Formulary for 30 days only. Is this order for less than 31 days? MLP Requires Cosign / Formulary for 30 days only. Is this order for less than 31 days? MLP Requires Cosign / Non-Formulary Use Criteria:
**01. Control of severe agitation in psychiatric patients** **02. When lack of sleep causes an exacerbation of psychiatric illness** **03. Part of a prolonged taper schedule** **04. Detoxification for substance abuse** **05. Failure of standard modalities for seizure disorders ( 4th line therapy)** **06. Long-term use for terminally ill patients for palliative care ( e.g. hospice patients)****07. Adjunct to neuroleptic therapy to stabilize psychosis** **08. Second line therapy for anti-mania** **09. Psychotic syndromes presenting with catatonia ( refer to BOP Schizophrenia Clinical Practice Guideline)****10. Akathisia which is non-responsive to beta blocker at maximum dose or unsuccessful conversion to another antipsychotic agent**

Non-Formulary Approval required after 30 days. MLP Requires Cosign

Formulary for 30 days only. Is this order for less than 31 days? MLP Requires Cosign / Formulary for 30 days only. Is this order for less than 31 days? MLP Requires Cosign / Non-Formulary Use Criteria:
**01. Control of severe agitation in psychiatric patients** **02. When lack of sleep causes an exacerbation of psychiatric illness** **03. Part of a prolonged taper schedule** **04. Detoxification for substance abuse** **05. Failure of standard modalities for seizure disorders ( 4th line therapy)** **06. Long-term use for terminally ill patients for palliative care ( e.g. hospice patients)****07. Adjunct to neuroleptic therapy to stabilize psychosis** **08. Second line therapy for anti-mania** **09. Psychotic syndromes presenting with catatonia ( refer to BOP Schizophrenia Clinical Practice Guideline)****10. Akathisia which is non-responsive to beta blocker at maximum dose or unsuccessful conversion to another antipsychotic agent**

Non-Formulary Approval required after 30 days. MLP Requires Cosign

Not to be used in hypertensive urgencies and emergencies. Maximum formulary limit of seven days. NON-Formulary; 1. For use in opiate detoxification only, non-formulary request may be submitted after detox protocol nitiated. Oral test dose followed by clonidine patch is preferred protocol mechanism. 2. Dose taper over 2 to 4 days for arriving inmates taking greater than 1 mg per day. Refer to clonidine withdrawal guidance, particularly for patients on concomitant beta blocker therapy. Non-formulary request may be submitted after taper initiated. 3. Use in clozapine induced hypersalivation (CIH) after failure or contraindication to benztropine, amitriptyline, and alpha blocker. NOTE: Including combination therapy with benztropine and an alpha blocker for 12 weeks. 4. Use in Tourette’s Syndrome. 5. Use in Hypertensive Urgency/Emergency poses more risk than benefit. Refer to 2006 P&T minutes for guidance.

Non-Formulary Approval required after 30 days. MLP Requires Cosign

Not to be used in hypertensive urgencies and emergencies. Maximum formulary limit of seven days. NON-Formulary; 1. For use in opiate detoxification only, non-formulary request may be submitted after detox protocol nitiated. Oral test dose followed by clonidine patch is preferred protocol mechanism. 2. Dose taper over 2 to 4 days for arriving inmates taking greater than 1 mg per day. Refer to clonidine withdrawal guidance, particularly for patients on concomitant beta blocker therapy. Non-formulary request may be submitted after taper initiated. 3. Use in clozapine induced hypersalivation (CIH) after failure or contraindication to benztropine, amitriptyline, and alpha blocker. NOTE: Including combination therapy with benztropine and an alpha blocker for 12 weeks. 4. Use in Tourette’s Syndrome. 5. Use in Hypertensive Urgency/Emergency poses more risk than benefit. Refer to 2006 P&T minutes for guidance.

Non-Formulary Approval required after 30 days. MLP Requires Cosign

Not to be used in hypertensive urgencies and emergencies. Maximum formulary limit of seven days. NON-Formulary; 1. For use in opiate detoxification only, non-formulary request may be submitted after detox protocol nitiated. Oral test dose followed by clonidine patch is preferred protocol mechanism. 2. Dose taper over 2 to 4 days for arriving inmates taking greater than 1 mg per day. Refer to clonidine withdrawal guidance, particularly for patients on concomitant beta blocker therapy. Non-formulary request may be submitted after taper initiated. 3. Use in clozapine induced hypersalivation (CIH) after failure or contraindication to benztropine, amitriptyline, and alpha blocker. NOTE: Including combination therapy with benztropine and an alpha blocker for 12 weeks. 4. Use in Tourette’s Syndrome. 5. Use in Hypertensive Urgency/Emergency poses more risk than benefit. Refer to 2006 P&T minutes for guidance.

30 Day Formulary Restriction. Formulary OTC medications may only be prescribed as a maintenance medication associated with ongoing follow up in a chronic care clinic