dru g formulary - Kern Health Systems

KFHC DRUG FORMULARY 37GENERIC BRAND FORMSTopical – Anti-infective, continued • SEE PREVIOUS PAGE G Selenium Selsun® 2.5% shampoo G Silver Sulfadiazine Silvadene® 1% creamTopical – AntifungalAmphotericin B Fungizone® 3% cream, oint, lotion G Econazole Spectazole® 1% creamRestriction: Restricted to pts. who have recently failed first line agents. (Clotrimazole, Miconazole) G Ketoconazole Nizoral® 2% creamKetoconazole Nizoral AD® 1% OTC shampoo G Nystatin Mycostatin® 100000 units/gm cream & oint, powderOxiconazole Oxistat® 1% cream G Terbinafine Lamisil® 1% crRestriction: Restricted to pts. who have recently failed first line agents. (Clotrimazole, Miconazole)Topical – Antifungal – Glucocorticoid G Clotrimazole & Betamethasone Lotrisone® 1%-0.5% cream G Nystatin & Triamcinolone Mycolog® cream, ointTopical – AntineoplasticFluorouracil Efudex® 1%, 5% cream, 1%, 2%, 5% solnTopical – Antiviral G Podofilox Condylox® 0.5% gel or solnTopical – ContraceptiveNorelgestromin - Ethinyl Estradiol Ortho-Evra®150mcg/20mcg/day patchRestriction: Plan does not cover replacement patches. Limited to 3 patches/28 days or 6 patches/56 days.DiaphragmTopical – Estrogens G Estradiol Climara® Biweekly- 0.025mg, 0.0375mg, 0.075mg, 0.1mgVivelle®Weekly- 0.025mg, 0.05mg, 0.075mg, 0.1mg patchTopical – Glucocorticoid Low Potency G Betamethasone Valisone® 0.05% cream, oint, lotion, Valerate-0.01%,0.1% cream, 0.1% oint, 0.05%, 0.1% lotionContinued on next page