dru g formulary - Kern Health Systems

20GENERIC BRAND FORMSKFHC DRUG FORMULARYCholinesterase Inhibitor, continued • SEE PREVIOUS PAGE G Rivastigmine Exelon® 1.5mg, 3mg, 4.5mg, 6mg capsuleRestriction: Prior authorization required, MMSE.Drug Dependency TherapyDisulfiram Antabuse® 250mg, 500mg tablet G Nicotine patches NicodermCQ® 7mg, 14mg, 21mg patchesRestriction: Requires current certificate of cessation counseling. 2 trials per 12 month period. G Varenicline Chantix® 0.5mg, 1mg tabletRestriction: Prior authorization required.Gastrointestinal – Antidiarrheal G Diphenoxylate & Atropine Lomotil® 2.5mg/5ml liquid, 2.5mg tablet G Paregoric2mg/5ml liquidGastrointestinal – AntiemeticDronabiol Marinol® 2.5mg, 5mg, 10mg capsuleRestriction: Restricted to use by KHS plan Oncologist. G Granisetron Kytril® 1mg tabletRestriction: Prior authorization required. G Ondansetron Zofran® 4mg, 8mg tablet, ODTRestriction: Allow up to 3 days of therapy per month/treatment. G Prochlorperazine Compazine® 5mg, 10mg tablet, 15mg cr capsule,2.5mg, 5mg, 10mg suppository, 5mg/5ml syrup G Promethazine Phenergan® 6.25mg/5ml, 25mg/5ml syrup,12.5mg, 25mg, 50mg tablet or suppositoryRestriction: Restricted to pts. > 2 yo. G Trimethobenzamide Tigan® 100mg, 250mg, 300mg capsulesGastrointestinal – DigestantAmylase, Lipase, & Proteasevarying strengths -capsule, tablet,chewable tablet, ec tabletRestriction: Prior authorization required. G Ursodiol Actigall® 300mg capsuleRestriction: Prior authorization required.