Microsoft word - attch d clinical formulary policy - revision #1.doc
DEPARTMENT OF HEATLH AND HUMAN SERVICES CLINICAL FORMULARY Effective Date: January 1, 2005 CLINICAL FORMULARY TABLE OF CONTENTS SECTION TITLE PAGE NUMBER(S) PREFACE This is a managed care clinical formulary or book containing the names of drugs and their uses. Those concerned with the prescribing, dispensing, and reimbursement of medicines within the Department should refer to this book in choosing quality cost-effective treatment. A managed care clinical formulary is different from a hospital clinical formulary in that it does not include dosage forms and actual drug cost. (Actual costs change frequently and, therefore, do not remain accurate over time). Instead, this clinical formulary lists the relative cost of therapy. The drugs and guidelines on this clinical formulary have been approved for use by the Department Director. CRITERIA OF CHOICE Examples of the criteria used to determine the clinical formulary status of products include the following:
Effect on ER visits and hospitalizations
This clinical formulary is intended to be a helpful guide in the decision-making process. The final choice of the drug rests solely with the prescriber. PRODUCT NAME This is the most common brand name of the drug. GENERIC NAME This is the generic or chemical name of the drug. GENERIC SUBSTITUTION Generic substitution is the process by which a pharmacist dispenses a generic equivalent of a product rather than the branded product. Generic substitution will be done whenever a generic equivalent is available. When medical necessity dictates that a branded product be used, approval using the off-formulary process will be necessary.
CLINICAL FORMULARY ORGANIZATION The clinical formulary is organized by a combination of therapeutic classes and diagnoses. The drug products are listed by generic name (small print in left column) and common brand name (large print in right column). NONFORMULARY DRUGS When a patient requires a drug (either nonprescription or prescription) for medical reasons that is not on the clinical formulary, approval to use the drug must be obtained from the Chief of Medical Services. It is the responsibility of the medical services provider attending to the patient to obtain the Chief of Medical Services’ approval for off-formulary drugs whether the drug was prescribed by themselves or recommended by a consultant and subsequently deemed medically necessary by themselves. Nonformulary psychotropic medication shall be approved by the Chief of Medical Services. The Chief of Medical Services’ approval for all off-formulary drugs is to be obtained according to the attached Guidelines “Approval of Nonformulary Medications.” CLINICAL FORMULARY MAINTENANCE POLICY All clinical formulary decisions will be made by the Clinical Formulary Committee. Additions/Deletions: The addition/deletion of drugs to the clinical formulary will be based on comparative efficacy and drug-specific parameters. Evaluations will be based on information from respected medical references, primary literature, and standard-of-practice guidelines. Cost will be considered in clinical formulary decisions when little or no difference exists in comparative efficacy and drug-specific parameters. If you have any comments or concerns regarding the clinical formulary or a request to have a drug reviewed by the Chief of Medical Services, please submit the following: CLINICAL FORMULARY CHANGE REQUEST
(Please send this form directly to the Clinical Formulary Committee)
Drug involved (generic name): Person completing form (name, profession, facility, phone number): Reason for request (please attach any supporting articles or literature and provide your comments):
THIS IS REQUIRED Other comments: ____________________________________________________ PLEASE DO NOT WRITE BELOW THIS LINE OAKLAND COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES OFF FORMULARY MEDICATION REQUEST
Facility:__________________________________
Requesting Medical Services Provider:______________________________________________
Medical condition being treated:___________________________________________________
Personal history (medical condition): _______________________________________________
______________________________________________________________________________
Allergies: _____________________________________________________________________
Present medications: ____________________________________________________________
Drug requested: ________________________________________________________________ Request is:
Rational for requesting nonformulary medication:_____________________________________
______________________________________________________________________________
______________________________________________________________________________
Comments:____________________________________________________________________
_____________________________________________________________________________
Signature:_______________________________________
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Request for Review (additional information supplied):__________________________________
______________________________________________________________________________
Comments: ____________________________________________________________________
______________________________________________________________________________
Signature: _______________________________________ Date: _________________________
ANTIMICROBIALS AND INFECTIOUS DISEASE ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS 12 NEUROLOGICAL DRUGS BLOOD MODIFIERS CARDIOVASCULAR AGENTS INFLAMMATORY DISEASES PSYCHIATRIC
ANTIDEPRESSANT AND ANTIOBSESSIONAL MEDICATIONS
EYE, EAR AND NOSE GASTROINTESTINAL DRUGS HORMONES DIABETES MELLITUS
MISCELLANEOUS SKIN & MUCOUS MEMBRANE AGENTS
WOMENS HEALTH RESPIRATORY DRUGS SUPPLEMENTS I.V. SOLUTIONS MISCELLANEOUS DRUGS Schedule B Schedule A ANTIMICROBIALS AND INFECTIOUS DISEASE
Antibiotics are considered to be either first line agents or second line agents. First line agents signified by (FL) are to be tried first unless one of the following conditions exists:
Prior history of failure of the first line agent in a reoccurring infection. Allergy or history of prior adverse side effects of the first line agent.
Patient is HIV positive or otherwise significantly immune-compromised
making the use of a first line agent dangerous in that patient.
Culture report showing resistance to first line agents. Sanford’s “Guide to Microbial Therapy” lists second line drug as
Second line agents are signified by (SL) and are generally to be used after a first line agent. When a second line agent is used as the initial treatment for any infection, the rationale for the medical necessity of its use must be documented in the medical record. A. BETA LACTAM ANTBIOTICS MACROLIDES TETRACYCLINES FLUOROQUINOLONES SULFONAMIDES AND SULFONES ANTI-TUBERCULOSIS/ANTI-MYCOBACTERIAL AGENTS ANTI-VIRALS Amantadine SYMMETREL Combination Therapy:
Interferon alfa-2b, recombinant Injection
NUCLEOTIDE/NUCLEOSIDE ANALOGUES NNTI – NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS PI – PROTEASE INHIBITORS FIXED DOSE COMBINATION MEDICATIONS ANTI-FUNGALS I. MISCELLANEOUS ANTI-INFECTIVES
*For Aspirin allergy or contra-indication only 5. CARDIOVASCULAR AGENTS
ANTIARRHYTHMICS AND CARDIAC GLYCOSIDES ANTIHYPERTENSIVES 1. DIURETICS 2. BETA BLOCKERS 3. ALPHA AND BETA BLOCKERS 4. CALCIUM CHANNEL BLOCKERS 5. ACE INHIBITORS 6. ANGIOTENSIN II RECEPTOR ANTAGONIST 7. ALPHA ADRENERGIC BLOCKERS AND CENTRALLY ACTING Clonidine (ORAL ONLY) CATAPRES 8. VASODILATORS NITRATES ANTIHYPERLIPIDEMICS
HMG CO-A reductase inhibitors (do not use with protease inhibitors) Lovastatin
6. PAIN AND INFLAMMATORY DISEASES NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
B. NARCOTIC ANALGESICS MODERATE PAIN
Hydrocodone bitartrate and acetaminophen
SEVERE PAIN NARCOTIC ANTAGONIST: OTHER ANALGESTIC ANTI GOUT MEDICATIONS NEUROPATHIC PAIN Amitriptyline 7. PSYCHIATRIC MEDICATIONS General Guidelines:
When possible, do not use two medications of the same type (e.g., two
antidepressants, two antipsychotics, or two mood stabilizers) when one would suffice. When two or more of the same type of medication are prescribed at the same time, the rationale must be documented in the chart (i.e., mental health progress note) initially and then at least semiannually thereafter.
When possible, do not prescribe more than a one- or two-week supply of
medication during a therapeutic trial. Once a maintenance phase is reached, one month orders with renewals can be written, if appropriate.
If dosage changes are required before the current supply of medication is
exhausted, a new prescription must be written by the psychiatrist.
A. ANTIDEPRESSANT AND ANTIOBSESSIONAL MEDICATIONS
Guidelines Regarding Antidepressant Medications:
Generic fluoxetine is the first choice agent when an antidepressant is
required if there are no medical reasons to do otherwise. Valid medical reasons to not choose fluoxetine include (but are not limited to) previous nonresponse or intolerable side effects. The psychiatrist may then choose any of the other antidepressant medications in the clinical formulary. Despite their lower costs, as indicated in the clinical formulary, due to their toxicity in overdose, use of tricyclic and other nonselective cyclic antidepressants is not encouraged unless their use is clinically indicated. Patients who were prescribed antidepressant medications other than the above first choice agent prior to the promulgation of these guidelines and are doing well may (and should) remain on their current medication unless there are medical reasons to do otherwise. When patients are not receiving the first choice agent above, the rationale must be documented in the chart (i.e., mental health progress note) initially and then at least semiannually thereafter.
Nefazodone (due to its current “black box” warning) and amoxapine (due
to its infrequent use) are not included in this section. Those patients currently prescribed and therapeutically benefiting from nefazondone or amoxapine may be continued on these agents by the prescribing psychiatrist submitting an off-formulary request to the Chief of Medical Services during the three-month grace period following the promulgation of these guidelines.
ANTIPSYCHOTIC MEDICATIONS Guidelines Regarding Antipsychotic Medications: Risperdone and ziprasidone are the first choice agents when an antipsychotic
medication is required if there are no medical reasons to do otherwise. Valid medical reasons to not choose risperidone or ziprasidone include (but are not limited to) previous nonresponse or intolerable side effects to these agents or medical contraindications to their use. If an adequate therapeutic trial of either risperidone or ziprasidone fails or produces intolerable side effects, the psychiatrist may then choose any of the other antipsychotic medications in the clinical formulary. Due to its risk of agranulocytosis and related need for near perfect patient compliance, exacting monitoring requirements, and cost, clozapine is considered a third line agent to be used after the failure of other antipsychotic medications or when otherwise clinically indicated. Patients who were prescribed antipsychotic medications other than the above first choice agents prior to the promulgation of these guidelines and are doing well may (and should) remain on their current medication unless there are medical reasons to do otherwise. When patients are not receiving one of the first choice agents above, the rationale must be documented in the chart (i.e., mental health progress note) initially and then at least semiannually thereafter.
Haloperidol HALDOL Chlorpromazine (not spansule)
MOOD STABILIZER MEDICATIONS Guidelines Regarding Mood Stabilizer Medications: All medication, listed in the Mood Stabilizer Medication area in clinical
formulary Section 7: Psychiatric Medications, are currently considered first choice agents.
Gabapentin is not included in the clinical formulary as a mood stabilizer due
to lack of scientific evidence of its efficacy as a primary agent in the treatment of mania. Those patients currently prescribed and therapeutically benefiting from gapapentin may be continued on this agent by the prescribing psychiatrist submitting an off-formulary request to the Chief of Medical Services during the three month grace period following the promulgation of these guidelines.
Lithium carbonate Carbamazepine TEGRETOL Divalproex
ANTI-ANXIETY/HYPNOTIC MEDICATIONS Guidelines Regarding Anti-Anxiety/Hypnotic, Beta Adrenergic Receptor Antagonist, and Anti-Parkinsonian Medications: Current data is not available to support guidelines in addition to existing
comments and directions presently contained in the clinical formulary.
BETA ADRENERGIC RECEPTOR ANTAGONISTS STIMULANTS / ATTENTION DEFICIT HYPERACTIVITY DISORDER 8. EYE, EAR AND NOSE
1. ANTI-INFECTIVES (OPHTHALMIC)
2. ANTI-INFLAMMATORIES
3. ANTIGLAUCOMA AGENTS
TOPICAL Timolol MISCELLANEOUS OPHTHALMIC DRUGS
Tetracaine (local anesthetic) PONTOCAINE
1. ANTI-INFECTIVES AND OTHER DRUGS Polymyxin/neomycin/hydrocortisone CORTISPORIN
The Art and Architecture of Powerful Questions "The important thing is to never stop questioning.” Einstein invites us to continue questioning. Why? This query provokes a variety of impassioned responses: • Questions are a prerequisite to learning. • Questions are a window into creativity and insight. • Questions motivate fresh thinking. • Questions challenge outdated
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