dru g formulary - Kern Health Systems

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6GENERIC BRAND FORMSKFHC DRUG FORMULARYAnti-bacterial – Quinolone, continued • SEE PREVIOUS PAGE G Ofloxacin Floxin® 200mg, 300mg, 400mg tabletAnti-bacterial – Sulfonilamide G Sulfadiazine500mg tablet G Sulfamethoxazole & Trimethoprim Bactrim®/Septra®400mg-80mg, 800mg-160mg, 200mg-40mg/5ml susp G Sulfasalazine Asulfidine® 250mg/5ml susp, 500mg tablet & ec tablet G Sulfisoxazole Gantrisin® 500mg/5ml susp & syrup, 500mg tabletAnti-bacterial – Tetracycline G Doxycycline Vibramycin® 50mg, 100mg capsule, 100mg tablet G Minocycline Dynacin® 50mg, 75mg, 100mg capsulesRestriction: Restricted to plan dermatologists. Failed Doxycycline therapy. G Tetracycline Sumycin® 125mg/5ml susp, 250mg, 500mg capsule or tabletAnticholinergic G Dicyclomine Bentyl® 10mg/5ml syrup, 10mg, 20mg capsule, 20mg tabletGlycopyrrolate Robinul® 1mg, 2mg tablet G Hyoscyamine Levsin® 0.125mg/ml dropsAnti-infective G Metronidazole Flagyl® 250mg, 500mg tabletAnti-infective – AntifungalAuthorization will not be allowed for cosmetic purposes and maximum therapy is 6 weeks forfingernails, 12 weeks for toenails. Sanford, et al, suggest that Terbinafine (Lamisil®) 250mg QDhas one of the highest effectiveness rates (70-81%) of the FDA approved treatments. Sanfordrecommends ascertaining the ALT & AST levels prior to initiation of therapy since these <strong>dru</strong>gsshould not be used in chronic or active liver disease. KOH or positive culture required. G Clotrimazole Mycelex® 10mg troche G Fluconazole Diflucan® 50mg, 100mg, 150mg, 200mg tabletRestriction: Restricted to pts. w/cancer, AIDS or AIDS related conditions, or coccidioides immitis (Valley Fever). The150mg is restricted to female pts. w/vaginal candidiasis and a quantity of 2 tablets in 30 days. A multiple day regimenalternative should be considered for patients failing 2 tablets in less than 30 days. Patients having multiple vaginalinfections should be considered for authorization of 100mg weekly for 6 months.Griseofulvin & Ultramicrosize Grisactin® 125mg/5ml susp (microsize)Restriction: Suspension is for children < 12 yo.Continued on next page
KFHC DRUG FORMULARY 7GENERIC BRAND FORMSAnti-infective – Antifungal, continued • SEE PREVIOUS PAGE G Itraconazole Sporanox® 100mg capsuleRestriction: Failed fluconazole therapy. G Ketoconazole Nizoral® 200mg tablet G Nystatin Mycostatin® 100000 units/ml susp, 500,000u tablet G Posaconazole Noxafil® 40mg/ml suspRestriction: Prior authorization required. G Terbinafine Lamisil® 250mg tabletRestriction: 12 week therapy maximum duration.Anti-infective – Antihelmintic G Atovaquone Mepron® 750mg/5ml suspRestriction: Prior authorization required. G Mebendazole Vermox® 100mg chewable tabletThiabendazole Mintezol® 500mg/5ml susp, 500mg chewable tabletAnti-infective – LeprosyClofazimine Lamprene® 50mg, 100mg capsuleDapsone25mg, 100mg tabletAnti-infective – Antimalarial G Chloroquine Aralen® 250mg tablet G Hydroxychloroquine Plaquenil® 200mg tabletPrimaquine26.3mg tabletAnti-infective – AntiprotozoalFurazolidone Furoxone® 50mg/15ml susp, 100mg tablet G Paromomycin Humatin® 250mg capsulePyrimethamine Daraprim® 25mg tabletAnti-infective – Anti-tubercularCycloserine Seromycin® 250mg capsule G Ethambutal Myambutal® 100mg, 400mg tablet G Isoniazid INH® 50mg/5ml syrup, 50mg, 100mg, 300mg tabletIsoniazid & Rifampin Rifamate® 150mg-300mg capsuleContinued on next page
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