San Diego County Medical Services Drug Formulary

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San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementFurosemide OralLasixPotassium Sparing DiureticsSpironolactone OralAldactoneThiazidesChlorthalidone 25mg, 50mg,100mg tablet OralHydrochlorthiazide (HCTZ)OralIndapamide OralMetolazone OralHygrotonHydrodiuril, Oretic,Esidrix, MicrozideLozolZaroxolynLimited to 1 tablet per dayCombination DiureticsSpironolaone & HCTZ OralTriamterene & HCTZ OralAldactazideDyazide, Maxzide-25, Maxzide 75/50VasodilatorsHydralazine HCL OralMinoxidil OralApresolineLonitenAnaphylaxis Therapy AgentsEpinephrine HCl Injection(Anaphylaxis)Epinephrine-ChlorpheniramineEpipen, Epipen Jr.Ana-KitBile SequestrantsCholestyramine Powder CanOral Cholestyramine Powder& Packets OralQuestran/Lite,PrevaliteAntihyperlipidemics: FenamatesGemfibrozil OralLopidFenofibrate OralTricor, Triglide, etcLimited to CMS and Coverage Initiativesonly. Contingent Therapy: For concurrenttherapy with Simvastatin or patient failingtherapy with or intolerant to gemfibrozil.Limited to 1/day the following strengths,dosage forms, and NDCs: 54mg tablet(NDC: 00115-5511-10), 67mg capsule (NDC:00115-0511-01, and 134mg capsule (NDC:00115-0522-01).Antihyperlipidemics: HMG-CoA Reduase InhibitorJune 2009 Page 10 of 42
San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementLovastatin Oral Mevacor Limited to 1 tablet/daySimvastatin Oral Zocor Limited to 1 tablet/dayNicotinic Acid DerivativesNiacin Tab CRNiaspanContingent Therapy: For patient failingtherapy with or intolerant to niacin. Limitedto 1 tablet/dayAntihistamines-AlkylaminesCyproheptadine HCL OralDiphenhydramine HCLcapsule, tablet OralPromethazine HCL OralPromethazine HCL SupposRectalPeriactinRESPIRATORY AGENTSBenadryl, DiphedrylPhenergan,Phenergan FortePhenerganAntihistamines-Non-SedatingLoratadine 10mg Tab Oral(OTC)ClaritinLimited to 1 tablet/dayNasal SteroidsFlunisolide 0.025% NasalFluticasone Propionate NasalExpectorantsGuaifenesin OralNasalideFlonaseOrganidin NR,Diabetic Tus,Robitussin, NaldeconSrCode 1 Restriction: For diagnosis of nasalpolyps, chronic sinusitis, or asthma. Limitedto 1 unit/monthCode 1 Restriction: For diagnosis of nasalpolyps, chronic sinusitis, or asthma. Limitedto 1 unit/monthMiscellaneous RespiratorySodium Chloride Soln Nebu0.9%Broncho SalineDecongestant orDecongestant CombinationsBrompheniramine &Pseudoephedrine Syrup, ElixirOralChlorpheniramine &Phenylephrine Elixir 2-5mg/5ml OralBromfed, Dimetapp,Bromtapp,BromanateNovahistineJune 2009 Page 11 of 42
Page 1 and 2: DRUG FORMULARYCounty Medical Servic
Page 3 and 4: Denials and AppealsSan Diego County
Page 5 and 6: San Diego County Medical Services D
Page 9: San Diego County Medical Services D
Page 31 and 32: Aspirin Buffered 325mg Tab Oral, 17
Page 33 and 34: Diphenhydramine HCL Oral, 11Dipheno
Page 36 and 37: Miscellaneous Respiratory Inhalants
Page 38: Propylthiouracil Oral, 7Prostagland
Page 41 and 42: Customer Service Help Desk: (800) 7

San Diego County Medical Services Drug Formulary

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