FOX ARMY HEALTH CENTER

PHARMACY FORMULARY REFERENCE

HOURS OF OPERATION:

Monday thru Friday 7:30am – 4:00pm

Peak times are between 11:30 – 13:30 and all day Fridays

2019 Holiday and Training Closure Schedule on last page

**Please check our monthly training closure schedule as it varies!**

ORDER REFILLS AHEAD OF TIME BY:

Phone: 256-842-7337or 800-223-9531 or

Online: www.tricareonline.com

**Please check formulary status of medications, as they may change.**

This FORMULARY can also be found on line at

www.redstone.amedd.army.mil

Click on .pdf (paper form)

Suzette Baker, RPh, BS, Pharm CHIEF, PHARMACY SERVICE

REDSTONE ARSENAL, AL 35809-7000

JULY 2019

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FOREWARD This guide is published for the use of the customers of Fox Army Health Center. It is intended as an aid to understanding the services available at Fox Army Health Center’s Pharmacy and is not an official publication of this organization of the Department of the Army. While we have attempted to provide information representative of the questions most often asked by our customers, this guide does not portend to be all inclusive or exclusive to services offered. Specific questions should be directed to the pharmacy staff.

GENERAL INFORMATION

AR 40-3 requires that medical care and services be provided only to eligible beneficiaries. The military I.D. card is a tool that helps us meet this requirement. Medication(s) will not be issued for a patient who is over the age of 10 years unless a valid military I.D. card (or a paper photocopy of the front and back of the ID Card) for that patient is presented to pharmacy services. (Electronic devices with picture of ID Cards are not accepted.)

TELEPHONE NUMBERS:

Outpatient pharmacy: (256) 955-8888 ext. # 1701 (allow 24 business hours for return call)

Automated phone-in refill system: (256) 842-7337 or 1-800-223-9531 On-line refill requests: www.tricareonline.com

GENERAL DISPENSING POLICIES Maintenance medications:

Maintenance Medication (NON-controlled) Physicians may write for up to a 90 day supply with 3 refills

All Prior Authorizations must be hand delivered with the prescription-do not send to Tricare Narcotics and Scheduled III-V Controlled Substances: Physicians may write for a maximum

of a 30 day supply with 5 refills (for a total of six months) Schedule II Substances: drugs may be written for a maximum of a one month supply and are

NOT refillable. Schedule II narcotic (controlled substance) prescriptions must be hand-carried with

original signature of prescriber (electronic or verbal submissions are not accepted). Narcotic prescription refills may be filled no sooner than two (2) days prior to actual due

date of refill prescription (28 days from the date it was last picked up).

Exception: Ritalin, Adderall, Concerta (or equivalents) may be given up to a 90-day supply for Attention Deficit Disorder and No Refills. Testosterone and seizure products may be given up to a 90-day supply with one refill.

Electronically transmitted prescriptions from providers are not filled until the patient presents to pharmacy, pulls appropriate category service ticket and requests the prescription. Paper prescriptions are still preferred due to unforeseen transmission errors.

Prescriptions expire after ONE year from the original date it was written for most medications

Controlled substances prescriptions expire SIX months from the original date written.

FAHC follows dispensing policy outlined by the Dept. of the Army; Health Affairs and TRICARE which include quantity limits and formulary/Non-formulary designations.

In the event of a manufacture recall to the patient, for a medication affected and dispensed from FAHC, a staff member will attempt to contact you (please assure your contact information is up-to-date in DEERS). Otherwise continue to take your medication(s).

FORMULARY INDEX Therapeutic Category – page # Therapeutic Category – page#

Alzheimers/Dementia - 4 Analgesics/Anti-Inflammatory/Opioids - 4 Anti-Anxiety - 4 Anti-Coagulants/Blood Thinner (Circulation) - 4 Anti-Convulsants (Epilepsy,Parkinsons) - 5 Anti-Depressants / Bipolar - 5 Anti-Emetics (Nausea/Vomiting) - 5 Anti-Histamine/Decongestant/Cough/Allergy - 5, 6 Anti-Microbials (Antibiotics/Bacteria/ Fungal/ Parasitic/Viral) -6 Anti-Psychotics (Psychiatrics) - 6 Anti-Rheumatics (Arthritis/Rheumatoid Arthritis) -7 Attention Deficit/Narcolepsy - 7 Attention Deficit/Non-Stimulants - 7 Cholesterol/Lipid Lowering - 7 Contraceptives (Birth Control) – 7, 8 Corticosteroids- Oral - 9 Dental Agents - 9 Diabetic Agents & Supplies - 9 Diuretic (Fluid Retention) - 9 Electrolyte Replacement - 9 Emergency Meds (Insect kit/Substance Abuse) 10 Erectile Dysfunction - 10 Fertility Medication - 10 Gastro-Intestinal Agents (Acid Reflux/Heartburn)- 10

G-I Agents Other (GI Prep kits/IBS/Gall Bladder/etc)- 10 Genito-Urinary Agents (Bladder/Prostate) -10 Gout Agents - 11 Hormones (Estrogen/Progestin/Testosterone) - 11 Hypertensive/Cardiac(Blood Pressure/Heart)- 11,12 Immunologic/Biologic(RA/Psoriasis/Crohn’s) - 12 Migraine Agents - 12 Muscle Relaxants - 13 Nasal Sprays/Rinses – 13 Neurological Agent (Nerve Pain/Restless Leg) - 13 Oncology/Cancer - 13 Ophthalmics (Eye Care) - Antibiotics/Antivirals - 13 Ophthalmics (Eye Care)-(Glaucoma/allergy/etc)-14 Osteoporosis/Bone Loss - 14 Otic (Ear Care) Preparations - 14 Prostate Medication - 14 Respiratory- 15 Sedative Hypnotics (Sleep Aids) - 15 Smoking Cessation - 15 Thyroid/Anti-Thyroid Agents - 15 Topical Agents - 15,16 Vaginal Preparations - 16 Vitamins and Minerals – 16

*Dye-free products are not stocked and are not available for order at this pharmacy*

**All Prior Authorization Forms must be hand delivered or faxed with prescription to FAHC pharmacy** For medications not available at this facility please check with your alternate Tricare pharmacy options:

Express Scripts Mail Order Pharmacy: 800-238-6095

Your local Tricare Retail Pharmacy

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Alzheimers / Dementia

Donepezil (Aricept equiv) 5mg; 10mg tabs Memantine (Namenda equiv) immediate release tablets only – 5mg & 10mg (excludes Namenda XR)

Rivastigmine patch (Exelon equiv) 4.6mg/24 hrs; 9.5mg/24 hrs; 13.3mg/24 hrs patch

ANALGESICS / ANTI-INFLAMMATORY / OPIOIDS Acetaminophen (Tylenol equiv) 325mg tabs and 500mg (excludes 650mg tabs) Acetaminophen elixir for Children (Tylenol Elixir equiv) 160mg/5ml Acetaminophen w/ Codeine elixir (Tylenol w/Codeine Elixir equiv) 120mg/12mg per 5mls *controlled substance** Acetaminophen w/ Codeine #3 (Tylenol#3 equiv) 300mg/30mg tabs *controlled substance* Aspirin (enteric coated) 81mg tabs; 325mg enteric-coated tabs (excludes chewable tabs)

Celecoxib (Celebrex equiv) 100mg; 200mg caps Diclofenac (Voltaren, Voltaren DR equiv) 75mg delayed-release tabs, 50mg immediate release tabs Etodolac (Lodine, Lodine XL equiv) 400mg; 500mg; 500mg XL tabs Fentanyl transdermal system (Duragesic equiv) 25; 50; 75; 100 mcg/hour patch *controlled substance* Ibuprofen (Motrin equiv) 400; 600; 800mg tabs Indomethacin (Indocin, Indocin SR equiv) 25mg; 50mg; 75mg SR caps Ketorolac Tromethamine (Toradol equiv) 10mg tabs *maximum qty of #24 tabs*

Lidocaine (Lidoderm) Adhesive Patch 5% (700mg/patch) maximum 3 boxes/30 days Meloxicam (Mobic equiv) 7.5mg; 15mg tabs Meperidine (Demerol equiv) – 50mg tabs only *controlled substance* Morphine immediate release oral (MSIR equiv) 15mg; 30mg tabs *controlled substance* Morphine sustained-release (Ms Contin equiv) 15mg; 30mg; 60mg; 100mg; 200mg tabs *controlled substance* Nabumetone (Relafen equiv) 500mg; 750mg tabs Naproxen immediate-release (Naprosyn; Anaprox DS equiv) 250mg; 375mg; 500mg; 550mg tabs Hydrocodone/Acetaminophen (Norco tabs equiv) 5/325mg; 7.5/325mg; 10/325mg tabs *controlled substance* Hydrocodone /Acetaminophen (Norco liquid equiv) 7.5/325mg per 15ml (tablespoonful) *controlled substance*

Oxycodone immediate-release (Roxicodone, Oxy IR equiv) 5mg; 10mg; 15mg;, 20mg; 30mg tabs *controlled substance* Oxycodone sustained-release (Oxycontin equiv) 10mg; 15mg; 20mg; 30mg; 40mg; 60mg; 80mg tabs *controlled substance* Oxycodone/Acetaminophen (Percocet equiv) 5/325mg; 7.5/325mg; 10/325mg tabs *controlled substance* Piroxicam (Feldene equiv) 10mg; 20mg caps Salsalate (Disalcid equiv) 500mg tabs Tramadol (Ultram equiv) Immediate-Release only 50mg; QTY LIMIT: 30-day limit for *controlled substances*

Ultracet equiv (Tramadol/Acetaminophen) 37.5mg/325mg; QTY LIMIT: 30-day limit/controlled substance; maximum of 240 tabs/30 days

Anti-Anxiety

Buspirone (Buspar equiv) 5mg; 10mg 15mg tabs Clonazepam oral (Klonopin) 0.5mg; 1mg; 2mg tabs *controlled substance* Clorazepate oral (Tranxene) 7.5mg tabs only *controlled substance* Diazepam (Valium) 2mg; 5mg tabs *controlled substance* Hydroxyzine HCL oral (Atarax) 10mg; 25mg tabs Hydroxyzine Pamoate (Vistaril equiv) 25mg caps Chlordiazepoxide/Clidinium (Librax equiv) 5mg/2.5mg caps Lorazepam (Ativan) 0.5mg, 1mg, 2mg tabs *controlled substance*

Anti-Coagulants - (Circulation/Blood Thinners) Apixaban (Eliquis) 2.5mg; 5mg tabs Cilostazole (Pletal equiv) 50mg; 100mg tabs Clopidogrel (Plavix) 75mg tabs Dipyridamole (Persantine equiv) 25mg tabs Enoxaparin (Lovenox equiv) 30mg; 40mg; 60mg; 80mg; 100mg; 120mg; 150mg injection Prasugrel (Effient) 10mg tabs Rivaroxaban (Xarelto) 10mg; 15mg; 20mg tabs Warfarin sodium (GENERIC only) all strengths

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Anti-Convulsants/ Epilepsy/Parkinson Amantadine (Symmetrel equiv) 100mg caps Benztropine (Cogentin equiv) 0.5mg; 2mg tabs Carbamazepine (Tegretol equiv) 100mg; 200mg tabs Carbamezapine XR (Tegretol XR equiv) 100mg; 200mg; 400mg tabs Carbamezapine Suspension (Tegretol Suspension equiv) 100mg/5ml Clonazepam (Klonopin equiv) 0.5mg; 1mg; 2mg tabs *controlled substance* Clorazepate (Tranxene equiv) 7.5mg tabs only *controlled substance* Diazepam (Valium equiv) 2mg; 5mg tabs *controlled substance* Divalproex (Depakote, Depakote ER, Depakote Sprinkles equiv) 250mg SR; 250mg ER and 500mg ER; 125mg sprinkles Lamotrigine (Lamictal equiv) 25mg; 50mg; 150mg; 200mg tabs and 5mg; 25mg Chewtabs Leviteracetam (Keppra equiv) 250mg; 500mg; 750mg; 1000mg; 500mg XR; 750mg XR tabs Oxcarbazepine (Trileptal) 150mg; 300mg; 600mg tabs Phenobarbital 32.4 mg tabs *controlled substance* Phenytoin (Dilantin brand only) 30mg; 100mg caps; 50mg chew tabs; 125mg/5ml suspension Primidone (Mysoline) 50mg; 250mg tabs Sinemet equiv (Carbidopa/Levodopa) – Immediate-release 10/100, 25/100, 25/250mg tabs Sinemet ER equiv (Carbidopa/Levodopa ER) 25/100mg; 50/200mg tablet Topiramate (Topamax equiv) 25mg; 50mg; 100mg; 200mg tabs; and 15mg & 25mg sprinkle capsules Trihexyphenidyl (Artane equiv) 2mg tabs Zonisamide (Zonegran equiv) 25mg; 100mg caps **allergy alert - this is a SULFA drug**

Anti-Depressants / Bipolar

Amitriptyline (Elavil) 10mg; 25mg; 50mg; 100mg tabs Bupropion SR (Wellbutrin SR equiv) 100mg; 150mg tabs Bupropion XL (Wellbutrin XL equiv) 150mg; 300mg tabs Citalopram (Celexa equiv) 10mg; 20mg; 40mg tabs Doxepin (Sinequan equiv) 10mg; 25mg; 50mg caps Duloxetine (Cymbalta equiv) 20mg; 30mg; 60mg caps Escitalopram (Lexapro equiv) 10mg; 20mg tabs Fluoxetine (Prozac equiv) 10mg; 20mg caps Imipramine (Tofranil equiv) 10mg; 25mg tabs Mirtazapine (Remeron) 15mg; 30mg tabs only (excludes ODT) Nortriptyline (Pamelor equiv) 10mg; 25mg caps Paroxetine (Paxil equiv) 10mg, 20mg; 30mg tabs Paroxetine CR (Paxil CR equiv) 25mg caps Sertraline (Zoloft equiv) 25mg; 50mg; 100mg tabs Trazodone (Desyrel equiv) 50mg; 100mg tabs Venlafaxine Immediate-release (Effexor equiv) 25mg; 75mg tabs Venlafaxine XR (Effexor XR equiv) 37.5mg; 75mg; 150mg caps

Anti-Emetics (Nausea/Vomiting)

Ondansetron liquid (Zofran equiv) 4mg/5ml Ondansetron tablets (Zofran equiv) – 8mg oral tabs; 4mg ODT and 8mg ODT (Oral Disintegrating Tabs) Prochlorperazine (Compazine equiv) – 5mg; 10mg tabs Promethazine (Phenergan equiv) 25mg tabs Promethazine liquid (Phenergan equiv) 6.25mg/5ml Promethazine (Phenergan equiv) 12.5mg; 25mg suppositories Scopolamine Base (Transderm Scop patch) 1.5mg/72hr (Motion sickness prevention only)

Anti-Histamines / Decongestants / Cough Suppressants / Allergy Benzonatate Perles (Tessalon equiv) 100mg Brompheniramine/Pseudoephedrine (Bromfed DM liquid equiv) 2/30/10mg per 5ml **Limit 1 mo. w/refills** Cetirizine liquid (Zyrtec liquid for Children) 5mg/5ml Cetirizine (Zyrtec equiv) 10mg tabs only Cyproheptadine liquid (Periactin equiv) 4mg tabs and 2mg/5ml oral solution Diphenhydramine liquid (Benadryl equiv) – 25mg caps and 12.5ml/5ml Fexofenadine (Allegra equiv) 60mg 180mg tabs Fexofenadine liquid (Children’s Allegra equiv) 30mg/5ml suspension Hydrocodone/Chlorpheniramine (Tussionex equiv ) 10/8mg suspension **Max qty of 4 ounces (115ml) dispensed**controlled

substance** Hydroxyzine (Atarax) 10mg; 25mg tabs and 10mg/5ml liquid

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Anti-Histamines / Decongestants / Cough Suppressants / Allergy cont. Guaifenesin sustained release (Mucinex equiv) 600mg tabs only Guaifenesin (Robitussin-generic) 100mg/5ml syrup Guaifenesin/Dextromethorphan (Robitussin DM-generic) 100mg/5mg per 5ml syrup Guaifenesin/Codeine (Cheratussin AC) syrup *controlled substance* Loratadine (Claritin equiv) 10mg Swallow tablets and Children’s Oral solution 5mg/5ml Meclizine (Antivert) 25mg tabs Montelukast (Singular equiv) – 4mg granules; 4mg & 5mg chewtabs; 10mg tabs Pseudoephedrine (Sudafed) 60mg tablets only (by prescription only)

Anti-Microbials (Antibiotics, Anti-Virals, Antifungals, Antiparasitic)

Acyclovir (Zovirax equiv) 200mg tabs and 400mg caps Albendazole (Albenza eqiuv) 200mg tabs Amantadine (Symmetrel equiv) 100mg caps Amoxicillin (Amoxil) 250mg; 500mg; 875mg tabs/caps Amoxicillin (Amoxil) 250mg/5ml; 400mg/5ml suspension Amoxicillin/clavulanate (Augmentin equiv) 250mg; 500mg; 875mg tabs and 1000mg XR tabs Amoxicillin/clavulanate (Augmentin equiv) 200mg/5ml; 250mg/5ml; 400mg/5ml; 600mg/5ml suspension Azithromycin (Zithromax, Zpack equiv) 250mg tabs and 100mg/5ml; 200mg/5ml suspension Cefprozil (Cefzil) 250mg tabs or 250mg/5ml suspension Cefuroxime (Ceftin) tablets only Cephadroxil (Duricef equiv) 500mg caps Cephalexin (Keflex equiv) 250mg; 500mg caps Cephalexin (Keflex equiv) 250mg/5ml suspension Cefdinir (Omnicef equiv) 300mg caps only Cefdinir (Omnicef equiv) 125mg/5ml; 250mg/5ml suspension Ciprofloxan (Cipro equiv) 250mg; 500mg tabs Clarithromycin (Biaxin & Biaxin XL equiv) 500mg tabs and 250mg/5ml suspension Clindamycin (Cleocin equib) 150mg; 300mg caps and 75mg/5ml oral suspension Dicloxacillin oral (Dynapen equiv) 250mg caps Doxycycline Hyclate (Vibramycin equib) 20mg; 100mg oral tabs/cap (excludes Doryx extended release) Doxycycline Monohydrate (Monodox equiv) 50mg; 100mg caps Erythromycin (Erythrocin equiv) and ERYC delayed release 250mg caps/tabs Ethanbutol (Myambutol) 400mg tabs Fluconazole (Diflucan equiv) 100mg; 150mg; 200mg tabs Griseofulvin oral (Gris-peg equiv) 250mg ultramicrosize tabs; 125mg/5ml microsize oral suspension. Isoniazid oral (INH) 100mg; 300mg tabs Itraconazole (Sporonox eqiuv) 200mg caps Levofloxacin (Levaquin equiv) 250mg; 500mg; 750mg tabs Methenamine (Hiprex, Urex) 1gm tabs Metronidazole (Flagyl) 250mg; 500mg tabs Minocycline (Minocin) 50mg; 100mg caps Nitrofurantoin USP (Macrodantin equiv) 50mg caps Nitrofurantoin Monohydrate/Macrocyrstals (Macrobid equiv) 100mg caps Nystatin 500,000U oral tabs (does not include Mycostatin Pastilles) Penicillin VK (Pen VK) 250mg; 500mg tabs and 250mg/5ml suspension Rifampin (Rifadin equiv) 300mg caps Sulfamethoxazole/trimethoprim (Bactrim DS/Septra DS equiv) 160mg/800mg tabs and 200mg/40mg per 5ml pediatric suspension Terbinafine (Lamisil equiv) 250mg tabs and cream Tetracycline 250mg caps Trimethoprim (Proloprim) 100 mg tabs Valacyclovir (Valtrex equiv) 500mg; 1gm tabs

Antipsychotics (Psychiatrics) Aripiprazole (Ability) all strengths Chlorpromazine (Thorazine equiv) 25mg; 50mg tabs Lithium (Lithobid equiv) 300mg tabs/caps and 300mg XR Olanzapine (Zyprexa equiv) 2.5mg; 5mg; 10mg tabs Quetiapine (Seroquel and Seroquel XR equiv) all strengths for both Risperidone (Risperdal equiv) 0.25mg; 0.5mg; 1mg; 2mg; 4mg tabs Ziprasidone (Geodon equiv) 20mg; 40mg; 60mg; 80mg tabs

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Anti-rheumatics (Arthritis/Rheumatoid Arthritis)

Azathioprine (Imuran equiv) 50mg tabs Hydroxychloroquine (Plaquenil equiv) 200mg tabs Humira (Adalimumab) 40mg injection (2 injections per box) **REQUIRES PRIOR AUTHORIZATION FORM**

Attention Deficit/Narcolepsy/STIMULANT **Per AR 40-3 Adderal (amphetamine) will not be dispensed to prevent daytime drowsiness**

Adderall (mixed amphetamine salts equiv) 5mg; 10mg; 20mg; 30mg tabs *controlled substance* Adderall XR (mixed amphetamine equiv) 5mg; 10mg; 20mg; 25mg; 30mg tabs *controlled substance* Armodafinil (Nuvigil) 50mg; 150mg; 200mg; and 250mg tabs *controlled substance* Dexmethylphenidate IR (Focalin IR) 5mg; 10mg tabs *controlled substance* (excludes Focalin XR) Dextroamphetamine (Dexedrine equiv) 5mg caps and 5mg; 10mg; 15mg spansules *controlled substance* Methylphenidate (Ritalin, Concerta equiv) 5mg; 10mg; 20mg tabs *controlled substance* Methylphenidate LA (Ritalin LA equiv) GENERIC ONLY 20mg; 30mg; 40mg caps *controlled substance* Methylphenidate XR (Quillivent XR Reconstitute equiv) 5mg/ml suspension *ordered upon request only- -requires 3 BUSINESS days minimum)

Modafinil (Provigil) 100mg & 200mg tabs *controlled substance*

Attention Deficit/NON-STIMULANT Atomoxetine (Strattera equiv) all strengths caps Clonidine ER (Kapvay ER) 0.1mg Guanfacine ER (Intuniv equiv) 1mg; 2mg; 3mg 4mg tabs

Cholesterol / Lipid Lowering

Atorvastatin (Lipitor) 10mg; 20mg; 40mg; 80mg tabs Cholestyramine (Prevalite) powder 60 x 4 grams Colestipol (Colestid equiv) 1gm tabs Ezetimibe (Zetia equiv) 10mg tabs Fenofibrate (Triglide equiv) 160mg tabs (only) Fenofibrate Nanocrystallized (Tricor equiv) 48mg; 54mg; 145mg tabs (excludes Trilipix delayed release) Gemfibozil (Lopid equiv) 600mg tabs Niacin SR (Niaspan equiv) 500mg; 750mg; 1000mg extended-release tabs Pravastatin (Pravachol equiv) 10mg; 20mg; 40mg; 80mg tabs Rosuvastatin (Crestor equiv) 10mg; 20mg; 40mg tabs Simvastatin (Zocor equiv) 5mg; 10mg; 20mg; 40mg; 80mg tabs

Contraceptives (Birth control)

LOW-DOSE MONOPHASIC

Product Estrogen Progestin

Orsythia Lutera Sronyx

Ethinyl Estradiol 20 mcg Levonorgestrel 0.1 mg

Gildess FE 1/20 Junel FE 1/20

Microgestin FE 1/20 Trina FE 1/20

Ethinyl Estradiol 20 mcg Norethindrone 1 mg

Levora Ethinyl Estradiol 30 mcg Levonorgestrel 0.15 mg

Cryselle-28 Elinest – 28

Low-Orgestrel-28 Ethinyl Estradiol 30 mcg Norgestrel 0.3 mg

Junel FE 1.5/30 Ethinyl Estradiol 30 mcg Norethindrone 1.5 mg

Apri Ethinyl Estradiol 30 mcg Desogestrel 0.15 mg

Ocella; Safyral; Syeda; Yasmin; Zarah Ethinyl Estradiol 30 mcg Drospirenone 3 mg

Zovia 1/35E Ethinyl Estradiol 35 mcg Ethynodiol Diacetate 1 mg

Estarylla; Mono-Linyah; MonoNessa; Ethinyl Estradiol 35 mcg Norgestimate 0.25 mg

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Ortho-Cyclen; Preifem, Sprintec

Alyacen 1/35; Cyclafem 1/35; Dasetta 1/35; Necon 1/35-28;

Norinyl 1/35; Nortrel 1/35; Pirmella 1/35

Ethinyl Estradiol 35 mcg Norethindrone 1 mg

HIGH-DOSE MONOPHASIC

Product Estrogen Progestin

Ogestrel 0.5/50-28 Ethinyl Estradiol 50 mcg Norgestrel 0.5 mg

Kelnor; Zovia 1/50E-28 Ethinyl Estradiol 50 mcg Ethynodiol Diacetate 1 mg

TRIPHASIC

Product Estrogen Progestin

Trinessa Lo Ortho Tri-Cyclen Lo

Ethinyl Estradiol 25 mcg

Norgestimate:

0.18 mg x 7 days

0.215 mg x 7 days

0.25 mg x 7 days

Caziant; Cyclessa Velivant

Ethinyl Estradiol 25 mcg

Desogestrel:

0.1 mg x 7 days

0.125 mg x 7 days

0.15 mg x 7 days

Trivora Myzilra

Levonest Enpresse

Ethinyl Estradiol:

30 mcg x 6 days

40 mcg x 5 days

30 mcg x 10 days

Levonorgestrel:

0.05 mg x 6 days

0.075 mg x 5 days

0.125 mg x 10 days

TriNessa Ethinyl Estradiol 35 mcg

Norgestimate:

0.18 mg x 7 days

0.215 mg x 7 days

0.25 mg x 7 days

Aranelle; Leena; Tri-Norinyl

Ethinyl Estradiol 35 mcg

Norethindrone:

0.5 mg x 7 days

1 mg x 9 days

0.5 mg x 5 days

Alyacen 7/7/7; Cyclafem 7/7/7; Dasetta 7/7/7; Necon 7/7/7; Nortrel 7/7/7; Pirmella 7/7/7

Ethinyl Estradiol 35 mcg

Norethindrone:

0.5 mg x 7 days

0.75 mg x 7 days

1 mg x 7 days

EXTENDED CYCLE

Product Estrogen Progestin

Jolessa Introvale; Quasense

Ethinyl Estradiol 30 mcg x 84 days Levonorgestrel 0.15 mg x 84 days

Gianvi; Loryna; Nikki; Vestura; Yaz

Ethinyl Estradiol 20 mg x 24 days Drosperidone 3 mg x 24 days

Contraceptives (Birth control) cont.

PROGESTIN ONLY PILLS

Product Progestin

Nora-BE (Camila, Errin, Heather, Jencycla, Jolivetta, Lyza,

Ortho Micronor)

Norethindrone 0.35 mg

Contraceptive Alternatives

Nuvaring (estonogestrel/Ethinyl Estradiol) vaginal ring Xulane Patch (equiv to Ortho Evra)

Contraceptive (Emergency)

Ella (Ulipristal Acetate) 30mg *dispensing limitations* Plan – B (Levonorgestrel 1.5mg) *dispensing limitations*

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Corticosteroids – Oral Budesonide (Entocort equiv) 3mg caps (Crohn’s Disease) Dexamethasone (Decadron equiv) 0.5mg, 0.75mg; 1.5mg, 4mg tabs and DexPak 1.5mg tabs (6-day, 10-day, 13-day pack) Fludrocortisone (Florinef equiv) 0.1mg tabs Methylprednisolone (Medrol, Medrol Dose Pack equiv) 4mg tabs Prednisone (Deltasone equiv) 5; 10; 20mg tabs Prednisolone (Pediapred, Prelone equiv) 5mg/5ml; 15mg/5ml liquid

Dental Agents

Chlorhexidine oral rinse (Peridex, PerioGard) Sodium Fluoride (PreviDent 5000 Plus) 1.1% paste Spearmint Triamcinolone (Kenalog-in-Orabase) paste Viscous Lidocaine (Xylocaine) 2% oral gel 100ml

Diabetic Agents/Supplies **All Prior Authorization Forms to be hand delivered or faxed with RX

to FAHC** Acarbose (Precose) 50mg tabs Exenatide (Bydureon) 2mg SQ pen (4 injections per box) REQUIRES PRIOR AUTHORIZATION FORM Exenatide ER (Bydureon BCise 2mg SQ pen (4 injections per box) REQUIRES PRIOR AUTHORIZATION FORM Glucometer Free Style Lite (only one type of meter on formulary** LIMITED TO ONE METER EVERY 5 YEARS** Glucometer Strips Free Style Lite test strips

Lancets (generic) Glimepiride (Amaryl equiv) 2mg; 4mg tabs Glipizide IR (Glucotrol immediate-release equiv) 5mg; 10mg tabs Glipizide XL (Glucotrol XL equiv) 5mg; 10mg XL tabs Glucogon Emergency Injectable Kit #1 Glyburide (Micronase) 0.25mg; 5mg tabs Insulin aspart (Novolog & Novolog mix) vials and Flexpens Insulin glargine (rDNA origin) Lantus Vials and Solostar pens

Insulin human 70/30 NPH and Regular vials Insulin Lispro (HUMALOG) vials, and Admelog Solostar kwikpen Insulin Lispro MIX 75/25 (Humalog Mix) Kwikpen Insulin PEN Needles Short – 1/4” (6mm) length, 32 gauge Metformin (Glucophage equiv) 500mg; 850mg; 1000mg tabs Metformin XR (Glucophage XR equiv) 500mg and 750mg XR tabs (Excludes 1000mg XR) Metformin/Glyburide (Glucovance) 1.25mg/250mg; 2.5mg/500mg; 5mg/500mg tabs Sitagliptin (Januvia) 25mg; 50mg; 100mg tabs REQUIRES PRIOR AUTHORIZATION FORM Sitagliptin/Metformin (Janumet) 50/500mg; 50/1000mg tabs REQUIRES PRIOR AUTHORIZATION FORM Sitagliptin/Metformin XR (Janumet XR) 50/500mg; 50/1000mg; 100/1000mg tabs (once daily dosing) REQUIRES PRIOR AUTHORIZATION FORM

Syringes, Insulin - Available in 1/2cc and 1cc, ½” 30G

Diuretics (Fluid Retention)

Bumetanide (Bumex) 1mg tabs Chlorthalidone (Hygroton) 25mg; 50mg tabs Furosemide (Lasix equiv) 20mg; 40mg tabs Hydrochlorothiazide (HCTZ) 12.5mg tabs; 25mg tabs; 50mg tabs Hydrochlorothiazide/triamterene (Maxzide equiv) 50mg/75mg tabs Indapamide (Lozol equiv) 1.25mg; 2.5mg tabs Spironolactone (Aldactone equiv) 25mg; 50mg tabs

Electolyte Replacement Magnesium Oxide (MagOx) 400mg tabs Potassium chloride (KDur, Klor) 8 mEq;, 10mEq; 20mEq tabs Potassium chloride powder for solution (KLor 20mEq packets) 100 packets/box

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Emergency Kit (Insect Sting / Substance Abuse)

Glucagon Emergency Kit Insect sting kit (Epi-Pen and Epi-pen Jr.) **Pharmacy needs to annotate allergy on file** (Manufacture shortage check with pharmacy)

Naloxone (Narcan equiv) Nasal Spray Naltrexone (Naltrexone) 50mg tabs

Erectile Dysfunction Sildenafil (Viagra equiv) 25mg; 50mg; 100mg tabs (Limit 6 tabs/month –Maximum 3 months/18 tabs)

Fertility Drugs

Clomiphene (Clomid equiv) 50mg tabs

Gastrointestinal Reflux Disease (GERD) Agents/Acid Reflux/Heartburn/Gas

Famotidine (Pepcid equiv) 20mg; 40mg tabs Omeprazole (Prilosec equiv) 20mg; 40mg caps Pantoprazole (Protonix equiv) 20mg; 40mg tabs Rabeprazole (Aciphex equiv) 20mg tabs

Gastrointestinal Agents (GI Prep Kits/ Diarrhea/Constipation/IBS/Crohn’s/Gallbladder)

Budesonide (Entocort equiv) 3mg caps (for Crohn’s disease) Chlordiazepoxide/clidinium (Librax equiv) Colyte / Golytely Bowel Prep **See other Bowel Prep kits below* Dicyclomine (Bentyl equiv) 10mg caps; 20mg tabs Docusate sodium (Colace equiv) 100mg caps Flavoxate (Urispas equiv) 100mg tabs Hyoscyamine (Levsin, LevBid equiv) 0.125mg SL; 0.375 tabs Lactulose (Cephulac equiv) Syrup 10gm/15ml Lomotil (diphenoxylate/atropine) 2.5mg/0.025mg tabs *controlled substance* Loperamide (Imodium equiv) 2mg caps Mesalamine (Lialda equiv) 1.2G delayed release Miralax equiv (propylene glycol 3350) powder for suspension (Max Qty Limit = 1 x 527gm bottle per 30 days) 17gm/dose

Metoclopramide (Reglan equiv) 10mg tablets Misoprostol (Cytotec equiv) 200mg tabs Moviprep Bowel Prep kit Pancrelipase (Creon equiv) delayed release capsules 3000mg; 6000mg; 12,000mg; 24,000mg; 36,000mg caps Prochlorperazine (Compazine equiv) – 5mg tabs Ranitidine (Zantac equiv) 300mg; 400mg (Excludes EFFERdos or GELdose) SuPrep Bowel Prep Kit Sucralfate (Carafate equiv) 1gm tabs and 1gm/10ml suspension Ursodiol (Actigal equiv) 300mg; 500mg caps

Genitourinary Agents (Bladder/Prostate)

Alfuzosin (Uroxatral equiv) 10mg tabs Doxazosin (Cardura equiv) 2mg; 4mg; 8mg tabs Desmopressin (DDAVP equiv) Nasal spray Desmopressin (DDAVP equiv) 0.1mg; 0.2mg tabs Oxybutynin (Ditropan equiv) 5mg Immediate-Release tabs Oxybutynin XL (Ditropan XL equiv) 5mg; 10mg XL tabs Prazosin (Minipres equiv) 1mg; 2mg; 5mg caps Phenazopyridine (Pyridium equiv) 100mg; 200mg tabs Potassium Citrate (Urocit-K) 5 mEq; 10 mEq; 15 mEq tabs Tamsulosin (Flomax equiv) 0.4mg caps Terazosin (Hytrin equiv) 1mg; 2mg; 5mg; 10mg caps Tolterodine LA (Detrol LA equiv) 2mg; 4mg caps (Excludes immediate-release tabs)

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Gout Agents Allopurinol (Zyloprim equiv) 100mg; 300mg tabs Colchicine 0.6mg only Probenecid (Benemid equiv) 500mg tabs

Hormones – Estrogen/ Progestin/Testosterone

Activella equiv (estradiol & norethindrone) 0.5mg/0.1mg; 1mg/0.5mg tabs Prempro equiv (conjugate estrogens/medroxyprogesterone acetate) 0.3/1.5; 0.45/1.5; 0.625/2.5; 0.625/5mg tabs Combipatch equiv (estradiol/norenthindrone) 50/140mcg (0.05/0.14mg) ; 50/250mcg (0.05/0.25mg) patch Conjugated estrogens (Premarin equiv) 0.3mg; 0.45mg; 0.625mg; 0.9mg;1.25mg tabs Conjugated estrogens (Premarin Vaginal Cream equiv) vaginal cream Estradiol (Estrace Vaginal Cream equiv) vaginal cream Estradiol (Vagifem equiv) 10mcg vaginal tab Estradiol 2mg Ring (ESTRING equiv) Estradiol patch equiv (Alora Patch: 0.05mg; 0.1mg) Twice-a-week dosing Estradiol patch equiv (Climara Patch) Once-a-week dosing Estradiol (Estrace equiv) 0.5mg; 1mg; 2mg tabs Estradiol (Minivelle; Vivelle Dot- transdermal equiv) 0.1mg/24hr patch Medroxyprogesterone (Provera equiv) 5mg; 10mg tabs Progesterone (Prometrium equiv) 100mg; 200mg caps Testosterone Cypionate (Depo-Testosterone) 200mg/ml injectable (Enanthate is EXCLUDED) *controlled substance* Testosterone Gel (Fortesta equiv) 60gm canister *controlled substance* 120 pumps/can REQUIRES PRIOR AUTHORIZATION FORM

HYPERTENSIVE/CARDIAC MEDICATIONS (Blood Pressure/Heart)

Ace Inhibitors/Angiotensin II Blocker – all generic only

Benazepril (Lotensin equiv) 5mg; 10mg; 20mg; 40mg tabs Captopril (Capoten) 25mg tabs Enalapril (Vasotec equiv) 5mg; 10mg tabs Fosinopril (Monopril equiv) 10mg; 20mg tabs Irbesartan (Avapro) 150mg; 300mg Lisinopril (Zestril, Prinivil equiv) 2.5mgl 5mgl 10mg; 20mg tabs Losartan (Cozaar equiv) 25mg; 50mg; 100mg tabs Losartin-HCTZ (Hyzaar equiv) 50/12.5; 100/12.5; 100/25mg tabs Ramipril (Altace equiv) 1.25mg; 2.5mg; 5mg; 10mg caps Telmisartan (Micardis equiv) 20mg; 40mg; 80mg tabs Telmisartan-HCT (Micardis/HCT equiv) 40/12.5; 80/12.5; 80/25mg tabs

Aldosterone Antagonists

Spironolactone (Aldactone) 25mg; 50mg tabs

Alpha-1-Adrenergic Blocker Doxazosin oral (Cardura equiv) 2mg; 4mg; 8mg tabs Prazosin (Minipres equiv) 1mg; 2mg; 5mg caps Terazosin (Hytrin equiv) 1mg; 2mg; 5mg; 10mg caps

Alpha/Beta-Adrenergic Blocker Carvedilol (Coreg equiv) 3.125mg; 6.25mg; 12.5mg; 25mg tabs Carvedilol CR (Coreg equiv) 10mg; 20mg; 40mg; 80mg caps

Antiadrenergic – Centrally Acting Clonidine (Catapres) 0.1mg; 0.2mg; 0.3mg tabs Clonidine (Catapress TTS) patches 0.1mg; 0.2mg; 0.3mg (contains medication patch and adhesive application use both for successful therapy)

Beta-Adrenergic Blockers – all generic only

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Atenolol (Tenormin equiv) 25mg; 50mg tabs Bisoprolol (Zebeta equiv) 5mg; 10mg tabs Labetalol (Normodyne) 100mg; 200mg tabs Metoprolol (Lopressor equiv) 25mg; 50mg; 100mg tabs Metoprolol Succinate (Toprol XL equiv) 25mg; 50mg; 100mg tabs Nadolol (Corgard equiv) 40mg; 80mg tabs Propranolol (Inderal, Inderal LA equiv) 10mg; 20mg; 40mg; 80mg tabs and 60mg; 80mg; 120mg; 160mg LA caps

Calcium Channel Blockers Amlodipine (Norvasc equiv) tablets 2.5mg; 5mg; 10mg tabs Amlodipine/Benazepril (Lotrel equiv) 2.5/10mg; 5/10mg; 5/20mg; 10/20mg, 5/40mg; 10/40mg caps Diltiazem (Cardizem equiv) 30mg; 60mg; 90mg tabs Diltiazem Sustained Release (Tiazac equiv) 120mg; 180mg; 240mg; 300mg; 360mg; 420mg SR caps (excludes 60mg SR) Felodipine (Plendil equiv) 2.5mg; 5mg; 10mg tabs Nifedipine Sustained Release (Adalat CC equiv) 30mg; 60mg; 90mg SR tabs Verapamil (Calan, Calan SR) 80mg; 180mg; 240 SR tabs (Excludes Verelan extended-release)

HYPERTENSIVE/CARDIAC MEDICATIONS (Blood Pressure/Heart) Cardiac Agents Amiodarone (Pacerone equiv) 200mg tabs Digoxin (Lanoxin equiv) 0.125mg, 0.25 tabs Dipyridamole (Persantine equiv) 0.25 tabs Flecainide (Tambocor equiv) 50mg; 100mg; 150mg tabs Magnesium Oxide (MagOx) 400mg tabs Propafenone (Rythmol) 150mg, 225mg, 325mg caps Sotalol (Betapace equiv) 80mg; 120mg; 160mg; 240mg tabs

Vasodilators Hydralazine oral (Apresoline equiv) 10mg; 25mg; 50mg tabs Isosorbide dinitrate oral (Isordil equiv) 10mg tabs only Isosorbide mononitrate (Imdur,Ismo equiv) 30mg; 60mg tabs Nitroglycerin patches (Nitro-Dur equiv) 0.2mg; 0.4mg patches Nitroglycerin sublingual (Nitrostat equiv tabs and sublingual spray)

Immunologics / Biologic Agent (Rheumatoid Arthritis/Psoriasis/Crohn’s) Adalimumab (Humira) 40mg/0.8ml Pen Inj Kit & 40mg/0.8ml Syringe Kit *(limited to these two only) REQUIRES PRIOR AUTHORIZATION FORM

Mycophenolate (Cellcept equiv) 250mg caps and 500mg tabs Tacrolimus (Prograf) 1mg caps

Migraine Agents

Acetaminophen/Butalbital/Caffeine (Fioricet equiv) 325/50/40mg tabs (only) *controlled substance* Aspirin/Butalbital/Caffeine (Fiorinal equiv) 325/50/40mg caps/tabs *controlled substance* Eletriptan (Relpax equiv) 20mg; 40mg tabs *Quantity limit: 12 tabs per 30 days* Imitrex *generic only* Quantity limits : 25mg & 50mg tabs limited to 18 tabs/30 days ; 100mg tabs limited to 9 tabs/30 days Imitrex Stat Dose equiv syringes Quantity limits : 8 syringes/30 days Imitrex *generic only* Nasal spray 20mg per unit Quantity limits: 6 units per 30 days; 18 units per 90 days Rizatriptan (Maxalt and Maxalt MLT equiv) 5mg; 10mg tabs Quantity limits: 12 tabs/30 days

Topiramate (Topamax equiv) tabs all strengths (excludes extended release tables) Zolmitriptan (Zomig equiv) 5mg tabs only Quantity limits: 12 tabs/30days Zolmitriptan (Zomig-ZMT equiv) 2.5mg; 5mg orally disintegrating tabs Quantity limit: 12 tabs/30 days

Muscle Relaxants

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Baclofen (Lioresal equiv) 10mg tabs Cyclobenzaprine (Flexeril equiv) 5mg; 10mg tabs Metaxalone (Skelaxin equiv) 400mg; 800mg tabs Methocarbamol (Robaxin equiv) 500mg; 750mg tabs Tizanidine (Zanaflex equiv) 4mg tabs only

Nasal Sprays and Rinses Azelastine (Astelin equiv) Nasal Spray (Excludes Astepro)

Fluticasone (Flonase equiv) nasal spray Ipratropium Bromide (Atrovent equiv) 0.03% and 0.06% nasal spray Saline (Ocean spray equiv) nasal spray Saline Rinse (Neil-Med) Starter Kit contains reusable bottle and 50 prefilled packets Saline Rinse (Neil-Med) Refill Kit contains 100 prefilled packets

Neurological Agents (Nerve Pain/Restless Leg Syndrome) Gabapentin (Neurontin equiv) 100mg; 300mg; 400mg 600mg; 800mg caps *30 day limit w/5 refills *controlled substance* Pramipexole (Mirapex equiv) 0.125mg; 0.25mg; 0.5mg tabs (immediate release) only (for Restless Legs Syndrome) Ropinirole (Requip equiv) (immediate release only) 0.25mg; 0.5mg; 1mg; 2mg; 3mg; 4mg; 5mg tabs

Oncology/Cancer

Antiandrogen Bicalutamide (Casodex equiv) 50mg tab

Antiestrogen Anastrazole (Arimidex equiv) 1mg tabs Exemestane (Aromasin equiv) 25mg tabs Letrozole (Femara equiv) 2.5mg tabs Tamoxifen (Nolvadex equiv) 10mg; 20mg tabs

Antimetabolite/Folic Acid Antagonist Methotrexate 2.5mg tablets only (excludes injectable)

Eye Care: Ophthalmics – Antibiotics/Antivirals Azasite (azithromycin equiv) 1% solution Bacitracin ointment Ciprofloxacin (Ciloxan equiv) ophthalmic drops and ointment Erythromycin (Ilotycin equiv) ointment Gentamycin (Garamycin equiv) drops and ointment Moxifloxacin (Vigamox equiv) drops 0.5% Neomycin/Polymyxin B sulfates/Gramicidin (Neosporin equiv) solution Neomycin/Polymyxin B sulfates/Hydrocortisone (Cortisporin equiv) drops and ointment Ofloxacin (Ocuflox equiv) 0.3% solution Sulfacetamide (Sulamyd equiv) solution Tobramycin (Tobrex equiv) drops and ointment Tobramycin/Dexamethasone (Tobradex equiv) drops and ointment Trimethoprim/Polymixin B (Polytrim equiv) drops

Eye Care: Ophthalmics – other (glaucoma, moisturizing, allergy, anti-inflammatory,

other)

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Atropine 1% solution 5ml bottle Azelastine (Optivar) 0.05% solution Bimatoprost (Lumigan equiv) 0.01% solution Brimonidine (Alphagan-P) 0.1%; 0.15% and 0.2% drops Brinzolamide/Brimonidine (Simbrinza equiv) 1%/0.2% drops Carboxymethylcellullose (Refresh Celluvisc PF equiv) 30ct/box- Preservative Free Diclofenac (Voltaren equiv) drops Difluprednate (Durezol equiv) 0.05% drops Dorzolamide (Trusopt equiv) drops Fluorometholone (FML equiv) 0.1% suspension Isopto Hyoscine (Scopolamine) drops Ketorolac Tromethamine (Acular) 0.5% drops; no refills Latanoprost (Xalatan equiv) solution *Generic only* <must be refrigerated> Levobunolol (Betagan equiv) 0.5% solution ONLY Loteprednol etabonate (Lotemax equiv) 0.5% gel only LiquifilmTears equiv (1.4% polyvinyl alcohol / 0.5% chlorobutanol, NaCl) with preservatives only (drops)

Nepafenac (Ilevro equiv) 0.3% suspension (once daily dosage) Nepafenac (Nevanac equiv) 0.1% suspension Olopatadine HCL (Patanol equiv) 0.1% solution Olopatadine HCL (Pazeo equiv) 0.7% solution Pilocarpine 1%; 2%; 4% SOLUTION only Prednisolone (Pred-Forte equiv) 1% solution 5ml bottle Prednisolone (Pred-Mild equiv) 0.25% solution 5ml bottle Sodium Chloride (Muro-128 equiv) 5% drops and 5% ointment Timolol, Timolol GFS (Timoptic, Timoptic XE equiv) 0.25%; 0.5% solution Timolol/Brimonidine (Combigan equiv) 0.2%/0.5% drops Timolol/Dorzolamide (Cosopt Plus equiv) solution

Osteoporosis / Bone Loss Alendronate (Fosamax equiv) 10mg; 35mg; 70mg tabs (Excludes Fosamax-D) Calcitrol (Rocaltrol equiv) 0.25mcg; 0.5mcg caps Ibandronate (Boniva equiv) 150mg tabs (once monthly) Raloxifene (Evista equiv) 60mg tabs

Ear Care: Otic Preparations

Carbamide peroxide (Debrox equiv) drops Ciprofloxacin/Dexamethasone (Ciprodex equiv) drops Fluocinolone (Dermotic) 0.1% solution Neomycin/Polymixin B/Hydrocortisone (Cortisporin equiv) solution and suspension

Prostate Medication

Alfuzosin (Uroxatral equiv) 10mg tabs Bicalutamide (Casodex equiv) 50mg tabs Doxazosin (Cardura equiv) 2mg; 4mg; 8mg tabs Finasteride (Proscar equiv) 5mg tabs Tamsulosin (Flomax equiv) 0.4mg caps Terazosin (Hytrin equiv) 1mg; 2mg; 5mg; 10mg caps

Respiratory (COPD, Asthma, Bronchodilator)-oral inhalers provided as HFA when

available Advair (Salmeterol/fluticasone) HFA and discus

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Albuterol MDI (ProAir) HFA inhaler Albuterol oral liquid Albuterol nebulizer solution for inhalation 1.25mg/3ml; 2.5mg/3ml – 30 per box Umeclidinium/Vilanterol (Anora Ellipta inhaler) 62.5mcg/25mcg MDI Budesonide nebulizer solution for inhalation (Pulmicort Respules) 0.25mg; 0.5mg; 1mg vials **30 per box (excludes inhaler)

Albuterol/Ipratropium (Combivent Respimat) inhaler *dosed 1 puff four times daily* Albuterol/Ipratropium (Duoneb equiv) 3mg nebulizer solution for inhalation – 30 per box Fluticasone oral inhaler (Flovent) HFA and diskus Glycopyrrolate (Robinul) 1 mg tab Ipatropium oral inhaler (Atrovent) MDI Ipatropium (Atrovent) nebulizer solution for inhalation **30 per box** Levalbuterol (Xopenex equiv) 0.31mg/3ml, 0.63mg/3ml, 1.25mg/3ml nebulizer solution (excludes (Xopenex equiv) MDI inhaler)

Montelukast (Singulair) 10mg tabs and 4mg; 5mg chewable tabs and 4mg granules Spacer (Aerochamber) and also Aerochamber w/mask (S, M, L) Salmeterol (Serevent) discus Terbutaline (Brethine) 2.5mg; 5mg tabs Theophylline SR 200mg; 400mg; 600mg Tiotropium (Spiriva) HandiHaler Tiotropium (Spirivia) RESPIMAT *ONE inhaler per 30 DAYS* 1.25mg/actuation and 2.5mcg/actuation

Umeclidinium (Incruse Ellipta) 62/5mg MDI inhaler

Sedative Hypnotic Agents / Insomnia (Sleep Aids) Eszopiclone (Lunesta equiv) 1mg; 2mg; 3mg tabs (30 day qty limit W/refills) *controlled substance* Temazepam (Restoril equiv) 7.5mg; 15mg; 30mg caps (30 day qty limit W/refills) *controlled substance* Trazodone (Desyrel equiv) 50mg; 100mg tabs Zolpidem (Ambien equiv) 5mg; 10mg tabs *controlled substance-30 day supply w/refills* *Max 5mg for females*

Zolpidem (Ambien CR equiv) 6.25mg and 12.5mg *controlled substance-30 day supply w/refills*

Smoking Cessation Agents

Nicoderm Patches 7mg; 14mg; 21mg Nicorette gum 50 pieces/box

Thyroid/Antithyroid Agents

Armour Thyroid 15mg; 30mg; 60mg; 90mg; 120mg (1/4gr, 1/2gr, 1gr, 1.5gr, 2 grain) tabs **excludes Nature Thyroid Brand** Levothyroxine (Synthroid brand only) all strengths tabs (excludes: Tirosint capsules)

Liothyronine (Cytomel equiv) 5mcg; 25mcg; 50mcg tabs Methimazole (Tapazole equiv) 5mg; 10mg tabs – for Hyperthyroidism Propylthiouracil (PTU) 50mg tabs

Topical Agents

Acyclovir (Zovirax) 5% ointment Adapalene (Differin) 0.1% gel Aluminum chloride hexahydrate (Drysol equiv) Augmented Betamethasone Dipropionate (Diprolene AF equiv) cream 15 gram and 50 gram Bacitracin topical ointment 30 gram Betamethasone Valerate (Valisone equiv) 0.1% cream 15gm tube Ciclopirox (Penlac equiv) 8% solution only Clindamycin (Cleocin-T equiv) solution only 60 ml Clindamycin gel, cream, lotion Clindamycin/Benzoyl Peroxide (Duac gel equiv) 1.2/5% gel

Topical Agents cont. Clobetasol cream (Temovate equiv) 0.05% cream/ointment/gel 15 gram; shampoo 118ml Clobetasol Foam (Olux equiv) Clotrimazole/Betamethasone dipropionate cream (Lotrisone equiv)

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Colloidal Sulfur/Salicylic Acid (Sebex equiv) 2% Shampoo Desonide (DesOwen equiv) cream Diclofenac (Voltaren GEL equiv) 1% gel (only) –100gram Diclofenac (PENNSAID equiv) 1.5% solution (**excluding 2% solution) Erythromycin 1.5% solution *excludes pads* Fluocinolone (Synalar equiv) 0.01% cream and solution Fluocinolone (Synalar equiv) 0.025% cream and ointment Fluocinonide (Lidex equiv) 0.05% cream; ointment; solution Fluocinonide (Lidex equiv) 0.1% cream Fluorouracil (Efudex equiv) 5% cream Gentamycin 0.1% (Garamycin equiv) cream Hydrocortisone 0.5%; 1%; 2.5% cream 2.5% lotion Hydrocortisone (Anusol-HC equiv) rectal cream and suppositories Hydrocortisone/Pramoxine (Proctofoam HC equiv) foam Hydroquinone (Eldoquin equiv) 4% cream Imiquimond (Aldara equiv) 5% cream Box of 24 single use packets Ketaconazole (Nizoral equiv) 2% Shampoo Lidocaine 2% JELLY 30gram Lidocaine 4% CREAM 30gram Lidocaine 5% OINT 35gram Lidocaine (Lidoderm) Adhesive Patch 5% (700mg/patch) maximum 3 boxes/30 days

Metronidazole (Metrocream equiv) 0.75% cream Metronidazole (Metrogel equiv) gel Mometasone (Elocon equiv) 0.1% cream Mupirocin (Bactroban equiv) ointment and cream Nystatin ointment & powder Permethrin (Elimite equiv) cream Pimecrolimus (Elidel equiv) cream Prilocaine/Lidocaine (EMLA equiv) 2.5/2.5% cream 30gram Selenium sulfide (Selsun equiv) 2.5% lotion (**excludes 1% Selsun Blue which is OTC) Silver sulfadiazine (Silvadene equiv) cream Tacrolimus (Protoptic equiv) 0.3% (<16yrs) and 0.1% (>15yrs) ointment Terbinafine (Lamisil Equiv) 1% cream Tretinoin (Retin-A equiv) CREAM only *NOT FOR COSMETIC USE* (excludes gel, ointment, and 0.1% MICRO)

Triamcinolone acetonide (Kenalog equiv) 0.1% cream, ointment, spray Triamcinolone/Nystatin (Mycolog equiv) cream

Vaginal Preparations

Clindamycin phosphate (Cleocin equiv) cream Clotrimazole (Gyne-Lotrimin-7 equiv) cream Conjugated Estrogens (Premarin equiv) cream Estradiol (Vagifem equiv) 10mcg tabs Estradiol (Estrace equiv) cream Metronidazole (Metrogel equiv) cream Miconazole (Monistat-7 equiv) 2% cream

Vitamins and Minerals B12 (Cyanocobalamine) 1000mcg/ml injection (note: prescription is needed for syringes) Ferrous Sulfate (Iron) 325mg immediate-release tabs Folic Acid 1mg tabs Cyanocobalamine/Pyridoxine/L-methylfolate (Foltx) 2/25/1.13mg tabs ICAR-C equiv (Carbonyl iron/Vit C) 100/250mg tabs ICAR-C Plus equiv (Carbonyl iron/Folic acid/Cyanocobalamine/Vit C) 100mg/1mg/25mcg/250mg tabs Magnesium Oxide (MagOx) 400mg tabs Prenatal vitamins with folic acid tabs *Limited to women of child bearing age* Prenatal Multi + DHA 200mg tabs *Limited to women of child bearing age* Prenatal + low iron 27mg tabs *Limited to women of child bearing age*

Calcitrol (Rocaltrol equiv) 0.25mcg; 0.5mcg caps Vitamin D2 50,000 IU (ergocalciferol) gel caps only Vitamin D3 50,000 IU (cholecalciferol) oral capsules (once weekly)

**** Note: In the event of a medication recall to the patient level for medication

affected and dispensed from FAHC; a Pharmacy staff member will attempt to

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contact you (please assure your contact information is current in DEERS).

Otherwise, continue to take your medication as directed.****

Pharmacy business hours: 07:30am – 4:00pm MON-FRI

CLOSURES **Varying days of each Month for training; check schedule for updates **Saturdays and Sundays **All noted Federal Holidays – See schedule next page

New patient information packets are available on our webpage

Information on how to transfer prescriptions TO our facility is available on our web page

Electronic prescriptions can be sent to: DOD REDSTONE

Electronic prescriptions sent by your doctor are not processed until you pull a ticket and request the prescription.

Due to frequent transmission errors beyond our control; it is recommended patients obtain a paper copy of the prescription.

FOX ARMY HEALTH CENTER HOLIDAY and TRAINING SCHEDULE

Calendar Year 2019 (Subject to mission requirement changes)

HOURS OF OPERATIONS: M-F 0730 - 1600

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Federal /Training Holiday observed (Full Day Closures):

Monday 2 SEP 2019 Thursday 28 NOV 2019 Friday 29 NOV 2019 Monday 14 OCT 2019 Tuesday 24 DEC 2019 Thursday 11 NOV 2019 Wednesday 25 DEC 2019

Routine/Individual Training, and Organizational Activity Days (Partial day closure):

Wednesday 24 JUL 2019 Closed from 0730 – 1300 Thursday 03 OCT 2019 Closed from 1130 – 1600 Wednesday 23 OCT 2019 Closed from 0730 - 1300

Fox Army Health Center is an ambulatory care clinic, and does not have an emergency room.

In case of emergency, dial 911.

Nurse Advice Lines (NALs) are available during non-duty hours at (256) 955-8888 or 1-800-223-9531 to provide care advice.