San Diego County Medical Services Drug Formulary
San Diego County Medical Services Drug Formulary
San Diego County Medical Services Drug Formulary
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<strong>San</strong> <strong>Diego</strong> <strong>County</strong> <strong>Medical</strong> <strong>Services</strong> <strong>Drug</strong> <strong>Formulary</strong>Generic NameRepresentativeBrand NameUtilization ManagementMalathion 0.5% LotionExternalPermethrin Cream Rinse 1%ExternalPermethrin Cream 5%ExternalPyrethrins-Piperonyl ButoxideExternalMiscellaneous TopicalCalcipotriene Soln ExternalCoal Tar (Crude) SolutionExternalOvideNix Cream RinseElimite, ActicinRid, A-200, ProntoDovonexCoal TarDiagnostic ReagentsAcetone TestGlucose Urine Test-(GlucoseOxidase)Glucose Urine Test-(CopperSulfate)DIAGNOSTIC PRODUCTSAcetest, KetostixDiastix, ClinistixClinitestGlucose Blood Test StripsMultiple Urine Test StripsUrine Glucose-Ketones TestStripsAscencia ContourAscencia Breeze 2ChemstripsChemstripsLimited to 50 per 30 days if not on insulin. Ifon insulin, allow limit 100 per 30 datys.Maximum of 3 fills/prescription. Limited toBayer Ascencia Contour Ascencia Breeze 2only.Limited to 51/month. Maximum of 3fills/prescriptionDiabetic SuppliesGlucose Blood CalibrationSolnGlucose Blood Monitoring KitControl SolutionsAscencia ContourAscencia Breeze 2Limited to 1 fill per year. Maximum of $60per fill. Limited to Ascencia Contour andBreeze 2 products.Insulin SyringesLancetsLancets DevicesB-D Insulin SyringesLancetsLancetsLimited to 100/month. Maximum of 3fills/prescriptionLimited to 51/month. Maximum of 3fills/prescriptionLimited to 2 fills/year, maximum$25/prescriptionJune 2009 Page 29 of 42
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