San Diego County Medical Services Drug Formulary

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San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementMontelukast Sodium OralZafirlukast OralSingulairAccolateContingent Therapy: For patient on currenttherapy with an inhaled steroid. Limited to30 tablets/monthContingent Therapy: For patient on currenttherapy with an inhaled steroid. Limited to60 tablets/monthAntiperistaltic AgentsDiphenoxylate w/ AtropineOralLoperamide HCL OralOpium Tinure 10% OralParegoric Tinure OralLomotil, LonoxGASTROINTESTINAL AGENTSImodium, ImodiumA-DOpium tinctureParegoric tinctureBelladonna AlkaloidsHyoscyamine Sulfate OralAntispasmodicsDicyclomine HCL OralAnticholinergic CombinationsPhenobarbital & BelladonnaAlkaloids OralLevsinex, Cystospaz-M, Levsin, Levsin SL,Anaspaz, Levbid,ColytrolBentylDonnatal, DonnatalExtentabH-2 AntagonistsFor Ulcer: Over 90% of gastric or duodenal ulcers are caused by H. pylori. If test results arepositive, patients should be treated with antimicrobials. Once H. pylori has been successfullyeradicated, continued maintenance therapy with Anti-Ulcer agents is no longer necessary.Cimetidine OralTagametFamotidine Tablet 40mg Oral PepcidRanitidine HCL Tablet 150mg,Zantac300mg OralAnti-Ulcers: Imidazoles (Proton-Pump Inhibitors)For Ulcer: Over 90% of gastric or duodenal ulcers are caused by H. pylori. If test results arepositive, patients should be treated with antimicrobials. Once H. pylori has been successfullyeradicated, continued maintenance therapy with Anti-Ulcer agents is no longer necessary.Omeprazole MagnesiumPrilosec (OTC) Limited to 2 tablets/dayTablet OralMiscellaneous Anti-UlcerJune 2009 Page 14 of 42
San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementSucralfate OralCarafateUlcer Anti-Infective W/ Proton Pump InhibitorsAmoxicillin Cap-Clarithro Tab-Lansopraz Cap CR Therapy PrevPacPack OralLimited 1 fill/6 monthsAnti-Emetics-AnticholinergicMeclizine OralAntivertGallstone Solubilizing AgentsUrsodiol Capsule 300mg OralGI StimulantsMetoclopramide HCL OralActigallReglanIntestinal AcidifiersLactulose (Encephalopathy)Syr 10gm/15mL OralCephulac, EnuloseCalulose, Cholac,GenerlacMisc. GIMesalamine Enema Rectal,Suppos Rectal, OralSulfasalazine Tab & EC OralAsacol, Canasa,Rowasa, PentasaAzulfidineLimited to 2520mL/6 months for enemaDigestive AidsAmylase-Lipase-ProteaseOralPancreaseGENITOURINARY PRODUCTSCalcium Acetate (Phosphate Binder)Calcium Acetate (PhosphatePhosLoBinder) Cap 667mg OralUrinary Anti-InfectivesNitrofurantoin Susp OralNitrofurantoinMacrocrystalline OralNitrofurantoin MonohydrateMacrocrystalline OralUrinary AntispasmodicsBethanechol Chloride OralHyoscyamine Tab 0.15 mgOralOxybutynin Chloride Tab &Syr OralFuradantinMacrodantinMacrobidUrecholineCystospazDitropanVaginal Anti-InfectivesJune 2009 Page 15 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 13: 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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