San Diego County Medical Services Drug Formulary

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San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementFluorometholone SuspOphthalmicFluorometholone Oint 0.1%OphthalmicFluorometholone AcetateSusp 0.1% OphthalmicPrednisolone Acetate Susp1% OphthalmicPrednisolone SodiumPhosphate Soln 1%OphthalmicFML Liquifilm, FMLForteFML S.O.P.Flarex, EfloneEconopred Plus,Omnipred PredForteInflamase ForteOphthalmic SteroidCombinationsLoteprednol etabonate-Tobramycin Susp 0.5-0.3%OphthalmicNeomycin-DexamethasonePhos Soln 0.5-0.1%OphthalmicSulfacetamide Sodium-Prednisolone Soln 10-0.25%OphthalmicSulfacetamide Sodium-Prednisolone Susp10-0.2%OphthalmicSulfacetamide Sodium-Prednisolone Susp 10-0.25%OphthalmicSulfacetamide Sodium-Prednisolone Susp 10-0.5%OphthalmicSulfacetamide Sodium-Prednisolone Oint 10-0.2%OphthalmicSulfacetamide Sodium-Prednisolone Oint 10-0.25%OphthalmicSulfacetamide Sodium-Prednisolone Oint 10-0.5%OphthalmicTobramycin-DexamethasoneSusp & Oint 0.3-0.1%OphthalmicNeomycin-Polymyxin-Dexamethasone Susp & Oint0.1% OphthalmicNeomycin-Polymyxin-HC SuspOphthalmicAll ophthalmic steroid combinations are coveredZyletNeo-DecadronVasocidinBlephamideIso CetapredMetimydBlephamide S.O.P.CetapredMetimyd,VascocidinTobradexMaxitrol, DexacidinCortisporinJune 2009 Page 24 of 42
San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementBacitracin-Polymyxin-Neomycin-HC OphthalmicOint 1%Cortisporin, AK-Spore HC, TripleAntibioticProstaglandin Agonists OphthalmicLatanoprost Soln 0.005%XalatanOphthalmicCycloplegicsAtropine Sulfate Soln 1%OphthalmicAtropine Sulfate Oint 1%OphthalmicCyclopentolate HCL Soln0.5%, 1%, 2% OphthalmicHomatropine HBr Soln 2%, 5%OphthalmicScopolamine HBr Soln 0.25%OphthalmicTropicamide Soln 0.5%, 1%OphthalmicIso AtropineOcu-tropineCyclogylIso HomatropineIso HyoscineMydriacyl, Infi-CyleCycloplegics Mydriatic CombinationsCyclopentolate w/Phenylephrine Soln 0.2-1% CyclomydrilOphthalmicScopolamine w/Phenylephrine Soln 0.3-10% Murocoll-2OphthalmicOphthalmic Decongestant CombinationsNaphazoline w/ AntazolineSoln 0.05-0.5% OphthalmicVasocon-ANaphazoline w/ PheniramineSoln 0.025-0.3% OphthalmicNaphcon-AOphthalmics – Direct ActingPilocarpine HCL Soln 0.5%,1%, 2%, 4%, 6% OphthalmicPilocarpine HCL Gel 4%OphthalmicAdrenergic MydriaticsDipivefrin Soln 0.1%OphthalmicAll ophthalmic miotic direct-acting agents are covered.Iso Carpine, PilocarPilopine HSPropine-CJune 2009 Page 25 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 23: 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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