San Diego County Medical Services Drug Formulary

More documents

Recommendations

Info

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementOphthalmic Anti-AllergicOlopatadine HCL SolnOphthalmicPatanolContingent Therapy: For patient failingtherapy with or intolerant to Naphcon-A orVasacon-AOphthalmic Non-Steroidal Anti-Inflammatory AgentsDiclofenac Sodium Soln 0.1%OphthalmicVoltarenFlurbiprofen Soln 0.03%OphthalmicOcufenKetorolac Tromethamine Soln0.4%, 0.5% OphthalmicAcular LS, AcularNepafenac Susp 0.1%OphthalmicNevanacBromfenac Sodium Soln0.09% OphthalmicXibromCode 1 Restriction: For OphthalmologistLimited to #2.5mL/30 daysCode 1 Restriction: For OphthalmologistLimited to #2.5mL/30 daysCode 1 Restriction: For OphthalmologistLimited to #3mL/30 daysCode 1 Restriction: For OphthalmologistLimited to #2.5mL/30 daysOtic SteroidsHydrocortisone W/ AceticAcid 1-2% Soln OticOtic MiscellaneousAcetic Acid 2% Soln OticCarbamide Peroxide 6.5%Soln OticVosol-HCVosolDebroxOtic Steroid Antibiotic CombinationsBenzocaine-Antipyrine 1.4-Auralgan5.4% Soln OticNeomycin-Polymyxin-HC Susp3.5mg/mL-10000 U/mL-1% Cortisporin OticOticNeomycin-Polymyxin-HC SolnCortisporin Otic1% OticMouth & Throat (Local)Lidocaine HCL in Viscous Soln2% (Mouth-Throat)Nystatin Susp 100000 U/mL(Mouth/Throat)Pilocarpine HCL 5mg TabOralTriamcinolone Acetonide inOrabase 0.1% (Mouth)Lidocaine ViscousMycostatin, Bio-StatinSalagenKenalogDERMATOLOGICAL PRODUCTSAntibiotics – TopicalMupirocin 2% Oint External Bactroban Limited to 60gm/monthJune 2009 Page 26 of 42
San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementAntifungals – TopicalCrotamiton ExternalNystatin ExternalTolnaftate Power ExternalEuraxMycostatin, Nystop,Pedi-DriTinactinTopical AntifungalsClotrimazole ExternalKetoconazole Cream 2%ExternalKetoconazole Shampoo 2%ExternalMiconazole Nitrate Cream2% ExternalDesenex, Lotrimin,Lotrimin AFNizoralNizoralMicatin, MonistatLimited to 120mL/monthAntifungals – Topical CombinationsClotrimazole w/Betamethasone Cream, LotrisoneExternalNystatin-TriamcinoloneMycolog IICream & Oint ExternalBurn ProductsSilver Sulfadiazine Cream 1%ExternalSilvadeneTar ProductsAllantoin-Coal Tar andCombinations ShampooExternalCoal Tar ExternalTegrin MedicatedShampoo 7%Fototar, G-Tar,Tegrin, MedotarCorticosteroids – TopicalBetamethasoneDipropionate Cream ExternalFluocinolone AcetonideCream, Soln ExternalFluocinonide Cream,Emusified Cream, Gel, Soln,Oint 0.05% ExternalDiprosone, MaxivateSynalar, Fluorosyn,Lidex, Lidex-ELimited to 90gm/mo for cream, & ointment,and 120ml/mo for lotion.Limited to 120 gm/mo for cream, &ointment, and 120ml/mo for solution.Limited to 120 gm/mo for cream, gel &ointment, and 120ml/mo for solution.June 2009 Page 27 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 25: 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

Create successful ePaper yourself

Delete template?

Save as template?