The community hospice____effecive: 4/1/97

HOSPICE APPROVED MEDICATIONS
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High Peaks Hospice & Palliative Care, Inc. (HPH&PC) has developed a formulary of drugs that are appropriate for managing pain and symptoms related to the terminal illness. The drugs listed are considered preferred drugs for hospice use. HPH&PC pays for medications related to the hospice diagnosis and for pain and symptom management for the terminal illness. Non-formulary drugs are considered for patients who fail with formulary drugs or for whom formulary drugs are contraindicated. Over the counter, non-prescription medications may be ordered, but are not approved for HPH&PC payment unless they are related to the hospice diagnosis. PROCEDURE
Before approving a drug for reimbursement by HPH&PC, the following utilization review should be conducted: • Medication the patient is currently taking • Drugs initiated since terminal illness • Appropriate therapy for this stage of patient’s illness All medications approved for HPH&PC will be reviewed at the 48 hour admission review and at each IDT for appropriateness for hospice. Medications approved for hospice use have up to a thirty day maximum supply given at a time. HOSPICE APPROVED MEDICATIONS
FORMULARY OF PREFERRED DRUGS
LISTED BY SYMPTOMS

Analgesics
Non-Opioid
Ibuprofen (Motrin) Naproxen (Naproysn) Calecoxib (Celebrex) Rofecoxib (Vioxx) Prednisone Dexamethasone (Decadron) Amitriptyline (Elavil) Nortriptyline Carbamezepine (Tegretol) Gabapentin (Neurontin) Clonazepam (Klonopin) Hyrocodone + APAP Oxycodone + APAP Codeine Codeine + APAP Propoxyphene/NAP/APAP Oxycodone (Oxycontin) Morphine Fentanyl (Duragesic, Sublimaze, Actiq) Hydromorphone (Dilaudid) Methadone
Dyspnea/Breathlessness

Broncholdilators
Albuterol (Proventil) Ipratropuim (Atrovent) HOSPICE APPROVED MEDICATIONS


Anxiety/Agitation

Benzodiazepines
Lorazepam (Ativan) Alprazolam (Xanax) Diazepam (Valium) Hydroxyzine (Atarax) Risperdal (Risperidone)
Nausea/Vomiting

Gastric Stasis
Metoclopramide (Reglan) Cimetidine (Tagamet)
Chemorecoptor trigger zone agents
Phenotheazines Procholorperazine (Compazine) Chloropromazine (Thorazine) Butyropherones Haloperidol (Haldol) Trimethobenzamide (Tigan)
Vestibular Agents

Cerebral Cortex Agents
Benzeodiazepines Alprazolam (Xanax) Lorazepam (Ativan) HOSPICE APPROVED MEDICATIONS

Depression
Amitiriptyline (Elavil) Nortriptyline (Pamelor) Sertraline (Zoloft) Trazodone hydrochloride (Desyrel) Paroxetine (Paxil) Fluoxetine (Prozac)
Constipation

Diuretics
Furosemide (Lasix) Spironolactone (Aldactone) Zaroxolyn (Metolazone)

Antipsychotics
Risperdol (Risperidone) Haloperidol (Haldol) Chlorpromazine Hydrochloride (Thorazine)
Anticonvulsants
Phenytoin (Dilantin) Carbamazepine (Tegretol)
Terminal Secretions

Oral Thrush
Mycostatin (Nystatin) Mycelex (Lotrimin, Clotrimazole) Miles Mixture

Source: http://www.highpeakshospice.org/files/public/Policies/Clinical_Policies/Hospice_Approved_Medicaitons_CP222_U0708.pdf