San Diego County Medical Services Drug Formulary

More documents

Recommendations

Info

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementGlucocorticosteroidsCortisone Acetate OralDexamethasone OralHydrocortisone Tab OralPrednisolonePrednisolone SodiumPhosphate PowderPrednisolone SodiumPhosphate OralPrednisone OralMineralocorticoidsFludrocortisone Acetate OralENDOCRINE_AND METABOLIC DRUGSCortisoneDecadron, DexoneCortefPrelonePrednisoloneMeticorten,Deltasone,Liquid PredFlorinefDIABETIC AGENTSHuman InsulinLimited to vials only.Insulin Aspart Inj 100 U/mL Novolog Limited to 2 vials/monthInsulin Aspart Prot & Aspart Inj100 U/mLNovolog MixInsulin Detemir Inj U/mL LevemirInsulin Glargine Inj 100 U/mL Lantus (vials only) Limited to 4 vials/monthInsulin Lispro Inj 100 U/mL HumalogInsulin Lispro Prot & Lispro Inj100 U/mL (75-25)Humalog Mix 75/25Insulin Regular Inj 100 U/mL Humulin R, Novolin R Limited to 2 vials/monthInsulin Regular Inj 500 U/mL Humulin R Limited to 2 vials/monthInsulin Isophane Inj 100 U/mL Humulin N, Novolin N Limited to 2 vials/monthInsulin Regular & Isophane Inj100 U/mLInsulin Regular & Isophane Inj100 U/mL (50)Humulin 70/30Novolin 70/30Humulin 50/50Limited to 2 vials/monthLimited to 2 vials/monthInsulin Zinc Inj 100 U/mL Humulin L, Novolin L Limited to 2 vials/monthSulfonylureasGlimepiride Oral Amaryl Limited to 1/tablet/day for 1mg & 2mg and2 tablets/day for 4mgGlipizide Tab OralGlucotrolGlyburide Oral Diabeta, Micronase Limited to 120/30 daysGlyburide Micronized Glynase Limited to 120/30 daysBiguanides–MetforminMetformin HCL Oral Glucophage Limited to 2500 mg/dayJune 2009 Page 6 of 42
San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementOther AntidiabeticsGlucagon Kit InjectionGlucose Chew Tab OralThiazolidinedionesPioglitazone OralRosiglitazone OralThyroid HormonesLevothyroxine Sodium OralLiothyronine Sodium OralGlucagon KitBD – Glucose ChwActosAvandiaSynthroid, L-Thyroxine,Levothroid, Levoxyl,EuthyroxCytomelContingent Therapy: Second-line agent tobe used in combination with an oraldiabetes agent or insulin. Limited to #1/dayContingent Therapy: Second-line agent tobe used in combination with an oraldiabetes agent or insulin and continuingtherapy only. Limited to #1/dayAvailable as “Do Not Substitute”Antithyroid AgentsMethimazole OralPropylthiouracil OralTapazolePropylthiouracil (PTU)VasopressinCabergoline OralDesmopressin Acetate Oral,Nasal SprayDostinexDDAVPAnti-ArrhythmiaDisopyramide PhosphateOralDofetilide OralFlecainide Acetate OralMexiletine HCLMoricizine HCL OralProcainamide HCL OralPropafenone HCL OralQuinidine Gluconate CR OralQuinidine Sulfate Tab OralACE InhibitorsBenazepril HCL OralCaptopril OralEnalapril OralLisinopril OralCARDIOVASCULAR AGENTSAll Anti-Arrhythmia are formularyNorpace CRTikosynTambocorMexiletineEthmozinePronestylRythmolQuinidineQuinidexLotensinCapotenVasotecPrinivil, ZestrilJune 2009 Page 7 of 42
Page 1 and 2: DRUG FORMULARYCounty Medical Servic
Page 3 and 4: Denials and AppealsSan Diego County
Page 5: San Diego County Medical Services D
Page 9 and 10: 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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?