dru g formulary - Kern Health Systems

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18GENERIC BRAND FORMSKFHC DRUG FORMULARYCentral Nervous System – Hypnotic G Chloral Hydrate Noctec® 250mg/5ml, 500mg/5ml syrup, 325mg, 500mg,650mg suppos, 250mg, 500mg capsuleCentral Nervous System – Migraine G Butabarbital, Caffeine, & Fioricet® 50mg-40mg-325mg tabletsAcetaminophenRestriction: 50 tablets maximum per month. G Butabarbital, Caffeine, & Aspirin Fiorinal® 50mg-40mg-325mg capsule/tabletsRestriction: 50 capsules maximum per month.Ergotamine & Caffeine Cafergot® 1mg-100mg tablet, 2mg-100mg supposErgotamine Tartarate2mg sl tablet G Isometheptene, Midrin® 65mg/100mg/325mg capDichloralphenazone & APAPRestriction: 45 capsules maximum per month.Central Nervous System – Migraine – TriptanThe Triptan medications are the largest expense category of the anti-migraine drugs. The Triptanmedications are restricted a maximum number of tablets per 30 days period and 3 dispensings in a365 days period. Patients whose demand exceeds the 3 fills are recommended to be considered forprophylactic medications and for a Neurology referralMedicationCost/9 tablets G Sumatriptan (Imitrex®) 50-100mg $20Almotriptan (Axert®) 12.5mg $182Eletripan (Relpax®) 40mg $234Zolmitriptan (Zomig®) 5mg $248Almotriptan Axert® 12.5mg tabletRestriction: 12 tablets in 40 days and with a maximum of 2 fills in a 12 month period.Eletripan Relpax® 40mg tabletRestriction: 6 tablets in 20 days and with a maximum of 4 fills in a 12 month period. G Sumatriptan Imitrex® 50mg, 100mg tablet onlyRestriction: Restricted to 9 tablets in 30 days with a maximum of 3 fills in a 12 month period.Zolmitriptan Zomig® 5mg tablet onlyRestriction: Restricted to 9 tablets in 30 days with a maximum of 3 fills in a 12 month period.
KFHC DRUG FORMULARY 19GENERIC BRAND FORMSCentral Nervous System – AntipsychoticFor Kern Family Health Care (KHS Medi-Cal) most of the straight antipsychotic agents are carved out to Medi-Cal. Pleasesee Appendix. For The Healthy Families Program patients these agents are covered though some may require priorauthorization- again see appendix.Central Nervous System – SedativeMany references on insomnia recommend against prescribing sedative medication on a nightly basis.KHS will promote this utilization. These medications will be restricted to the treatment of insomniaand 15 per 30 days. For those patients experiencing morning drowziness from the regular strengths ofthe Formulary medications low dose Temazepam (Restoril® 7.5mg) is offered. The newer insomniamedications such as Lunesta® and Sonata® require failure of Formulary medications and priorauthorization. G Temazepam Restoril® 15mg, 30mg capsule G Zolpidem Ambien® 5mg, 10mg tabletCentral Nervous System – StimulantRestricted to pts. between the ages of 4 and 16 years old with ADD/ADHD. G Amphetamine Combination Adderall®, Adderall XR® 5mg, 10mg, 20mg, 30mg tablet, 5mg, 10mg, 15mg,20mg, 25mg, 30mg cr tablet G Dextro-amphetamine Dexedrine® 5mg, 10mg tablet, 10mg, 15mg, cr capsules G Dexmethylphenidate Focalin®, Focalin XR® 5mg, 10mg tablet, 5mg, 10mg,15mg, 20mg,30mg capsuleLisdexamfetamine Vyvanse® 20mg, 30mg, 40mg, 50mg, 60mg, 70mg capsulesRestriction: Try and fail generic amphetamines first. G Methylphenidate Ritalin® 5mg, 10mg, 20mg tablet, 20mg cr tabletCholinergic G Bethanechol Urecholine® 5mg, 10mg, 25mg, 50mg tabletNeostigmine Prostigmin® 15mg tablet G Pyridostigmine Mestinon® 60mg tablet, 180mg cr tabletCholinesterase Inhibitor G Donepezil Aricept® 5mg, 10mg tabletRestriction: Prior authorization required, MMSE.Continued on next page
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