San Diego County Medical Services Drug Formulary

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementIpratropium BromideIpratropium BromideInhalation IpratropiumBromide Inhalation SolnAtropine SulfateAtrovent, AtroventHFAAtropine SulfateMast Cell StabilizersCromolyn Sodium Inhalation Intal Limited to 30/month for aerosol solutionNedocromil SodiumInhalationTiladeBeta AdrenergicsAlbuterol InhalationAlbuterol Sulfate AeroInhalationAlbuterol Sulfate OralAlbuterol Sulfate Soln NebuInhalatioPirbuterol InhalationSalmeterol Xinafoate PowderDisks InhalationTerbutaline Sulfate OralAdrenergic CombinationsAlbuterol-Ipratropium AerosolInhalationFluticasone-Salmeterol InhalAerosol, Pwdr DiskusXanthines (Theophylline)Aminophylline OralTheophylline Cap CR OralTheophylline Tab OralTheophylline Tab CR OralTheophylline Elixir, Soln OralVentolin, ProventilVentolin HFA,Proventil HFAVentolin, ProventilVentolin, ProventilMaxair, MaxairAutohalerSerevent DiskusBrethineCombiventAdvair HFA, AdvairAminophylineSlo-Bid, Slo-Phyllin,Theo-24Slo-Phyllin, Theolair,Quibron-TTheo-Dur, Theolair-SR, Uniphyl, Uni-DurSlo-PhyllinLimited to Proair HFA only and 2cannisters/monthLimited to 1 unit/monthCode 1 Restriction: For diagnosis of COPDPA required. For patient failing therapy withor intolerant to inhaled steroids, Atrovent,Combivent, or Spiriva. Limited to 1unit/monthAll generic Xanthine products are covered.Steroid InhalantsBeclomethasoneDipropionate Inhal AeroFluticasone PropionateInhalationLeukotriene Receptor InhibitorsQVARFlovent HFAContingent Therapy: For patient failingtherapy with QVAR. Limited to 1 unit/monthJune 2009 Page 13 of 42