San Diego County Medical Services Drug Formulary

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San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementPotassium Chloride Tab CR8mEq, 10mEq, 15mEq &20mEq OralPotassium Chloride Oral Liq10% & 20% OralPotassium & SodiumPhosphates for Soln 278-164-250mg/75mL, Powder 278-164-250mg & 280-160-250mgOralSlow-K, Klor-Con, K-Tabs, K-Dur, Klortrix,Kaon-CLKlorvess, Kaochlor,Kay Ciel KCL, Kaon-CL SFNeutraphosPotassium Removing ResinSodium Polystyrene SulfonateSusp 15gm/60mL Oral/RectalSodium Polystyrene SulfonatePowder OralSodiumSodium Chloride InjectionSPSKayexalateNormal Saline (IV)Folic AcidFolic Acid OralIronFerrous Fumarate OralFerrous Gluconate OralFerrous Sulfate OralCoumarin AnticoagulantsWarfarin Sodium Tab OralPlatelet Aggregation InhibitorsDipyridamole Tab OralFolic AcidHEMATOLOGICAL AGENTSFeostatFerrous GluconateIron, Slow-Fe, Feosol,Fer-In-Sol, FeratabCoumadinPersantineHeparins And Heparinoid-Like AgentsEnoxaparin Sodium Injection Lovenox Limited to 14 units/6 monthsFondaparinux Sodium 2.5mg/0.5mL InjectionArixtraLimited to 7 units/7 daysThienopyridine DerivativesClopidogrel Bisulfate Tab OralOphthalmic AntibioticsPlavixCode 1 Restriction: For diagnosis of TIA,stroke, stent, or patient failing therapy orintolerant to Aspirin.TOPICAL PRODUCTSAll ophthalmic Anti-Infectives are coveredJune 2009 Page 22 of 42
San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementBacitracin Oint 500 U/gmOphthalmicCiprofloxacin HCL Oint & Soln0.3% OphthalmicErythromycin Oint 5mg/gmOphthalmicGatifloxacin 0.3% SolnOphthalmicGentamicin Sulfate Soln &Oint 0.3% OphthalmicLevofloxacin 0.5% SolnOphthalmicMoxifloxacin 0.5% SolnOphthalmicOfloxacin Ophth Soln 0.3%OphthalmicSodium Sulfacetamide 10%OphthalmicTobramycin Sulfate Soln &Oint 0.3% OphthalmicOphthalmic Beta-BlockersBetaxolol HCL Soln -.5% & 1%and Susp 0.25% OphthalmicCarteolol HCL Soln 1%OphthalmicMetipranolol HCL Soln 0.3%OphthalmicLevobunolol HCL Soln 0.25%& 0.5% OphthalimcTimolol Maleate Soln 0.25% &0.5% OphthalmicTimolol Maleate Soln (GelForming) 0.25% & 0.5%ophthalmicAK-TracinCiloxanLlotycinZymarGaramycin,GenopticQuixinVigamoxOcufloxBleph-10, SodSulamydTobrexBetoptic, Betoptic-SOcupressOptipranololBetaganTimopticTimoptic XEAll ophthalmic beta-blockers are coveredOphthalmic Carbonic Anhydrase InhibitorsBrinzolamide Susp 1%AzoptOphthalmicOphthalmic Carbonic Anhydrase Inhibitors – Beta-Blocker CombinationDorzolamide-Timolol Soln 2-Cosopt0.5% OphthalmicOphthalmic SteroidsDexamethasone Susp 0.1%OphthalmicDexamethasone SodiumPhosphate Soln OphthalmicMaxidexDecadron, Dexa-solJune 2009 Page 23 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 21: 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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