Cha formulary draft

Narcotic Equivalents *
Pain (Adjuvants)
Urinary Incontinence
Approximate Equi-analgesic Doses:
Special Note
codeine
[120 mg; 200 mg]
Wound Management
fentanyl
Reflux (GERD)
[0.1 mg; n/a]
hydrocodone
IN-SIGHT HOSPICE
[n/a; 30 mg]
DRUG FORMULARY
hydromorphone
& Cost Index
[1.3-1.5 mg; 7.5 mg]
COMMUNITY HOSPICES OF AMERICA
levorphanol
is pleased to provide our IN-SIGHT Pain
[n/a; 4 mg]
Management & Palliative Care Formulary
with Cost Index. The IN-SIGHT formulary
Secretions (Excessive)
*Hospice is responsible for paying for medication deemed meperidine
is designed to assist practitioners in
appropriate by the Hospice Interdisciplinary Team (IDT) [75 mg; 300 mg]
selecting appropriate and cost-effective
Community Hospices of America, Inc.
drugs for their COMMUNITY HOSPICES
methadone
OF AMERICA patients. The drugs on this
H o s p i c e A d m i s s i o n C r i t e r i a
Seizures
formulary have been reviewed by the
[10 mg; 10-20 mg]
pharmacy department and found
1 . D i a g n o s e d w i t h a t e r m i n a l
appropriate for formulary inclusion.
morphine
Comments and suggestions from
[10 mg; 30-60 mg]
2 . H a s a l i f e e x p e c t a n c y o f s i x
practicing physicians have also been
incorporated to ensure that the form ulary
m o n t h s o r l e s s , a s
oxycodone
is reflective of current medical practice.
d e t e r m i n e d b y t h e a t t e n d i n g
[n/a; 15-30 mg]
Items highlighted in GREEN are CHA
p h y s i c i a n A N D t h e h o s p i c e
preferred products. Items that are RED
i n t e r d i s c i p l i n a r y t e a m
oxymorphone
are CHA’s NON-preferred. Items in Blue
3 . I s s e e k i n g p a l l i a t i v e ( p a i n &
[1 mg; n/a]
are alternates.
s y m p t o m r e l i e f ) r a t h e r t h a n
************************
Cost Indexes are provided to assist the
c u r a t i v e t re a t m e n t .
pentazocine
practitioners in understanding the costs of
4 . A d m i s s i o n t o h o s p i c e
[30 mg; 100 mg]
the medications they prescribe for hospice
s e r v i c e s i s a p p r o v e d b y t h e
patients. Hospice is reimbursed by
a t t e n d i n g p h y s i c i a n &
Medicare/Medicaid at a rate of $100+ per
H o s p i c e m e d i c a l d i r e c t o r
day. ALL CARE (meds, DME, nursing,
5 . T h e p a t i e n t , f a m i l y , a n d
CNA, MSW, pastoral care, physician
consults, therapies, bereavement, etc)
a t t e n d i n g p h y s i c i a n
must be achieved from that $100+ per
u n d e r s t a n d t h a t a r t i f i c i a l , l i f e -
day. It is imperative that CHA contain our
p r o l o n g i n g p r o c e d u r e s a r e
costs, but never compromise quality of
n o t c o n s i s t e n t w i t h h o s p i c e
care. Thank you for using this tool to
assist us.
6 . T h e p a t i e n t I S N O T r e q u i r e d
t o b e h o m e b o u n d .
7 . L i v e s i n t h e h o s p i c e s e r v i c e
Community Hospices of America, Inc.
Anorexia-Cachexia-Wt. Loss
Bowel Obstruction (Complete)
Diarrhea
Cost/Day
Pain (Opiods)
Cost/Day
Constipation
Dyspnea (Also consider anxiolytics)
Transdermal Fentanyl (Patch)(Duragesic)$$$$$$$$ Anxiety/Restlessness
Delirium
Agitation Associated w Dementia
Antipsychotics
Insomnia
Pain (Non Opiod)
Midazolam ONLY for intentional sedation$$$$ Depression (Antidepressants)
Nausea/Vomiting
Asthenia (Fatigue & Weakness)
Symptom/Condition
Preferred
Alternate
NON-Preferred
Community Hospices of America, Inc.
Tramadol Hcl w APAP (Generic Ultracet)$$$$$$ Community Hospices of America, Inc.
Community Hospices of America, Inc.
Community Hospices of America, Inc.

Source: http://hospicecarela.com/documents/druglist.pdf