dru g formulary - Kern Health Systems

Non-Formulary or Restricted Medication List • Prior Authorization RequirementsKFHC DRUG FORMULARY 57GENERIC BRAND CRITERIADipyridamole/Aspirin Aggrenox® Pt. needs to fail generic Aspirin & Dipyridamole orPlavix®.Imiquimod Aldara® Pt. needs to fail Condylox®.Erythromycin, Benzoyl Peroxide Benzmycin® Pt. needs to use generic ingredients separately.Tolterodine Detrol® Pt. needs to fail generic Ditropan.Oxybutynin Ditropan XL® Pt. needs to fail regular release generic Ditropan®.Pimercolimus Elidel® Pt. needs to fail topical Steroids (triamcinolone,betamethasone). Not allowed under the age of 2 years.Raloxifene Evista® Pt. needs to fail Plan estrogens or desire not to take anestrogen.Ziprasidone Geodon® Pt. needs to fail Zyprexa® or Seroquel®(Healthy Families Only). For all other KHS Medi-Calpts. the psychotherapeutic medications are coveredby fee for service Medi-Cal.Insulin pen cartridges Insulin Pen systems Reserved for pts. who have either sight and/orNovolog® Humalog® coordination problems such as Parkinsonism.Physician needs to submit a referral documentinglimitation of pt.PEG Nu-lytely® Use generic Go-lytely® (PEG soln).Formula PowderStandard formulas are available through WIC. Plan allowsfor specialty formula for premature infants, pleaseprovide gestational age, birth weight and current rate.Other specialty formulas require prior authorization withsupporting documentation.Doxycycline Periostat® Pt. needs to fail 50mg or 100mg Formulary Doxycycline.Tacromilus Protopic® Pt. needs to fail topical Steroids (Triamcinolone,Betamethasone). Not allowed under 2 years of age.Non-Formulary or Restricted Medication ListContinued on next page