San Diego County Medical Services Drug Formulary

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San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementAdrenolytics-CentralClonidine HCL OralMethyldopa OralCatapresAldometAvoid in elderly patientsAlpha-BlockersDoxazosin Mesylate OralPrazosin HCL OralTerazosin OralCarduraMinipressHytrinAngiotensin II InhibitorsOlmesartan OralValsartan OralBenicarDiovanCode 1 Restriction: For patient failingtherapy with or intolerant to ACE Inhibitors.Limited to 1/dayCode 1 Restriction: For patient failingtherapy with or intolerant to ACE Inhibitors.Limited to 1/dayAngiotensin II Inhibitor CombinationsOlmesartan-HCTZ Oral Benicar HCTValsartan OralDiovan HCTCode 1 Restriction: For patient failingtherapy with or intolerant to ACE Inhibitors.Limited to 1/dayCode 1 Restriction: For patient failingtherapy with or intolerant to ACE Inhibitors.Limited to 1/dayAnti-Anginals, OtherDipyridamole OralPersantineBeta-Blockers Non-SelectivePropranolol HCL OralSotalol HCl OralInderal, Inderal LABetapace,Betapace AFPatients with asthma or COPD at any levelof severity should not receive non-selectivebeta blockers.BetaBlockers Cardio-SelectiveAtenolol OralMetoprolol Succinate SR OralMetoprolol Tartrate OralTenorminToprol XLLopressorBeta-Blockers may worsen airway diseases.Use caution when using these medicationsin asthma/COPD patients.Code 1 Restriction: For Heart Failure.Limited to 1 tablet/dayAlpha-Beta BlockersPatients with asthma or COPD at any levelof severity should not receive non-selectivebeta blockers.June 2009 Page 8 of 42
San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementCarvedilol Tab Oral Coreg Code 1 Restriction: For Heart Failure or MI.Limited to 2 tablets/dayLabetalol HCL OralTrandate,NormodyneCalcium BlockersAmlodipine Besylate Oral Norvasc Limited to 1 tablet/dayDiltiazem HCL CR OralCardizem SR,Diltiazem ERDiltiazem HCL OralCardizemDiltiazem HCL SR/24hr Oral Dilacor XR,Nimodipine Cap OralNimotopVerapamil HCL Tab Oral Calan, IsoptinVerapamil HCL Tab CR Oral Calan SR, Isoptin SRDigitalisDigoxin OralLanoxinNitratesIsosorbide Dinitrate OralIsosorbide Dinitrate SL OralIsosorbide Mononitrate OralNitroglycerin Buccal OralNitroglycerin SL Tab & AerOralNitroglycerin Intravenous SolnNitroglycerin CR OralNitroglycerin Oint 2%TransdermalNitroglycerin TD TransdermalIsordil, SorbitrateIsosorbide DinitrateOral Tabs & ChewTabsIsordilMonoket, ISMOImdurNitrogardNitrostat, Nitrotab,NitroquickNitroglycerinNitro-Time, NitroglynNitrobid, NitrolNitro-Dur, Minitran,Transderm-Nitro,Deponit, NitrodiscCarbonic Anhydrase InhibitorsAcetazolamide OralAcetazolamide SR OralMethazolamide OralAcetazolamideDiamox SequelsNeptazaneLoop DiureticsJune 2009 Page 9 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 7: 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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