•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

Southern Health Partners

DRUG FORMULARY
Effective: April, 2013

This is a confidential work product of
Southern Health Partners, Inc.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 1
Effective: January 2013; Updated April 2013

SHP 000183

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

TABLE OF CONTENTS
Introduction
Ordering of Controlled Medication / Narcotic Usage
Revisions and/or Updates to the Formulary
Inventory Control
Outdated, Deteriorated Medications, Expired Medications
Medication Brought in by the Inmate Upon Arrest
Medication Administration Procedures and Information
Verification of Medications
Non-Formulary Medication Prior Approval Form
Physician Request for use of a non-formulary Medication Order

Page 3
Page 3
Page 4
Page 4
Page 4
Page 4
Page 4
Page 5
Page 7
Page 8

Drug Formulary Listing:
Allergy / Antihistamine / Cough / Cold / Decongestant
Page 9
Analgesic / Antipyrectic / NSAID / Gout
Page 9
Anaphylaxis
Page 9
Antacid / Ulcer Therapy / GI
Page 10
Antifungal Agents
Page 10
AIDS / HIV / Antiviral
Page 10
Antiobiotics / Antiviral / Antiinfectives
Page 11
Anticoagulants / Blood Modifiers
Page 11
Anticonvulsants
Page 12
Anti-Diarrheal Agents / Anti-Emetics
Page 12
Antilipemics / Statins
Page 12
Asthma / Bronchial / COPD / Respiratory
Page 12
Bladder Stimulant
Page 13
Cardiovascular / Anti-Hypertensive Agents / Diuretics
Page 13
Diabetic Preps
Page 13
Ear drops
Page 14
Glaucoma Eye Drops
Page 14
Hormonal Agents
Page 14
Laxatives / Stool Softeners
Page 14
Lipid / Cholesterol Lowering Agents
Page 15
Mental Health Agents
Page 15
Migraine
Page 15
Muscle Relaxants
Page 16
Obstetrics (Medications safe for pregnancy)
Page 16
Ophthalmologic Agents
Page 16
Pain Medications
Page 16
Statins
Page 16
Thyroid
Page 17
Topicals
Page 17
Tuberculosis
Page 17
Vitamins
Page 17
Miscellaneous
Page 18
Emergency Cart/Stock Recommendations
Page 18
Administration of Medication Training Course Information
Page 19
FORMS: Drug Disposal Form; Physician Request for Use of a Non-Formulary Medication; Medication Intake/Release Form

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 2
Effective: January 2013; Updated April 2013

SHP 000184

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

INTRODUCTION
The overall purpose of this Formulary is to provide a list of approved medications to treat the majority of disease
states/conditions in a therapeutically safe and financially acceptable manner. The SHP formulary is a list of medications
considered by SHP professional staff and pharmacists to ensure high quality, cost-effective drug therapy for the population
served.
NON-FORMULARY DRUG ORDERS
If a non-formulary drug is prescribed/requested, the pharmacy will fax back a Non-Formulary Prior Approval Form (see
attached forms). The pharmacist will review the use of non-formulary medications and suggest possible alternative therapies
to stay within the formulary drug list, by faxing the form to the site. Once the physician has reviewed the alternative therapies
and selected an alternative, the form will then be faxed back to the pharmacy for implementation. If the Physician does not
agree with suggested therapies, and still would like to use the non-formulary medication, the physician must then complete the
enclosed Non-Formulary Request Form which must be faxed directly to the corporate office (fax 423-553-5645) for review.
The corporate office will contact the physician and/or site Medical Team Administrator as to a decision via fax transmittal or
phone contact.





Several medications must use automatic stop dates and should be reviewed prior to re-order.
Generic substitution will be automatic unless unavailable.
Dental use of narcotics for pain management should not exceed 2 days
Any inmate who is receiving a narcotic must be placed on medical observation for the duration of the medication
order.

ORDERING OF CONTROLLED MEDICATION
The facility, as a general rule, will not order or administer controlled substances for detainees unless approved by the Medical
Director. Alternatives to controlled substances will first be considered when choosing a medication for pain, headache, or
cough. Ultram, Anaprox, Naproxen, and Ibuprofen (several strengths) are possible non-narcotic pain-relieving choices. In the
case of cough, alternatives might include Robitussin, Robitussin DM, or Phenergan Expectorant (without Codeine).
When situations arise that the physician needs to prescribe a controlled medication, the Medical Team Administrator and/or
medical staff shall advise the jail administrator as to the intent to administer a narcotic medication. Notice of the intent to
administer a controlled substance will enable the jail staff to implement any necessary operational protocols (i.e. housing
issues, etc.). Strict documentation of each dose administered and a “running” inventory will be kept for each drug on the
controlled substances inventory sheet supplied by the pharmacy. The staff will take special attention towards the medication
being properly ingested so that possible improper use of the drug by the detainee does not occur at a later time.
EXAMPLES OF COMMONLY-USED CONTROLLED SUBSTANCES THAT WILL NOT BE ADMINISTERED WITHOUT
MEDICAL DIRECTOR ORDERS:
Class II – Demerol, Percocet, Percotan, Ritalin, Tylox, MS Contin, Oxycontin, Oxycodone, Methadone, Fentanyl
Class III – Vicodin, Lorcet, Lortab, Tylenol with Codeine
Class IV – Darvocet, Xanax, Ativan, Ambien, Librium, Valium, Soma, Soma Compound, Phenobarbital, Restoril
Class V – Novahistine DH, Phenergan with Codeine, Lyrica

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 3
Effective: January 2013; Updated April 2013

SHP 000185

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

REVISIONS AND/OR UPDATES TO THE FORMULARY:
The Formulary is revised and updated as needed. Your cooperation with the use of this Formulary is most appreciated.
Please submit any revisions, updates, to the corporate office at:
Southern Health Partners, Inc., Attn: Operations Department
2030 Hamilton Place Blvd., Ste. 140, Chattanooga, TN 37421 Phone: 423-553-5635, Fax: 423-553-5645
INVENTORY:
It is expected that all SHP facilities will keep an acceptable level of inventory of medications. At no time is an inmate to go
without needed medication. Keep in mind when ordering as to holiday schedules.
OUTDATED, DETERIORATED, EXPIRED DRUGS:
Examine drug stock at regular intervals of not more than six (6) months duration and remove from stock all outdated and
deteriorated drugs. This includes a patient’s medication that has been brought in from the outside. Stock must be rotated so
the shortest dated stock will be used first. No outdated or deteriorated drug may be kept for patient use. Under no
circumstances shall any drug be administered that is in a deteriorated condition or that bears a date of expiration that has
been reached.
Drugs must be destroyed in the proper manner using the Drug Disposal Form.
MEDICATION BROUGHT IN BY THE INMATE UPON ARREST
If inmate arrives with a validly prescribed medication in a proper container, the medication is to be logged in and, if a narcotic,
secured under lock and key. The inmate should be informed that if the SHP medical staff do not approve for the medication
use in the facility (under Physician’s Order), it will not be stored at the facility. Complete the Medication Intake/Release Form
with the inmate as notice of the procedure. The inmate must choose to either designate a family member to pick up his/her
medications within the next five (5) days or agree to have medication destroyed within the regular procedure. If the inmate
authorizes a family member to pick up the medication, only that person will be allowed to pick up the medication when medical
staff are present to release such to the family member. A copy of the family member’s driver’s license will be required, and
should be stapled to the Medication Intake/Release Form as verification. Keep all Medication Intake/Release Forms in a
folder in the medical office for review and audit.
In all cases, medications received must be counted and should be witnessed by a second person, documented in writing, and
properly secured. If medication is valid, and count is correct according to prescription information on bottle, and the site
Medical Director approves such for patient’s condition, the medication can be used from the patient’s own supply. Once
medications have been exhausted, the medication order is to be done through normal course (i.e. family continues to bring
medication, medication ordered through pharmacy, etc.).
At no time should an inmate/patient go without needed medication as prescribed by the Medical Director.
MEDICATION ADMINISTRATION:
Medications are to be administered in accordance with the policy/procedure set up by SHP and the Facility. All medications
are to be recorded on a Medication Administration Record (MAR) by SHP employee(s).
It is imperative the person designated to pass medications is either a licensed medical professional or trained to pass
medications by a licensed medical professional. SHP provides training information if needed.
Medication Passes are to be done by medical staff and/or trained corrections officers during the set times for distribution to the
inmates. Due to security constraints, unforeseen emergencies, etc., medications may be passed within one (1) hour of the
prescription time.
Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 4
Effective: January 2013; Updated April 2013

SHP 000186

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

PROCEDURE:
1.
The nurse must have an officer with him/her at all times during medication pass;
2.

The nurse will call out the inmate’s name that is to receive medications. No other inmate should approach the
nurse unless their name has been called. If an inmate doesn’t answer, or doesn’t come up to receive meds,
then they will miss pill call for that time. They may submit a sick call slip to be seen by medical staff within the
medical unit. The nurse will not return to the pod to pass an individual’s medication due to their not responding
when called. EXCEPTION: TB drugs, by law, cannot be refused. If an inmate on such drugs doesn’t come up to
receive meds, the Officer should be notified to go to inmate’s cell and have inmate come to the nurse for med
pass. If the inmate still refuses, notify the Jail Administrator and your Region Representative for further
instruction and handling.

3.

The nurse will not do sick call, address complaints, or handle any other matters during medication pass (unless
there is an emergency).

4.

The inmate is responsible for bringing a cup of water with them to receive their medication.

5.

Any inmate who is verbally abusive or disrespectful to the nursing staff will be removed from the nurse
medication pass area. This individual will not receive his/her medication, but rather be brought down to the
medical unit at a later time to receive such medication.

6.

If the officers suspect an inmate is cheeking or hoarding medication, please alert the medical staff. They will do
alternative methods of medication distribution to that inmate (for example, floating meds in water, or crushing the
medication). Note to medical staff: You must get a physician’s order to crush or float meds since there are
several medications which cannot be administered in this manner.

The officer’s help in accomplishing the above procedures will be greatly appreciated. This will allow medical staff to pass
medications in a quick and efficient manner, thus reducing the amount of officer time medical would need to accomplish this
task.
NOTES:
 If an inmate wants to discuss his medical problem/condition at the time of med pass, make him aware that he/she must
complete a sick call slip and will be seen at the proper time, not at med pass. This excludes obvious emergencies.
 The inmates will learn the proper procedure for med pass through continuity. Officers, please help the medical staff by
keeping inmates away from the nurse when passing medication, unless that inmate has been called.
VERIFICATION OF MEDICATIONS
At some point, the medical staff will review a patient who did not come into the facility with medication, but states he/she takes
medication. The following will give you guidance as to SHP’s procedure for this type of request:
1.

The patient must sign an Authorization for Release of Medical Information to the Facility, thereby allowing SHP to
verify the last treatment received, and any medication orders.

2.

Further, the patient must be asked where they last filled the prescription (Pharmacy Name, City/State). It is
imperative we find out if the patient has been compliant with treatment prior to incarceration.

3.

Contact the above resources given to verify treatment plans, course of medication, etc.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 5
Effective: January 2013; Updated April 2013

SHP 000187

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

4.

If medication has been verified as current, we will need to order appropriately through the use of our Drug Formulary
and the Physician’s Treatment Protocols. Contact the Medical Director for guidance if needed.

5.

If medication cannot be verified, or the patient was not taking the medication consistently prior to incarceration, then
the patient must be reviewed by the Medical Director to determine if the course of treatment is to continue. This
patient may be monitored as to possible condition to determine any type of medical condition (blood sugar checks,
blood pressure checks, etc.).

6.

Document all of your findings/information regarding the verification process on a Progress Note for the patient’s
medical record.

NOTE: If the patient comes in with pill bottles full of medicine, and the medicine in the pill bottle is appropriate as prescribed
on the bottle, and the pill count is correct in relation to the fill date and date you check it, and the medication is for a chronic
condition, you may administer the medication as directed on the bottle until such time the medication can be properly verified
through the pharmacy and/or the patient’s physician provider.
Feel free to contact your Region Representative and/or VP of Operations, with any questions and/or suggestions you may
have in this regard.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 6
Effective: January 2013; Updated April 2013

SHP 000188

• I Southern Health
•~~
Partners
V

Your Partner In Affordable Inmate Healthcare

****************************************************************************************************
THIS IS AN EXAMPLE/SAMPLE OF THE FORM WHICH WILL BE SENT FROM THE PHARMACY TO THE SITE
UPON THE ORDERING OF A NON-FORMULARY MEDICATION.

NON-FORMULARY MEDICATION
PRIOR APPROVAL FORM
Physician’s Name:
Date:

Site:
Fax to Pharmacy at :

Patient’s Name:
Prescription Order for:
The above non-formulary medication has been requested by you according to the Southern Health
Partners, Inc. Formulary. The following medication(s) are examples of other formulary-approved
medications which may be used as alternatives:

0

If you do not agree with any of the above alternatives, please complete the Non-Formulary Request
Form and fax it to the SHP corporate office at 423-553-5645. Thank you.
If you agree with any of the above noted alternatives, please state the new order:
Patient Name:
Date of Order:
Dosage:

Medication Order:
Directions:

Physician’s Signature:

Date:

This form will be sent to the site Physician from the Pharmacy upon any Non-Formulary Medication Order.
Generic substitution will be automatic if available.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 7
Effective: January 2013; Updated April 2013

SHP 000189

Southern Health
Partners
Your Partner In Affordable Inmate Healthcare

•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

This is a copy of the form to be used by the SITE when requesting a nonformulary medication.
*******************************************************************************************
TO: CORPORATE OFFICE
Upon completion, FAX Request form to the SHP corporate office at: (423) 553-5645

PHYSICIAN REQUEST FOR USE OF A NON-FORMULARY MEDICATION
From: Dr.

Site:

Date:
I am requesting the following non-formulary medication as stated below. If you can provide me with suggestions of possible
alternative therapies to stay within the formulary drug list, I will consider those options.
Inmate’s Name:
Ordering Physician:

ID #
Print:

Non-Formulary Drug Requested:
Estimated Duration of Usage:
Reason for Non-Formulary Request:

List of Formulary Agents and Dose Previously Used:

CORPORATE OFFICE REVIEW:
Approved: (YES / NO) Date:
Reason for Denial:
Corporate Representative Signature:
Date Faxed to Physician at Site:
Date Faxed to Pharmacy:

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 8
Effective: January 2013; Updated April 2013

SHP 000190

g

V

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

DRUG FORMULARY:
Note:
(**DNC**) = Do Not Crush this medication. Note the various medication suffixes: XL, Sr, CR,
etc. These medications are never to be crushed.
All non-formulary medications must be referenced through the use of a drug index or by
consulting the pharmacy vendor.

ALLERGY / ANTIHISTAMINE / COUGH / COLD DECONGESTANT
Generic Name
Decongestine / D-Amine
Carbinoxamine/Pseudephedrine
Cholrtrimetron
Cimetidine
Diphenhydramine
Guaifenesin
Guaifenesin DM
Hydroxyzine Pamoate (capsules)
Ocean Spray
Saline Solution
Montelulkast

Trade Name
Deconamine
Deconamine

Cost Factor
$$
$$

Tagamet
Benadryl
Robitussin
Robitussin DM
Vistaril (costs less than Atarax)

$
$
$
$$
$

Singular

ANALGESIC / ANTIPYRECTIC / NSAID / GOUT
Generic Name
Acetaminophen/Phenyltolox
Allopurinol
Aspirin
Etodolac
Ibuprofen
Indomethacin
Ketoprofen
Meloxicam
Naproxen
Probenicid/colchicine

Trade Name
Percogesic/Phenylgesic
Aloprim
Aspirin
Motrin (use 400mg)
Indocin (**DNC**)
Naprosyn
Probenicid/colchicine

Cost Factor
$
$
$$
$
$$
$$$
$
$

ANAPHYLAXIS
Generic Name
Benadryl
Epinephrine
Methylprednisolone

Trade Name
Epipen
Solu-Medrol

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Cost Factor
$
$

Confidential
Page: 9
Effective: January 2013; Updated April 2013

SHP 000191

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

ANTACID / ULCER THERAPY / GI
Generic Name
Aluminum/Magnesium
Hydrox/Simethicone
Aluminum Hydrox / Mag Trisil
Belladonna Alkaloids
Bismuth Subsalicylate Tab / Liquid
Calcium Cabonate
Cimetidine
Dicyclomine Tab/Cap
Famotidine
Metroclopramide
Omeprazole
Ranitidine (costs less than Tagamet/Pepcid)

Trade Name
Mylanta II Susp
Gaviscon tab
Donnatal
Pepto Bismol
Tums
Tagamet – watch Drug Interactives
Bentyl
Pepcid
Reglan
Prilosec / Prilosec OTC
Zantac (preferred H2 blocker)

Cost Factpr
$
$
$
$
$
$$
$$
$$
$$
$

ANTIFUNGAL AGENTS
Generic Name
Fluconazole
Nystatin
Lamisil Cream 1%
Lamisil PO
Tolnafate Cream

Trade Name
Diflucan

Cost Factpr
$$$
$
$$
$

AIDS / HIV / ANTIVIRAL
Generic Name
Keletra
Lamivudine
Nelfinavir
Norvir
Reyataz
Tenofovir
Zidovudine

Trade Name

Cost Factpr

Epivir
Viracept

$$$
$$$

Viread
Tuvada
Combivir
Retrovir

$$$
$$$
$$$
$$$

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 10
Effective: January 2013; Updated April 2013

SHP 000192

g

V

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

ANTIBIOTICS / ANTIVIRAL / ANTIINFECTIVES
Generic Name
Acyclovir Cap
Amantadine Cap
Amoxicillin
Azithromycin
Sulfamethoxazole
Ceftriaxone
Cephalexin
Ciprofloxacin
Clindamycin
Clotrimazole / Betamethasone
Doxycycline
Erythromycin Stearate Tab **
Fluconazole
Isoniazid****
Permethrin 1% (for Lice)
Permethrin 5% (for Scabies)
Invermectin
Metronidazole
Miconazole
Neomycin/Polymixin B/Bacitracin
Nitrofurantoin

Trade Name
Zovirax
Symmetrel
Amoxicillin / Amoxil (less than Penicillin) /
Augmentin
Zithromax
Bactrim (FIRST CHOICE BEFORE
MACROBID)
Rocephin
Keflex (use Amoxil when indicated)
Cipro – Use Bactrim first for UTI (**DNC**)
Cleocin
Lotrisone / Lotrimin
Vibramycin
Erythrocin
Diflucan – Now cheaper than OTC Vag
Preps
Isoniazid (INH)
Nix
Elimite
Stromectol
Flagyl
Micatin / Monistat
Neosporin
Macrobid (ONLY to be used if Cipro and
Bactrim have failed)
Mycostatin
Penicillin / Pen-Vee-K
Deltasone / Orasone
Rifadin
Silvadene
Bactrim
Tinactin
Septra DS / Bactrim DS

Cost Factor
$$
$$
$

$
$$
$$
$
$
$
$$
$
$$
$
$
$

Nystatin
$$
Penicillin
$$
Prednisone
Rifampin
Silver Sulfadiazine
$$
Trimethoprim-sulfamethoxazole
Tolnaftate
$
Trimethoprim/Sulfamethoxazole
$
** Dental Use only
****May received free through county health department – Check with Health Dept.

ANTICOAGULANTS / BLOOD MODIFIERS
Generic Name
Aspirin
Clopidogrel
Warfarin

Trade Name
Aspirin
Plavix
Coumadin

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Cost Factor
$
$$
$$
Confidential
Page: 11
Effective: January 2013; Updated April 2013

SHP 000193

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

ANTICONVULSANTS
Generic Name
Carbamazepine
Divalproex Sodium

Trade Name
Tegretol
Depakote (use Valproic Acid – give

Cost Factor
$$
$$$

with food if GI upset occurs) (**DNC**)

Oxcarbazepine 300mg BID
Phenobarbital
Phenobarbital
Phenytoin
Dilantin
Topiramate 25mg BID
Valproic Acid
Depakene (preferred over Depakote)
NOTE: Depakote is converted to Valproic Acid in the gut.

$$
$
$$
$
$$

ANTI-DIARRHEAL AGENTS / ANTI-EMETICS
Generic Name
Bismuth Subsalicylate Tablets
Loperamide
Promethazine

Trade Name
Pepto Bismol
Imodium
Phenergan
Lomotil
Reglan

Cost Factor
$
$
$$

Trade Name

Cost Factor
$

ANTILIPEMICS / STATINS
Generic Name
Gemfibrozil
Fenofibrate
Simvastatin
Lovastatin

Lopid
Tricor
Zocor
Mevacor

$$
$

ASTHMA / BRONCHIAL / COPD / RESPIRATORY
Generic Name
Trade Name
Advair discus (Use QVAR + Albuterol if possible)
Albuterol Sulfate Inhalant Solution
Proventil Inhalant / ProAir HFA
Beclomethasone
QVAR
Ipratropium Bromide Oral Inhalant (for Atrovent

Cost Factor
$$$$
$
$$$
$$$

COPD ONLY)

Ipratropium Bromide Inhalant Solution (for Atrovent Inhalant

$

COPD ONLY)

Methylprednisolone
Metrapoterenol
Theophylline Timed Release

Solu-Medrol
Metaprel / Alupent
TheoDur

$$
$

Ipratropium Nebulizer solution is less than MDI.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 12
Effective: January 2013; Updated April 2013

SHP 000194

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

BLADDER STIMULANT
Generic Name
Tamsulosin hcl

Trade Name

Cost Factor

Flomax

CARDIOVASCULAR / ANTI-HYPERTENSIVE AGENTS / DIURETICS
Generic Name
Amlodipine
Aspirin
Atenolol
Benazipril 10 or 20mg QD
Bisoprolol/HCTZ 2.5/6.25mg QD
Carvedilol 6.25mg BID
Clonidine
Diltiazem
Diltiazem SR
Diltiazem ER
Diltiazem CD
Diltiazem XR
Enalapril
Furosemide
Hydrochlorothiazide
Isosorbide Dinitrate

Trade Name

Cost Factor

Norvasc
Aspirin
Tenormin

Catapres
Cardizem
Cardizem SR (**DNC**)
Cardizem CD (**DNC**)
Cardizem CD (**DNC**)
Dilacor XR
(**DNC**)
Vasotec (preferred ACE Inhibitor)
Lasix
HCTZ
Isordil

$$
$$
$
$
$
$$
$$
$$
$$
$$
$
$
$
$$

Lisinopril/HCTZ

Lisinopril/HCTZ 20/25

Lisinopril
Methyldopa/Methyldopate
Metroprolol
Metolazone 5mg QD
Nifedipine
Nitroglycerin Sub Ling
Quinapril 10mg QD
Plavix

Zestril
Aldomet
Lopressor

Prazosin
Propranolol
Ramipril 2.5mg QD
Spironolactone
Triamterene / HCTZ
Verapamil

Minipress
Inderal

$
$$

Aldactone
Maxzide
Calan

$$
$
$$

Procardia
Nitrostat
Clopidogrel – Needs to go through NF
process (overused) > $125/month

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

$
$$
$$$
$
$$
$$

Confidential
Page: 13
Effective: January 2013; Updated April 2013

SHP 000195

g

V

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

DIABETIC PREPS
Generic Name
Trade Name
Glimepiride 4mg QD
Glipizide
Glucotrol
Glyburide
Micronase/Novo-Glyburide
Humalog, Insulin
Humulin
Insulin NPH
Novolin – N
Insulin Human Regular
Novolin-R
Insulin 70/30
Novolin 70/30
Metformin
Glucophage
Novolin – Humulin are interchangeable, don’t stock both.

Cost Factor
$$
$

$$$
$$$
$$$
$$

EAR DROPS
Generic Name

Trade Name

Cost Factor

Maxitrol Ophalmic Susp.
Boric Acid
Cortisporin Otic

$

GLAUCOMA EYE DROPS
Generic Name
Timolol
Latanoprost 0.005%

Trade Name

Cost Factor

Timoptic
Xalatan

$
$

HORMONAL AGENTS
Generic Name
Levothyroxine

Trade Name

Cost Factor

Levoxyl
Menest
Provera

$
$

LAXATIVES / STOOL SOFTENERS
Generic Name
Bisacodyl
Docusate Sodium
Milk of Magnesia
Sod Phosphate / Biphosphate Enema
Lactulose
Metamucil

Trade Name
Dulcolax (**DNC**)
Colace
MOM
Fleets Enema
Lactulax
Metamucil

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Cost Factor
$
$
$
$
$

Confidential
Page: 14
Effective: January 2013; Updated April 2013

SHP 000196

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

LIPID / CHOLESTEROL LOWERING AGENTS
Generic Name
Fenofibrate
Simvastatin
Atorvastatin

Trade Name

Cost Factor

Tricor
Zocor
Lipitor (ONLY IF SIMVASTATIN
IS NOT EFFECTIVE)

MENTAL HEALTH AGENTS
Generic Name
Amitriptyline / Triavil 2-25 & 4-50
Benztropine Mesylate
Buproprion
Buspirone
Citalopram
Chlordiazepoxide
Clonazepam
Doxepin 75mg QD or 25mg TID
Fluoxetine
Fluphenazine
Haloperidol
Hydroxyzine HCI
Lithium Carbonate
Lorazepam
Mirtazapine 15mg QD
Olanzapine
Paroxetine 20mg QD or 40mg QD
Risperidone

Trade Name
Elavil (preferred TCA)
Cogentin
Wellbutrin SR/XL
Buspar
Celexa (preferred SSRI)
Librium
Klonopin

Cost Factor
$$
$
$$

Prozac (preferred SSRI)
Prolixin
Haldol
Vistaril
Lithium Carb
Ativan
Zyprexa
Risperdal (use when conventional
antipsychotics fail)

$$
$
$
$
$
$$
$$
$
$
$
$$
$$
$$
$$$

Sertraline
Zoloft
Trazodone
Desyrel
$
Trifluoperazine
Stelazine
$$
Valproic Acid
Depakene
$$
Venlafaxine 37.5mg BID
Effexor XR
$$
Mental Health medications are subjected to regular review for therapeutic value for patient.

MIGRAINE

(not to exceed 10 days of therapy per month without MD on-site
review/visit)
Generic Name
Trade Name
Cost Factor
Propranolol *
Inderal
*must be given daily as preventative.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 15
Effective: January 2013; Updated April 2013

SHP 000197

g

V

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

MUSCLE RELAXANTS
Generic Name
Cyclobenzaprine
Methocarbamol
Tizanidine 4mg QD

(not to exceed 10 days of therapy per month)
Trade Name
Cost Factor
Flexeril
Robaxin
$
$

OBSTETRICS – Medications safe for pregnancy
Generic Name
Nystatin
Miconazole 3
Amoxil
Keflex
Pseudofed
Claritin

OPHTHALMOLOGIC AGENTS
Generic Name
Artificial Tears
Bacitrac/neomycin/Polymix Opth
Eye Wash
Gentamycin Opth Sol
Tetrahydrozoline HCI Opth solution

Trade Name
Artificial Tears
Neosporin Opth Oint/Solution –
Use in place of Cortisporin Otic
Eye Wash
Garamycin Opth
Visine Opth Solution

Cost Factor
$
$
$
$$
$

PAIN MEDICATIONS
Generic Name
Trade Name
Cost Factor
Tylenol
Motrin
Ibuprofen
Naproxen
Neurontin
Gabapentin
Ultram
Tramadol
**Alternatives to controlled substances will first be considered when choosing medication for
pain. All controlled substances administered must by reviewed/prescribed by the SHP Site
Physician. See Ordering of Controlled Medication section.

STATINS
Generic Name
Fenofibrate
Lovastatin

Trade Name
Tricor
Mevacor
Niacin

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Cost Factor
$
$$

Confidential
Page: 16
Effective: January 2013; Updated April 2013

SHP 000198

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

THYROID
Generic Name
Levothyroxine

Trade Name
Synthroid

Cost Factor
$

TOPICALS (Generics must be purchased through Medical Supplier, not Pharmacy)
Generic Name
Alcohol
Benzocaine
Calamine Lotion
Clotrimazole Vaginal Cream
Gentamicin Sulfate Oint
Hemorrhoidal Suppositories
Hydrocoritsone Suppositories
Hydrocortisone Ointment / Cream
Hydrogen Peroxide
Nystatin/Triamcinolone Cream / Oint
Silver Sulfadiaxine Cream
Sodium Chloride Nasal Spray
Tolnaftate Cream
Tolnaftate Topical Solution

Trade Name
Alcohol
Anbesol / Ora-jel
Calamine Lotion
Fem Care Vaginal Cream –
Consider Diflucan 150mg po x1
Garamycin Oint
Preparation H
Anusol HC Supp
Hydrocortisone
Peroxide
Mycolog Cream / Oint
Silvadene Cream
Ocean Spray
Tinactin Cream
Tinactin Solution

TUBERCULOSIS
Generic Name
Isoniazid
Ethambutol
Rifampin
Pyrazinamide

Trade Name
Myambutol
Rifadin
Tebrazid

VITAMINS
Generic Name
Ascorbic Acid
Ferrous Sulfate
Folic Acid
Magnesium Oxide
Multivitamin and Minerals
Potassium Chloride Caps
Prenatal Plus
Pyridoxine
Sodium Bicarbonate
Thiamine Hydrochloride
Cyanocobalamin

Trade Name
Vitamin C
Ferrous Sulfate (**DNC**)
Folic Acid
Mag Oxide
Multivitamin
Micro-K
Prenatal Vitamins
Vitamin B-6
Vitamin B-1
Vitamin B-12

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 17
Effective: January 2013; Updated April 2013

SHP 000199

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

MISCELLANEOUS
Generic Name
Trade Name
Antivert (for Vertigo)
Flu Vaccine *
Fluzone
Ipecac Syrup
Ipecac Syrup
Lidocaine Injection
Xylocaine
Tetanus / Diptheria Vaccine
Decavac
Tuberculin test
Aplisol
 For use with Chronic Care Patients only

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 18
Effective: January 2013; Updated April 2013

SHP 000200

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

Emergency Cart/Stock Recommendations:
The following is a list of stock medications which must be kept on site for use in emergencies or if a patient’s meds have run out and the
re-order has yet to be received, etc. This list must be reviewed and approved by the site physician based upon their need and orders. In
cases where stock medications have run out, it is imperative to re-order for stock a.s.a.p. The quantity to be kept on site depends upon the
size of the jail – please consult with your physician as to your use and need to order. This listing is a sampling, and therefore any additions
should be written in at the Additions section. Any deletions or unnecessary stock items should be crossed off this list. Once completed, a
copy of the signed form should be placed within the Policy and Procedure Manual under Pharmaceuticals Policy.

Name of Drug

Dosage

Quantity

OTCs

Amoxicillin
Cephalexin (Keflex)
Doxycycline
Erythromycin
PenVK
Septra DS

500mg
500mg
100mg
500mg
500mg

30
30
30
30
30
30

Benadryl 25mg 30
Lidocaine
Sodium Chloride 0.9%
Thiamine (for detox)
Multi Vitamins (for detox)
PreNatal Vitamins
Lindane
Antifungal cream
KY (foil packs)
AB ointment (foil packs)
Iodine prep pads
Povidone Iodine
HC cream (foil packs)
Alamag tabs
Chlorpheneramine 4mg
Pseudoephedrine 30mg
Kaopectate
Acetaminophen 325mg
Ibuprofen 200mg
Aspirin 325mg

Tetanus Toxoid
Glucagon / Glucose Paste/Tabs
Insulin Regular 70/30N 2 vials
Clonidine
Clonidine
Dyazide
Dilantin
Nitroglycertin
Librium
Tagamet
Humabid LA
Tigan Suppositories
Albuteral Inhaler
Silver sulfidiazine cream
Cortisporin ear gtts
Sulfacetamide eye gtts
Gentamycin eye gtts
Antidiarrheal agent
Charcoal

0.1mg
0.2mg

30
30

100mg
0.4mg
25mg
200mg

30
15
30
15
30

Quantity

3
1
1 tube
1
1
1

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 19
Effective: January 2013; Updated April 2013

SHP 000201

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

ADMINISTRATION OF MEDICATION TRAINING
The following training has been established to teach correctional officers how to administer medication other than
by injection. Prior to administering any medication, correctional officers must complete this training course and
medication test. A certificate will be issued to the correctional officer upon completion of the training course and
with a passing test grade.
Upon completion of this training course, you, the correctional officer, should be able to:
1.

Identify the legal and ethical responsibilities associated with administering medications;

2.

Identify the five rights of medication;

3.

Identify the differences between use, misuse, and the abuse of medications;

4.

Describe policies concerning the usage of prescription or non-prescription medications;

5.

List the components of a properly-labeled prescription;

6.

Describe how information can be obtained from some acceptable written source, e.g. Drug Handbook
or Physician’s Desk Reference;

7.

Know when not to administer medication;

8.

Recognition of the basic abbreviations, symbols, and terminology associated with medication usage;

9.

Define medication errors, identify prevention techniques, and list the procedures for reporting errors.;

10.

Recognize possible effects of major drug groups;

11.

Describe action(s) to be taken by the provider when adverse effects are recognized;

12.

Identify policies relating to the proper storage of medications;

13.

Describe the procedures for the disposal of medication;

14.

Know the proper procedure for using the Medication Administration Record.

LEGAL AND ETHICAL RESPONSIBILITY
When administering medications, you are legally responsible for making sure you comply with the requirements
that medications be in original containers and properly labeled.
The privilege of being able to perform this function is granted to those who successfully pass an approved
medication training program. As a participant in the provision of medications, you are expected to carry out your
role in a manner which protects the recipient of service from harm.
A basic understanding of the medications which you are administering is important to the inmate’s overall wellbeing. Therefore, you are responsible for obtaining needed information on medications so you can carry out your
role in an appropriate manner.
It is expected both from a legal and ethical standpoint you will not knowingly participate in practices which are
outside of your legally permissible role or which may endanger the well being of the receipt.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 20
Effective: January 2013; Updated April 2013

SHP 000202

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

THE FIVE RIGHTS OF MEDICATION
You must be certain you are administering the right drug to the right person in the right amount at the right time
using the right route. Each time a drug is taken, you must systematically and conscientiously check your
procedure against these five rights.
Right Drug: to ensure you are administering the right drug, you must compare the medication administration
record with the pharmacy label. Make sure they match.
Right Person: in order to make sure you have the right person, you have to know the individual. Check arm
bands, ask the patient their name.
Right Amount: be sure to check the right dosage by comparing the medication administration record and the
pharmacy label to make sure they agree.
Right Time: when a physician prescribes a drug, he/she will specify how often the drug is to be taken. For
example – once a day; twice a day.
Right Route: medications must be administered properly in order for them to have the proper effect on the body.
For example – Oral means by mouth; Topical means place directly on the skin; Eye drops are placed in the eye.
So, you may give the medication only when you are sure you have the:
Right Drug Right Person Right Amount Right Time

Right Route

THE USE, MISUSE, AND ABUSE OF MEDICATIONS
Use of medication is appropriate when:
1. The physician has prescribed the medication for the person taking it;
2. The person takes the correct amount prescribed by the physician or as directed by the label in an
over the counter medication;
3. The person takes the medication at the proper times for the number of days indicated.
Misuse of medication occurs when:
1. The person takes medication prescribed for someone else;
2. The person changes the amount of the medication taken thinking that “is this amount is good,
more must be better.”
3. The person does not take the medication at the correct times or length of time required.
4. The person keeps unused medications beyond the expiration date for “future use.”
Abuse of medication occurs when:
1. A person gets prescriptions from several different physicians for the same false symptoms;
2. A person takes drugs to such a level that he/she is unable to function properly and his behavior is
strange.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 21
Effective: January 2013; Updated April 2013

SHP 000203

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

PRESCRIPTION AND NON-PRESCRIPTION MEDICATION
Prescription medication includes all drugs which must be ordered by a physician and be provided by
the physician or a pharmacist. It is provided for a single person who has a specific condition which
the physician is treating by using the prescription drug.
Nonprescription medication is also called “over the counter” or OTC drugs. They can be purchased
without a prescription. Common OTC drugs include pain relievers such as aspirin or Tylenol and
certain cold remedies like Robitussin. Even OTC medications are meant to be used for specific
reasons. The symptoms which can be helped by an OTC medication are listed on the label.
PROPERLY LABELED PRESCRIPTIONS
A prescription functions as a written order from the physician to the pharmacist. The pharmacist will
then provide the medication in a container which has a pharmacy label. The label should contain at
least as much information as the physician’s prescription.
For example:
Pharmacy’s phone number, name and address
Name of Person for whom medication is intended
Name, strength of each pill, and number of pills in container
Directions for taking the medication
Prescription number (given by the pharmacy) and the physician’s name
Number of times the medication may be reordered
Expiration date of medication.
RESOURCES AVAILABLE FOR OBTAINING INFORMATION ABOUT SPECIFIC MEDICATIONS
For OTC medication, the information concerning how to use the drug and how to properly store it is
printed on the package or bottle. Also, any pharmacist can provide answers to questions on use and
storage as well.
For prescription medication, the following resources are available concerning how to use the drug and
how to properly store it:
1. The container itself should give directions for use including whether it should be taken with or
without food, should be refrigerated, etc.
2. The pharmacy listed on the container can be called to ask for information.
3. The person’s physician listed on the container can be contacted for information.
4. A Physician’s Desk Reference book will give detailed information about a drug, as will a Drug
Handbook. Both of these reference books can be easily purchased from a book store.
5. The Office of Narcotics and Dangerous Drugs can send you printed information on a specific
drug. Have the local number posted for ease of use.
DO NOT ADMINISTER MEDICATION:
1. If the container label is not legible;
2. If the medication has expired;
3. If you have any doubt that you have the right person, right drug, right dosage, right time, or right
route.
4. If the medication in the container is the not the right medication. Most drug reference books will
have pictures of the medication.
Note: If you float meds at your facility, only do so right before giving the medication to the person.
Some medications lose potency if left floating in water too long.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 22
Effective: January 2013; Updated April 2013

SHP 000204

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

THE ADMINISTRATION OF A MEDICATION
When giving a medication, especially liquid, it is advisable that an accurate measuring device be
used. Most pharmacies will provide a free measuring cup upon request.
Some of the more common measurements you may want to be aware of include:
2 tbsp = 1 fluid ounce
1 tbsp = ½ fluid ounce
1 tsp = 1/3 tablespoon
The prescription labels with which you will come into contact will be written in a manner that is easy to
understand (example: take one teaspoon every four hours). The following are frequently used
medical abbreviations dealing with prescriptions:
Bid = twice a day
Qid = four times a day
Cap = capsule
Oz = ounce
Fl = fluid
When you, the correctional officer, gives the person his/her medication, you become responsible for
assuring that the five rights of medication are followed. In addition to the five rights, there are some
additional safeguards to help minimize medication risks. They are:
DO give your full attention to the task.
DO ask the person their name for confirmation.
DO check the patient’s mouth to make sure the medication has been swallowed.
DON’T give medication from a container which has a label that cannot be read.
DON’T take medication from another person’s container.
DON’T hide a medication error.
Sometimes a medication label will not have the time to take the medication written. The label may
simply say “take three times a day”. A rule of thumb:
4 times a day = 4 hours between doses;
3 times a day = at mealtimes (check to see if to be given before or after meals)
2 times a day = early morning and late evening, usually a 12 hr difference.

DOCUMENTATION
When you give a medication to a person, it is important to document the date and time given. This is
especially important if you share the responsibility of giving medication with another person at your
facility. Further, this information may be needed in a lawsuit if an inmate claims he did not receive
his/her medication.
A Medication Administration Record (MAR) is the best documentation record to be used. An example
of a recommended MAR is attached to this outline.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 23
Effective: January 2013; Updated April 2013

SHP 000205

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

MEDICATION ERRORS
A medication error occurs when any one or more of the five rights of medication are missed and/or
violated. A medication error has occurred if:
1.
2.
3.
4.

A person took the wrong med.
A person took the wrong dose.
A person took the medication at the wrong time or even if the medication wasn’t given at all.
The medication was taken by the wrong route.

If a medication error occurs, you must immediately notify your supervisor and medical staff.
Depending upon the medication, simple observation may be all that’s needed. You should write up
an incident report regarding the error for review by the Jail Administrator.
If they error is a
medication that may cause an allergic reaction, you may want to send the patient the local
emergency room for evaluation.
THE EFFECTS OF MAJOR DRUG GROUPS
For each person’s protection and safety, it is important for you to notice the effect a medication can
have upon a person. The time factor between taking a medication and its onset of action can be
found in the PDR or by asking the pharmacist. Each medication has a different time for onset of
action. Basically, a medication can have no effect; a desired effect; or an undesired effect. For
example:
a. A person taking cough syrup for a cough. After one day there is no improvement in the
cough. This is an example of a medicine having no effect.
b. A person taking two aspirins for a headache and within the hour the headache is relieved.
This is an example of a medicine having a desired effect.
c. A person taking penicillin for a strep throat. An hour after taking the medication, the
person has developed a very itchy red rash. This is an example of an undesired effect.
In order to know what effect medications may have on a person, you must be somewhat familiar with
the desired effect of medication group. Here are some examples:
1.
2.
3.
4.
5.

Heart medicines (example: HCTZ) – are used to change the heart functions;
Anticonvulsants (example: Phenobarbitol) – are used for seizure disorders;
Antibiotics (example: Penicillin) – are used to fight infections
Fever, pain relievers (example: Tylenol) – used to fight fevers, pain.
Psych medicines (example: Trazodone) – used for psychiatric conditions, mood elevators.

If you notice a person having an adverse reaction to a medication, notify medical staff immediately.
Depending upon the type of reaction, you may need to send the patient to the local emergency room
for evaluation and treatment. Keep in mind some reactions can be very swift (obstructing airway)
while others may be slow acting (itchy rash).
STORAGE OF MEDICATION
The following measures for storage of medications are suggested:
a. Medications are to be kept in a labeled container as received by the pharmacist.
b. Medications must be kept in an area which is locked and access is controlled.
c. Any medications which must be refrigerated (insulin) should be done in a refrigerator
separate from food and drinks.

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 24
Effective: January 2013; Updated April 2013

SHP 000206

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

d. Storage areas are to be kept clean and organized and medication should be stored
under proper conditions of temperature, light, and moisture.
DISPOSAL OF MEDICATION
When a prescription is discontinued or if a medication is left after an inmate is released, the
medication needs to be properly disposed. In many cases, a log should be kept of drug disposal (see
attached form) with the medications being flushed down the toilet or returned to the pharmacist for
destruction.

DEFINITIONS:
Administer:

to give out, insert, or apply medication to a person.

Controlled Substance: Medications that have the potential to be addictive and used in a way other than the
medication was prescribed. A system must be in place to account for receipt, administration, and disposition of
each medication deemed to be a controlled substance.
Dispense:
Preparing and packaging a prescription medication in a container with information required by
state and federal law.
Medication Administration Record (MAR):
A record that lists all of the medications ordered for the resident,
including routine or regularly scheduled medications and PRN medications. It is used to document or record the
administration of medications.
Medication Pass:

Scheduled time of the day when medications are administered to residents.

OTC Medications:
Over-the-counter or non-prescription medications. Medications which can be purchased
or obtained without a prescription.
PRN:

as needed or if necessary. PRN medications need not be scheduled to be administered at specific times.

Side effects:

Any effect other than the desired effect.

ABBREVIATIONS / COMMON MEDICAL TERMINOLOGY
Doses: gm = gram
mg = milligram
mcg = microgram
cc = cubic centimeter
ml = milliliter
tsp = teaspoonful
tbsp = tablespoonful
gtt = drop
ss = 1/2
oz = ounce
mEq = milliequivalent
Times: QD = every day
BID = twice a day
TID = three times a day
QID = four times a day
q_h = every
hours
Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 25
Effective: January 2013; Updated April 2013

SHP 000207

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

qhs = at bedtime
ac = before meals
pc = after meals
PRN = as needed
QOD = every other day
ac/hs = before meals and at bedtime
pc/hs = after meals and at bedtime
STAT = immediately

Routes of Administration:

po = by mouth
pr = per rectum
OD = right eye
OS = left eye
OU = both eyes
AD = right ear
AS = left ear
AU = both ears
SL = sublingual (under the tongue)
SQ = subcutaneous (under the skin)
Per GT = through gastrostomy tube

Other: MAR = medication administration record
OTC = over the counter
SIG = label or directions

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 26
Effective: January 2013; Updated April 2013

SHP 000208

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

DRUG DISPOSAL FORM
Appropriate medical staff may use this form for disposal/destruction of controlled or non-controlled
drugs; however, when listing controlled drugs a separate form must be used and not combined with
other prescription drugs. A medical staff witness and/or correctional staff representative must be
present upon the disposal/destruction of medication along with the person destroying the medication.
This form must be kept on file within the medical unit for review by any audit committee/representative.
Site Name:

Today’s Date:

Site Address:
Drug Name

Method of Disposal:

Drug Strength

Quantity

Returned to Pharmacy for disposal/destruction
Flushed into sewer system
Other – Describe:

Signature of Medical Staff:
Printed Name:

Date:

Witness’ Signature:
Printed Name:

Date:

SHP Form 12/06

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 27
Effective: January 2013; Updated April 2013

SHP 000209

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

TO: CORPORATE OFFICE

Upon completion, FAX Request form to the SHP corporate office at: (423) 553-5645

PHYSICIAN REQUEST FOR USE OF A NON-FORMULARY MEDICATION
From: Dr.

Site:

Date:
I am requesting the following non-formulary medication as stated below. If you can provide me
with suggestions of possible alternative therapies to stay within the formulary drug list, I will
consider those options.
Inmate’s Name:
Ordering Physician:

ID #
Print:

Non-Formulary Drug Requested:
Estimated Duration of Usage:
Reason for Non-Formulary Request:

List of Formulary Agents and Dose Previously Used:

CORPORATE OFFICE REVIEW:
Approved: (YES / NO) Date:
Reason for Denial:
Corporate Representative Signature:
Date Faxed to Physician at Site:
Date Faxed to Pharmacy:

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 28
Effective: January 2013; Updated April 2013

SHP 000210

•v"

I Southern Health
Partners
You r Partner In Affordab le Inmate Healthcare

Intake/Release
Medication or Supplies Form
I, _________________________________________, (nurses name) have received the following
medications/medical supplies:
__________________________________________________________________ Qty. ________
__________________________________________________________________ Qty. ________
__________________________________________________________________ Qty. ________
__________________________________________________________________ Qty. ________
__________________________________________________________________ Qty. ________
__________________________________________________________________ Qty. ________
for __________________________________________________________ (inmate name) at the
__________________________________________ County Jail on ______________ (date).
I
, (inmate name) understand my medication/supplies may be used by the
medical staff in continuity of care to my prescription/condition, upon approval by the site Medical Director.
I _______________________________, (inmate name) understand that if I am released from this facility and I
do not return to pick up my medication/supplies within 5 days, then it will be destroyed as per policy stated.
I
, (inmate name) may designate the following person to pick up my
medication/supplies within 5 days of my incarceration, otherwise I understand my medication/supplies will be
destroyed in accordance with SHP procedures:
Designated Person/Relationship:
Inmate Signature

Date

Nurses Signature

Date

Witness Signature
Date
--------------------------------------------------------------------------------------------------------------------To be completed by Medical Staff ONLY:
Medication and/or Supplies were released to:
Name:
Date Released:
Nurses Signature

Date

Witness Signature

Date

Southern Health Partners, Inc. DRUG FORMULARY

**Generic substitution will be automatic, if available

Confidential
Page: 29
Effective: January 2013; Updated April 2013

SHP 000211