Prescribing Guidelines for High Cost Medications

CLASS: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

DRUGS INCLUDED: All Non-Steroidal Anti-Inflammatory Drugs except Aspirin

Products, Ibuprofen, and Indomethacin.

GUIDELINES: Patients prescribed these NSAIDs should have demonstrated treatment

failure on less costly alternatives appropriate for the patient's condition.

CLASS: Cholesterol and Lipid Lowering Agents

DRUGS INCLUDED: Mevacor (Lovastatin), Lorelco (Probucol), Lopid (Gemfibrozil)

GUIDELINES: Therapeutic progression to more costly cholesterol lowering agents

should be preceded by trials and/or incorporation of less costly approaches. In all cases

this will include dietary therapy and may include use of Niacin or resins.

CLASS: Selected High Cost Antibiotics

DRUGS INCLUDED: Ceclor (Cefaclor), Pediazole (Erythromycin/ Sulfisoxazole),

Augmentin (Amoxicillin Clavulinate), Cipro (Ciprofloxacin), Suprax (Cefixime)

GUIDELINES: Use of these more expensive antibiotics should be limited to patients

who have failed on more traditional, less costly antibiotics or where indicated by culture

and sensitivity test results. These drugs may also be used for conditions where they are

specifically indicated as first line therapy agent.

CLASS: Smoking Cessation Aids

DRUGS INCLUDED: Nicotine gum

GUIDELINES: Nicotine Gum will not be prescribed or dispensed to patients without

proof of participation in a behavioral modification program. Quantities shall be limited to

one box of gum per week per patient for a maximum of twelve weeks. Practitioners shall

not continue to prescribe Nicotine Gum for patients who are still smoking after two

weeks of gum use.