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Djj.state.ga.us

GEORGIA DEPARTMENT OF JUVENILE JUSTICE
MEDICATION FORMULARY
(by class)
effective 7/1/12
All medications listed on the formulary will be supplied in generic form if available. Branded items
will be supplied when the generic form is not available. All commercially manufactured strengths
will be considered formulary for the particular dosage form listed. Sustained release forms or
other specially formulated dosages will be nonformulary unless specifically listed below.

1. ANTI-INFECTIVES
ORALS AND INJECTABLES
Antibacterials
Amoxicillin/Clavulanate (Augmentin)(Augmentin XR) cap/tab to use as diluent for injection. Ciprofloxacin (Cipro) cap/tab Antifungals
Griseofulvin Microsized/Ultramicrosized (Grifulvin-V) cap/tab Antituberculars
Antivirals
**HIV Agents
**Since these items are seldom used in our population,approval from the DJJ Medical Director is required.
These items may have to be specially orderedby the pharmacy.
TOPICALS
NOTE: LOTIONS OR GELS ARE NONFORMULARY UNLESS LISTED BELOW
Antibacterials
Neomycin/Polymixin/Bacitracin (Neosporin) oint/crm Silver Sulfadiazine (SSD;Silvadene) oint/crm Antifungals
Nystatin/Triamcinilone (Mycolog) oint/crm Antivirals
Scabicides/Pediculocides
Vaginal Preparations
Clotrimazole (Gyne-Lotrimin/Mycelex) oint/crm Misc. Preparations
2. OPTHALMIC AGENTS
Antibacterials/Steroidals
Gentamycin (Garamycin) oint/crm/soln/susp Sulfacetamide (Bleph-10) oint/crm/soln/susp Decongestants
Lubricants
Diagnostic Agents
3. OTIC AGENTS
Ascetic Acid soln/suspAntipyrin-Benzocaine (Auralgan) soln/susp Neomycin/Polymixin/Hydrocort. (Cortisporin) soln/susp 4. RESPIRATORY AGENTS
Bronchodilators
Albuterol (Proventil)(Proventil HFA) cap/tab/inhaler/soln/susp Leukotriene Receptor Antagonist
Inhalation Steroids/Nasal Preparations
Antihistamines/Decongestants/Cough&Cold
Analgesic Throat Lozenges (Cepacol)Chlorpheniramine (Chlor-Trimeton) cap/tab (Reg release & SR) Diphenhydramine (Benadryl) cap/tab/soln/susp/inj Hydroxyzine HCl/Pam.(Atarax/Vistaril) cap/tab Loratidine/Pseudoephedrine 24hour (Claritin D) cap/tab Guafensin (Robitussin) soln/susp/syrupGuafensin/Dextromethorphan (Robitussin DM) soln/susp/syrup Other Respiratory Related
Purified Protein Derivative (Aplisol;Tubersol) inj 5. CARDIOVASCULAR AGENTS
Central Acting Agents
Beta Blockers
Propranolol Reg & SR (Inderal)(Inderal LA) cap/tab Metoprolol Reg & SR (Lopressor)(Toprol XL) cap/tab Ace Inhibitors
Cardiac Glycosides
Diuretics
6. CENTRAL NERVOUS SYSTEM AGENTS
Analgesics
APAP with Codeine (Tylenol #3) cap/tab/soln/susp Acetaminophen (Tylenol) cap/tab/soln/suspHydrocodone with APAP (Lortab,Lorcet) cap/tab/soln/susp Analgesics/NSAIDs
Ibuprofen (Motrin;Advil) cap/tab/soln/susp Anticonvulsants/Antimanics
Lithium Carbonate Reg &SR (Lithium;Lithium ER) cap/tab Divalproex Sodium Reg& SR (Depakote;Depakote ER) cap/tab Valproic Acid (Depakene) cap/tab/soln/susp Antidepressants
Bupropion (Wellbutrin;Wellbutrin XL) cap/tab [Wellbutrin SR is Nonformulary]
Anti-emetics/Antivertigos
Promethazine (Phenergan) cap/tab/supp/inj Anti-Migraine Agents
Antiparkinson Agents
Antipsychotic Agents
***Aripiprazole (Abilify) cap/tab
*** DENOTES DRUG THAT REQUIRES PRIOR APPROVAL FROM DJJ CONSULTING
PSYCHIATRIST BEFORE IT CAN BE SUPPLIED!

Ziprasidone (Geodon) cap/tab/**inj. ** Injection will be limited to night boxstock in designated mental healthfacilities. Anxiolytics
** Injection will be limited to night boxstock in designated mental healthfacilities. Hydroxyzine HCL/Pam.(Atarax/Vistaril) cap/tab ADHD Agents
Amphetamines/(Dextro) Reg & SR (Adderall;Adderall XR) cap/tab reg--5mg,7.5mg,10mg,12.5mg,15mg,20mg,30mgSR--5mg,10mg,15mg,20mg,25mg,30mg Methylphenidate ER (Concerta only) cap/tab Metadate is Nonformulary
*** DENOTES DRUG THAT REQUIRES PRIOR APPROVAL FROM DJJ CONSULTING
PSYCHIATRIST BEFORE IT CAN BE SUPPLIED!

Muscle Relaxants
7. DERMATOLOGICALS
Topical Corticosteroids
LOTIONS ARE NONFOMULARY UNLESS STATED
Low Potency
Medium Potency
Fluocinonide Acetonide (Synalar;Lidex) crm/oint
Triamcinolone Acet.(Kenalog;Aristocort) crm/oint High Potency
Betamethasone Valerate (Valisone) crm/oint/lot Anti-Dandruff/Antiseborrheic Agents
Antiacne Agents
Keratolytics
Podophyllin Resin (Podicon-25) topical soln/susp Misc. Preparations
Protectants/Emollients
Ammonium Lactate (Lac-Hydrin) 12% lotionLanolin/Mineral oil (Thera-Derm) lotion 8. ENDOCRINE AGENTS
Insulins/Diabetic Agents
Insulins (Lispro/Aspart, Reg., NPH., Lantis/Levemir, mix (70/30--75/25) Progestins
Oral Contraceptives
Norgestimate/Ethinyl Estradiol (Ortho Tri Cyclen) cap/tab Norethindrone/Ethinyl Estradiol (Ortho Novum) cap/tab Steroids
Thyroid Agents
9. GASTROINTESTINAL AGENTS
Antidiarrheal/Antimotility Agents
Bismuth Subsalicylate (Pepto-Bismol) cap/tab/soln/suspCyproheptadine (Periactin) cap/tabDicyclomine (Bentyl) cap/tab Indigestion/Anti-Ulcer
Lactaid/Lactaid Ultra cap/tabCalcium Carbonate (Tums) chewable tab Magnesium/Alum. Hydroxide soln/suspMagnesium/Alum. Hydroxide/Simethicone soln/suspOmeprazole (Prilosec) cap/tab Laxatives
Bisacodyl (Dulcolax) cap/tab/suppCitrate of Magnesia soln/suspDioctyl Sodium Sulfosuccinate (DSS;Colace) cap/tab Fleets Enema soln/suspFibertabs (FiberLax) cap/tabMilk of Magnesia soln/suspPEG (Miralax) powderPsyllium Powder (Metamucil) powder Anorectal Preparations
Hemorrhoidal (Anusol;Preparation H) oint/crm/suppHemorrhoidal HC (Anusol HC) oint/crm/supp 10. VITAMINS & NUTRITIONAL SUPPLEMENTS
Vitamins/Minerals/Supplements
Multivitamin/Multivitamin with Iron (various) cap/tab Omega 3 Fish oil cap/tabPotassium Chloride (K-Tabs) cap/tab Prenatal vitamins with Folic Acid (various) tcap/tab 11. ORAL ANTISEPTICS/ANALGESICS
Chlorhexidine Gluconate (Peridex) soln/susp Lidocaine viscous (Xylocaine) topical soln/gel 12. URINARY TRACT RELATED
Adequate studies in pregnant women have not demonstrated a risk to the fetus during the first trimester of pregnancy & there is no evidence of risk in latertrimesters.
Animal studies have shown an adverse effect on the fetus, but there are noadequate studies in humans. Benefits of the drug in pregnant women may beacceptable despite the potential risk.
There is evidence of human fetal risk, but the potential benefits from the use ofthe drug in pregnant women may be acceptable despite it's potential risk.
DO NOT USE! Studies in humans demonstrate fetal abnormalities or adversereaction reports indicate evidence of fetal risk. The risk of use in pregnantwomen clearly outweighs any possible benefit.

Source: http://www.djj.state.ga.us/Policies/DJJPolicies/Chapter11/Attachments/DJJ11.27AttachmentA.pdf

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