dru g formulary - Kern Health Systems

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2GENERIC BRAND FORMSKFHC DRUG FORMULARYAnalgesics – Narcotic, continued • SEE PREVIOUS PAGE G Hydromorphone Dilaudid® 1mg, 2mg, 4mg tablet, 3mg supposRestriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnosis.Levorphanol Levo-Dromoran® 2mg tabletRestriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnosis. G Methadone Dolophine® 5mg, 10mg tabletRestriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnosis. G Morphine MS-Contin® 10mg/5ml, 20mg/5ml oral soln, 20mg/ml conc,10mg, 15mg, 30mg tablet, 15mg, 30mg, 60mg,100mg, 200mg cr tabletRestriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnosis. G Oxycodone Oxy-Contin® 5mg, 30mg tablet, 10mg, 20mg, 40mg,80mg cr tabletRestriction: Restricted to use by KHS plan Oncologists or Pain Specialist Physicians. (For other physicians the pt. needsto fail time release morphine and/or methadone. Authorizations are considered on an individual basis). G Oxycodone w/Acetaminophen Percocet® 5mg-325mg tablet, 5mg-500mg capsuleRestriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnosis.Oxymorphone Numorphan® 5mg supposRestriction: Limited to cancer patients or plan Pain Specialist Physicians. Authorization required for other diagnosis. G Tramadol Ultram® 50 mg tabletRestriction: Tramadol is not recommended for pts. with abuse potential. Contraindicated with alcohol, hypnotics, centrallyacting analgesics, opioids, and psychotropic agents. Seizures and serotonin syndrome may occur with antidepressants,triptans, lithium, enzyme inducing medications, and some antibiotics.Analgesics – Non-narcotic G Choline & Magnesium Trisalicylates Trilisate®500mg/5ml liquid, 500mg, 750mg, 1000mg tabletsRestriction: Restricted to pts. that have RA.
KFHC DRUG FORMULARY 3GENERIC BRAND FORMSAnti-bacterialInappropriate use of antibiotics is a concern nationwide. Resistance to antibiotics is growingnationally. Additionally, antibiotics are ineffective on viral infections. Uncomplicated bronchitisdoes not warrant antibiotic use. Please reference www.AWARE.md or 916-779-6620 for moreinformation on appropriate use of antibiotics. KHS has limits on days supply and number of fillsper month on many antibiotics to help ensure appropriate use. A 10 day supply every 30 days is inplace for the cephalosporins, macrolides, penicillins, and quinolone classes. Prior authorizationjustifying the necessity for longer or more frequent dosing will be needed for therapies exceedingthose limits.Anti-bacterial – Cephalosporin G Cefaclor Ceclor® 250mg, 500mg capsuleRestriction: Restricted to pts. > 50 yo with lower respiratory infections. G Cefadroxil Duricef® 500mg capsule, 1g tabletRestriction: Restricted to pts. > 50 yo with lower respiratory infections. G Cefdinir Omnicef® 125mg/5ml susp, 250mg/5ml suspRestriction: Restricted to pts. with OM < 8 yo failing 1st line ABX’s. G Cefpodoxime Vantin® 50mg/5ml, 100mg/5ml susp, 100mg, 200mg tabletRestriction: Restricted to pts. with OM < 8 yo failing Omnicef. G Cefprozil Cefzil® 250mg, 500mg tabletRestriction: Restricted to pts. > 50 yo with lower respiratory infection. G Cefuroxime Ceftin® 125mg, 250mg, 500mg tabletRestriction: Restricted to pts. > 50 yo with lower respiratory infections. G Cephalexin Keflex® 125mg/5ml, 250mg/5ml susp, 250mg,500mg capsuleAnti-bacterial – MacrolideZithromax® 250mg tablets have a maximum of 6 (5 days therapy) as the <strong>dru</strong>g continues working fora number of additional days.TherapyDays Supply CostErythromycin 500mg QID 10 $13Azithromycin® 500mg x1, 250mg QD 5 $15Clarithromycin® 500mg ii QD 10 $18Continued on next page
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