San Diego County Medical Services Drug Formulary
San Diego County Medical Services Drug Formulary
San Diego County Medical Services Drug Formulary
- No tags were found...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>San</strong> <strong>Diego</strong> <strong>County</strong> <strong>Medical</strong> <strong>Services</strong> <strong>Drug</strong> <strong>Formulary</strong>Generic NameRepresentativeBrand NameUtilization ManagementMiscellaneous AnticonvulsantsCarbamazepine Tab SR OralCarbamazepine Chew TabOralCarbamazepine Susp OralGabapentin 400mg Cap,400mg, 600mg, & 800mgTablet OralPrimidone Tablet OralZonisamide Capsule OralTegretol XRTegretolTegretolNeurontinMysolineZonegranLimited to patient intolerant to or failingtherapy with carbamazepine tabletsFor CMS & Coverage Initiative: Limited to 6capsules/day for 400mg capsules, 6tablets/day for 400mg tablets, 5 tablets/dayfor 600mg tablets, and 4 tablets/day for800mg tabletsCode 1 Restriction: Limited to diagnosis ofseizureAntiparkinsonian AgentsAll agents are covered.Central Muscle RelaxantsBaclofen Tab Oral Lioresal, Lioresal DS Limited to 4 tablets/dayCyclobenzaprine HCL 10mgTab OralFlexerilLimited to 3 tablets/dayMethocarbamol Oral Robaxin Limited to 6 tablets/dayAntimyasthenic AgentsNeostigmine Bromide Tab15mg OralPyridostigmine Bromide OralProstigminMestinonVitamin B-3Niacin OralNiacinNUTRITIONAL PRODUCTSVitamin B-6Pyridoxine HCL Cap , CapCR, Tab OralVitamin B-6Code 1 Restriction: For use with INH onlyVitamin KPhytonadione Tab 5mg OralMephytonNutritional Supplements (Ryan White Program)Nutritional Supplement LiquidBoost, EnsureRyan White Program: Limited to21600mL/fill, 3 fills/yearPotassiumPotassium Chloride Cap CR8mEq & 10mEq OralMicro-KJune 2009 Page 21 of 42
Change language