dru g formulary - Kern Health Systems

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Non-Formulary or Restricted Medication List • Prior Authorization Requirements58 KFHC DRUG FORMULARYNon-Formulary or Restricted Medication ListGENERIC BRAND CRITERIAFluoxetine Prozac® Pt. needs to fail generic immediate release Fluoxetine and90 mg weekly dose demonstrate a compliance problem. This strength isusually restricted to mental health providers.Interferon inj & Ribavirin orally Rebetron® If pt. has Hepatitis C refer to Hepatitis C programas they case manage the KHS Hepatitis C patients.Initial referral needs to include the viral load andgenotype lab results (and biopsy results if performed).Zaleplon Sonata® Pt. needs to fail Restoril®, Ambien®.Ketorolac Toradol® Pt. needs to fail Formulary NSAIDs. Medication has anallowed maximum of 5 days therapy.Levalbuterol Xopenex® Pt. needs to fail correctly dosed albuterol. If patient is notresponding to a short acting bronkodilator, the physicianneeds to consider inhaled steroid. Plan mayrequire a Pulmonologist consult.Bupropion Zyban® Pt. must provide a certificate from a recent smokingcessation class. Pt. probably should not be on otherantidepressant medications. Requires nicotinepatch therapy.
KFHC DRUG FORMULARYAAcarbose 23Accolate ® 35Accupril ® 11Acebutolol 13Acetaminophen 41Acetasol HC ® 32Acetazolamide 29Acetic Acid 38Actonel ® 32Acetylcysteine 35Actigall ® 20Actos ® 24Acular ® 30Acular LS ® 30Acyclovir 8Adalat ® 14Adalat CC ® 14Adderall ® 19Adderall XR ® 19Advair ® 35AeroBID ® 34Aerochamber ® 35Albalon ® 44Albuterol 34Albuterol HFA 34Alcaine ® 28Alcohol 47Aldactone ® 14Aldomet ® 11Alendronate 32Alesse ® 31Alkeran ® 10Allopurinol 9Almotriptan 18Alphagan ® 29Alphagan P ® 29Altace ® 11Altretamine 9INDEX–GENERIC and BRANDAluminum Acetate 47Aluminum Acetate w/AceticAcid 32Aluminum Carbonate 42Aluminum Hydroxide 42Aluminum & MagnesiumHydroxides 42Alum. & Mag. Hydroxides w/Simethicone 42Alum. Hydroxide & Mag.Trisilicate 42Alum. Hydroxide & Mag.Carbonate 42Alupent ® 34Amaryl ® 24Ambien ® 19Aminophylline 36Amiordarone 11Amitriptyline 16Amlodipine 13Amoxicillin 5Amoxicillin/Clavulanate 5Amoxil ® 5Amphetamine Combination 19Amphojel ® 42Amphotericin B 37Ampicillin 5Amylase, Lipase, & Protease 20Anafranil ® 16Anastrozole 9Ansaid ® 28Antabuse ® 20Anthralin 38Antivert ® 43Anturane ® 9Anusol-HC ® 44Apresoline ® 14Apidra ® 24Aralen ® 7Aranesp ® 23Arava ® 10Aricept ® 19Arimidex ® 9Aristocort ® 25Armour Thyroid ® 26Asacol ® 21ASA 41Ascriptin ® 41Aspirin 41Aspirin, Alum & Mg Hydroxides,Calcium Carbonate 41Astelin ® 35Asulfidine ® 6Atarax ® 32Atenolol 13Ativan ® 17Atorvastatin 12Atovaquone 7Atropine 30Atrovent ® HFA 35Augmentin ® 5Auralgan ® 32Auranofin 10Avandia ® 24Avapro ® 11Axert ® 18Azathioprine 10, 26Azelastine 28, 35Azithromycin 4Azopt ® 29BBacitracin 28, 47Bacitracin & Polymyxin 28Baclofen 26Bactrim ® 6Bactroban ® 36Balsalazide 21Baraclude ® 9Basaljel ® 42Beclomethasone 34Benadryl ® 44Benadryl Decongestant ® 45Benazepril 11Benemid ® 9Benicar ® 11Bentyl ® 6Benzagel ® 47Benzocaine & Antipyrine 32Benzonatate 33Benzoyl Peroxide 47Betagan ® 29Betamethasone 37, 38Betapace ® 12Betaxolol 13, 29Bethanechol 19Betopic ® 29Biaxin ® 4Bicalutamide 9Bimatoprost 29Bisacodyl 43Bismuth Subsalicylate 43Blocadren ® 13Blood Glucose Strips 47Brethine ® 34Brimonidine 29Brinzolamide 29Bromfed ® 45Bromocriptine 9Brompheniramine 44Brompheniramine &Phenylephrine 44Brompheniramine &Pseudoephedrine 44,45Budesonide 34, 36Bupropion 17Buspar ® 17Buspirone 17INDEX–GENERIC and BRAND
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viKFHC DRUG FORMULARYTopical - Misc
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KFHC DRUG FORMULARY 5GENERIC BRAND
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dru g formulary - Kern Health Systems

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