUD *Must have scheduled appt* LEVOTHYROXINE Synthroid Tabs: all strengths LIDOCAINE HCL Xylocaine Gel: 2%, 30 ml Soln: 2%, 100 ml Lidoderm Top Patch: 5% LISINOPRIL Zestril Tabs: all strengths LISINOPRIL/HCTZ Zestoretic Tabs: all strengths LITHIUM CARBONATE Lithium Tabs: all strengths Lithium citrate Syrp: 8mEq/5ml LOPERAMIDE Imodium Caps: 2 mg LORATADINE Claritin Tabs: 10 mg Syrup: 1 mg/ml LORAZEPAM Ativan Tabs: all strengths LOSARTAN Cozaar Tabs: all strengths LOSARTAN/HCTZ Hyzaar Tabs: all strengths LOTEPREDNOL Alrex Susp: 0.2%, 5 ml LUBRICANT Lacrilube Opth oint: 3.5 g LUVOXAMINE Luvox Tabs: 100 mg MEBENDAZOLE Vermox Chew Tabs: 100 mg MECLIZINE Antivert Tabs: all strengths 15
  • 16. MEDROXYPROGESTERONE Depo Provera Injection: 150 mg **Must have appt for administration** MEDROXYPROGESTERONE Provera Tabs: all strengths MEFLOQUINE Lariam Tabs: 250 mg MELOXICAM Mobic Tabs: 7.5, 15 mg METAXOLONE Skelaxin Tabs: 800 mg METFORMIN HCL Glucophage Tabs: all strengths Glucophage XR XR Tabs: all strengths METHOCARBAMOL Robaxin Tabs: all strengths METHOTREXATE Rhemstrex Tabs: 2.5 mg METHYLDOPA Aldomet Tabs: all strengths METHYLPHENIDATE Ritalin C-II *Tabs: all strengths SR Tabs: 20 mg METHYLPHENIDATE XR Concerta C-II Tabs: all strengths METHYLPREDNISOLONE Medrol Tabs: 4 mg, dosepack METOCLOPRAMIDE HCL Reglan Tabs: all strengths Liq: 5 mg/5 ml METOPROLOL Lopressor Tabs: all strengths Toprol XL Tabs: all strengths METRONIDAZOLE Flagyl Tabs: all strengths METRONIDAZOLE Metrogel-Vaginal Gel: 0.75%, 70 g MINOCYCLINE Minocin Caps: all strengths MI PASTE PLUS MI Paste Dental paste MOISTURIZING CREAM Eucerin cream Cream MOMETASONE Elocon Cream: 15g, 30g MOMETASONE Nasonex Nasal spray Asmanex Twisthaler MOMETASONE/FORMOTEROL Dulera Inhaler MONITOR, BLOODGLUCOSE Precision Xtra Kit AccuCheck Aviva MONTELUKAST Singulair Tabs: all strengths Oral granules: 4 mg MORPHINE SULFATE IR Morphine C-II Tabs: all strengths MORPHINE SULFATE ER MS Contin C-II ER Tabs: all strengths MOXIFLOXACIN Vigamox Oph Soln: 0.5%, 5ml MULTIVITAMIN PEDIATRIC Poly Vi Sol w/Iron Soln: 50 ml SOLUTION W/IRON MULTIVITAMIN W/ FLUORIDE Poly Vi Flor Soln: 50 ml Chew Tab: 0.25mg, 0.5 mg MUPIROCIN Bactroban Oint: 15 g NAPROXEN Naprosyn Tabs: all strengths Naproxen sodium Tabs: all strengths Susp: 125mg/ 5ml NEFAZODONE Serzone Tabs: 150 mg NEOMYCIN/POLYMYXIN/HC Cortisporin HC Soln, Susp: 10 ml NEOMYCIN/POLYMYXIN/ Neosporin Ophth oint BACITRACIN NEOMYCIN/POLYMYXIN/ Neosporin Oph soln 10 ml GRAMICIDIN NIACIN Niaspan *CR Tabs: all strengths NICOTINE Nicoderm Patches: all strengths NIFEDIPINE Adalat CC *SR Tabs: all strengths Procardia Caps: 10 mg NITROFURANTOIN Macrobid Caps: 100 mg Macrodantin Caps: all strengths NITROGLYCERIN Nitrostat, Nitrobid, Nitro SL Tabs: 0.4 mg Dur SL Spray: 0.4 mg SR Caps: all strengths Patches: all strengths NORETHINDRONE Micronor 28 day packs 16
  • 17. NORTRIPTYLINE Pamelor Caps: all strengths Soln: 10mg/5ml NYSTATIN Niastat Cream: 15 g Oint: 15 g Powder 100,000 unit Susp: 100,000 units/60 ml OFLOXACIN Ocuflox Oph Soln: 0.3% 5 ml OFLOXACIN Floxin Otic Soln: 5 mL OLANZAPINE Zyprexa Tabs: all strengths OLOPATADINE Patanol Oph soln: 0.1 % 5 ml OMEPRAZOLE Priolosec Caps: all strengths OXYBUTYNIN Ditropan Tabs: 5mg OXYBUTYNIN ER Ditropan XL Tabs: all strengths OXYCODONE/ Percocet Tabs: 5/325 mg ACETAMINOPHEN OXYMETAZOLINE Afrin nasal spray Soln: 0.05% (15 ml) PANTOPRAZOLE Protonix Tabs: 40mg PAROXETINE Paxil Tabs: all strengths PENICILLIN VK PenV K, Veetids Susp: 125mg/5ml, 250 mg/5 ml Tabs: all strengths PERMETHRIN Elimite, Nix Cream: 5%, 60 g Cream: 1%, twinpack 60 ml PHENAZOPYRIDINE Pyridium Tabs: all strengths PHENOBARBITAL Phenobarbital Tabs: 15, 30, 60, 100 mg Liq: 20 mg/5 ml PHENYLEPHRINE Mycifrin Oph soln: 2.5%, 15 ml PHENYTOIN Dilantin Caps: 100 mg Tabs Chew: 50 mg Susp: 125mg/5ml PILOCARPINE Pilocar Oph Soln: all strengths Oph Gel 4% PIMECROLIMUS Elidel Tube: 15 g, 30 g PIOGLITAZONE Actos Tabs: all strengths PIOGLITAZONE/ Actoplus met Tabs: 15/850, 15/500 mg METFORMIN POLYETHYLENE GLYCOL Trilyte Pwd for Reconst: 4 L POLYETHYLENE GLYCOL 3350 Miralax Powder: 527, 255 g POLYMYXIN B/TRIMETHOPRIM Polytrim Oph soln: 5 ml POTASSIUM BICARBONATE/POT Klorvess Packets: 20 mEq CHLORIDE Box of 30 POTASSIUM CHLORIDE Klor-con ER Tabs: all strengths Powder packet: 20 mEq Soln: 20 mEq/15 ml Micro K CR Caps: 10 mEq PRAVASTATIN Pravachol Tabs: all strengths PRAZOSIN Minipress Caps: all strengths PREDNISOLONE Prelone/Orapred Liq: 15 mg/5 ml PREDNISOLONE ACETATE Pred Forte Oph Susp: 1%, 5 ml Pred Mild Oph Susp: 0.12% PREDNISOLONE ACETATE/ AKCide Oph oint SULFACETAMIDE PREDNISONE Orasone, Deltasone Tabs: all strengths Syrup: 5mg/5ml PRENATAL VITAMINS + FOLIC ACID Natalins Tabs : PNV with 1mg folic acid **Limited to women age 45 and younger** PRENISOLONE SODIUM PHOSPHATE Inflamase Susp: 1/8%, 1%, 5 ml PRIMAQUINE Primaquine Tabs: 23.6 mg PRIMIDONE Mysoline Tabs: all strengths PROBENECID Benemid Tabs: 500 mg PROCHLORPERAZINE Compazine Tabs: all strengths Supps: 25 mg PROGESTERONE Prometrium Caps: 100, 200 mg 17
  • 18. PROMETHAZINE Phenergan Tabs: all strengths Supps: all strengths Syrp: 6.25mg/5ml PROMETHAZINE/DEXTROMETHORPH Phenergan DM Syrp: 120 ml AN PROPARACAINE Ophthaine Soln: 0.5%, 15 ml PROPOXYPHENE/ Darvocet-N 100 Tabs: 100/650 mg ACETAMINOPHEN PROPRANOLOL Inderal Tabs: 10, 40 mg Inderal LA LA Caps: 80 mg PROPYLTHIOURACIL PTU Tabs: 50 mg PSEUDOEPHEDRINE Sudafed Tabs: 30, 120 mg Liq: 30 mg/5 ml PYRAZINAMIDE PZA Tabs: 500 mg PYRIDOSTIGMINE Mestinon Tabs: 60 mg PYRIDOXINE Vitamin B6 Tabs: all strengths QUETIAPINE Seroquel Tabs: all strengths Seroquel XR XR: all strengths RALOXIFENE Evista Tabs: 90 mg RANITIDINE Zantac Tabs: all strengths Syrup: 15 mg/ml RIFAMPIN Rifadin Caps: 300 mg RIMEXOLONE Vexol Oph Susp: 1% RISPERIDONE Risperdal Tabs: all strengths Soln 1mg/ml RIZATRIPTAN Maxalt Tabs: all strengths Maxalt MLT MLT tabs: all strengths **DoD Quantity limit 36 tablets/90 days** ROVUSTATIN Crestor Tabs: all strengths **DoD requires Prior Authorization from MD SALICYLIC ACID Clear Away Plasters: 40% SALINE NASAL SPRAY Sea-mist Soln: 0.65% SALMETEROL Serevent Diskus *Inhaler: 18 mcg, 200 sprays/unit Serevent Neb Soln: 0.02%/2.5 ml, 30 unit SALISALATE Disalcid Tabs: 500, 750 mg SCOPOLAMINE Transderm Scop Patch: 1.5 mg SELENIUM SULFIDE Selsun Shampoo: 2.5% 120 ml SERTRALINE Zoloft Tabs: all strengths Liq: 20mg/ml SILVER SULFADIAZINE Silvadene 1% cream SIMVASTATIN Zocor Tabs: all strengths SIMVASTATIN/EZETIMIBE Vytorin Tabs: all strengths SODIUM CHLORIDE 0.9% Normal saline 3ml vials for Nebulization SPACER Optichamber Device Optichamber w/mask Aerochamber w/mask SPIRONOLACTONE Aldactone Tabs: all strengths SUCRALFATE Carafate Tabs: 1 g Liq: 1 g/10 ml SULFACETAMIDE Sulamyd, Bleph-10 Oph soln: 10%, 15 ml Opth oint: 3.5 g SULFACETAMIDE SODIUM/ Vasocine Opth oint: 10%/0.5% PREDNISOLONE ACETATE SULFACETAMIDE SODIUM/ Isopto Catapred Susp: 10%/0.25%, 15ml. PREDNISOLONE ACETATE SULFACETAMIDE/ Plexion Cleanser: 6oz SULFUR CLEANSER SULFAMETHOXAZOLE/ Pediazole Susp:600/200 mg/5 ml ERYTHROMYCIN 18
  • 19. SULFAMETHOXISOLE/ Bactrim, Septra, Bactrim DS Tabs: all strengths TRIMETHOPRIM Sulfatrim Susp:40/200 mg /5 ml SULFASALAZINE Azulfidine Tabs: 500 mg EC Tabs: 500mg SUMATRIPTAN Imitrex Tabs: 25, 50 mg **DoD Quantity limit 54 tablets/90 days** Tabs: 100 mg **DoD Quantity limit 27 tablets/90 days** SUMATRIPTAN Imitrex Stat Dose Kit all strengths TAMOXIFEN Nolvadex Tabs: all strengths TAMSULOSIN Flomax Caps: 0.4mg TELMISARTAN Micardis, Tabs: all strengths TELMISARTAN/HCTZ Micardis HCT Tabs: all strengths TEMAZEPAM Restoril C-IV Caps: all strengths TERAZOSIN Hytrin Caps: all strengths TERBUTALINE Brethine Tabs: 5 mg TERCONAZOLE Terazol 7 Cream: 0.4%, 20 g TETRACYCLINE Achromycin Caps: all strengths THEOPHYLLINE Theo-24 24 hr Caps: all strengths Theodur *12 hr Tabs: all strengths *Liq: 80 mg/15 ml Uniphyl *24 hr Tabs: 400mg THIAMINE Vitamin B1 Tabs: all strengths TIMOLOL MALEATE Timolol Oph soln: all strengths Timoptic XE Gel: all strengths TIOTROPIUM Spiriva Inh w/ device: 18 mcg TOBRAMYCIN Tobrex Soln: 0.3%, 5 ml TOBRAMYCIN/DEXAMETHASONE Tobradex Susp: 0.3%/0.1%, 2.5 ml Opth Oint: 3.5 g TOLNAFTATE Tinactin Soln: 1%, 10 ml TOLTERODINE Detrol LA SR Caps: all strengths TOPIRAMATE Topamax Tabs: all strengths TRAMADOL Ultram Tabs: all strengths **DoD Quantity Limit 240 tabs per 30 days** TRAZADONE Desyrel Tabs: 50, 100, 150, 300 mg TRETINOIN Retin A, Avita Cream: all strengths **Limited to persons <36 yrs of age** TRIAMCINOLONE Kenalog in Orabase Paste: 0.1% 5 g T TRIAMCINOLONE Kenalog *Cream: 1%, 5% Spray: 15 mcg/spray. 63g Ointment: 1% TRIAMTERENE/HCTZ Maxzide Tabs: 37.5/25, 75/50 mg TRIHEXYPHENIDYL Artane Tabs: all strengths *Elixir: 0.4mg/ml TRIMETHOBENZAMIDE Tigan Caps: 300 mg TRIMETHOPRIM/POLYMYXIN B Polytrim Soln: 10 ml TROPICAMIDE Mydriacyl Soln: 1%, 15 ml VALACYCLOVIR Valtrex Tabs: all strengths VALPROIC ACID Depakene Liq: 250 mg/5ml VALSARTAN Diovan Tabs: all strengths VALSARTAN/HCTZ DiovanHCT Tabs: all strengths VARDENAFIL Levitra Tabs: all strengths Under 40? Need prior authorization form **DoD Quantity limit 18 tablets/90 days** VARENECLINE Chantix Tabs: Starter pack, continuing treatment pack (0.5, 1 mg tabs) **Must be enrolled in Smoking Cessation class** VENLAFAXINE Effexor, Effexor XR XR Caps: all strengths VERAPAMIL Calan Tabs: 80 mg SR Tabs: all strengths 19
  • 20. WARFARIN Coumadin Tabs: all strengths XYLITOL Spry Gum Dental chewing gum ZIPRASIDONE Geodon Caps: all strengths ZOLPIDEM Ambien C-IV Tabs: all strengths ZOMITRIPTAN Zomig/Zomig ZMT Tabs: all strengths/Oral disintegrating tabs **DoD Quantity limit 36 tablets/90 days** 20
  • 21. Quick List for Common Uses For Asthma/Allergies For Blood pressure For Cholesterol Inhalers: Albuterol (Ventolin/Proventil ACEs: benazepril (Lotensin), captopril Statins: atorvastatin (Lipitor), HFA), levalbuterol (Xopenex) MDI, (Capoten), lisinopril (Zestril) pravastatin (Pravachol), simvastatin salmeterol (Serevent Diskus) (Zocor) ARBs: candesartan (Atacand), losartan Nebulizer solutions: albuterol, (Cozaar), telmisartan (Micardis), Other: Ezetimibe (Zetia), fenofibrate budesonide (Pulmicort), ipratropium valsartan (Diovan) (Lofibra), niacin (Niaspan), gemfibrozil (Lopid) Other: montelukast (Singulair) BBs: atenolol (Tenormin), carvedilol (Coreg), metoprolol succinate (Toprol Combo: ezetimibe/simvastatin Steroids: fluticasone (Flovent HFA) XL), metoprolol tartrate (Lopressor) (Vytorin) mometasone (Asmanex) CCBs: amlodipine (Norvasc), diltiazem Combo: albuterol/salmeterol (Advair & ER (Tiazac), felodipine (Plendil), Advair HFA), budesonide/formoterol nifedipine SR (Adalat CC), verapamil (Symbicort) (Calan SR) Allergies: cetirizine (Zyrtec), loratadine Diuretics: furosemide (Lasix), HCTZ, (Claritin), fexofenadine (Allegra), spironolactone, triamterene/HCTZ cetirizine/pseudoephedrine (Zyrtec-D) (Maxzide) Nasal: azelastine (Astelin), fluticasone Combos: benazepril/amlodipine (Flonase), mometasone (Nasonex), (Lotrel), lisinopril/HCTZ (Zestoretic) fluocinonide (Nasarel) losartan/HCTZ (Hyzaar), telmisartan/HCTZ (Micardis HCT), valsartan/HCTZ (Diovan HCT) For Diabetes For Migraines Controlled Substances Oral Agents: Glipizide (Glucotrol & Triptans: rizatriptan (Maxalt & Maxalt The state of California requires Glucotrol XL), Glyburide (Micronase), MLT), sumatriptan (Imitrex), that controlled substances MUST Metformin (Glucophage & Glucophage zolmitriptan (Zomig & Zomig ZMT) be written on a California Security XR), pioglitazone (Actos), [Please note DoD quantity limitations] Prescription pad. pioglitazone/metformin (Actoplusmet) Acetaminophen/butalbital/caffeine C-II: Adderall and Adderall XR, Ritalin, Insulin: Novolog (aspart), Novolin N (Fioricet) Concerta, Morphine IR, MS Contin, (NPH), Novolin R (regular), Novolin Percocet 70/30 (NPH/Reg), Novolog Mix 70/30 (NPH/Reg), Lantus (glargine) C-III: Tylenol w/ codeine #3, Codeine sulfate, Vicodin, and Vicodin ES Syringes: 0.5 ml, 1ml. BD Sharps container for disposal. Insulin Pen C-IV: Alprazolam (Xanax), Clonazepam needles (Klonapin), diazepam (Valium), lorazepam (Ativan), temazepam Blood glucose monitors/test strips: (Restoril), zolpidem (Ambien). Accu-chek Aviva, Precision Xtra (box of 50 test strips) C-V: Robitussin AC (qty of 120ml), Lomotil Lancets (box of 200): Accu-chek Softclix for Aviva Accu-check Soft NOTE: C-II: no refills allowed C-III-V: touch plus lancet device for Precision prescription only valid for 6 months. Xtra. Refills are allowed but may not exceed 6 months 21
  • 22. Quick Reference Telephone List Emergencies............................................................ 911 Emergencies from cell phone on base................... 661- 277- 4541 Poison Control ...................................................... 800-222-1222 Appointments: Family practice ...................................................... 661-277-7118, option 1, then 1 Pediatrics................................................................ 661-277-7118, option 1, then 2 Flight Surgeon’s Office.......................................... 661-277-7118, option 1, then 3 Optometry.............................................................. 661-277-7118, option 1, then 4 Physical Therapy.................................................... 661-277-7118, option 1, then 5 Dental Clinic.......................................................... 661-277-2872 Family Advocacy................................................... 661-277-5292 Flight Surgeon’s Office.......................................... 661-277-7118 option 3 Health and Wellness Center.................................... 661-277-8480 Immunizations.........................................................661-277-3427 Laboratory............................................................... 661-277-2306 Mental Health..........................................................661-277-5291 Managed Care......................................................... 661-277-6969 NurseLine................................................................ 661- 275-6877, or 888-762-3842 Patient Administration........................................... 661-275-2668 Pharmacy................................................................ 661-277-9896 Physical Therapy.................................................... 661-277-3891 Primary Care Clinic............................................... 661-277-7118 Public Health.......................................................... 661-275-2694 Radiology................................................................ 661-277-2681 TriWest/TRICARE................................................. 888-874-9378 Base Exchange: Main Store 258-1078 Commissary 277-4589 Family Child Care Program 275-4FCC/275-4322 Golf Course 275-PUTT/275-7888 Information, Tickets and Travel (leisure) 275-TRIP/275-8747 Base Schools Switchboard 258-4411 Security Forces 277-3340 Retiree Activity Office 277-4931 22