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 ManagementTetracyclinesDoxycycline Hyclate Cap50mg & 100mg, Tab 100mgOralTetracycline HCl OralAmebicidesIodoquinol OralAminoglycosidesNeomycin Sulfate OralAntihelminticsMebendazole OralPyrantel Pamoate OralThiabendazole OralVibramycin,VibratabSumycinYodoxinNeomycin Sulfate,Neo-FradinVermoxPin-X, AntiminthMintezolAll Antihelmintics are coveredAntifungalsFluconazole Tab 150 mg Oral Diflucan Limited to 1 tablet/fill, 2 fills/monthGriseofulvin Microsize Oral Grifulvin VGriseofulvin Ultramicrosize Gris-pegKetoconazole Tab Oral NizoralNystatinMycostatinAntimalarialsChloroquine Phosphate TabOralHydroxychloroquine SulfateOralPrimaquine Phosphate OralPyrimethamine OralQuinine Sulfate Tab 324mgOralAralenPlaquenilPrimaquinephosphateDaraprimQualaquinAntimycobacterial AgentsIsoniazid OralNydrazidRifampin Oral Rifadin PA required for Tuberculosis.Antiviral – Herpes AgentsAcyclovir OralAntineoplastic AgentsZoviraxANTINEOPLASTIC AGENTSAll oral FDA-approved cancer therapy iscovered up to $350. PA required for agentsgreater than than $350.June 2009 Page 5 of 42
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