dru g formulary - Kern Health Systems

Recommendations

Info

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
KFHC DRUG FORMULARY 33GENERIC BRAND FORMSRespiratory – Antihistamine – Antitussive, continued • SEE PREVIOUS PAGE G Promethazine & Phenergan DM® 6.25mg-15mg/5ml syrupDextromethorphanRestriction: Only for patients > 2 yo. G Promethazine, Phenylephrine Phenergan-VC Codeine® 5mg-6.25mg-10mg/5ml syrup& CodeineRestriction: Only for patients > 2 yo. Plan allows maximum 240 mls per 30 days. G Pseudoephedrine, Chlorpheniramine Cardec-DM®15mg-12.5mg-4mg syrup& DextromethorphanRestriction: Only for patients < 6 yo.Respiratory – Antihistamine – Decongestant G Promethazine & Phenylephrine Phenergan-VC® 6.25mg-5mg/5ml syrupRestriction: Only for patients > 2 yo.Respiratory – Antiserotonin G Cyproheptadine Periactin® 2mg/5ml syrup, 4mg tabletRespiratory – Antitussive G Benzonatate Tessalon® 100mg, 200mg perles G Saturated solution of potassium SSKI® 1g/ml solniodideRespiratory – Antitussive – Expectorant G Codeine & Guaifenesin Robitussin AC® 10mg-100mg/5ml soln or syrupRestriction: Plan allows maximum 240 mls per 30 days. G Codeine, Guaifenesin & Robitussin DAC® 10mg-100mg-30mg/5ml syrupPseudoephedrineRestriction: Plan allows maximum 240 mls per 30 days. G Terpin Hydrate & CodeineRestriction: Plan allows maximum 75 mls per 30 days.10mg/5ml elixir
Page 4: iiKFHC DRUG FORMULARYNon-Formulary
Page 8: viKFHC DRUG FORMULARYTopical - Misc
Page 11 and 12: KFHC DRUG FORMULARY 3GENERIC BRAND
Page 39: KFHC DRUG FORMULARY 31GENERIC BRAND
Page 44 and 45: 36GENERIC BRAND FORMSKFHC DRUG FORM
Page 50 and 51: OVER THE COUNTER DRUGS42 KFHC DRUG
Page 52 and 53: OVER THE COUNTER DRUGS44 KFHC DRUG
Page 54 and 55: 46 KFHC DRUG FORMULARY*See Healthy
Page 64 and 65: Non-Formulary or Restricted Medicat
Page 66 and 67: Non-Formulary or Restricted Medicat
Page 68 and 69: KFHC DRUG FORMULARYINDEX-GENERIC an
Page 74: KFHC DRUG FORMULARYINDEX-GENERIC an

dru g formulary - Kern Health Systems

Create successful ePaper yourself

Delete template?

Save as template?