Download 99th MDG NELLIS PHARMACY FORMULARY

99th MDG NELLIS PHARMACY FORMULARY
Mike O’ Callaghan Federal Hospital
I. Anti-Infective Agents
Cephalosporins
Cefuroxime Axetil (Ceftin) Tabs 250mg; Susp 250mg / 5ml
Cepodoxime Proxetil (Vantin) Tabs 200mg; Susp 100mg / 5ml
Ceprozil (Cefzil) Susp 250mg / 5ml
Cephalexin (Keflex) Caps 250mg, 500mg; Susp 250mg / 5ml
Fluoroquinolones
Ciprofloxacin (Cipro) Tabs 500mg
Levofloxacin (Levaquin) Tabs 250mg, 500mg, 750mg
Moxifloxacin (Avelox) Tabs 400mg
Macrolides
Azithromycin (Zithromax) Susp 200mg / 5ml
Azithromycin (Zithromax, Z-pak) Tabs 250mg, 500mg TRI-paks
Azithromycin 1 gram packets (Zithromax) (restricted to MOFH providers only)
Clarithromycin XL (Biaxin XL) Tabs 500mg
Erythromycin (Ery-Tab) Tabs 333mg
Erythromycin (EryPed 200) Susp 200mg / 5ml
Penicillins
Amoxicillin (Trimox) Susp 250mg / 5ml, 400mg / 5ml
Amoxicillin (Trimox) Caps 250mg, 500mg
Amoxicillin / Clav (Augmentin) Tabs 500-125mg, 875-125mg
Amoxicillin / Clav (Augmentin) Chew Tabs 400-57mg
Amoxicillin / Clav (Augmentin) Susp 400-57.5mg / 5ml, ES 600-42mg / 5ml
Dicloxacillin (Dynapen) Caps 250mg
Penicillin V Potassium (Pen VK) Tabs 250mg
Penicillin V Potassium (Pen VK) Oral Susp 250mg / 5ml
Sulfonamides
Sulfisoxazole (Gantrisin) Oral Susp 500mg / 5mL
Sulfamethoxazole 800mg / Trimethoprim 160mg (Bactrim DS) Tabs
Sulfamethoxazole 200mg / Trimethoprim 40mg (Bactrim Pediatric) Susp
Tetracyclines
Doxycycline (Vibramycin) Tabs 100mg
Minocycline (Minocin) Caps 100mg
Tetracycline (Achromycin) Caps 250mg
Other
Clindamycin (Cleocin) Caps 150mg
Dapsone (Avlosufon) Tabs 25mg
Metronidazole (Flagyl) Tabs 250mg
Nitrofurantoin (Macrodantin) Caps 50mg
Nitrofurantoin (Macrobid) Caps 100mg
Nitrofurantoin (Furadantin) Oral Susp 25mg / 5ml
Anti-fungals
Fluconazole (Diflucan) Tabs 100mg, 150mg, 200mg
Gentian Violet 1% Top Soln
Griseofulvin (Gris-PEG) Tabs 125mg (ultra-microsized)
Griseofulvin (Grifulvin-V) Oral Susp 125mg / 5ml (microsized)
Nystatin (Mycostatin) Oral Susp 100,000u / ml
**For Topical Items, see IV. Dermatologic Agents
Anti-viral
Amantadine (Symmetrel) Caps 100mg
Acyclovir (Zovirax) Susp 200mg / 5ml
Acyclovir (Zovirax) Caps 200mg
Acyclovir (Zovirax) Tabs 800mg
Valacyclovir (Valtrex) Tabs 500mg, 1gm
***The brand names in the listings below are for reference use only and do not signify the product dispensed***
Anti-parasitic
Anti-platelets / Anti-coagulants
Hydroxychloroquine (Plaquenil) Tabs 200mg
Aspirin Enteric Coated (Ecotrin) Tabs 81mg, 325mg
Mebendazole (Vermox) Chewtabs 100mg
Aspirin / Dipyridamole (Aggrenox) Caps 200-25mg
Metronidazole (Flagyl) Tabs 250mg
Clopidogrel (Plavix) Tabs 75mg
Metronidazole (Metrogel) Vaginal 1% gel
Warfarin (Coumadin) Tabs 1mg, 2mg, 2.5mg, 5mg, 7.5mg, 10mg
Anti-tubercular Agents
Ethambutol (Myambutol) Tabs 100mg, 40 mg
Isoniazid (INH) Tabs 100mg, 300mg
Isoniazid (INH) Syrup 50mg / 5ml
Pyrazinamide Tabs 500mg
Rifampin (Rifadin) Caps 300mg
II. Cardiovascular Agents
Anti-anginals
Nitroglycerin SL Tabs 0.3mg, 0.4mg, 0.6mg
Nitroglycerin Linqual Pump Spray
Nitroglycerin (Nitro-Dur) Transdermal Patches 0.2mg/hr, 0.4mg/hr
Isosorbide Dinitrate (Isordil) Tabs 10mg, 40mg SR
Isosorbide Monohydrate (Imdur) Tabs 30mg, 60mg
Anti-hyperlipemics
Colestipol (Colestid) Tabs 1gm, 5gm granules
Ezetimibe (Zetia) Tabs 10mg
Ezetimibe/Simvastatin (Vytorin) Tabs 10-20mg, 10-40mg, 10-80mg
Fenofibrate (Triglide) Tabs 50mg, 160mg
Gemfibrozil (Lopid) Tabs 600mg
Nicotinic Acid (Niacin, Vitamin B3) Tab 50mg
Niaspan ER Tabs 500mg, 750mg, 1000mg
Pravastatin (Pravachol) Tabs 10mg, 20mg, 40mg, 80mg
Simvastatin (Zocor) Tabs 5mg, 10mg, 20mg, 40mg, 80mg
Anti-hypertensives
Amlodipine (Norvasc) Tabs 5mg, 10mg
Amlodipine/Benazepril (Lotrel) Caps 2.5-10mg, 5-10mg, 5-20mg, 5-40mg,
10-20mg, 10-40mg
Atenolol (Tenormin) Tabs 50mg
Captopril (Capoten) Tabs 25mg
Carvedilol (Coreg) Tab 3.125mg, 6.25mg, 12.5mg, 25mg
Clonidine (Catapres) Tabs 0.1mg, Patches 0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr
Diltiazem (Cardizem) Tabs 60mg
Diltiazem (Tiazac SR) Caps 120mg, 180mg, 240mg, 300mg
Doxazosin (Cardura) Tabs 2mg, 8mg
Felodipine (Plendil) Tabs 2.5mg, 5mg, 10mg
Hydralazine (Apresoline) Tabs 10mg, 25mg
Labetalol (Trandate) Tabs 200mg
Lisinopril (Prinivil, Zestril) Tabs 5mg, 10mg, 20mg, 40mg
Lisinopril/Hydrochlorothiazide Tabs 10-12.5mg, 10-25mg, 20-12.5mg, 20-25mg
Methyldopa (Aldomet) Tabs 250mg
Metoprolol Succinate (Toprol XL) Tabs 25mg, 50mg, 100mg, 200mg
Metoprolol Tartrate (Lopressor) Tabs 50mg
Nifedipine SR (Adalat CC) Tabs 30mg, 60mg, 90 mg
Prazosin (Minipress) Caps 1mg, 2mg, 5mg
Propranolol (Inderal) Tabs 10mg, 40mg
Propranolol (Inderal LA) Caps 80mg
Telmisartan (Micardis) 20mg, 40mg, 80mg
Telmisartan/hydroclorothiazide (Micardis HCT) 40-12.5mg, 80-12.5mg, 80-25mg
Terazosin (Hytrin) Caps 1mg, 2mg, 5mg, 10mg
Verapamil (Calan) Tabs 80mg, 120mg
Verapamil (Calan) SR Tabs 180mg, 240mg
Anti-hypertensives for Diabetes Mellitus
Losartan Potassium (Cozaar) Tabs 25mg, 50mg, 100mg (for MOFH providers,
must have comment of diabetetic patient with hypertension in comment field; for Civilian
scripts – comment on script of diabetic patient with hypertension)
Anti-hypertensives for Coronary Heart Failure
Candesartan Cilexetil (Atacand) Tabs 16mg, 32mg (for MOFH providers, must have
comment of Congestive Heart Failure Patient in comment field; for Civilian scripts – comment
on script of Congestive Heart Failure Patient)
Diuretics
Acetazolamide (Diamox) Tabs 250mg; 500mg Sequels
Furosemide (Lasix) Tabs 40mg; Oral Soln 10mg / ml
Hydrochlorothiazide (HCTZ) Caps 12.5mg; Tabs 25 mg, 50 mg
Hydrochlorothiazide/Triamterene (Maxzide) Tabs 25-37.5mg, 50-75mg
Spironolactone (Aldactone) Tabs 25mg
Anti-arrhythmics
Amiodarone (Cordarone, Pacerone) Tabs 200mg
Digoxin (Lanoxin) Tabs 0.125mg, 0.25mg
Digoxin (Lanoxin Ped elixir) 50mg / ml
Procainamide (Pronestyl) Caps 250mg
Procainamide (Procan SR) Tabs 500mg
Quinidine Gluconate (Quinaglute) Tabs 324mg
Sotalol (Betapace) Tabs 80mg, 120mg
III. Central Nervous System Agents
Anti-convulsants
Carbamazepine (Tegretol) Chewtabs 100mg; Tabs 200mg
Carbamazepine (Tegretol) Susp 100mg / 5ml
Carbamazepine XR (Tegretol XR) Tabs 100mg, 200mg, 400mg
Clonazepam (Klonopin) Tabs 0.5mg, 1mg
Diazepam (Valium) Tabs 5mg
Divalproex Sodium (Depakote) Tabs 125mg, 250mg
Divalproex Sodium (Depakote ER) Tabs 250mg, 500mg
Ethosuximide (Zarontin) Caps 250mg
Gabapentin (Neurontin) Caps 100mg, 300mg, 400mg; Tabs 600mg
Lamotrigine (Lamictal) Tabs 100mg, 200mg
Oxcarbazepine (Trileptal) Tabs 300mg, 600mg
Phenobarbital Tabs 30mg
Phenobarbital Elixir 20mg / 5ml
Phenytoin (Dilantin) Caps 100mg
Phenytoin (Dilantin Infatabs) Chewtabs 50mg
Phenytoin (Dilantin) Oral Susp 125mg / 5ml
Primidone (Mysoline) Tabs 50mg, 250mg
Topiramate (Topamax) Tab 25mg, 100mg
Valproic Acid (Depakene) Syrup 250mg / 5ml
Valproic Acid Caps 250mg
Anti-depressants
Amitriptyline (Elavil) Tabs 10mg, 25mg
Bupropion (Wellbutrin) Tabs SR 100mg, 150mg
Buspirone (Buspar) Tabs 5mg, 10mg
Citalopram (Celexa) Tabs 20mg, 40mg
Clomipramine (Anafranil) Caps 25mg
Desipramine (Norpramin) Tabs 10mg, 50mg
Doxepin (Sinequan, Adapin) Caps 25mg
Fluoxetine (Prozac) Caps 10 mg, 20 mg
Imipramine (Tofranil) Tabs 10mg, 25mg
Nortriptyline (Pamelor) Caps 10mg, 25mg
Paroxetine (Paxil) Tabs 20mg, 40mg
Sertraline (Zoloft) Tabs 25mg, 50mg, 100mg
Trazodone (Desyrel) Tabs 100mg
Venlafaxine XR (Effexor XR) Caps 37.5mg, 75mg, 150mg
Mood Stabilizer / Neuroleptics
Lithium Carbonate (Eskalith) Caps 300mg
Haloperidone (Haldol) Tabs 1mg, 5mg
Olanzapine (Zyprexa) Tabs 5mg, 10mg (restricted to psych providers)
Risperidone (Risperdal) Tabs 1mg, 2mg, 3mg
Quetiapine (Seroquel) 25 mg, 100 mg (restricted to psych providers)
Ziprasidone (Geodon) 20mg, 40mg, 80mg (restricted to psych providers)
effective May 2008
Anti- Parkinson’s Agents
Amantadine (Symmetrel) Caps 100mg
Benztropine (Cogentin) Tabs 2mg
Bromocriptine (Parlodel) Tabs 2.5 mg; Caps 5mg
Carbidopa / Levodopa (Sinemet) Tabs 10-100mg, 25-100mg, 25-250mg
Carbidopa / Levodopa CR (Sinemet CR) Tabs 50-200mg
Selegiline (Eldepryl) Caps 5mg
Trihexphenidyl (Artane) Tabs 2mg
Anxiolytics / Sedatives / Hypnotics
Alprazolam (Xanax) Tabs 0.5mg
Clonazepam (Klonopin) Tabs 0.5mg, 1mg
Diazepam (Valium) Tabs 5mg
Lorazepam (Ativan) Tabs 1mg
Temazepam (Restoril) Caps 15mg, 30mg
Zolpidem (Ambien) Tabs 10mg
Central Nervous System Stimulants
Atomoxetine (Strattera) Caps 10mg, 18mg, 25mg, 40mg, 60mg
Dextroamphetamine (Dexedrine) Tabs 5mg
Dextroamphetamine / Amphetamine (Adderall) Tabs 10mg
Dextroamphetamine / Amphetamine (Adderall XR) Caps 10mg, 20mg, 30mg
Methylphenidate (Ritalin) Tabs 5mg, 10mg
Methylphenidate SR (Ritalin SR) Tabs SR 20mg
Methylphenidate (Concerta) Tabs Extended release 18mg, 27mg, 36mg, 54mg
Migraine Agents
Acetaminophen 325mg / Butalbital 50mg / Caffeine 40mg (Fiorcet) Tabs
Acetaminophen / Isometheptene / Dichloralphenazone (Midrin) Caps
Aspirin 325mg / Butalbital 50mg / Caffeine 40mg (Fiorinal) Tabs
Ergotamine 1mg / Caffeine 100mg (Wigraine, Cafergot) Tabs
Sumatriptan (Imitrex) Injection 6mg
Sumatriptan (Imitrex) Nasal Spray 20mg
Zolmitriptan (Zomig ZMT) Oral Disintegrating Tablet 2.5mg & 5 mg
IV. Dermatologic Agents
Acne Products
Adapalene (Differin) Gel 0.1%
Benzoyl Peroxide Gel 5%
Tretinoin (Retin A) Cream 0.025%, 0.05%, 0.1%; Gel 0.025%
Antibiotics – Topicals
Bacitracin Oint
Clindamycin (Cleocin T) Soln 1%
Erythromycin Soln 2%
Metronidazole (Metrogel) Gel 1%
Silver Sulfadiazine (Silvadene) Cream 1%
Anti-fungals – Topicals
Clotrimazole (Lotrimin) Cream 1%; Soln 1%
Ketoconazole (Nizoral) Cream 2%
Miconazole (Monistat Derm) Cream 2%
Nystatin (Mycostatin) 100,000 units / gm Cream; Oint
Anti-parasitic - Topical
Crotamiton (Eurax) Cream 10%
Permethrin (Elimite) Cream 5%
Pyrethrins (Rid) Shampoo 2oz (restricted to MOFH providers only)
Anti-psoriatics- Topical
Calcipotriene (Dovonex) Cream 0.005%; Soln 0.005%
Pimecrolimus (Elidel) Cream 1%
Selenium sulfide (Selsun) Shampoo 2.5%
Tacrolimus (Protopic) Oint 0.1% (restricted to Dermatologists)
Corticosteroids-Topical
Azelaic acid (Azelex) Cream 20%
Betamethasone Dipropionate Augmented (Diprolene) Oint 0.05%
Betamethasone Valerate (Valisone) Lotion 0.1%
Clobetasol Propionate (Temovate) 0.05%; Cream; Oint; Soln
Desonide (Desowen) 0.05% Cream, Oint
Desoximetasone (Topicort) Oint 0.25%; Gel 0.05%
Fluocinolone (Synalar) Cream, Oint 0.025%, 0.01%; Soln 0.01%
Fluocinonide (Lidex) 0.05%; Cream; Gel; Oint
Hydrocortisone 1% Cream; Oint; Lotion
Triamcinolone (Kenalog) Cream 0.1%, 0.5%; Oint 0.025%, 0.1%, 0.5%
Local Anesthetics-topical
Dibucaine (Nupercainal) Oint 1%
Lidocaine (Xylocaine) Oint 5%; Jelly 2%
Lidocaine/Prilocaine (Emla) Cream 2.5% / 2.5%
Misc-Topical
Aluminum chloride (Drysol) Soln 20%
Fluorouracil (Efudex) Cream 5%
Hydroquinone (Eldoquin Forte) Cream 4%
Imiquimod (Aldara) Cream 5%
Mupirocin (Bactroban) Oint 2%
Ointment Base (Absorbase)
Pimecrolimus (Elidel) Cream 1%
Salicylic Acid Liquid (Duofilm) 17%
Salicylic Acid Plaster (Medi-Plast) 40%
Tacrolimus (Protopic) Oint 0.1% (restricted to Dermatologists)
Urea (Carmol-20) Cream 20%
Zinc Oxide Oint
V. Gastrointestinal Agents
Hyoscyamine/Atropine/Phenobarbital/Scopalamine (Donnatal) Tabs, Elixir
Bisacodyl (Dulcolax) Tabs 5mg; Supps 10mg
Bismuth Subsalicylate (Pepto-Bismol) Chewtabs 262mg
Bowel Evacuation Kit
Cimetidine (Tagamet) Tabs 400mg
Co-lyte / Golytely Oral Solution
Dicyclomine (Bentyl) Tabs 20mg
Docusate Sodium (Colace) Caps 100mg
Diphenoxylate 2.5mg /Atropine 0.025mg (Lomotil) Tabs
Esomeprazole Magnesium (Nexium) Caps 20mg, 40mg
Fleets Enema
Fleets Oral Saline Laxative (Fleet Phospha Soda)
Hydrocortisone (Cortenema) Enema 100mg / 60ml
Hyoscyamine (Levsin) Tabs 0.125mg
Hyoscyamine SR (LevBID) Tabs 0.375mg
Lactulose (Cephulac) Syrup 10mg / 15ml
Loperamide (Imodium) Caps 2mg
Magnesium Citrate Oral Soln
Mesalamine (Asacol) Tabs 400mg delayed release
Metoclopramide (Reglan) Tabs 10mg
Misoprostol (Cytotec) Tabs 100mcg, 200mcg
Omeprazole (Prilosec) Caps 20mg
Pancreatic Enzymes (Pancrease) Caps (Amylase/Lipase/Protease)
Polyethylene Glycol 3350 (Glycolax/Miralax) Oral Powder 17g/dose
Ranitidine (Zantac) Tabs 150mg; Syrup 15mg / mL
Sulfasalazine (Azulfidine) Tabs 500mg
Anti-emetics
Meclizine (Antivert) Tabs 25mg
Metoclopramide (Reglan) Tabs 10mg
Prochlorperazine (Compazine) Tabs 5mg
Prochlorperazine (Compazine) Supps 25mg
Promethazine (Phenergan) Tabs 25mg
Promethazine (Phenergan) Supps 12.5mg, 25mg
VI. Genitourinary Agents
Urinary Tract Agents
Finasteride (Proscar) Tabs 5mg
Oxybutynin (Ditropan) Tabs 5mg
Phenazopyridine (Pyridium) Tabs 100mg
Tolterodine (Detrol LA) Caps 4mg
Alfuzosin (Uroxatrol ) Tabs 10mg
VII. Metabolic / Endocrine Agents
Androgens
Danocrine (Danazol) Caps 200mg
Methyltestosterone (Android) Caps 10mg
Testosterone Cypionate Injection 200mg / ml
Corticosteroids
Cortisone Acetate Tabs 25mg
Dexamethasone (Decadron) Tabs 0.5mg, 4mg
Fludrocortisone Acetate (Florinef) Tabs 0.1mg
Hydrocortisone (Cortef) Tabs 10mg
Methylprednisolone (Medrol) Tabs 4mg, Dosepak 4mg
Prednisolone (Prelone) Oral liquid 15mg / 5ml
Prednisone (Deltasone) Tabs 1mg, 5mg, 20mg, 50mg
Diabetic Supplies
Glucose Test Strips (Precision Xtra)
Lancets
Syringes, Insulin 0.5ml (Lo-Dose) (1/2cc); 1ml (1cc)
Alcohol, Isopropyl Pads 70%
Gout Agents
Allopurinol (Zyloprim) Tabs 100mg, 300mg
Colchicine Tabs 0.6mg
Indomethacin (Indocin) Caps 25mg
Probenecid (Benemid) Tabs 500mg
Hormone Replacement Therapy
Estradiol (Alora) Patch 0.05mg, 0.1mg
Estradiol (Vagifem) Vaginal Tabs 25mcg
Estrogen Conjugated (Premarin) Tabs 0.3mg, 0.45mg, 0.625mg, 1.25mg
Estrogen Conjugated 0.45mg/Medroxyprogesterone 1.25mg (PremPro) Tabs
Estrogen Conjugated 0.625mg/Medroxyprogesterone 2.5mg (PremPro) Tabs
Estrogen Conjugated 0.625mg/Medroxyprogesterone 5mg (PremPro) Tabs
Estrogen Conjugated (Premarin) Vaginal Cream
Medroxyprogesterone (Provera) Tabs 2.5mg, 10mg
Norethindrone Acetate (Aygestin) Tabs 5mg
Hypoglycemic Agents
Glipizide (Glucotrol) Tabs 5mg
Glucagon Emergency Kit 1 mg Vial Injection
Glyburide (Diabeta, Micronase) Tabs 5mg
Glyburide, micronized (Glynase) Tabs 3mg
Insulin NPH (Novolin N)
Insulin NPH/Regular 70/30 (Novolin 70/30)
Insulin Glargine (Lantus)
Insulin Aspartate (Novolog)
Insulin Regular (Novolin R)
Metformin (Glucophage) Tabs 500mg, 850mg, 1000mg
Metformin XR (Glucophage XR) Tabs 500mg
Metformin/Rosiglitazone (Avandamet) Tabs 2-500mg, 4-500mg
Rosglitazone (Avandia) Tabs 4 mg, 8mg
Oral Contraceptives---Monophasic
Drospirenone 3mg/Ethinyl Estradiol 0.02mg (YAZ) 28s
Drospirenone 3mg/Ethinyl Estradiol 0.03mg (YASMIN) 28s
Ethinyl Estradiol 35mcg/Ethynodiol 1mg (Demulen 1/35) 28s
Ethinyl Estradiol 0.02mg/ Levonorgestrel 0.1mg (Lessina) (Levlite) 28s
Ethinyl Estradiol 0.03mg/ Levonorgestrel 0.15mg (Levora) (Nordette) 28s
Ethinyl Estradiol 20mcg/Norethindrone 1mg (Loestrin Fe) 1/20 28s
Ethinyl Estradiol 20mcg/Norethindrone 1mg (Loestrin) 1/20 21s
Ethinyl Estradiol 30mcg/Norgestrel 0.3mg (Lo-Ovral) 28s
Ethinyl Estradiol 35mcg/Norgestimate 0.25mg (Ortho Cyclen) 28s
Ethinyl Estradiol 50mcg/Norgestrel 0.5mg (Ovral) 28s
Ethinyl Estradiol 35mcg/Norethindrone 1mg (Ortho Novum 1/35) (Norinyl 1/35) 28s
Mestranol 50mcg/Northindrone 1mg (Norinyl 1+50) (Ortho Novum 1/50) 28s
Oral Contraceptives---Triphasic
Ethinyl Estradiol 30/40/30mcg/Levonorgestrel 0.05/0.075/0.125mg (Trivora) 28s
Ethinyl Estradiol 35mcg/Norethindrone 0.5/0.75/1mg (Ortho Novum 7-7-7) 28s
Ethinyl Estradiol 25mcg/Norgestimate 0.18/0.215/0.25mg (Ortho Tri-Cyclen
LO) 28s
Ethinyl Estradiol 35mcg/Norgestimate 0.18/0.215/0.25mg (Ortho Tri-Cyclen)
(TriNessa ) 28s
Oral Contraceptives---Progestin Only
Norethindrone 0.35mg (Nor QD) 28s
Contraceptives-Other
Ethinyl Estradiol 20mcg/Norelgestromin 150mcg/24 Hrs (Ortho Evra) Patches
Levonorgestrel (Plan B) Tabs 0.75mg 2s
Thyroid Agents
Levothyroxine (Synthroid) Tab 0.025mg, 0.05mg, 0.075mg, 0.088mg, 0.1mg,
0.112mg, 0.125mg, 0.137mg, 0.15mg, 0.175mg, 0.2mg
Liothyronine (Cytomel) Tabs 25mcg
Methimazole (Tapazole) Tabs 10mg
Propylthiouracil (PTU) Tabs 50mg
VIII. Musculoskeletal Agents
Analgesics NSAIDS
Acetaminophen (Tylenol) Tabs 325mg
Acetaminophen (Tylenol) Infant Drops 80mg / 0.8mL
Acetaminophen (Tylenol) Elixir 160mg / 5mL
Ibuprofen (Motrin) Tabs 400mg, 600mg, 800mg; Susp 100mg / 5ml
Indomethacin (Indocin) Caps 25mg
Meloxicam (Mobic) Tabs 15mg
Naproxen (Naprosyn) Tabs 500mg
Piroxicam (Feldene) Caps 20mg
Salsalate (Disalcid) Tabs 750mg
Sulindac (Clinoril)Tabs 150mg
Tramadol (Ultram) Tabs 50mg
Analgesics Opioids
Acetaminophen 300mg / Codeine 30mg (Tylenol #3) Tabs
Acetaminophen 120mg / Codeine 12mg / 5mL Elixir
Acetaminophen 500mg / Hydrocodone 5mg (Lortab/Vicodin) Tabs
Acetaminophen 500mg / Hydrocodone 7.5mg (Lortab) Tabs
Acetaminophen 500mg / Hydrocodone 7.5mg / 15ml (Lortab) Soln (maximum
473ml per script with up to 5 refills)
Acetaminophen 325mg / Oxycodone 5mg (Percocet) Tabs
Acetaminophen 650mg / Propoxyphene 100mg (Darvocet N-100) Tabs
Codeine Sulfate Tabs 30mg
Fentanyl (Duragesic) Patch 25mcg, 50mcg, 75mcg, 100mcg
Hydromorphone (Dilaudid) Tabs 4mg
Meperidine (Demerol) Tabs 50mg
Meperidine (Demerol) Syrup 50mg / 5mL
Methadone (Dolophine) Tabs 10mg
Morphine Sulfate (MSIR) Tabs 15mg, 30mg
Morphine Sulfate Oral Soln 10mg / 5ml, 20mg / 5ml
Morphine Sulfate SR (MS Contin, Oramorph) Tabs 15mg, 30mg, 60mg
Oxycodone CR (Oxycontin) Tabs 10mg, 40mg
Anti-rheumatic Agents
Azathioprine (Imuran) Tabs 50mg
Hydroxychloroquine (Plaquenil) Tabs 200mg
Leucovorin Calcium (Wellcovorin) Tabs 5mg
Methotrexate (Rhematrex) Tabs 2.5mg
Penicillamine (Cuprimine) Caps 250mg
Sulfasalazine (Azulfidine) Tabs 500mg
Skeletal Muscle Relaxants
Baclofen (Lioresal) Tabs 10mg
Carisoprodol (Soma) Tabs 350mg
Cyclobenzaprine (Flexeril) Tabs 10mg
Methocarbamol (Robaxin) Tabs 500mg
Tizanidine (Zanaflex) Tabs 4mg
Misc
Alendronate (Fosamax) Tabs 10mg, 35mg, 70mg
Alendronate/Vitamin D (Fosamax D) Tabs 70mg-2800units
Pyridostigmine (Mestinon) 60mg Tabs, 180mg Timespan/SR Tabs
Raloxifene (Evista) Tabs 60mg
IX. Ophthalmic Agents
Anti-Infectives
Ciprofloxacin (Ciloxin) Soln 0.3%
Dexamethasone / Neomycin / Polymyxin B (Maxitrol) Oint
Erythromycin Ophth Oint
Gentamicin (Garamycin) Oint 0.3%; Soln 0.3%
Neomycin / Polymyxin B / Bacitracin (Neosporin) Oint
Neomycin / Polymyxin B / Gramicidin (Neosporin) Soln
Polymyxin B / Bacitracin (Polysporin) Oint
Polymyxin B / Trimethoprim (Polytrim) Soln
Prednisolone Acetate 0.2% / Sulfacetamide Sodium 10% (Blephamide) Oint
Prednisolone Acetate 0.2% / Sulfacetamide Sodium 10% (Blephamide) Soln
Sulfacetamide Sodium (Sulamyd, Bleph-10) Soln 10%
Tobramcyin / Dexamethasone (Tobradex) Soln (restricted to
Optometrists/Ophthalmologists)
Anti-Inflammatory / Allergy
Fluoromethalone (FML) Soln 0.1%
Pheniramine 0.3% / Naphazoline 0.025% (Naphcon A/Visine A) Soln
Ketorolac (Acular LS) 0.4% Soln (restricted to Optometrists/Ophthalmologists)
Lodoxamide (Alomide) Soln 0.1%
Olopatadine (Patanol) Soln 0.1%
Prednisolone (Pred-Forte) Soln 1%
Mydriatics
Cyclopentolate (Cyclogyl) Soln 1%
Isopto-Homatropine Soln 5%
Glaucoma
Betaxolol S (Betoptic S) Susp 0.25%
Bimatoprost (Lumigan) Soln 0.03% (restricted to Optometrists/Ophthalmologists)
Brimonidine (Alphagan P) Drops 0.15%
Dipivefrin (Propine) Soln 0.1%
Dorzolamide 2% / Timolol 0.5% (Cosopt) Drops (restricted to
Optometrists/Ophthalmologists)
Dorzolamide (Trusopt) Soln 2%
Latanoprost (Xalatan) Soln 0.05%
Levobunolol (Betagan) Soln 0.5%
Medrysone (HMS) Soln 1%
Pilocarpine (Isoptocarpine) Soln 1%, 2%, 3%, 4%
Pilocarpine (Pilopine HS) Gel 4%
Timolol (Timoptic) Soln 0.25%, 0.5%
Timolol (Timoptic XE) Gel Forming Soln 0.5%
Misc
Cyclosporine (Restasis) Dropperettes 0.05% (restricted to
Optometrists/Ophthalmologists – 1 Box only with up to 5 refills )
Lacri-lube Oint (Generic EQ.)
LiquiTears Soln (various Artificial Tears) (Not Preservative Free)
Sodium Chloride (Muro 128) Oint 5%; Soln 5%
X. Otic Agents
Acetic Acid (Domeboro) Soln 2%
Antipyrine/Benzocaine (Auralgan/Aurodex) Soln
Ciprofloxacin 0.3% / Dexamethasone 0.1% (Ciprodex) Soln
Bacitracin / Neomycin / Polymyxin B / Hydrocortisone (Cortisporin) Susp
Ofloxacin (Floxin) Soln 0.3%
XI. Respiratory Agents
Anti-histamines / Decongestants / Cough / Cold / Allergy
Benzonatate (Tessalon) Gelcaps 100mg
Cetirizine HCl (Zyrtec) Tabs 10mg
Chlorpheniramine (CTM) Tabs 4mg ; Syrup 2mg / 5ml
Chlorpheniramine 8mg/Pseudoephedrine 120mg (Deconamine SR) Caps
Cyproheptadine (Periactin) Tabs 4mg
Diphenhydramine (Benadryl) Caps 25mg
Diphenhydramine (Benadryl) Elixir 12.5mg / 5ml
Guaifenesin 100mg / Codeine 10mg / 5ml Syrup (Robitussin AC)
Guaifenesin 100mg / Dextromethorphan 10mg / 5ml Syrup (Robitussin DM)
Hydroxyzine Pamoate (Vistaril) Caps 25mg
Hydroxyzine HCl (Atarax) Tabs 10mg, 25mg; Syrup 10mg / 5ml
Loratadine (Claritin) Tabs 10mg; Syrup 5mg / 5ml
Meclizine (Antivert) Tabs 25mg
Pseudoephedrine (Sudafed) Tabs 30mg; Syrup 30mg / 5ml
Pseudoephedrine 30mg / Triprolidine 1.25mg / 5ml (Actifed) Syrup
Pseudoephedrine 60mg / Triprolidine 2.5mg (Actifed) Tabs
Asthma Medications
Aerochamber (Small with mask, Medium with mask, Large with no mask)
Albuterol HFA (Proventil HFA, Ventolin HFA) Inhaler 90mcg / puff
Albuterol (Proventil, Ventolin) Soln 0.5%
Albuterol (Proventil, Ventolin) Inhalation Neb PREMIX Soln 0.083%
Albuterol (Proventil, Ventolin) Tabs 2mg
Budesonide (Pulmicort Respules) Inh 0.5mg / 2ml, 0.25mg / 2ml (restricted to
Pediatrics)
Cromolyn Sodium (Intal) Inhalation Neb Soln 20mg / 2ml Vials
Flunisolide (Aerobid M) Inhaler 250mcg / puff
Fluticasone HFA (Flovent HFA) Inhaler 44mcg, 110mcg, 220 mcg / puff
Fluticasone/Salmeterol (Advair Diskus) 100/50, 250/50, 500/50 Inhaler
Ipratropium Bromide (Atrovent HFA) Inhaler 18mcg / puff
Ipratropium Bromide (Atrovent) Inhalation Neb Soln 0.02%
Ipratropium Bromide 18mcg / Albuterol Sulfate 103mcg (Combivent) Inhalation
Aerosol
Levalbuterol Tartrate (Xopenex HFA) Inhalation Aerosol 45mcg / puff
Montelukast (Singulair) Chewtabs 4mg, Tabs 5mg, 10mg
Salmeterol (Serevent) Diskus 50mcg / dose
Sodium Chloride 0.9% Inhalation Solution 5ml Unit-Dose Vial
Theophylline (Theodur) Tabs 200mg, 300mg
Theophylline (Uniphyl) Tabs 400mg
Tiotropium Bromide Inhalation Powder (Spiriva) Handihaler
Triamcinolone (Azmacort) Inhaler 100mcg / puff
Nasal Preparations
Desmopressin Acetate (DDAVP) Spray 0.1%, 10mcg / 0.1ml
Flunisolide (Nasalide) Spray 0.025%, 25mcg / spray
Fluticasone Propionate (Flonase) Spray, 50mcg / spray
Oxymetazoline HCl (Afrin) Spray 0.05%
Sodium chloride (Ocean) Drops / Spray 0.65%
Sumatriptan (Imitrex) Unit Dose Spray 20mg
XII. Vaginal Preparations
Clotrimazole (Gyne-Lotrimin/Mycelex 7) Cream 1%
Clindamycin (Cleocin) Cream 2%
Estradiol (Vagifem) Vaginal Tabs 25mcg
Estrogen Conjugated (Premarin) Cream 0.625mg / gm
Metronidazole (Metrogel) Gel 0.75%
Terconazole (Terazol 7) Cream 0.4%
XIII. Vitamin / Mineral / Electrolyte Agents
Calcium 500mg w Vitamin D 200IU (OsCal D) Tabs
Cyanocobalamine (Vitamin B-12) 1000mcg / ml Injection
Ergocalciferol (Calciferol Drops) Oral Soln (restricted to Pediatrics only)
Ferrous Sulfate Tabs 325mg
Ferrous Fumarate 50mg / Docusate Sodium 40mg (Ferro-Sequels) Tabs
Folic Acid (Folate) Tabs 1mg
Magnesium Oxide (Mag-Ox) Tabs 400mg
Nicotinic Acid (Niacin, Vitamin B3) Tabs 50mg
Niaspan ER Tabs 500mg, 750mg, 1000mg
Polyvitamins with Fluoride Drops 0.5mg / ml
Potassium Chloride (K-Dur) Tabs 20mEq
Potassium Citrate (Urocit K) Tabs 10mEq
Prenatal Vitamins / Minerals Tabs (limited to women up to and including age 45 per
DoD BCF guidelines)
Pyridoxine (Vitamin B6) Tabs 50mg
Phytonadione (Vitamin K) Tabs 5mg
Thiamine (Vitamin B1) Tabs 50mg
Other
Alprostadil (Edex) Syringes 10mcg, 20mcg 40mcg (Maximum of 6 injections per
month / 1 month supply only)
Clomiphene (Clomid) Tabs 50mg
Disulfiram (Antabuse) Tabs 250mg
Donepezil (Aricept) Tabs 5mg, 10mg
Epinephrine (Epipen Jr, Epipen) Autoinjector 0.15mg, 0.3mg
Isotretinoin (Accutane) Caps 10mg, 20mg, 40mg (restrict to dermatology /
s.m.a.r.t. prescribers)
Lidocaine HCl (Xylocaine) Viscous Soln 2%
Methylergonovine Maleate (Methergine) Tabs 0.2mg
Pilocarpine (Salagen) Tabs 5mg
Sodium Citrate with Citric Acid (Bicitra) Oral Soln
Vardenafil (Levitra) Tabs 10mg, 20mg (6 per month / Maximum of 18 per 90 days –
DoD Prior Authorization for < 50 years)
Smoking Deterrents****
Bupropion SR (Zyban) Tabs 150mg
Nicotine Patch (Nicoderm CQ) 7mg / day, 14mg / day, 21mg / day
Varenicline (Chantix) Starter Pack, Tabs 0.5mg, 1mg
**** Patients must have proof of enrollment in smoking
cessation program sponsored by HAWC (Max 1 course of
therapy)
Bolded items are preferred agents within class
XIV. Misc Agents
Hemorrhoid Agents
Hemorrhoidal HC (Anusol HC) Supps 25mg
Hydrocortisone Rectal Cream 2.5%
Hydrocortisone Rectal Foam 1% (Proctofoam HC)
Main (Hospital) Pharmacy
Process in-house provider scripts
(M-F: 0730-1800)
4700 Las Vegas Blvd North
Nellis AFB, NV 89191-6601
TEL. NO: (702) 653-3201
Satellite Pharmacy
Process refills (M-F: 0900-1800)
Process civilian scripts
(M-F 0900-1730)
Bldg 340 (Old BX, behind theater)
Nellis AFB, NV 89191-6601
TEL. NO: (702) 652-6011
Phone in refills: (702) 652-5359
800-822-5077 (NV)
800-237-8981 (outside NV)
Both Pharmacies closed: All federal holidays and specially designated ‘down’
days
-The pharmacy must use generic medication whenever possible so please
write all medications generically.
-A prescription written as “Dispense as Written” may not be accepted.
- TELEPHONE PRESCRIPTIONS: Per Air Force directives, no pharmacy staff
member may receive a prescription over the phone. This also includes
prescription renewals. The pharmacy can, however, accept a change or
substitution.
- NON-CONTROLLED PRESCRIPTIONS: Are honored up to 365 days from
the date the prescription was written. Antibiotic prescriptions over 10 days old
will be filled at the discretion of the pharmacy. Prescriptions for maintenance
medications may be written for up to a 90 day supply with a maximum of 3
refills when requested by prescriber. All other non-controlled prescriptions
may be written for up to 30 days supply with a maximum of 11 refills. State
and Federal laws maintain that all prescriptions be originally signed by the
provider; stamped/copied signatures are NOT acceptable. ‘Indications’ are
highly encouraged to prevent prescription errors.
- CONTROLLED PRESCRIPTIONS:
Prescriptions for Schedule 3, 4 or 5
medications will be honored for 6 months from the date they were written with
up to 5 refills. Prescriptions for Schedule 2 medications will be honored for 14
days from the date they were written with no refills. Quantities are not to
exceed 30 day supplies (except stimulants). Providers are reminded to
include their DEA number on all controlled prescriptions. Controlled
prescriptions must be written separate from legend drugs on a different
prescription form. Scheduled 3-5 items can be written together on the
same form. Only scheduled 2 items can be written with other
scheduled 2 items.
Anti-Neoplastic Agents
Busulfan (Myleran) Tabs 2mg
Chlorambucil (Leukeran) Tabs 2mg
Cyclophosphamide (Cytoxan) Tabs 50mg
Fluorouracil (Efudex) Cream 5%
Leucovorin Calcium (Wellcovorin) Tabs 5mg
Megestrol Acetate (Megace) Tabs 40mg
Methotrexate (Rheumatrex) Tabs 2.5mg
Tamoxifen (Nolvadex) Tabs 10mg
Dental Preparations
Chlorhexidine (Peridex / Periogard) Oral Soln 0.12%
Polyvitamins with Fluoride Drops 0.5mg / ml
Sodium Fluoride Toothpaste 1.1% (Prevident 5000 Plus)
Sodium Fluoride Oral Soln 0.5mg / ml
Triamcinolone (Kenalog) Dental Paste 0.1%
DISPENSING POLICIES / PROCEDURES
- FAXED PRESCRIPTIONS: are not accepted.
- STAMPED PRESCRIPTIONS: are not acceptable. All paper prescriptions
MUST be originally signed by the prescriber.
TRICARE Online (TOL) Pharmacy Refill is a new capability
that allows authorized beneficiaries to securely request prescription
refills from the TOL website (www.tricare.mil). TOL Pharmacy
Refill serves as a secure portal to the MHS prescription refill
system, AudioCARE, and is compliant with Health Insurance
Portability and Accountability Act (HIPAA) and Joint Commission
(JC) standards.
Authorized beneficiaries will have the ability to request refills of
those prescriptions that are refillable, check the status of their refill
requests, link to the TRICARE Mail Order Pharmacy (TMOP) web
page and, at MTFs so enabled, to request that refills be mailed
from the VA Consolidated Mail-Out Pharmacy (CMOP).
- WEBSITE: this formulary and
other information about the
pharmacy are also available at http://www.nellis.af.mil/
under the Nellis AFB Links: “Medical Services”. Click the
Medical Services link and scroll to the Pharmacy section.
Click on “Download the formulary” to view the formulary.
- Although medications are provided at no cost to our patients, this service is
not free—the American taxpayer pays the bill. Please consider less expensive
alternatives whenever possible when prescribing. Department of Defense
preferred formulary items are designated by bold print.