ASL base cream by benbenzhou

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									Long Term Care FormularyASL - 01
SECTION                                     SUBJECT                                         PAGE


AUTOMATIC SUBSTITUTION LIST                 Drug Substitutions                                  1 of 8
(ASL)                                                                                         ___________
                                                                                              YY   MM DD
                                                                              Original        99    06 24
                                                                              Revised         08    08 28
                                                                              Revised         10    03 25

PURPOSE

In order to simplify drug therapy, orders for one medication may be automatically substituted using a
different, but therapeutically equivalent medication. These substitutions are approved by the Long Term
Care Pharmacy and Therapeutics Committee.

LISTING

                   DRUG ORDERED                                      DRUG DISPENSED
            Name            Strength   Frequency            Name             Strength       Frequency
 Actonel®                         5 mg       daily alendronate (Fosamax®           70 mg          weekly
                                                   Restricted Status (RS – 19)
 acyclovir (Zovirax®)           200 mg             famciclovir (Famvir®)           Refer to renal dosing
                                                                                              guidelines
                                800 mg     5x/day
 alendronate (Fosamax®)             10 mg        daily Restricted Status (RS – 19)        70 mg      weekly
 alginic acid compound (Maalox HRF®, Gaviscon®)       Lowest Cost Alternative
 Alphagan®                                            Lowest Cost Alternative; Restricted Status (RS-14)
 aluminum/magnesium hydroxide (Diovol®, Maalox®)      Lowest Cost Alternative
 aluminum/magnesium hydroxide/simethicone             Lowest Cost Alternative
 (Diovol Plus®, Maalox Plus®)
 amcinonide 0.1% (Cyclocort®)                         fluocinonide 0.05% (Lidex®)
 High Potency Corticosteroids
 ampicillin (Penbritin®)  250 - 500 mg            qid amoxicillin (Amoxil®)         250 – 500 mg           tid
 Apo-K® extended release                              Lowest Cost Alternative
 amoxicillin                                      qid amoxicillin                                          tid
 Bactroban®                                           Autosubstitution to Polysporin®
 Becloforte® MDI                                      Autosubstitution to fluticasone
 beclomethasone MDI (Becloforte®)                     Autosubstitution to fluticasone
 betamethasone dipropionate 0.05% (Diprosone®)        fluocinonide 0.05% (Lidex®)
 High Potency Corticosteroids
 betamethasone dipropionate Glycol Base 0.05%         clobetasol 17-propionate (Dermovate®)
 (Diprolene®)
 Very High Potency Corticosteroids
Long Term Care FormularyASL - 01
SECTION                                       SUBJECT                                            PAGE


AUTOMATIC SUBSTITUTION LIST                   Drug Substitutions                                    2 of 8
(ASL)                                                                                             ___________
                                                                                                  YY     MM DD
                                                                                Original          99       06 24
                                                                                Revised           08       08 28
                                                                                Revised           10       03 25

                  DRUG ORDERED                                           DRUG DISPENSED
           Name              Strength      Frequency           Name                  Strength          Frequency
Biaxin®                    250 – 500mg            bid Zithromax®; unless                 500 mg        daily on day
                                                      meets Restricted                      then                  1
                                                      Status (RS – 30)                    250mg
                                                      criteria                                        daily X 4
                                                                                                          days
bimatoprost (Lumigan®)                                   latanopost (Xalatan®); Restricted Status (RS-14)
brimonidine (Alphagan®)                                  Lowest Cost Alternative; Restricted Status (RS-14)
buproprion SR                   150 mg            bid bupropion XL                    300 mg tab
                                                      once daily
calcium                        1000 mg           daily                                500 mg           bid
                             (elemental)                                          (elemental)
                                                             500 mg elemental calcium is thought to be
                                                                  maxiumim absorbed at a time
calcium carbonate                                        Lowest Cost Alternative
(Tums® Extra Strength)
Cascara®                                                 Senokot®
ciprofloxacin (Cipro®)                                   Restricted Status (RS-02) criteria
Cipro®                                                   Restricted Status (RS-02) criteria
Clarithromycin (Biaxin®)   250 – 500mg            bid Zithromax®; unless                    500 mg     daily on day
                                                      meets Restricted                         then               1
                                                      Status (RS – 30)                       250mg
                                                      criteria                                            daily X 4
                                                                                                              days
clobetasone 17-butyrate (Eumovate®)                    betamethasone valerate 0.1% (Celestoderm®,
Intermediate Potency Corticosteroids                   Betnovate®, Valisone®)
cefaclor (Ceclor®)         250 -500mg              tid cefuroxime (Ceftin®)      250 -500mg                    bid
Cerumenex®                                               mineral Oil (Light)
Common Cold Preparations                                 Actifed®
Combivent® Nebulizer Sol’n                               salbutamol (Ventolin®)/ ipratropium (Atrovent®) single
                                                         agent MDIs unless meets Restricted Status (RS –
                                                         21) criteria
Cosopt®                                                  To be substituted with single entity agents when
                                                         therapy is more cost effective; Restricted Status (RS-
                                                         14)
decongestants                                            Sudafed® lowest cost alternative
Long Term Care FormularyASL - 01
SECTION                                           SUBJECT                                           PAGE


AUTOMATIC SUBSTITUTION LIST                       Drug Substitutions                                   3 of 8
(ASL)                                                                                                ___________
                                                                                                     YY    MM DD
                                                                                     Original        99      06 24
                                                                                     Revised         08      08 28
                                                                                     Revised         10      03 25

                 DRUG ORDERED                                             DRUG DISPENSED
        Name                   Strength        Frequency          Name                   Strength         Frequency
Decadron® injection                                        Depo-Medrol® injection
Delsym®                                                    Lowest cost Alternative
desonide 0.05% (Tridesilon®)                               betamethasone valerate 0.05% (Celestoderm® V/2,
Low potency corticosteroid                                 Betnovate®)
desoximethasone 0.05% (Topicort® Mild)                     betamethasone valerate 0.1% (Celestoderm®,
Intermediate Potency Corticosteroids                       Betnovate®, Valisone®)
desoximetasone 0.25% (Topicort®)                           fluocinonide 0.05% (Lidex®)
High Potency Corticosteroids
dexamethasone (Decadron®) injection                        Depo-Medrol® injection
dextromethorphan (Benylin®, Delsym®)                       Lowest Cost Alternative
Diamicron®                           80 mg          daily No longer restricted                   March         2010
Didrocal®                                                  alendronate (Fosamax®)                70 mg        weekly
                                                           Restricted Status (RS-
                                                           19)
Didronel®                                                  alendronate (Fosamax®)                70 mg        weekly
                                                           Restricted Status (RS-
                                                           19)
diflorasone diacetate 0.05% (Florone®, Flutone®)           fluocinonide 0.05% (Lidex®)
High Potency Corticosteroids
Dilantin® Suspension                                       Dilantin® tab/cap
diltiazem (Tiazac® ER)                                     diltiazem (Tiazac® XC)
Dioval®, Dioval Plus®                                      Lowest Cost Alternative
dorzolamide/timolol maleate (Cosopt®)                      To be substituted with single entity agents when
                                                           therapy is more cost effective; Restricted Status (RS-
                                                           14)
Eryc®                               333 mg           q8h erythromycin base                      250 mg           q6h
                                                         (E-Mycin®, Erythromid®)
erythromycin salts                                         erythromycin base
etidronate (Didronel®, Didrocal®)                          alendronate (Fosamax®)                70 mg        weekly
                                                           Restricted Status (RS-
                                                           19)
Eye Scrub® topical                                         J & J Baby Shampoo
famotidine (Pepcid®)                 20 mg                 ranitidine (Zantac®)                 150 mg
                                     40 mg                                                      300 mg
fenofibrate (Lipidil Micro®, Lipidil Supra®)               Lowest Cost Alternative fenofibrate
ferrous sulphate                    300 mg                 ferrous gluconate                    300 mg     300 mg tab
Long Term Care FormularyASL - 01
SECTION                                          SUBJECT                                               PAGE


AUTOMATIC SUBSTITUTION LIST                      Drug Substitutions                                      4 of 8
(ASL)                                                                                                  ___________
                                                                                                       YY     MM DD
                                                                                   Original            99       06 24
                                                                                   Revised             08       08 28
                                                                                   Revised             10       03 25

                 DRUG ORDERED                                             DRUG DISPENSED
          Name                    Strength    Frequency            Name                     Strength         Frequency
Floxin®                                                   Restricted Status (RS-02)
flumethasone pivalate 0.03% (Locacorten®)                 betamethasone valerate 0.05% (Celestoderm® V/2,
Low potency corticosteroid                                Betnovate®)
fluocinolone acetonide (Synalar®, Synamol®) 0.025%        betamethasone valerate 0.1% (Celestoderm®,
Intermediate Potency Corticosteroids                      Betnovate®, Valisone®)
fluocinolone acetonide 0.01% (Synalar® Mild,              betamethasone valerate 0.05% (Celestoderm® V/2,
Synamol® Mild)                                            Betnovate®)
Low potency corticosteroid
fluocinonide 0.01% (Lidex®)                               betamethasone valerate 0.1% (Celestoderm®,
Intermediate Potency Corticosteroids                      Betnovate®, Valisone®)
Fluoroquinolones oral [ciprofloxacin (Cipro®),            Restricted Status (RS-02) criteria
norfloxacin (Noroxin®), levofloxacin (Levaquin®,
ofloxacin (Floxin®)]
flurandrenolide 0.05% (Drenison®)                        betamethasone valerate 0.1% (Celestoderm®,
Intermediate Potency Corticosteroids                     Betnovate®, Valisone®)
Fosamax®                          10 mg            daily Restricted Status (RS –19)    70 mg        weekly
fusidic Acid (Fucidin®)           cream/ung               autosubstitution to Polysporin
Garasone® ophthalmic/otic                                 Sofracort® ophthalmic/otic

gatifloxacin eye drops                                    moxifloxacin eye drops Restricted Status (RS-10)
Gaviscon®                                                 Lowest Cost Alternative
gliclazide (Diamicron®)               80 mg        daily No longer restricted                      March          2010
halcinonide 0.1% (Halog®)                                 fluocinonide 0.05% (Lidex®)
High Potency Corticosteroids
halcinonide 0.025% (Halog®)                               betamethasone valerate 0.1% (Celestoderm®,
Intermediate Potency Corticosteroids                      Betnovate®, Valisone®)
halobetasol propionate 0.05% (Ultravate®)                 Clobetasol 17 – propionate (Dermovate®)
Very High Potency Corticosteroids
hydrocortisone 17-valerate 0.2% (Westcort®)               betamethasone valerate 0.05% (Celestoderm® V/2,
low potency corticosteroid                                Betnovate®)
ipratropium (Atrovent®)             0.25 mg               ipratropium bromide                      2 puffs
Nebulizer Solution                   0.5 mg               Inhaler unless meets                     4 puffs
                                                          Restricted Status (RS-
                                                          21) crtieria
Isosorbide mononitrate                60 mg               isosorbide dinitrate (Isordil®)          20 mg             tid
(Imdur®)
isosorbide dinitrate (Isordil®)                           Lowest Cost Alternative
Long Term Care FormularyASL - 01
SECTION                                      SUBJECT                                              PAGE


AUTOMATIC SUBSTITUTION LIST                  Drug Substitutions                                     5 of 8
(ASL)                                                                                             ___________
                                                                                                  YY     MM DD
                                                                                Original          99      06 24
                                                                                Revised           08      08 28
                                                                                Revised           10      03 25

                  DRUG ORDERED                                         DRUG DISPENSED
           Name             Strength    Frequency              Name                    Strength        Frequency
K-10®                                                  Lowest Cost Alternative
K-Dur®                                                 Lowest Cost Alternative
Kaochlor®                                              Lowest Cost Alternative
ketoconazole (Nizoral®)         cream                  clotrimazole (Canesten®)
Lamisil®                        cream                  clotrimazole (Canesten®)
                                                       unless meets Restricted Status (RS-17) criteria
Levaquin®                                              Restricted Status (RS-02) criteria
levofloxin (Levaquin®)                                 Restricted Status (RS-02) criteria
Lipidil Supra®                 160 mg                  Lipidil Micro® (or lowest             200 mg
                                                       cost alternative fenofibrate)
Locacorten Vioform® Cream/Ointment                     betamethasone/nystatin cream (1:1)
Loprox® Cream/Lotion                                   clotrimazole (Canesten®) cream/solution
Lumigan®                                               latanoprost (Xalatan®); Restricted Status (RS-14)
Maalox®, Maalox Plus®                                  Lowest Cost Alternative
Maalox HRF®                                            Lowest Cost Alternative
MS Contin®                                             M-Eslon®
Macrobid®                      100 mg              bid nitrofurantoin regular                50 mg            qid
Macrodantin®                   100 mg              bid nitrofurantoin regular                50 mg            qid
magnesium/aluminum Antacids (Maalox®/Diovol®)          Lowest Cost Alternative
magnesium/aluminum/simethicone Antacids (Maalox® Lowest Cost Alternative
Plus/Diovol® Plus)
Magnolax®                                              magnesium hydroxide (Milk of Magnesia®)
methylprednisolone acetate 0.25% (Medrol®)             hydrocortisone (Cortate®)
lowest potency corticosteriod
miconazole (Monistat®)                                 clotrimazole (Canesten®)
Micro-K®                                               Lowest Cost Alternative
mometasone furoate 0.1% (Elocom®)                      betamethasone valerate 0.1% (Celestoderm®,
Intermediate Potency Corticosteroids                   Betnovate®, Valisone®)
morphine sulphate sustained release (MS Contin®)       M- Eslon®
Mycil® foot powder                                     Desenex® foot powder
Mycostatin® vaginal tabs                               Clotrimazole (Canesten®)              200 mg
                                                       vaginal tablets
Nebulized Medications                                  Restricted Status (RS-21)
Long Term Care FormularyASL - 01
SECTION                                            SUBJECT                                         PAGE


AUTOMATIC SUBSTITUTION LIST                        Drug Substitutions                                6 of 8
(ASL)                                                                                              ___________
                                                                                                   YY     MM DD
                                                                                   Original        99       06 24
                                                                                   Revised         08       08 28
                                                                                   Revised         10       03 25

                 DRUG ORDERED                                              DRUG DISPENSED
         Name             Strength              Frequency            Name            Strength           Frequency
Neosporin® Cream/Ointment                                   Polysporin® Cream/Ointment
Neosporin® Eye/Ear Drops                                    Polysporin® Eye/Ear Drops
nifedipine (Adalat®)               5 mg Bite and swallow    captopril                  12.5 mg tab given sublingual
                                        for hypertensive    (Capoten®)
                                        crisis
                                  10 mg                                                    25 mg tab given sublingual
Nilstat® vaginal tabs                                       clotrimazole (Canesten®)             200 mg
                                                            vaginal tablets
Nitrates, Topical                                           Lowest Cost Alternative
nitrofurantoin                       100 mg           bid nitrofurantoin regular                  50 mg         qid
nitroglycerin ointment (Nitrol®)                            Lowest Cost Alternative
nitroglycerin oral – SR (Nitrong®)                          Isordil®
nitroglycerin patch (Nitro-Dur®)                            Lowest Cost Alternative
nitroglycerin spray (Nitrolinglual®Spray, Nitrospray®)      Lowest Cost Alternative
nitroglycerin sublingual (Nitrolingual®)                    Lowest Cost Alternative
nitroglycerin tab (Nitrostat®)                              Lowest Cost Alternative
Nitro-Dur®                                                  Lowest Cost Alternative
Nitrol®                                                     Lowest Cost Alternative
Nitrolingual®                                               Lowest Cost Alternative
Nitrolingual® Spray                                         Lowest Cost Alternative
Nitrospray®                                                 Lowest Cost Alternative
Nitrostat®                                                  Lowest Cost Alternative
norfloxacin (Norfloxin®)                                    Restricted Status (RS-02) criteria
norfloxacin ophthalmic                                      ciprofloxacin (Ciloxan®) ophthalmic
Noroxin®                                                    Lowest Cost Alternative; unless meets Restricted
                                                            Status (RS-02) criteria
Noroxin® ophthalmic                                         ciprofloxacin (Ciloxan®) ophthalmic
nystatin (Mycostatin®, Nilstat®) vaginal tabs               clotrimazole (Canesten®)         200 mg
                                                            vaginal tablets
ofloxacin (Floxin®)                                         Restricted Status (RS-02) criteria
olive oil                                                 Mineral Oil
Penbritin®                       250-500 mg           qid amoxicillin (Amoxil®)        250 – 500 mg               tid

penicillin G                     500,000 unit               penicillin V (PVF-K)        500,000 unit
Long Term Care FormularyASL - 01
SECTION                                          SUBJECT                                         PAGE


AUTOMATIC SUBSTITUTION LIST                      Drug Substitutions                                7 of 8
(ASL)                                                                                            ___________
                                                                                                 YY     MM DD
                                                                                 Original        99      06 24
                                                                                 Revised         08      08 28
                                                                                 Revised         10      03 25

                DRUG ORDERED                                             DRUG DISPENSED
           Name                 Strength      Frequency              Name               Strength      Frequency
penicillin V (PVF-K)                250 mg                penicillin V (PVF-K)              300 mg            tid
pindolol (Visken®)                     5 mg               acebutolol                       100 mg
                                      10 mg               (Monitan®/Sectral®)
potassium chloride (Apo®K, K-10®, K-Dur®,                 Lowest Cost Alternative potassium chloride tablets,
Kaochlor®, Micro-K®, Slow-K®) tablets, capsules,          capsules, liquids
liquids
Premarin® Vaginal Cream                                   Lowest Cost Alternative Estrogen Vaginal Cream
risedronate (Actonel®)                                    alendronate (Fosamax®             70 mg          weekly
                                                          Restricted Status (RS – 19)
salbutamol (Ventolin®)            2.5 mg                  salbutamol (Ventolin®) Inhaler; 2 puffs
Nebulizer Solution                  5 mg                  unless meets
                                                                                          4 puffs
                                                          Restricted Status (RS – 21)
                                                          criteria
scopolamine gel                                           scopolamine Patch                                weekly
Slow-K® extended release                                  Lowest Cost Alternative
tamsulosin                                                Tamsulosin controlled release tablet
                                                          Restricted Status (RS-07)
terbinafine (Lamisil®) Cream                              Canesten® Cream unless meets Restricted Status
                                                          (RS-17) criteria
Travatan®                                                 latanoprost (Xalatan®); Restricted Status (RS-14)
travoprost (Travatan®)                                    latanoprost (Xalatan®); Restricted Status (RS-14)
triacinolone acetonide 0.5% (Aristocort-C®)               fluocinonide 0.05% (Lidex®)
High Potency Corticosteroids
triamcinolone acetonide 0.025% (Aristocort-D®)            betamethasone valerate 0.05% (Celestoderm® V/2,
low potency corticosteroid                                Betnovate®)
triamcinolone acetonide 0.1% (Kenalog®,                   betamethasone valerate 0.1% (Celestoderm®,
Aristocort-R®)                                            Betnovate®, Valisone®)
Intermediate Potency Corticosteroids
Tums® Extra Strength                                      Lowest Cost Alternative
valacyclovir (Valtrex®)     1g                            famciclovir (Famvir®)         500 mg
Visken®                        5 mg                       acebutolol (Moniton®/100mg
                                                          Sectral®)
Vitamin B with C Preparations                             Lowest Cost Alternative
Vitamin D                                                 Lowest Cost Alternative
Xalacom®                                                  To be substitued with single entity agents when therapy
                                                          is more cost effective; Restricted Status (RS-14)
Long Term Care FormularyASL - 01
SECTION                            SUBJECT                         PAGE


AUTOMATIC SUBSTITUTION LIST        Drug Substitutions                8 of 8
(ASL)                                                              ___________
                                                                   YY     MM DD
                                                        Original   99      06 24
                                                        Revised    08      08 28
                                                        Revised    10      03 25

								
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