Rchc formulary in excel format_122712.xls

CODE 1 - RESTRICTED TO MILD-MODERATE DEMENTIA FOR CODE 1 - MAX (# 45 TABS/FILL), (3 FILLS/75 DAYS) CODE 1 - MAX (# 10 PATCHES/FILL), (3 FILLS/75 DAYS) CODE 1 - MAX (# 10 PATCHES/FILL), (3 FILLS/75 DAYS) CODE 1 - MAX (# 10 PATCHES/FILL), (3 FILLS/75 DAYS) CODE 1 - MAX (# 10 PATCHES/FILL), (3 FILLS/75 DAYS) CODE 1 - Restricted to a TOTAL of 90 tablets per 30 day period of Norco TAB CODE 1 - Restricted to a TOTAL of 90 tablets per 30 day period of Norco TAB CODE 1 - MAX (#90 TABS/FILL), (3 FILLS/75 DAYS) CODE 1 - MAX (#120 TABS/FILL), (3 FILLS/75 DAYS) MAX 10 MG (#240 TABS/FILL), (3 FILLS/75 DAYS) CODE 1 - MAX (#90/FILL), (3 FILLS/75 DAYS) Restricted to patients receiving new prescriptions from Spine Clinic/Infusion Center or maintained on this medication.
CODE 1 - MAX (#30 TABS/FILL), (3 FILLS/ 75 DAYS) CODE 1 - Max (#30/FILL), (3 FILLS/75 days) CODE 1 - No max tab restriction if Rx written by pschiatry or neurology. All TAB other prescribers restricted to max 90 tabs per 30 day period.
CODE 1 - MAX (#30 TABS/FILL), (3 FILLS/ 75 DAYS) CODE 1 - MAX (#30 TABS/FILL), (3 FILLS/ 75 DAYS) CODE 1 - Max (#30/FILL), (3 FILLS/75 days) Antibiotic - Cephalosporin, 1st Gen Cephalexin Antibiotic - Cephalosporin, 1st Gen Cephalexin Antibiotic - Cephalosporin, 1st Gen Cephalexin Antibiotic - Cephalosporin, 1st Gen Cephalexin Antibiotic - Cephalosporin, 1st Gen Cephalexin Antibiotic - Cephalosporin, 1st Gen Cephalexin Antibiotic - Cephalosporin, 3rd Gen Cefdinir CAP 300 mg, SUSP 125 mg/mL, SUSP 250 mg/5 mL CODE 1 - MAX (#10 TABS/FILL), (2 FILLS/30 DAYS) CODE 1 - MAX (#10 TABS/FILL), (2 FILLS/30 DAYS) CODE 1 - MAX (#10 TABS/FILL), (2 FILLS/30 DAYS) CODE 1 - MAX (# 8 TABS/FILL), (2 FILLS/ 30 DAYS) CODE 1 - MAX (# 30 TABS/FILL), (2 FILLS/ 30 DAYS) CODE 1 - MAX (# 30 TABS/FILL), (2 FILLS/ 30 DAYS) CODE 1 - MAX (#20 TABS/FILL), (2 FILLS/30 DAYS) CODE 1 - MAX (# 30 TABS/FILL), ( 2 FILLS/ 30 DAYS) Trimethoprim/Sulfamethoxazole; Co- Septra, Septra DS, Bactrim, Bactrim Trimethoprim/Sulfamethoxazole; Co- Septra, Septra DS, Bactrim, Bactrim Trimethoprim/Sulfamethoxazole; Co- Septra, Septra DS, Bactrim, Bactrim Trimethoprim/Sulfamethoxazole; Co- Septra, Septra DS, Bactrim, Bactrim Antibiotic - Sulfonamide/Macrolide Erythromycin/Sulfisoxazole Antibiotic - Sulfonamide/Macrolide Erythromycin/Sulfisoxazole Antibiotic - Sulfonamide/Macrolide Erythromycin/Sulfisoxazole TAB 150mg, 300mg, 600 mgSUSP 60 mg/mL (250 mL) TAB (SR) 100 mg, 150 mgTAB (XL) 150 mg, 300 mg TAB (ER) 37.5 mg, (ER) 75 mg, (ER) 150 mg Lantus will be dispensed in place of Levemir per P&T autosubstitution HUMALOG WILL BE DISPENSED IN PLACE OF APIDRA OR NOVOLOG INJ NOVOLIN R WILL BE DISPENSED IN PLACEOF HUMULIN R PER P&T INJ NOVOLIN 70/30 WILL BE DISPENSED IN PLACE OF HUMULIN 70/30 NOVOLIN N WILL BE DISPENSED IN PLACE OF HUMULIN N PER P&T INJ CODE 1 - Restricted to H. pylori treatment (FOR PTS WHO CANNOT TOLERATE PO, CANNOT HAVE NG TUBE, RESTRICTED TO TREATMENT OF ANOREXIA ASSOCIATED W/ WT LOSS IN AIDS PATIENTS AND ONCOLOGY PATIENTS.
CODE 1 - AIDS AND AIDS RELATED CONDITIONS CODE 1 - AIDS AND AIDS RELATED CONDITIONS RESTRICTED TO ONCHYMYCOSIS FOR 12 WEEKS OF THERAPY, AND MUST HAVE LIVER FUNCTION TESTS WITHIN NORMAL LIMITS. TAB 10 mg/10 mg, 20 mg/10 mg, 40 mg/10 mg 2nd LINE AGENT AFTER FAILURE ON DOXAZOSIN 2nd line agent after DMARDs and TNF blockersPatient Assistance Program Available CODE 1 - Only for use in treatment of cancer. PAP avail.
Patient assistance program available.
RESTRICTED TO INFUSION CENTER. PAP available.
Patient assistance program available.
Patient assistance program available.
Patient assistance program available.
CODE 1 - RESTRICTED TO INFUSION CENTER. PAP avail.
Patient assistance program available.
Patient assistance program available.
Patient assistance program available.
Patient assistance program available.
Patient assistance program available.
Patient assistance program available.
Patient assistance program available.
Patient assistance program available.
Antiretroviral, Cellular Chemokine Maraviroc CODE 1 - Age 16 years and older infected with only detectable CCR5- Antiretroviral, Non-Nucleoside RTI Delavirdine Antiretroviral, Non-Nucleoside RTI Efavirenz Antiretroviral, Non-Nucleoside RTI Efavirenz/Emtricitabine/Tenofovir Antiretroviral, Non-Nucleoside RTI Emtricitabine/Rilpivirine/Tenofovir Antiretroviral, Non-Nucleoside RTI Etravirine Antiretroviral, Non-Nucleoside RTI Nevirapine Antiretroviral, Non-Nucleoside RTI Rilpivirine CAP, delayed release, enteric coated 125 mg, 200 mg, 250 mg, 400 mg CODE 1 - HIV or Chronic Hepatitis B Virus infection TAB 75 mg, 150 mg, 300 mg, 400 mg, 600 mg Anti-Ulcer/Dyspepsia - H2 blocker Famotidine Anti-Ulcer/Dyspepsia - H2 blocker Famotidine Anti-Ulcer/Dyspepsia - H2 blocker Famotidine CODE 1 - AIDS AND AIDS RELATED CONDITIONS CODE 1: AGE > 65 YEARS WITH INTERMITTENT CLAUDICATION ORCODE 1: DIABETIC WITH INTERMITTENT CLAUDICATION CODE 1: AGE > 65 YEARS WITH INTERMITTENT CLAUDICATION ORCODE 1: DIABETIC WITH INTERMITTENT CLAUDICATION mL, 40 mg/0.4 mLINJ (SYRINGE) 60 mg/0.6 mLINJ (SYRINGE) 80 mg/0.8 mL, 100 mg /1 mLINJ (SYRINGE) 120 mg/0.8 mL, 150 mg /1 mL CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB 3 mg/30 mcg (# 28)CONDITIONS CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB 0.15 mg/30 mcg (# 84) CONDITIONS CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC PATCH 6 mg/0.75 mgCONDITIONSMax: 9 Patches/75 days CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB CODE 1 - DX OTHER THAN CONTRACEPTION AND DERMATOLOGIC TAB CODE 1 - Restricted to patients already using Accu-Chek Aviva Restricted to patients already using Accu-Chek Aviva glucometer.
CODE 1 - END STAGE RENAL DISEASE ON DIALYSIS CODE 1 - END STAGE RENAL DISEASE ON DIALYSIS Ergot Derivative, Anti-Parkinsonian Bromocriptine TAB 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, 1.25 mg, INJ 5 mg/mL (5 mL) vial Estrogen Derivative - Combination Estrogen/Medroxyprogesterone TAB 0.625 mg/2.5 mg, 0.625 mg/5 mg, 0.3 mg/1.5 mg (# 28) CODE 1 - MAX (# 20 SYRINGES/FILL), (2 FILLS/ YR) INJ (SYRINGE) 30 mg/0.3 mL, 40 mg/0.4 mLINJ (SYRINGE) 60 mg/0.6 mLINJ (SYRINGE) 80 mg/0.8 mL, 100 mg /1 mLINJ (SYRINGE) 120 mg/0.8 mL, 150 mg /1 mL CODE 1 - MAX (# 9 TABS/MONTH) or MAX (#6 INJ/MONTH) MAXIMUM #18/MONTH - PER MANUFACTURER RECOMMENDATION CODE 1 - MAX (# 9 TABS/MONTH) or MAX (#6 INJ/MONTH) MAXIMUM #18/MONTH - PER MANUFACTURER RECOMMENDATION CODE 1 - MAX (# 9 TABS/MONTH) or MAX (#6 INJ/MONTH) MAXIMUM #18/MONTH - PER MANUFACTURER RECOMMENDATION CODE 1 - MAX (# 9 TABS/MONTH) or MAX (#6 INJ/MONTH) MAXIMUM #18/MONTH - PER MANUFACTURER RECOMMENDATION CODE 1 - MAX (# 9 TABS/MONTH) or MAX (#6 INJ/MONTH) MAXIMUM #18/MONTH - PER MANUFACTURER RECOMMENDATION CODE 1 - Restricted to treatment of pulmonary hypertension.
MDI 40 mcg.INH (8.7 g)MDI 80 mcg/INH (8.7 g) MDI 45 mcg/21mcg, 115 mcg/21mcg, 230 mcg/21mcg POWDER for INH 100 mcg/50 mcg (#60)POWDER for INH 250 mcg/50 mcg (#60)POWDER for INH 500 mcg/50 mcg (#60) Restricted to dermatology or senior residents/attendings.
mgPATCH: 0.1 mg, 0.2 mg, 0.4 mg, 0.6 mg/hr CODE 1 - MAX (# 2 INJECTORS/FILL), (2 FILLS/YR) CODE 1 - MAX (# 2 INJECTORS/FILL), (2 FILLS/YR) CODE 1 - Restricted to patients with one of the following conditions: 1) Post UA/NSTEMI with or without a stent for a maximum of 12 months of therapy 2) Post UA/NSTEMI/stroke with or without a stent when aspirin is contraindicated or not tolerated for an indefinite period of time3) Other conditions require a TAR

Source: http://www.riversidecountyhealthcare.org/documents/RCHC_Formulary_by_CLASS_then_GENERIC_122712.pdf