dru g formulary - Kern Health Systems

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48 KFHC DRUG FORMULARY*See Healthy Families Exception Warning on Page 41GENERIC BRAND FORMSTopical – Anti-Infective/OTCOVER THE COUNTER DRUGSKetoconazole Nizoral AD® 1% shampooTopical – Astringent/OTC G Calamineplain, phenolated lotionTopical – Glucocorticoid/OTC G Hydrocortisone0.5%,1% cream,oint or lotionTopical – Miscellaneous/OTCCoal Tar2.5% emulsionTopical – Scabicide/OTC G Permethrin Nix® 1% cream rinse G Pyrethrins & Piperonyl Rid® 0.17%-2%, 0.18%-2.2%, 0.2%-1%, 0.2%-2%, 0.3%-3% liquidVaginal – Anti-infective/OTCButoconazole Mycelex® 2% vaginal cream G Clotrimazole Gyne-Lotrimin® 1% vaginal cream, 100mg vaginal tablet G Miconazole Monistat® 2% vaginal cream, vaginal kit, 100mg, 200mg vaginalsupposVitamins/OTC G Pediatric Vitamins Tri-Vi-Sol® ADC plain and w/iron dropsRestricted: Restricted to pts. < 5 yo. G Prenatal Vitamins w/Minerals,Iron & Folic AcidRestricted: Pregnant female pts. only. G Pyridoxine (Vitamin B-6) G Vitamin E0.1mg, 1mg FA capsule, 0.4mg, 0.8mg, 1mg FA tablet10mg, 25mg, 50mg, 100mg tablet400 IU, 1000 IU capsule
KFHC DRUG FORMULARYAppendix*See Healthy Families Exception Warning on Page 41GENERIC These medications are carved out BRAND by Medi-Cal as stated in the December FORMS 2011 Medi-Cal bulletin. The prescriptions for any of thecarved out medications are transmitted to Medi-Cal. If the claim for the above drugs is rejected by EDS for a Kern Family HealthCare patient with a message stating to bill the primary insurance it is likely the patient has insurance in addition to KernHealth Systems.Psychotherapeutic Agents for Kern Family Health Care Patients (KHS Medi-Cal Patients) are Carved Out to Fee for Service Medi-CalAmantadine*Aripipazole..................Abilify ®Asenapine.....................Saphris ®Benztropine..................Cogentin ®Biperidin.......................Akineton ®Chlorpromazine.............Thorazine ®Chlorprothixene.............Taractan ®Clozapine.....................Clozaril ®Selegiline.....................Emsam ®Fluphenazine................Prolixin ®Haloperidol...................Haldol ®Iloperidone...................Fanapt ® *Isocarboxazid..............Marplan ®LithiumLoxapine......................Loxitane ®Lurasidone....................Latuda ®Mesoridazine................Serentil ®Molindone....................Moban ®Olanzapine...................Zyprexa ®*Olanzapine/Fluoxetine.Symbyax ®*Paliperidone................Invega ®Perphenazine................Trilafon ®*Phenelzine..................Nardil ®*Pimozide....................Orap ®Procyclidine...................Kemadrin ®*Promazine..................Sparine ®*Quetiapine..................Seroquel ®*Risperidone.................Risperdal ®Thioridazine..................Mellaril ®Thiothixene...................Navane ®*Tranylcypromine..........Parnate ®*Trifluoperazine.............Stelazine ®*Trifluopromazine..........Vesprin ®Trihexyphenidyl.............Artane ®Ziprasidone...................Geodon ®Psychotherapeutic Agents for The Healthy Families Program patients are billed to Kern Health SystemsAlcohol, Heroin Detoxification and Dependency Treatment drugsAcamposate........................................Campral ®Buprenorphine/Naloxone......................Suboxone ®Buprenorphine.....................................Subutex ® Naltexone...........................................Revia ®49Abacavir............................ Ziagen ®Abacavir, Lamivudine........... Epzicom ®Abacavir, Lamivudine &Zidovudine......................... Trivizir ®Amprenavir........................ Agenerase ®Atazanivir.......................... Reyataz ®Darunavir........................... Prezista ®Delavirdine........................ Rescriptor ®Efavirenz........................... Sustiva ®Antiviral Agents Carved Out by Medi-CalEfavirenz, Emtricitabine,Tenofivir............................ Atripla ®Emtricitabine, Rilpivirine,Tenofovir........................... Complera ®Emtricitabine...................... Emitriva ®Enfuvirtide......................... Fuzeon ®Fosamprenavir................... Levixa ®Indinavir............................ Crixivan ®Lamivudine & Zidovudine..... Combivir ®Lamivudine........................ Epivir ®Lopinavir & Ritonavir........... Kaletra ®*Will require TAR from Medi-CalMaraviroc.......................... Selzentry ®Nelfinavir........................... Viracept ®Nevirapine......................... Viramune ®Raltegravir......................... Isentress ®Rilpivirine.......................... Edurant ®Ritonavir............................ Norvir ®Saquinavir......................... Invirase ®Stavudine.......................... Zerit ®Tenofovir........................... Viread ®Tenofovir, Emtricitabine........ Truvada ®Tipranavir.......................... Aptivus ®
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iiKFHC DRUG FORMULARYNon-Formulary
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Page 50 and 51: OVER THE COUNTER DRUGS42 KFHC DRUG
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dru g formulary - Kern Health Systems

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