Emergency Anti-TB Medication Buffer Stock Order

This order form is for local health jurisdictions (LHJs) to order anti-TB medications from the California Department of Public Health (CDPH) Tuberculosis (TB) Control Branch’s (TBCB) emergency TB medication buffer stock. In instances where there is a gap in the supply chain and patients are at risk of experiencing an interruption in treatment, TB programs can use CDPH-purchased medications as a stop-gap to ensure continuity of care.

Additional Resources

For additional resources such as reporting a TB drug access issue to CDPH, accessing links to external resources, or viewing current TB drug supply status updates, please visit the CDPH TBCB Drug Supply Extranet site .

List of Available Medications

Ethambutol 400 MG, 100 Tab

Isoniazid 300 MG, 30 Tab

Isoniazid 300 MG, 100 Tab

Levofloxacin 750 MG, 100 Tab

Levofloxacin 750 MG, 20 Tab

Linezolid 600 MG, 30 Tab

Pretomanid 200 MG, 26 Tab

Rifapentine (Priftin) 150 MG, 24 Tab (3x8 Blister Pack)

Pyrazinamide 500 MG, 90 Tab

Rifampin 300 MG, 60 Caps

Planning for Medications

Requests for medication are subject to availability and cannot be guaranteed.
Email confirmation is sent when an order is submitted and when it is approved.
Please allow up to 5 business days for delivery.

Attestations

By placing this order, you agree to the following:

No charge may be made for the anti-TB medications.

The LHJ certifies that requested medications serve as a stop gap for patients facing imminent interruption in the current treatment regimen. This gap is temporary and the LHJ implemented measures aimed at resolving the supply chain issue.

The LHJ certifies that the location receiving medications is licensed by the CA Board of Pharmacy to receive pharmaceutical products.

The LHJ will confirm receipt of medication shipment and keep an inventory log for CDPH-purchased anti-TB medications and record the use of these doses (e.g., anti-TB medications received, lot number, date dispensed, patient dispensed to, etc.) The LHJ will report inventory discrepancies to TBCB.

If CDPH-purchased anti-TB medications are given to a community provider for patient treatment, the provider will report to the LHJ, the above inventory information required for tracking.

LHJ and community providers agree to follow the standards for the storage and handling of anti-TB medications found in the specific medication's FDA package insert.

Local Health Jurisdiction (LHJ) Information

Organization Name

Authorized Pharmacist/Doctor’s Name

Local Health Jurisdiction

National Provider Information (NPI) number

LHJ Primary Point of Contact (Person Placing Order)

First Name

Last Name

Email Address

Verify Email Address

Phone Number

Delivery Point of Contact (Person Who Will Receive Shipment)

Delivery POC First Name

Delivery POC Last Name

Delivery Point of Contact Email

Delivery Point of Contact Phone

Secondary Delivery Contact Email

Delivery Address

Street

Building/Suite

City

County

Zip Code

Receiving Hours

Please enter amounts requested for each item below. Enter “0” if none requested.

Ethambutol 400 MG, 100 Tab

Isoniazid 300 MG, 30 Tab

Levofloxacin 750 MG, 20 Tab

Isoniazid 300 MG, 100 Tab

Levofloxacin 750 MG, 100 Tab

Pretomanid 200 MG, 26 Tab

Linezolid 600 MG, 30 Tab

Pyrazinamide 500 MG, 90 Tab

Rifapentine (Priftin) 150 MG, 24 Tab (3x8 Blister)

Rifampin 300 MG, 60 Caps

Additional Comments, Explanations, or Requests

This is not a production system. Please use this link for the CDPH Testing Task Force.

https://labsupport.powerappsportals.us/testingprograms

Order Form Instructions

Additional Resources

List of Available Medications

Planning for Medications

Attestations

By placing this order, you agree to the following:

Local Health Jurisdiction (LHJ) Information

LHJ Primary Point of Contact (Person Placing Order)

Delivery Point of Contact (Person Who Will Receive Shipment)

Delivery Address

Please enter amounts requested for each item below. Enter “0” if none requested.