San Diego County Medical Services Drug Formulary

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementButalbital-Acetaminophen50-650mg Cap, 50-325mg &50-650mg Tab OrallAcetaminophen-Caffeine-Butalbital 325-40-50mg Tab &Cap OralAspirin-Caffeine-Butalbital325-40-50mg Tab & Cap OralPhrenilin, SedapapEsgic, Esgic Plus,FioricetFiorinal, Fiortal,Butalbital CPD,FortabsNarcotic AgonistMethadone HCL OralDolophine,MethadoseMorphine Sulfate Tab Oral MSIR Limited to 12 tablets/dayMorphine Sulfate Tab CR OralMS Contin,Limited to 4 tablets/dayOramorph SRTramadol HCL Tab 50mg Oral Ultram Limited to 8 tablets/dayNarcotic CombinationsOxycodone w/Acetaminophen 5-325mg,7.5-325mg, & 10-325mg TabOralRoxicetMaximum acetaminophen daily dose =4gm/dayCodeine CombinationsAcetaminophen w/ Codeine300-15mg, 300-30mg, 300-60mg, 650-30 mg Tab OralAcetaminophen w/ CodeineElixir, Soln, Susp OralAspirin w/ Codeine 325-15mg, 325-30mg, & 325-60mgTab OralHydrocodone CombinationsAcetaminophen w/Hydrocodone 5-500mg, 7.5-750mg, 10-325mg Tab OralAcetaminophen w/Hydrocodone 7.5-500mg/15mL Soln OralTylenol/Codeine #2,#3, #4VopacTylenol/CodeineEmpirin/Codeine #2,#3, #4Lortab 5mg, Norco10-325mg, Vicodin,Vicodin ESLortab ElixerMaximum acetaminophen daily dose =4gm/dayLimited to 60 tablets/monthLimited to 500mL/monthLimited to 60 tablets/monthMaximum acetaminophen daily dose =4gm/dayRyan White Program: 5-500mg – Bill ADAPLimited to 240 tablets/30 days for 5-500mg(CMS & Coverage Initiative); 150 tablet/30days for 7.5-750mg, and 360 tablets/30 daysfor 10-325mgLimited to 500mL/monthOpioid CombinationsMaximum acetaminophen daily dose =4gm/dayJune 2009 Page 18 of 42