šŸ—ŗļø Overview

To prioritize patient safety, mitigate risk, and support root-cause, longevity-focused clinical strategies, BESA Health maintains a strict formulary restriction policy. Advanced Practice Providers (APPs) must adhere to the following prescribing boundaries regarding controlled substances and high-risk medications:

  • Strictly Prohibited Medications: The prescribing, renewing, or initiating of the following substances is strictly prohibited within this practice:
  • Promethazine (Phenergan): Promethazine (Promethazine) in any form (including oral, rectal, or injectable) or combination drug is not allowed to be prescribed at BESA Health.
  • Cough Syrups/Medications Containing Codeine: Any cough medication in liquid, tablet, or capsule form containing codeine is strictly prohibited.
  • Opiate Pain Medications (Telehealth Boundary): Do not prescribe opioids to patients if care is provided through telemedicine. This absolute restriction includes, but is not limited to: hydrocodone, codeine, oxycodone, morphine, fentanyl, hydromorphone, meperidine, oxymorphone, tramadol, methadone, and buprenorphine (Suboxone).
  • Stimulants Used in Weight Loss (Effective May 2023): The initiation or renewal of stimulant-class weight loss medications is prohibited. This includes, but is not limited to: Benzphetamine, Diethylpropion, Phendimetrazine, Phentermine, and Phentermine/topiramate (Qysmia).
  • Oxybate & Narcolepsy CNS Depressants: Sodium oxybate formulations (Xyrem, Xywav), ketamine, kratom, and psilocybin.
  • Methamphetamine: Any formulation containing methamphetamine, including Desoxyn.
  • Muscle Relaxants: Carisoprodol (Soma).
  • Prohibited Benzodiazepines:
    While select benzodiazepines are permitted for highly controlled, intermittent PRN use (see below), the following specific benzodiazepines are completely prohibited from being prescribed at BESA Health under any circumstances:
  • Chlordiazepoxide (including any combination medication such as Librax)
  • Clobazam (Sympazan, Onfi)
  • Clorazepate (Tranxene T-Tab)
  • Flurazepam
  • Quazepam (Doral)
  • Midazolam (Nayzilam, MKO Melt Dose Pack sublingual tablet)
  • Triazolam (Halcion)
  • Sedative-Hypnotic Sleep Medications (Z-drugs):
  • No Chronic Nightly Use: Under no circumstances should patients be prescribed chronic, nightly sedative-hypnotics (e.g., zolpidem/Ambien, eszopiclone/Lunesta, zaleplon/Sonata). If utilized for acute insomnia, they must be limited to short-term, intermittent use only.
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šŸ›‘ PROHIBITED COMBINATION PRESCRIPTIONSĀ 

Co-prescribing certain classes of controlled substances significantly amplifies clinical risk, drug-drug interactions, and adverse events. besa Health enforces strict limitations on the following medication combinations:
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1. ADHD Formulations (Stimulant Polypharmacy)

  • No Amphetamine/Methylphenidate Duplication: Do not combine any Amphetamine formulation (e.g., Adderall, Vyvanse, Mydayis) with any Methylphenidate formulation (e.g., Ritalin, Concerta) in the same patient regimen.

2. Anxiety & Insomnia Combinations (CNS Depressant Risk)

  • Benzodiazepines + Sedatives/Hypnotics: Do not combine benzodiazepines and controlled sedatives/hypnotics used for insomnia unless the frequency and quantity of the fills are strictly limited, and the clinical workflow guarantees that mixing or simultaneous ingestion of these medications is highly unlikely.
  • Concurrent Opioid/Buprenorphine Therapy: Do not prescribe benzodiazepines and/or controlled sedatives/hypnotics to any patient currently on chronic opioid therapy or buprenorphine due to the profound, life-threatening risk of respiratory depression.

3. ADHD Stimulants + Anxiolytics/Sedatives

Providers must actively reassess any patient currently prescribed ADHD stimulants who is also receiving ongoing PRN benzodiazepines for anxiety or PRN controlled sedatives/hypnotics for insomnia.

When evaluating these patients, the APP must perform and document a comprehensive clinical review covering:

  1. Clinical Synergy & Rationale: Review if the combination of being on both active stimulants and anxiolytics/sedatives makes clinical sense, or if one medication is simply treating the side effects of the other (e.g., stimulant-induced insomnia or anxiety).
  2. Non-Controlled Optimization: Review if further non-controlled substance (non-CS) medication adjustments or lifestyle therapies can be implemented in either class to successfully decrease the patient's need for controlled substances.
  3. Specialist Escalation: Review if a formal referral to psychiatry is indicated for more specialized psychiatric medication management and diagnostic clarification.

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šŸ’Š BENZODIAZEPINE PRESCRIBING BOUNDARIES & RESTRICTIONSĀ 

  • No Chronic Daily Use: Under no circumstances should patients be initiated on, or transitioned to, a chronic, daily benzodiazepine regimen.
  • Avoid for Insomnia: Benzodiazepines must not be prescribed for the primary treatment of insomnia; non-controlled, sleep-architecture-sparing, or root-cause lifestyle interventions must be utilized instead.
  • Permissible Long-Term PRN Use: A prescription for chronic daily benzodiazepine use is not the same as a long-term PRN benzodiazepine. Long-term benzodiazepine prescriptions are acceptable only if they are not taken daily and are reserved strictly for intermittent, as-needed (PRN) use.
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  • Preferred Benzodiazepines & Dosing Parameters (Intermittent PRN Only):
  • Lorazepam (Ativan) (Duration: 4ā€“6 hours)
  • Starting Dose: 0.5 mg once daily to twice daily (BID) PRN.
  • Maximum Dose: 1 mg BID PRN.
  • Quantity Limit: Maximum of #15 tablets per month.
  • Clonazepam (Klonopin) (Duration: 8ā€“10 hours)
  • Starting Dose: 0.5 mg once daily PRN.
  • Maximum Dose: 1 mg once daily (QD) PRN.
  • Quantity Limit: Maximum of #15 tablets per month.
  • Discouraged Benzodiazepines (Avoid Prescribing):
  • Alprazolam (Xanax) (Duration: 1ā€“2 hours)
  • Starting Dose: 0.25 mg once daily PRN. Max dose: 0.5 mg BID PRN. Max quantity: #12 tablets per month.
  • Avoid due to: Exceptionally short duration of action, which requires frequent dosing and significantly increases the risks of tolerance, physiological habituation, and severe rebound anxiety.
  • Diazepam (Valium) (Duration: 8ā€“10 hours active clinical effect)
  • Starting Dose: 2 mg once daily PRN. Max dose: 5 mg BID PRN. Max quantity: #12 tablets per month.
  • Avoid due to: Prolonged active metabolites, increased risk of complex CYP450 drug interactions, accumulation in adipose tissue, and higher risk for respiratory depression.
  • Other Restricted & Discouraged Substances:
  • Butalbital Combinations (e.g., Fioricet, Fiorinal): Any combination medication containing butalbital is highly discouraged and should be avoided due to high risks of medication overuse headaches (rebound headaches), physical dependence, and severe withdrawal profiles.
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šŸ–¼ļø Clinical Examples

Clinical Examples for Clarification:

  • Permissible PRN Prescription (Example): Lorazepam 1mg, 1 tablet by mouth daily as needed for anxiety, Dispense #15. The patient fills this prescription on average every 2 months (or longer) and has done so stably for years.
  • Prohibited Daily Prescription (Example): Clonazepam 1mg, 1 tablet by mouth twice daily, Dispense #60. The patient takes 2mg daily on a continuous basis with regular refills scheduled every 30 days.

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If you have any questions or would like more information, please reach out to the Delegating Physician.