1. HOLLOMAN AFB FORMULARY
DISPENSING POLICIES / refills. Prescriptions for Schedule 2
PROCEDURES medications will be honored for 7 days from
the date they were written with no refills.
MAIN Pharmacy Providers are reminded to include their DEA
280 First St, Bldg 15 number on all controlled prescriptions.
Holloman AFB, NM 88330
Open: 0730 – 1630, M-F - REFILL POLICY: Refills MUST be called
TEL. NO: (575) 572-2778 opt 4,1, and 4 in through the automated refill system at
FAX No: (575) 572-5781 572-7045. They may be called in 7 days
REFILL Pharmacy before the Rx should run out. Please allow
TEL. NO: (575) 572-7045 / 1-800-843-4682 for 2 duty days for refills to be ready.
The Pharmacy is closed: Saturday, Sunday, - Although medications are provided at no
all federal holidays and specially designated cost to our patients, this service is not free—
‘down’ days the American taxpayer pays the bill. Please
consider less expensive alternatives
-The pharmacy must use generic medication whenever possible when prescribing.
whenever possible so please write all
medications generically. TRICARE MAIL ORDER PHARMACY
(EXPRESS SCRIPTS): Contact 1-866-363-
-A prescription written as “Dispense as 8667 or www.express-scripts.com/TRICARE
Written” may not be accepted. for more information.
30 or 90 day supply:
-Drugs with narrow therapeutic margins will Active duty: No cost
not be generically substituted. All Other Beneficiaries: Generic $0,
Formulary Brand-Name: $13; Non-
- TELEPHONE PRESCRIPTIONS: Per Air Formulary Brand-Name: $43
Force directives, no pharmacy staff member
may receive a prescription called in from a Copayments at Retail Pharmacies are $5 for
provider. This also includes prescription generic drugs, $17 for brand name and $44
renewals. The pharmacy can, however, for non-formulary.
accept a change or substitution to a non-
controlled prescription if the original **The brand name in the listings are for
prescription is located within the pharmacy. reference only and do not signify the product
dispensed**
-Fax’s: New prescriptions for non-controlled
substances and controlled substances in
schedules III-V from providers offices,
hospitals, or nursing homes may be faxed.
- NON-CONTROLLED PRESCRIPTIONS:
Are honored up to 1 year from the date the
prescription was written. Antibiotic
prescriptions over 10 days old will be filled at
the discretion of the pharmacy.
Prescriptions for maintenance medications
may be written for up to a 90 day supply with
a maximum of 3 refills when requested by
prescriber. All other non-controlled
prescriptions may be written for up to 30
days supply with a maximum of 11 refills.
- CONTROLLED PRESCRIPTIONS(**):
Prescriptions for Schedule 3, 4 or 5
medications will be honored for 6 months
from the date they were written with up to 5

2. HOLLOMAN AFB FORMULARY
Amox / Clav (Augmentin) Griseofulvin (Grifulvin-V)
I. Anti-Infective Agents Tabs 250mg, 500mg, Oral Susp 125mg / 5
875mg mL (microsized)
Cephalosporins Amox / Clav (Augmentin) Griseofulvin Ultra (Gris-
Susp 125mg/5ml, Peg) Tabs 125mg
Cefdinir (Omnicef) Caps 400mg/5ml, Ketoconazole (Nizoral)
300 mg 600mg/5ml Tabs 200mg
Cefdinir (Omnicef) Susp Dicloxacillin (Dynapen) Ketoconazole (Nizoral) 2%
125mg/5ml, 250mg/5ml Caps 250mg Shampoo
Cefpodoxime (Vantin) Penicillin V Pot (Pen VK) Nystatin (Mycostatin) Tabs
Tabs 100mg, 200 mg Tabs 250mg, 500mg 500,000 units
Cefpodoxime (Vantin) Penicillin V Pot (Pen VK) Terbinafine (Lamisil) Tabs
Susp 100mg / 5mL Oral Susp 250mg /5mL 250mg
Cephalexin (Keflex) Caps
250mg, 500mg Sulfonamides Antiviral
Cephalexin (Keflex) Susp
250mg / 5mL Sulfamethoxazole 800mg / Amantadine (Symmetrel)
Trimethoprim 160mg Caps 100mg
Fluoroquinolones (Bactrim DS) Tabs Acyclovir (Zovirax) Caps
Sulfamethoxazole 200mg/ 200mg, Tabs 800mg,
Ciprofloxacin (Cipro) Tabs Trimethoprim 40mg Sus 200mg/5ml
100mg, 250mg, 500 (Bactrim Pediatric) Hydroxychloroquine
mg, Susp 250mg/5ml Susp (Plaquenil) Tabs
Levofloxacin (Levaquin) 200mg
Tabs 250mg, 500mg, Tetracyclines Metronidazole (Flagyl)
750mg, Sol 25mg/ml Tabs 250mg
Doxycycline (Vibramycin) Oseltamivir (Tamiflu) Tabs
Macrolides Tabs 100mg 75mg, Sol 6mg/ml
Tetracycline (Achromycin) Valcyclovir (Valtrex) Tabs
Azithromycin (Zithromax) Caps 250mg 500mg
Susp 200mg / 5mL Minocycline (Minocin)
Azithromycin (Zithromax) Caps 100mg Antitubercular Agents
Susp 100 mg / 5 mL
Azithromycin (Zithromax) Ethambutol (Myambutol)
Other
Z-pak Tabs 250mg, Tabs 100mg, 400mg
Tri-Pak 500mg, 1gm Isoniazid (INH) Tabs
packets Clindamycin (Cleocin) 100mg, 300mg
Clarithromycin (Biaxin) Caps 150mg, 300 mg Isoniazid (INH) Syrup
Tabs 250mg, 500mg Clindamycin (Cleocin) 50mg / 5mL
Erythromycin (Ery-Tab) Liquid 75mg/5ml Pyrazinamide Tabs 500
Tabs 250mg, 333mg, Nitrofurantoin mg
400mg (Macrodantin) Caps Rifampin (Rifadin) Caps
Erythromycin (EryPed) 50mg, 100mg 300mg
Susp 200mg/5mL, Nitrofurantoin (Macrobid)
400mg / 5mL Caps 100mg Antihelmintic Agent
Penicillins Antifungals Mebendazole (Vermox)
Chew Tab 100mg
Amoxicillin (Trimox) Susp Fluconazole (Diflucan)
250mg/5ml; Tabs 150mg, Susp
400mg/5mL 10mg/ml II. Cardiovascular
Amoxicillin (Trimox) Caps Agents
250, 500mg
2

3. Antianginals/Vasodilator MISC 80mg/12.5mg,
160mg/12.5mg,
Ezetimibe (Zetia) 160mg/25mg,
Nitroglycerin sl Tabs
Tabs10mg 320mg/12.5mg,
0.3mg, 0.4mg, Pump
Niacin (Niaspan Extended- 320mg/25mg
Spray, Oint 2%,
Release) Tabs 500mg,
Patches 0.1mg/hr,
750mg, and 1,000mg BETA BLOCKERS
0.2mg/hr, 0.3mg/hr,
Nicotinic Acid (Niacin) Tab
0.4mg/hr, 0.6mg/hr,
500mg Atenolol (Tenormin) Tabs
0.8mg/hr
25mg, 50mg, 100mg
Isosorbide Dinitrate Tabs
Antihypertensives Carvedilol (Coreg) Tabs
5mg, 10mg, 40mg SR
3.125mg, 6.25mg,
caps
ACE 12.5mg, and 25mg
Isosorbide Mononitrate
INHIBITORS/COMBIN Labetalol (Trandate) Tabs
(Imdur) Tabs 30mg,
ATION PRODUCTS 200mg
60mg, and 120mg
Metoprolol (Lopressor)
Amlodipine/Benazepril Tabs 25 mg, 50mg,
(Lotrel) Caps 2.5/10, and 100mg
Antihyperlipemics
5/10, 5/20, 10/20,
Metoprolol XL (Toprol XL)
5/40, 10/40 mg
Tabs 25mg, 50mg,
Captopril (Capoten) Tabs
BILE ACID 100mg, and 200mg
25mg, 50mg, and
SEQUESTRANT
100mg Propranolol (Inderal) Tabs
Lisinopril (Prinivil, Zestril) 10mg, 40mg
Colestipol (Colestid)
Tabs 2.5mg, 5mg,
granules 300gm/box Propranolol (Inderal LA)
10mg, 20mg, 30mg,
Colestipol (Colestid) Tabs Caps 60mg, 80mg,
and 40mg
1gram and 120mg
Lisinopril-HCTZ
(Zestoretic) Tabs 10-
FIBRIC ACID
12.5mg, 20-25mg, 20-
DERIVATIVES
12.5mg
Ramipril (Altace) Caps CALCIUM CHANNEL
Fenofibrate (TriCor) Tabs BLOCKERS
2.5mg, 5mg, 10mg
48mg, 145mg
Gemfibrozil (Lopid) Tabs Amlodipine (Norvasc)
ANGIOTENSIN II
600mg Tabs 2.5mg, 5mg,
BLOCKERS/COMBIN
ATION DIURETIC 10mg
HMG-CoA REDUCTASE Diltiazem (Tiazac) Tabs
INHIBITOR 60mg
Losartan (Cozaar) Tabs
25mg, 50mg, and Diltiazem (Tiazac SR)
Atorvastatin (Lipitor) Tabs Caps 120mg, 180mg,
100mg
10mg, 20mg, 40mg, 240mg, 300mg,
Losartan/HCTZ (Hyzaar)
80mg 360mg, and 420mg
Tabs 50/12.5mg,
Pravastatin (Pravachol) Felodipine (Plendil) Tabs
100/25mg
Tabs 10mg, 20mg, 2.5mg, 5mg, 10mg
Telmisartan (Micardis)
40mg, and 80mg Nifedipine SR (Adalat CC)
Tabs 20mg, 40mg,
Rosuvastatin(Crestor) Tabs 30g, 60mg, and
and 80mg
Tabs 5mg, 10mg, 20mg, 90mg
Telmisartan/Hctz (Micardis
40mg Verapamil (Calan) Tabs
HCT) 80mg/12.5mg,
Simvastatin (Zocor) Tabs 80mg
80mg/25mg,
5mg, 10mg, 20mg, 40mg, Verapamil (Calan SR)
40mg/12.5MG
and 80mg Tabs 120mg,180mg,
Valsartan (Diovan) Tabs
Ezetimibe/Simvastatin 240mg
40mg, 80mg, 160mg,
(Vytorin) Tabs 10/10,
320mg
10/20, 10/40, 10/80 mg
Valsartan/HCTZ (Diovan
HCT) Tabs
3

4. HOLLOMAN AFB FORMULARY
ALPHA-ADRENERGIC Primidone (Mysoline) Tabs
BLOCKERS LOOP 50mg, 250mg
Doxazosin (Cardura) Furosemide (Lasix) Tabs BENZODIAZEPINE
Tabs 2mg, 4mg, and 20mg, 40mg, sol
8mg 10mg/ml **Clonazepam (Klonopin)
Prazosin (Minipress) Tabs 0.5mg
Caps 1mg, 2mg, 5mg THIAZIDE/COMBINATION **Diazepam (Valium) Tabs
Terazosin (Hytrin) Caps POTASSIUM_ 5mg
1mg, 2mg, 5mg, 10mg SPARING
MISC
MISC. Chlorthalidone (Hygroton)
ANTIHYPERTENSIVES Tabs 25mg, 50mg Carbamazepine (Tegretol)
Hydrochlorothiazide Chewtabs 100mg;
Clonidine (Catapress TT (HCTZ) Caps 12.5mg Tabs 200mg, Sus
Patches) 0.1 mg, 0.2 Hydrochlorothiazide 100mg/5ml
mg, 0.3 mg (HCTZ) Tabs 25mg, Carbamazepine Extended
Clonidine (Catapres) 50mg Release (Tegretol XR)
Tabs 0.1mg Hydrochlorothiazide 25mg Tabs 400mg
Hydralazine (Apresoline) / Triamterene 37.5mg Divalproex Sodium
Tabs 10mg, 25mg (Maxzide-25) Tabs (Depakote) Tabs
Methyldopa (Aldomet) Indapamide (Lozol) Tabs 125mg, 250mg, Caps
Tabs 250mg 2.5mg Sprk 125mg
Metazolone (Zaroxolyn) Divalproex Sodium
Antiplatelets / Tabs 5mg (Depakote ER) Tabs
Anticoagulants 250mg, 500mg
POTASSIUM-SPARING Gabapentin (Neurontin)
Aspirin / Dipyridamole Caps100mg 300mg,
Spironolactone 400mg, 600mg,
(Aggrenox) caps (Aldactone) Tabs
5/200mg 800mg
25mg Phenytoin (Dilantin) Caps
Aspirin 81 mg Chewable
Tabs, 325mg Tabs 100mg
Aspirin (Ecotrin) EC Tabs Phenytoin (Dilantin
Antiarrhythmics Infatabs) Chewtabs
325mg
Dipyridamole 50mg
(Persantine) Tabs Amiodarone (Pacerone) Phenytoin (Dilantin) Oral
25mg Tabs 200mg susp 125mg / 5mL
Clopidogrel (Plavix) Tabs Digoxin (Lanoxin) Tabs Topiramate (Topamax)
75mg 0.125mg, 0.25mg, Caps 15mg, Tabs
Prasugrel (Effient) Tabs Sol 0.05/ml 25mg, 50mg. 100mg,
5mg,10mg Mexiletine (Mexitil) Caps 200mg
Warfarin (Coumadin) 250mg
Tabs 1mg, 2mg, Antidepressants
2.5mg, 3mg, 4mg,
5mg, 6mg, 7.5mg, and ALPHA-2 ANTAGONISTS
10mg III. Central Nervous Mirtazapine (Remeron)
System Agents Tabs 15mg
Diuretics
Anticonvulsants
CARBONIC
ANHYDRASE
INHIBITOR BARBITURATE
Acetazolamide (Diamox) **Phenobarbital (Luminal)
Tabs 250mg, Tabs 30mg; Syrup
500mgCaps 20mg/5ml
4

5. DOPAMINE-REUPTAKE Mood Stabilizer / BENZODIAZEPINE
INHIBITOR Antipyscotics
Alprazolam (Xanax) Tabs
Bupropion (Wellbutrin) 0.5mg
Aripiprazole (Abilify) Tabs
Tabs SR 100mg, Clonazepam (Klonopin)
2mg,5mg,10mg,15mg,
150mg Tabs 0.5mg
20mg
Diazepam (Valium) Tabs
Lithium Carbonate Caps
SELECTIVE SEROTONIN 5mg
150mg, Tabs 300 mg,
REUPTAKE Lorazepam (Ativan) Tabs
syp 8meq/5ml
INHIBITOR (SSRI) 1mg
Olanzapine (Zyprexa)
Temazepam (Restoril)
Tabs 2.5mg, 5 mg,
Citalopram (Celexa) Tabs Caps 15mg, 30mg
and 10mg
20mg, 40mg
Quetiapine (Seroquel)
Fluoxetine (Prozac) Caps
Tabs 25mg, 100mg,
10mg, 20mg, Sol
200mg, and 300mg
20mg/5ml MISC
Quetiapine Extended
Paroxetine (Paxil) Tabs
Release (Seroquel
20mg, 40mg Buspirone (Buspar) Tabs
XR) Tabs 150mg,
Sertraline (Zoloft) Tabs 5mg, 10mg
200mg, and 50mg
50mg, 100 mg, sol Zolpidem (Ambien) Tabs
Risperidone (Risperdal)
20mg/ml 5mg, 10mg
Tabs 0.25mg, 0.5mg,
1mg, 2mg, 3mg, Sol
SEROTONIN/NOREPINE Central Nervous System
1mg/ml
PHRINE INHIBITOR Stimulants/ADHD
Thioridazine (Mellaril)
(SNRI) Medications
Tabs 25mg, 100mg
Venlafaxine (Effexor) Tabs Atomoxetine (Strattera)
Anti- Parkinson’s Agents
75mg, 100mg; 10mg, 18mg, 25mg,
XR Caps 37.5mg, 75mg, 40mg, 60mg Caps
150mg ANTICHOLINERGIC **Dextroamphetamine
(Dexedrine) Tabs
SEROTONIN REUPTAKE Benztropine (Cogentin) 5mg; 10mg, 15mg SR
INHIBITOR/ANTAGO Tabs 0.5mg, 2mg Caps
NIST (SNIA) **Methylphenidate (Ritalin)
DOPAMINE AGONIST Tabs 5mg, 10mg
Trazodone (Desyrel) Tabs **Methylphenidate LA
50mg, 100mg Pramipexole (Mirapex) (Ritalin LA) Caps
Tabs .025mg, 0.75mg 10mg, 20mg, 30mg,
TRICYCLIC-(Limit of 30 Ropinirole (Requip) Tabs 40mg
day supply) 0.25mg,0.5mg,1mg, **Methylphenidate SR
5mg (Ritalin SR) Tabs SR
Amitriptyline (Elavil) Tabs Amantadine (Symmetrel) 20mg
10mg, 25mg, 100mg Caps 100mg **Methylphenidate
Doxepin (Sinequan) Caps Carbidopa / Levodopa (Concerta) Tabs Ext.
25mg, 100mg, 150mg, (Sinemet) Tabs 25/250 Release 18 mg, 27mg,
sol 10mg/ml mg, 25/100mg, 36mg, and 54mg
Imipramine (Tofranil) Tabs 10/100mg **D, L-amphetamine
10mg, 25mg Trihexyphenidyl (Artane) (Adderall) Tabs 5mg,
Nortriptyline (Pamelor) Tabs 2mg, 5mg; Elixir 10mg, 20mg
Caps 10mg, 25mg, sol 2mg/5ml **D, L-amphetamine
10mg/5ml (Adderall-XR) Caps
Anxiolytics / Sedatives / 5mg, 10mg, 15mg,
Hypnotics 20mg, 25mg, 30mg
5

6. HOLLOMAN AFB FORMULARY
Antibiotics – Topicals Fluocinonide (Lidex)
Cream, Ointment
0.05%
Bacitracin oint
Migraine Agents Fluocinolone (Derma-
Clindamycin (Cleocin) 1%
Smooth/FS) Oil 0.01%
Soln
SEROTONIN 5-HT1D Flurandrenolide (Cordran)
Erythromycin 2% Soln, Gel
AGONIST- (Limit Tape
Metronidazole (Metrogel)
Quantities) Hydrocortisone Cream
1% Gel
1%, 2.5%
Mupiricin (Bactroban) 2%
Sumatriptan (Imitrex) Hydrocortisone Valerate
Oint
Injection 6mg (Westcort) Cream0.2%
Silver sulfadiazine
Sumatriptan (Imitrex) Tabs Triamcinolone (Kenalog)
(Silvadene) Cream 1%
25mg, 50mg, and 0.1%; Cream, Spray
100mg
Antifungals – Topicals
Sumatriptan (Imitrex)
Nasal spray 5mg, ANESTHETIC/CORTICOS
20mg Clotrimazole (Lotrimin) TEROID
Zolmitriptan (Zomig) Tabs Topical sol 1%, Cream COMBINATION
2.5mg, 5mg 1%
Ketoconazole (Nizoral) 2% Pramozine/Hydrocortisone
MISC Cream, 2%Shampoo (Proctofoam HC)
Miconazole (Monistat Foam 1%/1%
**Acetaminophen 325 mg / Derm) Cream 2%
Butalbital 50 mg / Nystatin/Triamcinolone Local Anesthetics-
Caffeine 40mg (Mycolog) Cream topical
(Fiorcet) Tabs 100,000 units/0.1%
**Aspirin 325mg / Nystatin (Mycostatin)
Cepacol lozenges Reg
Butalbital 50mg / 100,000 units/gm
Lidocaine (Xylocaine) Oint
Caffeine 40mg Cream, Oint. Powder
5%; Jelly 2%; Visc
(Fiorinal) Tabs Terbinafine (Lamisil)
soln 2%
Divalproex Sodium Cream 1%
Lidoderm 5% Patches
(Depakote ER) Tabs
250mg, 500mg Antiparasitic – Topical
Misc-Topical
Permethrin (NIX) 1%
IV. Dermatologic Agents Aluminum chloride
Cream Rinse
(Drysol) Soln 20%
Permethrin (Elimite)
Acne Products Amlexanox (Aphthasol)
Cream 5%
Oral Paste 5%
Adapalene (Differin) Ammonium lactate (Lac-
Antiseborrheic Agent-
Cream & Gel 0.1% Hydrin) Lotion12%
Topical
Benzoyl Peroxide Gel Fluorouracil (Efudex)
2.5% Cream 5%
Clindamycin/Benzoyl Selenium sulfide (Selsun) Pimecrolimus (Elidel)
Peroxide (Benzaclin) Shampoo 2.5% Cream 1%
Gel Podofilox (Condylox) Soln
Tretinoin (Retin A) Cream Corticosteroids-Topical 0.5%
0.025%, 0.05%, 0.1%; Salicylic acid (Duofilm)
Gel 0.01%, 0.025% soln 17%
Betamethasone Valerate
(Age limit of 35 or Zinc Oxide Oint. 20%
(Valisone) Cream
younger) Diclofenac 1% Gel
0.1%
Isotretinoin (Accutane) (Voltaren Gel)
Clobetasol Propionate
Caps 10mg, 20mg, Clotrimazole-
(Temovate) Cream,
40mg Betamthasone Cream
Oint, Soln 0.05%
(Lotrisone)
6

7. Docusate sodium (Colace) Ondansetron (Zofran
Caps 100mg; ODT) 4mg, 8mg
150mg/15ml Syrup Ondansetron (Zofran) 2
Fleets Enema mg / mL liquid
Fleets Oral Saline Laxative
(PhosphaSoda)
GoLytely/CoLytely VI. Genitourinary Agents
Lactulose (Cephulac)
V. Gastrointestinal Syrup 10mg / 15ml Urinary Tract Agents
Agents MoviPrep
OVERACTIVE BLADDER
H2-ANTAGONIST ANTIDIARRHEALS AGENTS
Cimetidine (Tagamet) Bismuth subsalicylate Oxybutynin (Ditropan)
Tabs 400mg; (Pepto-Bismol) Tabs 5mg; 5mg/5ml
300mg/5ml Syrup Chewtabs 262mg Syrup
Ranitidine (Zantac) Tabs **Diphenoxylate/Atropine Oxybutynin ER (Ditropan
150mg; Syrup (Lomotil) Tabs XL) Tabs 5mg,
15mg/mL 2.5mg/0.025mg 10mg,15mg
Loperamide (Imodium) Solifenacin (Vesicare)
Caps 2mg Caps 5mg,10mg
PROTON PUMP
INHIBITORS MISC
Tolterodine (Detrol LA)
Esomeprazole (Nexium) Pancreatic Enzymes Caps 2mg, 4mg
Caps 20mg, 40mg (Pancreaze)
Omeprazole (Prilosec) Simethicone (Mylicon) URINARY ANALGESIC
Caps 10mg, 20mg Tabs 80mg
Sucralfate (Carafate) Tabs Phenazopyridine
ANTISPASMODIC 1gm (Pyridium) Tabs
AGENTS Sulfasalazine (Azulfidine) 100mg
Hyoscyamine / Atropine / Tabs 500mg; Entabs
Phenobarbital/ 500mg BPH AGENTS
Scopalamine Mesalamine (Asacol) Tabs
(Donnatal) Tabs 400 mg Alfuzosin (Uroxatral) Tabs
0.1037 mg/0.0194 10mg
mg/16.2mg/0.0065mg, Doxazosin (Cardura) Tabs
Elixir 16.2mg/5ml Antiemetics 2mg, 4mg, and 8mg
Belladonna 0.2 Terazosin (Hytrin) Caps
mg/Phenobarbital 40 Meclizine (Antivert) Tabs 1mg, 2mg, 5mg,
mg/Ergotamine 0.6mg 25mg 10mg
(Bellergal-S) Tabs Metoclopramide (Reglan) Finasteride (Proscar) Tabs
Dicyclomine (Bentyl) Tabs Tabs 10mg; 5mg
20mg, Caps 10mg sol Syrup 5mg/5ml Tamsulosin (Flomax) Cap
10mg/5ml Prochlorperazine 0.4mg
Chlordiazepoxide (Compazine) Tabs
/Clindinium (Librax) 5mg
Caps Prochlorperazine VII. Metabolic /
(Compazine) Supps Endocrine Agents
25mg
LAXATIVE Promethazine Androgens
(Phenergan) Tabs
Bisacodyl (Dulcolax) Tabs 25mg, Syp
5mg; Supps 10mg 6.25mg/5ml: **Testosterone Cypionate
Suppositories 12.5mg, Inj 200mg /mL
25mg **Fortesta 2% Gel
7

8. HOLLOMAN AFB FORMULARY
SULFONYLUREA
Corticosteroids AGENTS Gout Agents
Budesonide EC (Entocort) Glipizide (Glucotrol) Tabs Allopurinol (Zyloprim) Tabs
Cap 3mg 5mg 100mg, 300mg
Dexamethasone Glyburide (Diabeta, Probenecid (Benemid)
(Decadron) Tabs 1mg, Micronase) Tabs 5mg Tabs 500mg
4mg Glyburide micronized
Fludrocortisone (Florinef) (Glynase) Tabs 1.5mg,
Tabs 0.1mg 3mg, and 6mg Hormone Replacement
Hydrocortisone (Cortef) Glyburide Tabs 1.25mg, Therapy
Tabs 20mg 2.5mg
Methylprednisolone Estradiol (Estrace) Tabs
(Medrol-Dose Pak) BIGUANIDE 0.5mg, 1mg, 2mg
Tabs 4mg 21’S Estradiol Trans (Climara)
Prednisolone Oral Metformin (Glucophage) 0.05mg/day,
(Prelone) liquid 15mg / Tabs 500mg, 850mg. 0.1mg)/day
5mL 1000mg Estrogen Conj (Premarin)
Prednisone (Deltasone) Metformin XR Tabs 0.3mg, 0.45mg,
Tabs 1mg, 5mg, (Glucophage XR) 0.625mg, 0.9mg,
20mg, sol 5mg/5ml Tabs 500mg, 750mg 1.25mg
Prednisolone Sodium Estrogen Conjugated
Phosphate (Orapred) (Premarin) vaginal
15mg/5ml cream 0.625mg/g
THIAZOLIDINEDIONE/ Estrogen
COMBINATION Conj/Medroxyprogeste
rone (PremPro) Tabs
Diabetic Agents Pioglitazone (Actos) Tabs 0.3mg/ 1.5mg
15mg, 30mg, 45mg Estrogen
INSULIN Conj/Medroxyprogeste
MISC rone (PremPro) Tabs
Insulin NPH (Novolin N) 0.45mg/1.5mg
100units/ml 10ml Estrogen
Nateglinide (Starlix) Tabs
Insulin NPH / Regular Conj/Medroxyprogeste
60mg, 120mg
70/30 (Novolin 70/30) rone (PremPro) Tabs
100units/ml 10ml Sitagliptin (Januvia) Tabs 0.625mg /2.5mg
Insulin Regular (Novolin R) 50 mg, 100 mg Estrogen
100units/ml 10ml Conj/Medroxyprogeste
Sitagliptin / Metformin
Insulin Glargine (Lantus) rone (PremPro) Tabs
(Janumet) Tabs
100units/ml 10ml 0.625mg/5mg
50/500, 50/1000
Insulin Aspart (Novolog) Estropipate (Ogen) Tabs
100units/ml 10ml Sitagliptin/Metformin XR 0.625mg, 1.25mg
Insulin Glargine Pen Medroxyprogesterone
(Lantus Solostar) 15ml (Janumet XR) Tabs 50-
500, 50-1000, 100-1000 (Provera) Tabs 2.5mg,
per box 10mg
Insulin Aspart Pen Raloxifene (Evista) Tabs
(Novolog Flex Pen) Diabetic Supplies 60mg
15ml per box
Inusulin Aspart 70/30 Pen Glucose Test Strips Contraceptives
(Novolog 70/30 Flex (Precision XTRA)
Pen) Lancets Alesse
Insulin Lispro (Humalog) Syringes, insulin 0.5mL Depo-Provera 150mg/ml
10ml vial (Lo-Dose) 100s; 1mL Demulen 1/35-28
Insulin Lispro(Humalog 100s Jolessa (generic
Kwikpen) BD Pen Needles Original Seasonale)
and Short
8

9. Levlin Celecoxib (Celebrex) **Morphine sulfate SR (MS
Loestrin Fe 1/20, 1.5/30 100mg & 200mg Contin) Tabs 15mg,
Lo-Ovral Ibuprofen (Motrin) Tabs 30mg
Nor QD 400mg, 600mg, **Morphine sulfate IR
Ortho Cyclen(Mononessa) 800mg (MSIR) 15mg, 30mg
Ortho-Evra Transdermal Ibuprofen (Motrin) Susp **Oxycodone SR
patches 100mg / 5mL (Oxycontin) 5mg,
Ortho Tri-cyclen, Ortho Tri- Indomethacin (Indocin) 10mg,15mg, 20mg,
cyclen LO Caps 25mg 30mg
Ortho Novum 1/35, 1/50 Ketorolac (Toradool) Tabs
Ortho Novum 7-7-7 10mg (max 20/month) Antirheumatic Agents
Ovral Meloxicam (Mobic) Tabs
Triphasil / Trilevlen 7.5mg, 15mg Azathioprine (Imuran)
Desogen/Apri/Ortho-Cept Naproxen (Naprosyn) Tabs 50mg
Nuvaring Tabs 250mg, 275mg, Hydroxychloroquine
Yasmin 500mg, 550mg, (Plaquenil) Tabs
Yaz 125/5mlsusp 200mg
Plan B/ Next Choice Oxaprozin (Daypro) Tabs Methotrexate (Rhematrex)
600mg Tabs 2.5mg
Thyroid Agents Piroxicam (Feldene) Caps Sulfasalazine (Azulfidine)
20mg Tabs 500mg; ENtabs
Levothyroxine (Synthroid) Salsalate (Disalcid) Tabs 500mg
Tabs 0.025, 0.05, 500mg, 750mg
0.075, 0.088, 0.1, Sulindac (Clinoril) Tabs
0.112, 0.125, 0.15, 200mg
0.175mg Osteoporosis
Methimazole (Tapazole) Analgesics Opioids Agents/Bisphosphon
Tabs 10 mg ate
Propylthiouracil (PTU) **Acetaminophen 300mg /
Tabs 50 mg Codeine 30mg Alendronate (Fosamax)
(Tylenol #3) Tabs Tabs 5mg, 10mg,
**Acetaminophen 120mg / 35mg, 70mg
Codeine 10mg / 5mL Alendronate PlusD
LHRH Agonists Elixir 70mg/2800IU
**Acetaminophen Ibandronate (Boniva) Tabs
Goserelin (Zoladex) Hydrocodone 2.5mg, 150mg
3.6mg, 10.8mg (Lortab/Vicodin) Tabs: Raloxifene (Evista) Tabs
implants 325mg/5mg; 60mg
325mg/7.5mg; Risedronate (Actonel)
325mg/10mg; Tabs 35mg
VIII. Musculoskeletal 500mg/5mg
Agents **Acetaminophen Skeletal Muscle
Oxycodone Relaxant
Analgesics (Percocet) Tabs
325mg/5mg Baclofen (Lioresal) Tabs
Acetaminophen (Tylenol) 325mg/7.5mg 10mg
Tabs 325mg 325mg/10mg Cyclobenzaprine (Flexeril)
Acetaminophen (Tylenol) **Acetaminophen 500mg / Tabs 5mg, 10mg
Elixir 160mg/5mL Oxycodone 5mg Metaxalone (Skelaxin)
**Tramadol (Ultram) Tabs (Tylox) Caps Tabs 800mg (limit of
50mg **Codeine Tabs 30mg 30 day supply)
**Meperidine (Demerol) Methocarbamol (Robaxin)
Tabs 50mg, Inj. 50mg, Tabs 500mg
NSAIDS 100mg Orphenadrine (Norflex)
**Methadone Tabs 10mg- Tabs 100mg
(For pain only)
9

10. HOLLOMAN AFB FORMULARY
Tizanidine (Zanaflex) Tabs Prednisolone (Pred Mild)
4mg Soln 0.125% Acetic Acid (Domeboro)
Soln 2%
Glaucoma Antipyrine/Benzocaine
(Auralgan) Soln
Misc BETA_BLOCKERS Bacitracin / Neomycin/
Polymyxin
Pyridostigmine (Mestinon) Betaxolol S (Betoptic S) B/Hydrocortisone
Tabs 60mg Susp 0.25% (Cortisporin) Susp
Carteolol (Ocupress) Soln Carbamide(Debrox) Soln
1% 6.5%
IX. Ophthalmic Agents Timolol (Timoptic) Soln Ciprofloxacin /
0.25%, 0.5% Dexamethazone
Anti-Infectives Timolol (Timocptic-XE) Gel (Ciprodex)
0.25% 0.5%
Bacitracin oint
Ciprofloxacin (Ciloxin) ALPHA2-ADRENERGIC XI. Respiratory Agents
0.3% Soln; Oint 0.3% AGONIST
Erythromycin Oint 5mg/gm Antihistamines /
Gentamicin (Garamycin) Brimonidine (Alphagan-P) Decongestants /
Soln 0.3%; Oint 0.3% Drops 0.15% Cough / Cold /
Moxifloxacin (Vigamox) Brimonidine (Alphagan) Allergy
0.5% Soln Drops 0.2%
Neomycin / Polymyxin B / Dipivefrin (Propine) Soln ANTIHISTAMINES/ANTIHI
Gramicidin 0.1% STAMINE &
(Neosporin) Soln DECONGESTANT
Neomycin / Polymyxin B / PROSTAGLANDIN COMBO
Bacitracin (Neosporin)
Oint Latanoprost (Xalatan) Soln Brompheniramine/Pseudo
Polymyxin B / 0.05% ephedrine (Dimetapp)
Trimethoprim & (Dimetapp DM) Elixir
(Polytrim) Soln CHOLINERGIC AGENT Cetirizine (Zyrtec) Tabs 10
Sulfacetamide (Bleph-10) mg; Syrup 5mg/5mL
10% Soln, Oint Pilocarpine (Isoptocarpine) Chlorpheniramine (CTM)
Tobramycin/Dexamethaso Soln 0.5%, 1%, 2%, Tabs 4mg
ne (TobraDex) Susp, 4% Cyproheptadine (Periactin)
Oint Pilocarpine (Pilopine HS) Tabs 4mg
Tobramycin (Tobrex) Gel 4% Diphenhydramine
0.03% soln (Benadryl) Caps
NSAID 25mg, Tabs 25mg
Diphenhydramine
Anti-Inflammatory / Ketorolac (Acular LS) (Benadryl) Elixir
Allergy 0.4% Soln 12.5mg / 5mL
Fexofenadine (Allegra)
Misc Tabs 60mg, 180mg
Fluorometholone(FML)
Susp 0.1% Hydroxyzine HCl (Atarax)
Flurbiprofen (Ocufen) Soln Artificial Tears Tabs 10mg, 25mg,
Lodoxamide (Alomide) Celluvisc Drops Syrup 10mg/5ml
Soln 0.1% GenTeal 0.3% Soln Loratadine (Claritin) Tabs
Loteprednol (Lotemax) Sodium Chloride 5% 10mg, Syrup 5mg/5ml
Susp 0.5% (Muro) Ointment Meclizine (Antivert) Tabs
Olopatadine(Patanol) Soln Cyclosporine0.5% 25mg
0.1% (Restasis) Soln **Pseudoephedrine /
Prednisolone (Pred-Forte) Triprolidine tabs
Soln 1% (Actifed) Tabs
X. Otic Agents
10

11. ANTITUSSIVE Theophylline (Elixophyllin
CORTICOSTEROID, 80mg/15mL
Benzonatate (Tessalon) INHALED/COMBINATION
Perles 100mg PRODUCTS
Budesonide (Pulmicort
Respules) inhalation
Susp 0.25mg/2ml, Nasal Preparations
EXPECTORANT/COMBIN 0.5mg/2ml
ATION Flunisolide (Aerobid) ANTICHOLINERGIC
Inhaler 250mcg / puff AGENT
**Guaifenesin / Codeine Fluticasone (Flovent HFA)
30mg (Robitussin AC) Inhaler 44, 110, 220 Ipratropium (Atrovent)
Syrup mcg / puff Spray 0.3%, 0.6%
Guaifenesin / Fluticasone/Salmeterol
Dextromethorphan (Advair Diskus) ANTIHISTAMINE
(Robitussin DM) Syrup 100/50, 250/50,
500/50mcg Azelastine (Astelin Nasal)
Mometasone Furoate Spray 137mcg/spray
DECONGESTANT (Asmanex Twisthaler)
110mcg, 220mcg CORTICOSTEROID,
**Pseudoephedrine Budesonide/Formoterol INTRANASAL
(Sudafed) Tabs 30mg; (Symbicort) Inhaler
Syrup 30mg / 5mL 80/4.5, 160/4.5 Flunisolide (Nasarel)
Spray 25mcg
Asthma Medications MAST CELL STABILIZER Fluticasone (Flonase)
Spray
ANTICHOLINERGIC Cromolyn Sodium (Intal) Mometasone (Nasonex)
AGENTS Inhalant Soln 10 mg/ Spray
mL
Ipratropium Bromide SEROTONIN 5-HT1D
(Atrovent HFA) Inhaler LEUKOTRIENE AGONIST
17 mcg / puff RECEPTOR Sumatriptan (Imitrex)
Ipratropium Bromide ANTAGONIST Spray 5mg, 20mg
(Atrovent) Neb Soln
for inhalation 0.03% Montelukast (Singulair) VASOCONSTRICTOR
Tiotropium Bromide Tabs 4mg, 5mg,
(Spiriva) HandiHaler 10mg; Granules 4mg Oxymetazoline (Afrin)
Spray 0.05%
BETA2- MISC
AGONISTS/COMBINA MISC
TION PRODUCTS Inspirase (drug delivery
system for MDI’s) Desmopressin (DDAVP)
Albuterol HFA (Ventolin) Aerochamber (drug Spray 0.1%
Inhaler delivery system for Sodium chloride (Ocean)
Albuterol (Proventil) Soln MDI’s) Drops / Spray 0.65%
0.5% Sodium Chloride 5ml Neb
Albuterol (Proventil) Soln Soln
0.083% Theophylline (Theodur) XII. Vaginal Preparations
Albuterol (Proventil) Syrup Tabs 200mg, 300mg
2mg /5ml Theophylline Anhydrous Clotrimazole (Gyne-
Ipratropium / Albuterol (Theo-24) Caps Lotrimin) Cream 1%
(Combivent) Inhaler 300mg, Clindamycin (Cleocin)
Salmeterol Theophylline Anhydrous Cream 2%
Xinafoate(Serevent (Theophylline ER)
Diskus) Tabs 400mg
11

12. HOLLOMAN AFB FORMULARY
Estrogen Conjugated Pyridoxine (Vitamin B6)
(Premarin) Cream Tabs 50mg Hemorrhoidal HC Supps
0.625 mg / gm Thiamine (Vitamin B1) (Anusol HC)
Metronidazole (Metrogel) Tabs 50mg Hemorrhoidal Supps
Gel 0.75% (Anusol)
Terconazole (Terazol 3) Hydrocortisone Cream
Supps 2.5%
I. Misc Agents Pramozine/Hydrocortisone
(Proctofoam HC)
Antineoplastic Agents Foam 1%/1%
XIII. Vitamin / Mineral /
Electrolyte Agents Azathioprine (Imuran)
Tabs 50mg
Calcium 500mg with Vit D Fluorouracil (Efudex) Smoking Deterrents
(OsCal) Tabs Cream 5%
Cyanocobalamin (Vit B 12) Methotrexate Bupropion SR 150 mg
1,000mcg Tabs and (Rheumatrex) Tabs Nicotine Patch (Nicoderm)
1mg/ml injection 2.5mg 7mg / day, 14mg/day,
Ergocalciferol (Vitamin D2) Tamoxifen (Nolvadex) 21mg / day
caps 50,000IU Tabs 10mg Nicotine Gum 2mg, 4mg
Ferrous Sulfate Tabs
325mg Dental Preparations Other
Ferrous Sulfate Oral sol
15mg /0.6mL Chlorhexidine (Peridex /
Folic Acid Tabs 1mg Clomiphene (Clomid) Tabs
Periogard) Oral soln 50mg
Folic Acid, 0.12%
Cyanocobalamin, Donepezil (Aricept) Tabs 5
Sodium Fluoride (Luride) mg, 10mg
Pyridoxine (Foltx) Tabs 1.1mg (0.5mg Fl)
2.5mg/1mg/25mg Disulfiram (Antabuse)
Sodium Fluoride Oral soln Tabs 250mg
Magnesium Gluconate 0.5mg /mL
Tabs 500mg Epinephrine (Epipen Jr,
Sodium Fluoride Epipen) Autoinjector
Poly-Vi Sol Fe (multi- (PreviDent) 1.1% gel
vitamin for breastfed 0.15mg, 0.3mg
Sodium Flouride Methylergonovine
babies) (PreviDent Plus) 1.1%
Potassium Chloride Tabs (Methergine) Tabs 0.2mg
paste Memantine (Namenda)
10mEq, 20mEq; Stannous Fluoride
20mEq packets, Liq 10mg
(GelKam) 0.4% gel Sodium citrate with citric
10% Triamcinolone (Kenalog)
Prenatal Vitamins / acid 480ml (Bicitra)
Dental Paste 0.1% **Sildenafil HCL (Viagra)
Minerals Tabs (Age ClinPro 1.1% Paste
limit of 45 or younger.) Tabs 25mg, 50mg, 100mg
Vitamin D Caps 50,000 IU
Hemorrhoid Agents
12