San Diego County Medical Services Drug Formulary

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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
San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementButalbital-Acetaminophen-Caff w/ Cod 50-325-40-30mgCap OralButalbital-Aspirin-Caff w/Codeine 50-325-40-30mgCap OralPhrenilin w/ CodeineFiorinal w/ CodeineLimited to 30 capsules/monthLimited to 60 capsules/monthPropoxyphene CombinationsPropoxyphene-N w/ APAP 50-325mg Tab OralPropoxyphene-N w/ APAP100-650mg Tab OralDarvocet-N 50Darvocet-N 100Limited to 60 tablets/monthLimited to 60 tablets/monthNonsteroidal Anti-Inflammatory AgentsDiclofenac Potassium Oral CataflamDiclofenac Sodium EC Oral Voltaren Limited to 4 tablets/dayEtodolac Cap & Tab Oral LodineLimited to 3 capsules/day for 200mg &300mg capsules; 3 tablets/day for 400mgtablet and 2 tablets/day for 500mg tabletFenoprofen Calcium Oral NalfonFenoprofen Calcium OralIbuprofen OralMotrinIndomethacin Oral, SupposRectalIndocinMeloxicam Tab Oral Mobic Limited to 1 tablet/dayNaproxen OralNaprosynNaproxen Sodium Oral AnaproxOxaprozin Oral Daypro Limited to 2 tablets/dayPiroxicam OralFeldeneLimited to 2 capsules/day for 10mg and 1capsule/day for 20mgSulindac OralClinorilMethotrexateMethotrexate 2.5mg Tab OralRheumatrexMigraine ProductsAPAP-Isometheptane-Dichloral Cap 325-65-100mgOralMidrinSerotonin AgonistSumatriptan Spray NasalImitrex NSContingent Therapy: For patient failingtherapy with or intolerant to Cafergot,Midrin, Fioricet, or Fiorinal. Limited to 6units/monthJune 2009 Page 19 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 17: 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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