dru g formulary - Kern Health Systems

32GENERIC BRAND FORMSKFHC DRUG FORMULARYOsteoporosis – Biphosphonates G Alendronate Fosamax® 35mg, 70mg weekly tablet onlyRestriction: Restricted to pts. > 61 yo or having T-score < – 2.5 G Risdronate Actonel® 35mg weekly tabletRestriction: Prior authorization required.Otic G Aluminum Acetate w/Acetic Acid Domeboro Otic® 2% otic soln G Benzocaine & Antipyrine Auralgan® 1.4%-5.4% otic solnCiprofloxacin & Dexamethasone Ciprodex® 0.3%-0.4% otic suspRestriction: Restricted to Plan ENT providers. If the member recently failed Cortisporin® or Floxin® Otic considerationwill be given to a prior authorization request. G Hydrocortisone & Acetic Acid Acetasol HC® otic soln G Neomycin, Polymyxin & Cortisporin® otic susp or solnHydrocortisone G Ofloxacin Floxin® Otic 0.3% otic solnRestriction: 5 ml size only.Respiratory – AntihistamineLoratadine failure will be required prior to allowing branded non or low sedating antihistamines.1st generation antihistamines are considered to be more effective than the later generations.National guidelines suggest better outcomes with treatment with nasal steroids as opposed toantihistamines. The FDA recommends not to use antihistamines and cough preparations inindivduals less than 2 years of age.Allergic Rhinitis adult patients are recommended to be treated with Nasal Steroids. G Hydroxyzine Atarax® 10mg/5ml syrup, 10mg, 25mg, 50mg tablet,25mg, 50mg capsule G Cetirizine Zyrtec® 5mg, 10mg tablet, 1mg/ml liqRestriction: Limited to patients < 18 years old or asthma patients. Liquid allowed < 5 yo.Respiratory – Antihistamine – Antitussive G Promethazine & Codeine Phenergan w/Codeine® 6.25mg-10mg/5ml syrupRestriction: Only for patients > 2 yo. Plan allows maximum 240 mls per 30 days.Continued on next page