San Francisco Health Plan Medi

Transcription

San Francisco Health Plan Medi
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
SAN FRANCISCO HEALTH PLAN
Medi-Cal
Formulary
As of November 2014
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
San Francisco Health Plan Medi-Cal Formulary
The San Francisco Health Plan (SFHP), with the direction from the Pharmacy and Therapeutics
Committee (P&T), has developed a formulary to be used by members, clinicians, and pharmacists. The
P&T Committee is composed of the SFHP Medical Director, the SFHP Pharmacy Director, physicians from
various medical specialties and clinics, and community clinical pharmacists. The P&T meets quarterly to
review formulary changes based on quality of care considerations and sound pharmacoeconomic
principles.
The formulary is a list of drug products designed to reflect the most appropriate, high quality and costeffective drug therapies. The formulary is updated regularly and is subject to change without notice.
The formulary requires the continuous support of all our providers and pharmacists. Please contact us at
(415) 547-7818 x 7085 or pharmacy@sfhp.org if you have any questions regarding the formulary. The
SFHP Formulary can be easily accessed online from our website at
http://www.sfhp.org/providers/formulary/sfhp-formulary/.
Request for Addition or Deletion of a Drug to the Formulary
SFHP providers may request evaluation of drugs for addition to or deletion from the Formulary by
submitting the Formulary Modification Request Form which can be obtained on our website at
http://www.sfhp.org/providers/formulary/prior-authorization-requests/ or by emailing
pharmacy@sfhp.org.
Request for Non-Preferred Medications
Non-preferred or non-formulary medications may be authorized when there is clinical justification for
doing so. Clinicians can submit a prior authorization (PA) request in one of three different ways:
1. Download and Fax Prior Authorization Request Form to (855) 811-9330 for standard requests or
(855) 811-9331 for urgent requests.
2. Call our Pharmacy Benefits Manager (PBM) PerformRx at (888) 989-0091 to submit a verbal
request.
3. Submit online using the Online Pharmacy Prior Authorization Request Form.
The Prior Authorization Request Form and the Online Pharmacy Prior Authorization Request Form can
be accessed from our website at http://www.sfhp.org/providers/formulary/prior-authorizationrequests/.
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Brand Medication Policy
SFHP has a mandatory generic policy and requires generic substitution when an equivalent generic
product is available. Dispensing of brand name medications when generic equivalent is available will be
allowed only in the following cases:
 Pharmacy bills brand medication as DAW 5 (i.e. billed as a generic product)
 Pharmacy bills brand medication as DAW 8 (i.e. generic formulation is not currently available)
 Pharmacy is dispensing one of the following narrow therapeutic index drugs: Armour Thyroid,
Coumadin, Dilantin, Synthroid
For all other brand name medication requests, prior authorization with documentation of trial and
failure of 2 generic medications from different manufacturers will be required. All brand name
medication prior authorization requests will be reviewed by the SFHP Medical Director.
Medi-Cal Formulary Exclusions
The following drugs classes are excluded from the SFHP Medi-Cal formulary and are covered by fee-forservice Medi-Cal. TAR may need to be submitted to fee-for-service Medi-Cal for certain medications. For
more information, refer to the “Capitiated/Noncapitated Drugs” section in the “MCP: Two-Plan Model”
document available at Medi-Cal’s website (www.medi-cal.ca.gov).




Anti-psychotics
AIDs/HIV drugs (except didanosine, zidovudine; covered on SFHP Medi-Cal formulary)
o NOTE: tenofovir (Viread®) is used for treatment of HIV and Hepatitis B infections. SFHP
will cover the use of tenofovir for Hepatitis B indication only. Prior authorization request
will need to be submitted using the process outlined above.
Alcohol, heroin detoxification and dependency treatment drugs
Erectile dysfunction drugs
Medications in the following categories are excluded from the SFHP Medi-Cal formulary as not medically
necessary:
 Fertility agents
 Drugs for cosmetic indication (e.g. hydroquinone for hyperpigmentation of the skin)
Day Supply Policy
SFHP’s standard day supply policy is: 30 day supply for brand and 90 day supply for generic medications.
Exceptions to the 30 day supply policy for brand medications are as follows:
 90 day supply is allowed for all insulin products
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014


Up to 100 day supply is allowed for test strips and lancets
Up to 90 day supply for brand contraceptives (e.g. Nuvaring®, Ortho Evra® patch) AFTER a onemonth trial on the brand medication. Prior authorization request must be submitted explaining
the need for 90 day supply of brand medication and documenting that one-month trial has been
completed and no side effects were experienced.
Exceptions to the 90 day supply policy for generic medications are as follows:
 Effective 3/1/14, 30 day supply only is allowed for all opiate medications except tramadol
Formulary Restrictions (DUR edits)
Standard DUR edits applicable to SFHP formularies include: medication quantity, age, and gender
limitations. All DUR edits are based on FDA approved indications, standards of practice, safety and abuse
potential considerations. Visit our website at http://www.sfhp.org/providers/formulary/sfhp-formulary/
for detailed information on all active formulary restrictions.
Step Therapy (ST)
Step Therapy (ST) drugs will process at the point of sale at the pharmacy if the required medications
have been tried and failed with paid claims. If paid claims do not exist, a prior authorization request
must be submitted for consideration of coverage. Visit our website at
http://www.sfhp.org/providers/formulary/sfhp-formulary/ for detailed information on all active step
therapy rules.
Diabetic Supplies
The following diabetic supplies are covered:
 Glucometers: ACCU-CHEK Nano SmartView and ACCU-CHEK Aviva Plus, Accu-Chek Designer Care
Kit, 1 glucometer per 365 days
 Test strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with the
following quantity limits:
o 100 per 100 days for all members
o 400 per 100 days for members on insulin
o 800 per 100 days for members with gestational diabetes
 Lancets: ACCU-CHEK FastClix, Multiclix, SoftClix lancets, 100 day supply
Respiratory Supplies
The following respiratory supplies are covered for members under 19 years of age with quantity limit of
#2 per 365 days:
 Inhalers and inhaler assist devices
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014


Nebulizers
Peak flow meters
Formulary Document Details
The SFHP formulary document is listed by drug class and includes: drug name, dosage form, drug tier,
quantity limit and prior authorization, or step therapy requirements. Brand products are listed in all
uppercase letters and generic products are listed in all lowercase letters. Tier 1 drugs are formulary and
will pay at the point of sale if quantity limits, age, and gender limitations are met (see “Formulary
Restrictions (DUR edits)” above). Tier 2 drugs may require a Prior Authorization (see “Request for NonPreferred Medications” above) or Step Therapy (see “Step Therapy (ST)” above).
**Some medications may be listed as both Tier 1 and Tier 2 due to a particular strength being formulary
and another strength of the same medication requiring a prior authorization.
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Antihistamine Drugs
First Generation Antihistamines
aprodine
childrens complete allergy
chlorpheniramine maleate
chlorpheniramine maleate
CLEMASTINE FUMARATE
clemastine fumarate
cyproheptadine hcl
cyproheptadine hcl
diphenhydramine hcl
diphenhydramine hcl
diphenhydramine hcl
phenadoz
promethazine hcl
promethazine hcl
promethazine hcl
PROMETHAZINE VC PLAIN
promethegan
q-dryl
Second Generation Antihistamines
ALLEGRA ALLERGY CHILDRENS
ALLEGRA ALLERGY CHILDRENS
ALLEGRA ALLERGY CHILDRENS
ALLEGRA-D 24 HOUR ALLERGY& CONGESTION
allergy relief
cetirizine hcl
cetirizine hcl
cetirizine hcl
childrens loratadine
CLARINEX
desloratadine odt
desloratadine
fexofenadine hcl
loratadine
loratadine-d 12hr
loratadine-d 24hr
Anti-infective Agents
Anthelmintics
ALBENZA
BILTRICIDE
Antibacterials
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium
Dosage Form
Drug Requirements
Tier
/ Limits
TABS
CHEW
TABS
TBCR
SYRP
TABS
SYRP
TABS
CAPS
ELIX
TABS
SUPP
SOLN
SUPP
TABS
SYRP
SUPP
LIQD
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
SUSP
TABS
TBDP
TB24
TBDP
CHEW
SYRP
TABS
SYRP
SYRP
TBDP
TABS
TABS
TABS
TB12
TB24
1
1
2
2
1
1
1
1
1
2
2
2
1
1
1
1
TABS
TABS
1
1
CHEW
SUSR
1
1
PA
QL
PA
PA
PA
PA
PA
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Dosage Form
amoxicillin/clavulanate potassium
amoxicillin
AMOXICILLIN
amoxicillin
amoxicillin
ampicillin
AMPICILLIN
AUGMENTIN
AZITHROMYCIN
azithromycin
azithromycin
CAYSTON
CEDAX
CEFACLOR ER
cefaclor
CEFACLOR
cefadroxil
cefadroxil
cefadroxil
cefdinir
cefdinir
CEFDITOREN PIVOXIL
cefpodoxime proxetil
cefpodoxime proxetil
cefprozil
cefprozil
CEFTIBUTEN
CEFTIBUTEN
CEFTIN
cefuroxime axetil
cefuroxime axetil
cephalexin
cephalexin
ciprofloxacin er
ciprofloxacin hcl
ciprofloxacin
clarithromycin
clindamycin hcl
clindamycin hcl
clindamycin palmitate hcl
demeclocycline hcl
dicloxacillin sodium
DIFICID
doxycycline hyclate
TABS
CAPS
CHEW
SUSR
TABS
CAPS
SUSR
SUSR
PACK
SUSR
TABS
SOLR
SUSR
TB12
CAPS
SUSR
CAPS
SUSR
TABS
CAPS
SUSR
TABS
SUSR
TABS
SUSR
TABS
CAPS
SUSR
SUSR
SUSR
TABS
CAPS
SUSR
TB24
TABS
SUSR
TABS
CAPS
CAPS
SOLR
TABS
CAPS
TABS
CAPS
Drug Requirements
Tier
/ Limits
1
1
1
1
1
1
1
1
1
1
1
2
2
1
1
1
2
2
2
1
1
2
1
1
1
1
2
2
1
1
1
1
1
1
1
2
1
1
2
1
2
1
2
1
QL
QL
QL
QL
PA
PA
PA
PA
PA
PA
QL
PA
PA
QL
PA
QL
PA
PA
PA
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
doxycycline hyclate
doxycycline monohydrate
doxycycline monohydrate
doxycycline
doxycycline
E.E.S. GRANULES
e.s.p.
ERYPED 400
ERY-TAB
ERYTHROCIN STEARATE
ERYTHROMYCIN BASE
ERYTHROMYCIN ETHYLSUCCINATE
erythromycin
KETEK
levofloxacin
minocycline hcl
moxifloxacin hcl
neomycin sulfate
NOROXIN
OCUDOX
PCE
penicillin v potassium
penicillin v potassium
SULFADIAZINE
sulfamethoxazole/trimethoprim ds
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim
sulfasalazine
sulfasalazine
SUPRAX
SUPRAX
SUPRAX
TETRACYCLINE HCL
tobramycin
vancomycin hcl
vancomycin hcl
VIBRAMYCIN
XIFAXAN
Antifungals
fluconazole
fluconazole
griseofulvin microsize
griseofulvin microsize
griseofulvin ultramicrosize
TABS
CAPS
TABS
CAPS
SUSR
SUSR
SUSR
SUSR
TBEC
TABS
TABS
TABS
CPEP
TABS
TABS
CAPS
TABS
TABS
TABS
KIT
TBEC
SOLR
TABS
TABS
TABS
SUSP
TABS
TABS
TBEC
CHEW
SUSR
TABS
CAPS
NEBU
SOLR
CAPS
SYRP
TABS
1
2
2
2
2
1
1
1
1
1
1
1
1
2
1
1
2
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
2
2
SUSR
TABS
SUSP
TABS
TABS
1
1
1
1
1
QL
PA
PA
PA
PA
PA
QL
QL
PA
PA
PA
QL
QL
PA
QL
PA
QL
ST
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
ketoconazole
nystatin
nystatin
nystatin
terbinafine hcl
voriconazole
voriconazole
Antimycobacterials
DAPSONE
ethambutol hcl
ISONIAZID
isoniazid
pyrazinamide
rifabutin
rifampin
Antiprotozoals
atovaquone/proguanil hcl
atovaquone
chloroquine phosphate
hydroxychloroquine sulfate
mefloquine hcl
metronidazole
NEBUPENT
PENTAM 300
PRIMAQUINE PHOSPHATE
YODOXIN
Antivirals
acyclovir
acyclovir
acyclovir
adefovir dipivoxil
BARACLUDE
didanosine
entecavir
EPIVIR HBV
famciclovir
INFERGEN
lamivudine
OLYSIO
PEGASYS PROCLICK
PEGASYS
PEGASYS
REBETOL
RELENZA DISKHALER
TABS
POWD
SUSP
TABS
TABS
SUSR
TABS
1
1
1
1
1
2
2
TABS
TABS
SYRP
TABS
TABS
CAPS
CAPS
1
1
1
1
1
1
1
TABS
SUSP
TABS
TABS
TABS
TABS
SOLR
SOLR
TABS
TABS
2
1
1
1
1
1
2
2
1
1
CAPS
SUSP
TABS
TABS
SOLN
CPDR
TABS
SOLN
TABS
INJ
TABS
CAPS
SOLN
KIT
SOLN
SOLN
AEPB
1
1
1
2
2
1
2
2
2
2
2
2
2
2
2
2
1
QL
PA
PA
PA
PA
PA
QL
QL
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
ribavirin
ribavirin
rimantadine hcl
SOVALDI
TAMIFLU
TAMIFLU
TYZEKA
valacyclovir hcl
VALCYTE
VALCYTE
VIDEX PEDIATRIC
VIRAZOLE
VIREAD
VIREAD
zidovudine
zidovudine
zidovudine
Urinary Anti-infectives
MACRODANTIN
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
nitrofurantoin
trimethoprim
Antineoplastic Agents
CAPS
TABS
TABS
TABS
CAPS
SUSR
TABS
TABS
SOLR
TABS
SOLR
SOLR
POWD
TABS
CAPS
SYRP
TABS
2
2
1
2
1
1
2
2
2
2
1
2
2
2
1
1
1
CAPS
CAPS
CAPS
SUSP
TABS
1
1
1
1
1
AFINITOR
ALFERON N
ALKERAN
anastrozole
bicalutamide
capecitabine
CAPRELSA
CYCLOPHOSPHAMIDE
exemestane
FARESTON
flutamide
GLEEVEC
HYCAMTIN
hydroxyurea
INTRON-A W/DILUENT
INTRON-A
letrozole
megestrol acetate
megestrol acetate
TABS
SOLN
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
CAPS
TABS
CAPS
CAPS
SOLR
SOLN
TABS
SUSP
TABS
2
2
2
1
1
2
2
2
2
2
1
2
2
1
2
2
1
1
1
PA
PA
PA
QL
QL
PA
QL
ST
PA
PA
PA
PA
PA
PA
PA
PA
QL
PA
PA
PA
PA
PA
PA
PA
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
mercaptopurine
methotrexate
MYLERAN
NEXAVAR
REVLIMID
RHEUMATREX
SPRYCEL
SUTENT
SYLATRON
tamoxifen citrate
TARCEVA
TASIGNA
temozolomide
TREXALL
TYKERB
XALKORI
XTANDI
ZELBORAF
ZYTIGA
Autonomic Drugs
Anticholinergic Agents
ATROVENT HFA
chlordiazepoxide hcl/clidinium bromide
dicyclomine hcl
dicyclomine hcl
glycopyrrolate
hyoscyamine sulfate er
hyoscyamine sulfate
ipratropium bromide
oscimin
SPIRIVA HANDIHALER
TUDORZA PRESSAIR
Autonomic Drugs, Miscellaneous
CHANTIX STARTING MONTH PAK
CHANTIX
nicotine polacrilex
nicotine polacrilex
nicotine
NICOTROL INHALER
NICOTROL NS
Parasympathomimetic (Cholinergic) Agents
bethanechol chloride
donepezil hcl
EXELON
TABS
TABS
TABS
TABS
CAPS
TABS
TABS
CAPS
KIT
TABS
TABS
CAPS
CAPS
TABS
TABS
CAPS
CAPS
TABS
TABS
1
1
2
2
2
1
2
2
2
1
2
2
2
2
2
2
2
2
2
AERS
CAPS
CAPS
TABS
TABS
TB12
SUBL
SOLN
TABS
CAPS
AEPB
1
1
1
1
2
1
1
1
1
1
1
QL
TABS
TABS
GUM
LOZG
PT24
INHA
SOLN
1
1
1
2
1
2
2
QL
QL
QL
TABS
TABS
PT24
2
1
2
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
QL
QL
PA
QL
PA
PA
PA
QL
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
galantamine hydrobromide
galantamine hydrobromide
galantamine hydrobromide
MESTINON TIMESPAN
MESTINON
pilocarpine hydrochloride
PROSTIGMIN
pyridostigmine bromide
Skeletal Muscle Relaxants
baclofen
carisoprodol
cyclobenzaprine hcl
methocarbamol
tizanidine hcl
Sympatholytic (Adrenergic Blocking) Agents
alfuzosin hcl er
DIBENZYLINE
RAPAFLO
tamsulosin hcl
Sympathomimetic (Adrenergic) Agents
ADVAIR DISKUS
ADVAIR HFA
albuterol sulfate er
albuterol sulfate
albuterol sulfate
albuterol sulfate
AUVI-Q
childrens silfedrine
COMBIVENT RESPIMAT
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
ipratropium bromide/albuterol sulfate
levalbuterol hcl
LEVALBUTEROL
midodrine hcl
NASAL DECONGESTANT
pseudoephedrine hcl
SEREVENT DISKUS
SUDAFED 24 HOUR
sudogest 12 hour
sudogest
terbutaline sulfate
VENTOLIN HFA
XOPENEX HFA
CP24
SOLN
TABS
TBCR
SYRP
TABS
TABS
TABS
2
2
2
1
1
1
1
1
TABS
TABS
TABS
TABS
TABS
1
2
1
1
1
TB24
CAPS
CAPS
CAPS
2
1
2
1
AEPB
AERO
TB12
NEBU
SYRP
TABS
SOAJ
LIQD
AERS
SOAJ
SOAJ
SOLN
NEBU
NEBU
TABS
LIQD
TABS
AEPB
TB24
TB12
TABS
TABS
AERS
AERO
2
2
2
1
1
1
1
1
1
1
1
1
2
2
1
1
1
2
1
1
1
1
1
2
PA
PA
PA
QL
QL
QL
ST
QL
PA
PA
QL
PA
PA
PA
QL
QL
QL
QL
QL
QL
QL
ST
ST
PA
QL
QL
ST
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Blood Formation,Coagulation & Thrombosis
Antianemia Drugs
ferrous drops
ferrous sulfate
ferrous sulfate
FERROUS SULFATE
ferrous sulfate
HEMATOGEN FA
trigels-f forte
VITAFOL
Antithrombotic Agents
cilostazol
clopidogrel
EFFIENT
enoxaparin sodium
fondaparinux sodium
heparin sodium dcu
heparin sodium
PRADAXA
ticlopidine hcl
warfarin sodium
XARELTO
Hematopoietic Agents
ARANESP ALBUMIN FREE
EPOGEN
NEULASTA
NEUPOGEN
PROCRIT
PROMACTA
Hemorrheologic Agents
pentoxifylline er
Cardiovascular Drugs
alpha-Adrenergic Blocking Agents
doxazosin mesylate
prazosin hcl
terazosin hcl
Antilipemic Agents
atorvastatin calcium
cholestyramine light
cholestyramine light
cholestyramine
cholestyramine
colestipol hcl for oral suspension
colestipol hcl
Dosage Form
Drug Requirements
Tier
/ Limits
SOLN
ELIX
TABS
TBCR
TBEC
CAPS
CAPS
TABS
1
1
1
1
1
1
1
1
QL
TABS
TABS
TABS
SOLN
SOLN
SOLN
SOLN
CAPS
TABS
TABS
TABS
1
1
2
1
1
1
1
2
2
1
2
QL
SOLN
SOLN
SOLN
SOLN
SOLN
TABS
2
2
2
2
2
2
TBCR
1
QL
TABS
CAPS
CAPS
1
1
1
QL
TABS
PACK
POWD
PACK
POWD
PACK
GRAN
1
1
1
1
1
2
2
QL
QL
QL
ST
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
CRESTOR
fenofibrate micronized
fenofibrate micronized
fenofibrate
fenofibrate
fenofibrate
fenofibric acid dr
FENOFIBRIC ACID
FENOGLIDE
fluvastatin
gemfibrozil
LIPOFEN
lovastatin
micronized colestipol hcl
pravastatin sodium
simvastatin
VYTORIN
WELCHOL
WELCHOL
ZETIA
beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol/chlorthalidone
atenolol
bisoprolol fumarate/hydrochlorothiazide
bisoprolol fumarate
carvedilol
labetalol hcl
metoprolol succinate er
metoprolol tartrate
nadolol
pindolol
propranolol hcl er
PROPRANOLOL HCL
propranolol hcl
sotalol hcl
Calcium-Channel Blocking Agents
amlodipine besylate/atorvastatin calcium
amlodipine besylate
diltiazem cd
diltiazem hcl er
diltiazem hcl er
diltiazem hcl
felodipine er
TABS
CAPS
CAPS
TABS
CAPS
TABS
CPDR
TABS
TABS
CAPS
TABS
CAPS
TABS
TABS
TABS
TABS
TABS
PACK
TABS
TABS
2
1
2
1
2
2
2
2
2
2
1
2
1
2
1
1
2
2
2
2
CAPS
TABS
TABS
TABS
TABS
TABS
TABS
TB24
TABS
TABS
TABS
CP24
SOLN
TABS
TABS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
TABS
TABS
CP24
CP12
CP24
TABS
TB24
2
1
1
1
1
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
QL
PA
PA
PA
PA
QL
QL
QL
QL
QL
PA
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
nifedipine er
nifedipine
taztia xt
telmisartan/amlodipine
verapamil hcl er
verapamil hcl er
verapamil hcl sr
verapamil hcl
Cardiac Drugs
amiodarone hcl
DIGOXIN
digoxin
flecainide acetate
mexiletine hcl
NORPACE CR
propafenone hcl
QUINIDINE SULFATE ER
TIKOSYN
Hypotensive Agents
clonidine hcl er
clonidine hcl
clonidine hcl
guanfacine hcl
hydralazine hcl
KAPVAY DOSE PACK
methyldopa
minoxidil
RESERPINE
Renin-Angiotensin-Aldosterone Sys Inhib
benazepril hcl/hydrochlorothiazide
benazepril hcl
candesartan cilexetil/hydrochlorothiazide
candesartan cilexetil
CAPTOPRIL/HYDROCHLOROTHIAZIDE
captopril
enalapril maleate/hydrochlorothiazide
enalapril maleate
eprosartan mesylate
irbesartan/hydrochlorothiazide
irbesartan
lisinopril/hydrochlorothiazide
lisinopril
losartan potassium/hydrochlorothiazide
losartan potassium
TB24
CAPS
CP24
TABS
CP24
TBCR
CP24
TABS
1
1
1
2
1
1
1
1
TABS
SOLN
TABS
TABS
CAPS
CP12
TABS
TBCR
CAPS
1
1
1
1
1
1
1
1
1
TB12
TABS
PTWK
TABS
TABS
MISC
TABS
TABS
TABS
1
1
2
1
1
1
1
1
2
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
1
1
2
2
2
1
1
1
2
2
2
1
1
1
1
QL
QL
QL
PA
PA
QL
PA
PA
PA
PA
PA
PA
ST
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
quinapril hcl
spironolactone/hydrochlorothiazide
spironolactone
telmisartan/hydrochloroth
telmisartan/hydrochlorothiazide
telmisartan
trandolapril
valsartan/hydrochlorothiazide
valsartan
Vasodilating Agents
DILATRATE SR
dipyridamole
ISORDIL TITRADOSE
isosorbide dinitrate er
isosorbide dinitrate
isosorbide mononitrate er
isosorbide mononitrate
NITRO-BID
NITROSTAT
sildenafil
Central Nervous System Agents
Analgesics and Antipyretics
acetaminophen/codeine #2
acetaminophen/codeine #3
acetaminophen/codeine
acetaminophen/codeine
acetaminophen
acetaminophen
aspirin ec
aspirin
aspirin
butalbital/acetaminophen/caffeine
butalbital/acetaminophen/caffeine
butalbital/aspirin/caffeine
CAPITAL/CODEINE
CELEBREX
childrens ibuprofen
choline magnesium trisalicylate
codeine sulfate
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diclofenac sodium/misoprostol
diflunisal
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
1
1
1
2
2
2
2
2
2
PA
PA
PA
PA
PA
PA
CPCR
TABS
TABS
TBCR
TABS
TB24
TABS
OINT
SUBL
TABS
1
1
1
1
1
1
1
1
1
2
PA
TABS
TABS
SOLN
TABS
SUPP
TABS
TBEC
CHEW
TABS
TABS
CAPS
CAPS
SUSP
CAPS
SUSP
LIQD
TABS
TABS
TBEC
TB24
TBEC
TABS
1
1
1
1
1
1
1
1
1
1
2
2
1
2
1
1
1
2
1
2
1
2
QL
QL
QL
PA
PA
QL
ST
QL
PA
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Dosage Form
eql infant pain relief
etodolac er
etodolac
etodolac
FENOPROFEN CALCIUM
fentanyl
FEVERALL INFANTS
feverall
flurbiprofen
hydrocodone/acetaminophen
hydromorphone hcl
hydromorphone hcl
HYDROMORPHONE HCL
ibuprofen junior strength
ibuprofen
ibuprofen
INDOCIN
INDOCIN
indomethacin
KADIAN
KETOPROFEN ER
ketoprofen
ketorolac tromethamine
mapap
MECLOFENAMATE SODIUM
mefenamic acid
MELOXICAM COMFORT PAC
meloxicam
MELOXICAM
methadone hcl
methadone hcl
methadone hcl
methadone hcl
migraine formula
morphine sulfate er
morphine sulfate er
morphine sulfate
MORPHINE SULFATE
MORPHINE SULFATE
nabumetone
naproxen dr
naproxen sodium
naproxen
naproxen
SUSP
TB24
CAPS
TABS
TABS
PT72
SUPP
SUPP
TABS
TABS
TABS
LIQD
SUPP
CHEW
SUSP
TABS
SUPP
SUSP
CAPS
CP24
CP24
CAPS
TABS
LIQD
CAPS
CAPS
KIT
TABS
SUSP
CONC
SOLN
TABS
TBSO
TABS
TBCR
CP24
SOLN
SUPP
TABS
TABS
TBEC
TABS
SUSP
TABS
Drug Requirements
Tier
/ Limits
1
1
1
1
2
2
1
1
1
1
1
2
2
1
1
1
1
1
1
2
2
2
2
1
2
2
2
1
2
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
PA
PA
QL
QL
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
nortemp infants
OPANA ER (CRUSH RESISTANT)
oxaprozin
OXYCODONE HCL ER
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
OXYCONTIN
oxymorphone hydrochloride er
oxymorphone hydrochloride
pain relief childrens
piroxicam
ROXICET
salsalate
SPRIX
sulindac
tension headache relief
tolmetin sodium
TOLMETIN SODIUM
tramadol hcl
Anorexigenic Agents and Respiratory and CNS
Stimulants
amphetamine/dextroamphetamine
amphetamine/dextroamphetamine
dexmethylphenidate hcl
dextroamphetamine sulfate er
dextroamphetamine sulfate
methamphetamine hcl
methylphenidate hcl cd
METHYLPHENIDATE HCL ER
methylphenidate hcl er
methylphenidate hcl er
methylphenidate hcl sr
methylphenidate hcl
methylphenidate hydrochloride
modafinil
NUVIGIL
RITALIN LA
Anticonvulsants
BANZEL
BANZEL
SUSP
T12A
TABS
T12A
CONC
SOLN
TABS
TABS
TABS
TABS
T12A
TB12
TABS
SUSP
CAPS
SOLN
TABS
SOLN
TABS
TABS
CAPS
TABS
TABS
1
2
1
2
1
1
1
1
1
2
2
2
2
1
1
1
1
2
1
1
2
2
1
TABS
CP24
TABS
CP24
TABS
TABS
CPCR
TBCR
CP24
TBCR
TBCR
TABS
SOLN
TABS
TABS
CP24
1
2
1
2
1
2
2
1
2
2
1
1
1
2
2
2
SUSP
TABS
2
2
PA
PA
QL
QL
QL
PA
PA
QL PA
QL PA
PA
PA
PA
QL
QL
PA
QL
PA
QL
PA
PA
QL
PA
PA
QL
QL
QL
PA
PA
PA
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
carbamazepine er
carbamazepine er
carbamazepine
carbamazepine
carbamazepine
CELONTIN
clonazepam odt
clonazepam
DILANTIN
divalproex sodium dr
divalproex sodium er
divalproex sodium
ethosuximide
ethosuximide
felbamate
felbamate
gabapentin
gabapentin
gabapentin
GABITRIL
LAMICTAL ODT
LAMICTAL ODT
LAMICTAL STARTER/NOT TAKING
CARBAMAZEPINE
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT TAKING VALPROATE
LAMICTAL XR
lamotrigine er
lamotrigine starter/taking valproate
lamotrigine
lamotrigine
levetiracetam er
levetiracetam
levetiracetam
LYRICA
LYRICA
ONFI
ONFI
oxcarbazepine
oxcarbazepine
PEGANONE
phenytoin sodium extended
phenytoin
phenytoin
TB12
CP12
CHEW
SUSP
TABS
CAPS
TBDP
TABS
CAPS
TBEC
TB24
CPSP
CAPS
SOLN
SUSP
TABS
CAPS
SOLN
TABS
TABS
KIT
TBDP
KIT
1
2
1
1
1
1
2
1
1
1
1
1
1
1
2
2
1
1
1
2
2
2
2
KIT
2
PA
KIT
TB24
KIT
CHEW
TABS
TB24
SOLN
TABS
CAPS
SOLN
SUSP
TABS
SUSP
TABS
TABS
CAPS
CHEW
SUSP
2
2
2
1
1
1
1
1
2
2
2
2
1
1
2
1
1
1
PA
PA
PA
QL
PA
QL
QL
QL
PA
QL
QL
QL
QL
QL
QL
PA
PA
QL
QL
QL
PA
PA
PA
PA
QL
QL
QL
QL
QL
PA
PA
PA
PA
QL
QL
PA
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
phenytoin
POTIGA
primidone
SABRIL
SABRIL
STAVZOR
TEGRETOL-XR
tiagabine hydrochloride
topiramate
topiramate
valproic acid
valproic acid
VIMPAT
VIMPAT
zonisamide
Antimigraine Agents
rizatriptan benzoate odt
rizatriptan benzoate
sumatriptan succinate
SUMATRIPTAN
Antiparkinsonian Agents
APOKYN
bromocriptine mesylate
bromocriptine mesylate
carbidopa/levodopa er
carbidopa/levodopa
carbidopa
entacapone
NEUPRO
pramipexole dihydrochloride
ropinirole hcl
selegiline hcl
selegiline hcl
TASMAR
Anxiolytics, Sedatives, and Hypnotics
buspirone hcl
chlordiazepoxide hcl
DIASTAT ACUDIAL
DIAZEPAM
diazepam
EDLUAR
eszopiclone
flurazepam hcl
hydroxyzine hcl
SUSP
TABS
TABS
PACK
TABS
CPDR
TB12
TABS
CPSP
TABS
CAPS
SYRP
SOLN
TABS
CAPS
2
2
1
2
2
2
1
2
1
1
1
1
2
2
1
QL PA
PA
QL
PA
PA
PA
TBDP
TABS
TABS
SOLN
2
2
1
2
QL PA
QL
ST
QL
PA
SOLN
TABS
CAPS
TBCR
TABS
TABS
TABS
PT24
TABS
TABS
CAPS
TABS
TABS
2
1
2
1
1
1
1
2
1
1
1
1
2
PA
TABS
CAPS
GEL
GEL
TABS
SUBL
TABS
CAPS
SYRP
1
1
1
1
1
2
2
1
1
PA
QL
QL
QL
QL
PA
PA
QL
PA
QL
PA
QL
PA
QL
QL
QL
PA
PA
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
hydroxyzine hcl
hydroxyzine pamoate
INTERMEZZO
lorazepam
nighttime sleep aid
oxazepam
phenobarbital
phenobarbital
ROZEREM
temazepam
triazolam
zaleplon
zolpidem tartrate er
zolpidem tartrate
ZOLPIMIST
Central Nervous System Agents, Misc
STRATTERA
XYREM
Psychotherapeutic Agents
amitriptyline hcl
budeprion sr
bupropion hcl er
bupropion hcl sr
bupropion hcl xl
bupropion hcl
citalopram hydrobromide
citalopram hydrobromide
clomipramine hcl
desipramine hcl
doxepin hcl
doxepin hcl
duloxetine hcl
escitalopram oxalate
escitalopram oxalate
fluoxetine hcl
fluoxetine hcl
fluoxetine hcl
fluoxetine hcl
fluoxetine
fluvoxamine maleate
imipramine hcl
imipramine pamoate
mirtazapine odt
mirtazapine
TABS
CAPS
SUBL
TABS
TABS
CAPS
SOLN
TABS
TABS
CAPS
TABS
CAPS
TBCR
TABS
SOLN
1
1
2
1
1
1
1
1
2
1
2
2
2
1
2
CAPS
SOLN
2
2
TABS
TB12
TB12
TB12
TB24
TABS
SOLN
TABS
CAPS
TABS
CAPS
CONC
CPEP
SOLN
TABS
CAPS
SOLN
TABS
TABS
CAPS
TABS
TABS
CAPS
TBDP
TABS
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
2
1
1
1
2
2
1
PA
QL
PA
QL
PA
PA
PA
QL
PA
PA
PA
QL
QL
QL
QL
QL
PA
QL
QL
QL
QL
QL
PA
QL
QL
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
mirtazapine
nefazodone hcl
nortriptyline hcl
NORTRIPTYLINE HCL
paroxetine hcl
prochlorperazine maleate
prochlorperazine
sertraline hcl
sertraline hcl
trazodone hcl
venlafaxine hcl er
venlafaxine hcl
Contraceptives
TBDP
TABS
CAPS
SOLN
TABS
TABS
SUPP
CONC
TABS
TABS
CP24
TABS
2
1
1
1
1
1
1
1
1
1
1
1
FEMCAP
DEVI
OPTIONS GYNOL II VAGINAL CONTRACEPTIVE GEL
ORTHO DIAPHRAGM ALL-FLEX/65MM
DPRH
ORTHO DIAPHRAGM ALL-FLEX/70MM
DPRH
ORTHO DIAPHRAGM ALL-FLEX/75MM
DPRH
ORTHO DIAPHRAGM ALL-FLEX/80MM
DPRH
VCF VAGINAL CONTRACEPTIVE FILM
FILM
VCF VAGINAL CONTRACEPTIVE FOAM
FOAM
WIDE-SEAL SILICONE DIAPHRAGM KIT 60
DPRH
Devices
ACCU-CHEK AVIVA PLUS
KIT
ACCU-CHEK AVIVA
SOLN
ACCU-CHEK FASTCLIX LANCETS
MISC
ACCU-CHEK NANO SMARTVIEW
KIT
ACCU-CHEK SMARTVIEW CONTROL
LIQD
AEROCHAMBER PLUS FLOW-VU/SMALL MASK
MISC
ASTHMAPACK FOR CHILDREN
KIT
BD SAFETYGLIDE ALLERGY
MISC
SYRINGE/1ML/27GX1/2"
CURITY AMD ANTIMICROBIAL GAUZE SPONGES PADS
2"X2" 8 PLY
DEPEND EASY FIT UNDERGARMENT X-ABS
MISC
EXACTA-MIX EVA CONTAINER
MISC
G4 PLATINUM RECEIVER KIT
KIT
GUARDIAN REAL-TIME REPLACEMENT MONITOR DEVI
KERLIX AMD ANTIMICROBIAL SUPER SPONGES PADS
MEDI-JECTOR VISION
MISC
NESSI SPACER/MOUTHPIECE
DEVI
OMNIPOD
MISC
SENSURA STANDARD WEAR BASEPLATE
MISC
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA
QL
QL
QL
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
SILICONE MASK FOR BREATHERITE
CHAMBER/INFANT
TEST PLUG
TRUZONE PEAK FLOW METER
V-GO 20
XEROFORM OCCLUSIVE PETROLATUM GAUZE
STRIP/OVERWRAP 5"X9"
Diagnostic Agents
COAGUCHEK XS PT TEST STRIP
Diabetes Mellitus
ACCU-CHEK AVIVA PLUS
ACCU-CHEK SMARTVIEW STRIPS
Drug Hypersensitivity
PRE-PEN
Ocular Disorders
fluorescein-benoxinate
FLURA-SAFE
PAREMYD
Respiratory Function
ARIDOL
Urine and Feces Contents
KETOSTIX
Electrolytic, Caloric, and Water Balance
Alkalinizing Agents
potassium citrate er
sodium bicarbonate
Ammonia Detoxicants
enulose
lactulose
Caloric Agents
BOOST
ENSURE BONE HEALTH REVIGOR
ENSURE CLEAR
ENSURE CLINICAL STRENGTH REVIGOR
ENSURE MUSCLE HEALTH REVIGOR
ENSURE PUDDING
ENSURE/FIBER
ENSURE
ENSURE
GLYTACTIN BETTERMILK 10
GLYTACTIN BETTERMILK 15
PEDIASURE 1.0 CAL/FIBER
PEDIASURE 1.5 CAL WITH FIBER
PEDIASURE 1.5 CAL
MISC
1
MISC
DEVI
KIT
MISC
1
1
1
1
STRP
1
STRP
STRP
2
2
SOLN
1
SOLN
SOLN
SOLN
1
1
1
KIT
1
STRP
1
QL
TBCR
SOLN
1
1
QL
SOLN
SOLN
1
1
LIQD
LIQD
LIQD
LIQD
LIQD
PUDG
LIQD
LIQD
POWD
PACK
PACK
LIQD
LIQD
LIQD
2
2
2
2
2
2
2
2
2
2
2
2
2
2
ST
ST
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
PEDIASURE PEPTIDE 1.5 CAL
PEDIASURE SIDEKICKS CLEAR
PEDIASURE SIDEKICKS
PEDIASURE WITH FIBER
PEDIASURE
PKU 2
PKU 3
PKU COOLER 10
PKU EXPRESS20
PKU EXPRESS
PKU LOPHLEX LQ 20
PKU TRIO
SIMILAC EXPERT CARE NEOSURE/IRON
Diuretics
bumetanide
CHLORTHALIDONE
furosemide
furosemide
hydrochlorothiazide
hydrochlorothiazide
metolazone
torsemide
triamterene/hydrochlorothiazide
triamterene/hydrochlorothiazide
Ion-removing Agents
FOSRENOL
SEVELAMER CARBONATE
sodium polystyrene sulfonate
Replacement Preparations
calcium 600-d
calcium acetate
calcium acetate
calcium carbonate
CALCIUM CITRATE W/D
calcium/vitamin d
calvite p&d
MAGNESIUM GLUCONATE
magnesium oxide
magnesium
os-cal calcium + d3
oysco 500+d
oyster shell calcium 250+d
oyster shell calcium/vitamin d
oyster shell/vitamin d
LIQD
LIQD
LIQD
LIQD
LIQD
POWD
POWD
LIQD
PACK
PACK
LIQD
POWD
LIQD
2
2
2
2
2
2
2
2
2
2
2
2
2
TABS
TABS
SOLN
TABS
CAPS
TABS
TABS
TABS
CAPS
TABS
1
1
1
1
1
1
1
1
1
1
CHEW
TABS
SUSP
2
2
1
TABS
CAPS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
CHEW
TABS
TABS
TABS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
PA
PA
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
pediatric electrolyte
PHOSLYRA
PHOS-NAK POWDER CONCENTRATE
potassium chloride er
potassium chloride er
potassium chloride sr
potassium chloride
sodium chloride
zinc sulfate
Uricosuric Agents
probenecid
Eye, Ear, Nose & Throat Preparations
Antiallergic Agents
azelastine hcl
cromolyn sodium
cromolyn sodium
epinastine hcl
ketotifen fumarate
Antiglaucoma Agents
acetazolamide er
acetazolamide
betaxolol hcl
brimonidine tartrate
carteolol hcl
dorzolamide hcl/timolol maleate
dorzolamide hcl
latanoprost
levobunolol hcl
methazolamide
METIPRANOLOL
pilocarpine hcl
PILOPINE HS
timolol maleate
TRAVOPROST
Anti-infectives
bacitracin/polymyxin b
BACITRACIN
chlorhexidine gluconate
ciprofloxacin hcl
ear drops earwax removal aid
erythromycin
gentamicin sulfate
gentamicin sulfate
neomycin/polymyxin/gramicidin
SOLN
SOLN
PACK
CPCR
TBCR
TBCR
LIQD
TABS
CAPS
1
1
1
1
1
1
1
1
1
TABS
1
QL
SOLN
AERS
SOLN
SOLN
SOLN
2
1
1
2
1
QL
ST
QL
ST
CP12
TABS
SOLN
SOLN
SOLN
SOLN
SOLN
SOLN
SOLN
TABS
SOLN
SOLN
GEL
SOLN
SOLN
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
OINT
OINT
SOLN
SOLN
SOLN
OINT
OINT
SOLN
SOLN
1
1
1
1
1
1
1
1
1
QL
PA
QL
ST
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
neo-polycin
ofloxacin
sodium sulfacetamide
SULFACETAMIDE SODIUM
tobramycin sulfate
trimethoprim sulfate/polymyxin b sulfate
Anti-inflammatory Agents
BLEPHAMIDE S.O.P.
BLEPHAMIDE
budesonide
CIPRODEX
dexamethasone sodium phosphate
diclofenac sodium
flunisolide
fluorometholone
flurbiprofen sodium
fluticasone propionate
hydrocortisone/acetic acid
NASACORT ALLERGY 24HR
NASONEX
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/hydrocortisone
PRED MILD
prednisolone acetate
PREDNISOLONE SODIUM PHOSPHATE
sulfacetamide sodium/prednisolone sodium
phosphate
TOBRADEX
tobramycin/dexamethasone
triamcinolone acetonide
ZYLET
EENT Drugs, Miscellaneous
acetic acid
akwa tears renewed
artificial tears
artificial tears
baby ayr saline
deep sea nasal spray
HYPOTEARS
IOPIDINE
natures tears
OINT
SOLN
SOLN
OINT
SOLN
SOLN
1
1
1
1
1
1
OINT
SUSP
SUSP
SUSP
SOLN
SOLN
SOLN
SUSP
SOLN
SUSP
SOLN
AERO
SUSP
OINT
OINT
SUSP
SOLN
SUSP
SUSP
SUSP
SOLN
SOLN
1
1
2
2
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
OINT
SUSP
AERO
SUSP
1
1
2
2
SOLN
SOLN
OINT
SOLN
SOLN
SOLN
SOLN
SOLN
SOLN
1
1
1
1
1
1
1
1
1
QL
PA
QL
ST
QL
QL
QL
PA
QL
QL
ST
PA
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
tears naturale ii
tears naturale
THERATEARS
ultra fresh
Local Anesthetics
antipyrine/benzocaine
lidocaine viscous
Mydriatics
ATROPINE SULFATE
atropine-care
CYCLOGYL
cyclopentolate hcl
homatropaire
ISOPTO HOMATROPINE
tropicamide
Vasoconstrictors
eye allergy relief
NAPHAZOLINE HCL
tgt eye allergy relief
Gastrointestinal Drugs
Antacids and Adsorbents
calcium antacid
CALCIUM CARBONATE
maalox advanced maximum strength
maalox advanced
Antidiarrhea Agents
anti-diarrheal
DIPHENOXYLATE/ATROPINE
diphenoxylate/atropine
gnp pink bismuth
loperamide hcl
loperamide hcl
peptic relief
stomach relief
Antiemetics
CESAMET
dronabinol
EMEND
granisetron hcl
meclizine hcl
ondansetron hcl
ondansetron hcl
ondansetron odt
TIGAN
SOLN
SOLN
GEL
SOLN
1
1
1
1
SOLN
SOLN
1
1
OINT
SOLN
SOLN
SOLN
SOLN
SOLN
SOLN
1
1
1
1
1
1
1
SOLN
SOLN
SOLN
1
1
1
CHEW
TABS
SUSP
SUSP
1
1
1
1
TABS
LIQD
TABS
TABS
CAPS
LIQD
CHEW
SUSP
1
1
1
1
1
1
1
1
CAPS
CAPS
CAPS
TABS
TABS
TABS
SOLN
TBDP
SOLN
2
2
2
2
1
1
2
1
2
PA
PA
PA
PA
QL
PA
QL
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
travel sickness
Antiflatulents
gas relief
simethicone
simethicone
Anti-inflammatory Agents
APRISO
ASACOL HD
balsalazide disodium
CANASA
DELZICOL
LIALDA
LOTRONEX
mesalamine
PENTASA
Antiulcer Agents and Acid Suppressants
CARAFATE
cimetidine hcl
cimetidine
famotidine
famotidine
FIRST-LANSOPRAZOLE
FIRST-OMEPRAZOLE
lansoprazole
misoprostol
NEXIUM 24HR
omeprazole
omeprazole
pantoprazole sodium
PREVACID SOLUTAB
PROTONIX
ranitidine 75
ranitidine hcl
ranitidine hcl
ranitidine hcl
sucralfate
Cathartics and Laxatives
bisacodyl ec
bisacodyl
COLACE
COLYTE-FLAVOR PACKS
docusate calcium
docusate sodium & senna stimulant laxative/stool
softener
CHEW
1
SUSP
CAPS
CHEW
1
1
1
CP24
TBEC
CAPS
SUPP
CPDR
TBEC
TABS
ENEM
CPCR
2
1
1
1
1
1
2
1
1
SUSP
SOLN
TABS
SUSR
TABS
SUSP
SUSP
CPDR
TABS
CPDR
CPDR
CPDR
TBEC
TBDP
PACK
TABS
CAPS
SYRP
TABS
TABS
1
1
1
1
1
2
1
2
1
2
1
2
1
2
2
1
1
1
1
1
TBEC
SUPP
CAPS
SOLR
CAPS
TABS
1
1
1
1
1
1
PA
QL
QL
QL
QL
QL
PA
QL
QL
PA
QL
QL
ST
QL
QL
ST
PA
QL
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
docusate sodium
docusate sodium
enema ready-to-use
GLYCERIN ADULT
konsyl
magnesium citrate
metamucil original texture
METAMUCIL
MINERAL OIL
peg 3350/electrolytes
peg-3350/electrolytes
peg-3350/nacl/na bicarbonate/kcl
polyethylene glycol 3350
polyethylene glycol 3350
senna
senna
silace
SUPREP BOWEL PREP
Cholelitholytic Agents
ursodiol
Digestants
CREON
lactase enzyme
lactose fast acting relief
ZENPEP
GI Drugs, Miscellaneous
NUTRESTORE
Prokinetic Agents
metoclopramide hcl
metoclopramide hcl
Heavy Metal Antagonists
CAPS
LIQD
ENEM
SUPP
CAPS
SOLN
POWD
WAFR
OIL
SOLR
SOLR
SOLR
PACK
POWD
SYRP
TABS
SYRP
SOLN
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
CAPS
1
CPEP
TABS
TABS
CPEP
1
1
1
1
PACK
2
SOLN
TABS
1
1
CUPRIMINE
DEPEN TITRATABS
EXJADE
Hormones and Synthetic Substitutes
Adrenals
ASMANEX TWISTHALER 120 METERED DOSES
ASMANEX TWISTHALER 14 METERED DOSES
ASMANEX TWISTHALER 30 ME TERED DOSES
ASMANEX TWISTHALER 30 METERED DOSES
ASMANEX TWISTHALER 60 METERED DOSES
ASMANEX TWISTHALER 7 METERED DOSES
budesonide
CAPS
TABS
TBSO
1
1
2
AEPB
AEPB
AEPB
AEPB
AEPB
AEPB
SUSP
1
1
1
1
1
1
1
QL
QL
PA
QL
QL
PA
PA
QL
QL
QL
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
budesonide
CORTISONE ACETATE
dexamethasone
DEXAMETHASONE
dexamethasone
DULERA
FLOVENT DISKUS
FLOVENT HFA
fludrocortisone acetate
hydrocortisone
MEDROL
methylprednisolone dose pack
methylprednisolone
MILLIPRED
prednisolone sodium phosphate
prednisolone
PREDNISONE INTENSOL
PREDNISONE
prednisone
PULMICORT FLEXHALER
PULMICORT
QVAR
SYMBICORT
UCERIS
Androgens
ANDRODERM
ANDROGEL PUMP
ANDROGEL
ANDROXY
AXIRON
METHITEST
oxandrolone
testosterone cypionate
testosterone cypionate
TESTRED
Antidiabetic Agents
acarbose
APIDRA SOLOSTAR
APIDRA
BYDUREON
BYETTA
glimepiride
glipizide er
glipizide/metformin hcl
CP24
TABS
ELIX
SOLN
TABS
AERO
AEPB
AERO
TABS
TABS
TABS
TABS
TABS
TABS
SOLN
SOLN
CONC
SOLN
TABS
AEPB
SUSP
AERS
AERO
TB24
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
PT24
GEL
GEL
TABS
SOLN
TABS
TABS
SOLN
SOLN
CAPS
2
2
2
2
2
1
2
1
2
1
TABS
SOPN
SOLN
SUSR
SOPN
TABS
TB24
TABS
1
1
1
2
2
1
1
1
PA
QL
QL
QL
QL
QL
QL
QL
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Dosage Form
glipizide
glyburide micronized
glyburide/metformin hcl
glyburide
HUMALOG KWIKPEN
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 75/25 KWIKPEN
HUMALOG MIX 75/25
HUMALOG
HUMALOG
HUMULIN 70/30 PEN
HUMULIN 70/30
HUMULIN N U-100 PEN
HUMULIN N
HUMULIN R U-500 (CONCENTRATED)
HUMULIN R
JANUVIA
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXPEN
LEVEMIR
metformin hcl er
metformin hcl er
metformin hcl
nateglinide
NOVOLIN N
NOVOLIN R RELION
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG PENFILL
NOVOLOG
ONGLYZA
pioglitazone hcl/metformin hcl
pioglitazone hcl
repaglinide
RIOMET
SYMLINPEN 120
SYMLINPEN 60
tolazamide
TOLBUTAMIDE
TRADJENTA
VICTOZA
TABS
TABS
TABS
TABS
SOPN
SUPN
SUSP
SUPN
SUSP
SOCT
SOLN
SUPN
SUSP
SUPN
SUSP
SOLN
SOLN
TABS
SOPN
SOLN
SOPN
SOLN
TB24
TB24
TABS
TABS
SUSP
SOLN
SOPN
SUPN
SUSP
SOCT
SOLN
TABS
TABS
TABS
TABS
SOLN
SOPN
SOPN
TABS
TABS
TABS
SOPN
Drug Requirements
Tier
/ Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
2
2
1
2
1
2
1
1
1
1
1
1
1
2
2
1
2
2
2
2
1
1
2
2
QL
QL
PA
ST
ST
QL
PA
QL
PA
PA
PA
QL
PA
PA
PA
PA
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Antihypoglycemic Agents
GLUCAGON EMERGENCY KIT
GLUCOSE
Contraceptives
amethia
BEYAZ
camrese lo
chateal
cryselle-28
cyclafem 1/35
ELLA
falmina
GENERESS FE
gianvi
jolessa
junel fe 1.5/30
junel fe 1/20
kelnor 1/35
leena
levonorgestrel
LO LOESTRIN FE
microgestin 1.5/30
microgestin 1/20
mononessa
myzilra
NATAZIA
NECON 10/11-28
next choice one dose
nora-be
NORINYL 1+50
nortrel 0.5/35 (28)
nortrel 7/7/7
NUVARING
OGESTREL
ORTHO TRI-CYCLEN LO
philith
reclipsen
SAFYRAL
syeda
tri-legest fe
tri-sprintec
velivet
viorele
xulane
Dosage Form
Drug Requirements
Tier
/ Limits
KIT
CHEW
1
1
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
CHEW
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
RING
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
PTWK
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
2
1
1
1
1
1
1
1
1
2
1
1
2
1
1
1
1
1
1
PA
PA
QL PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
QL
QL
QL
QL
PA
QL
QL
QL
QL
QL
QL
QL
QL
PA
QL
QL
PA
QL
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
zenchent fe
ZOVIA 1/50E
Estrogens and Antiestrogens
ALORA
CENESTIN
CLIMARA PRO
COMBIPATCH
covaryx hs
covaryx
DEPO-ESTRADIOL
ENJUVIA
ESTRACE
estradiol valerate
estradiol/norethindrone acetate
estradiol
estradiol
ESTRASORB
ESTRING
ESTROGEL
estropipate
FEMRING
MENEST
MENOSTAR
PREMARIN
PREMARIN
PREMPHASE
PREMPRO
raloxifene hydrochloride
VAGIFEM
VIVELLE-DOT
Gonadotropins
SYNAREL
Parathyroid
calcitonin-salmon
FORTEO
Pituitary
desmopressin acetate
desmopressin acetate
STIMATE
Progestins
CRINONE
ENDOMETRIN
FIRST-PROGESTERONE VGS 100
COMPOUNDING KIT
CHEW
TABS
1
1
PTTW
TABS
PTWK
PTTW
TABS
TABS
OIL
TABS
CREA
OIL
TABS
PTWK
TABS
EMUL
RING
GEL
TABS
RING
TABS
PTWK
CREA
TABS
TABS
TABS
TABS
TABS
PTTW
1
1
1
1
1
1
1
2
1
1
1
1
1
2
2
2
1
1
2
1
1
1
1
1
1
1
1
SOLN
2
PA
SOLN
SOLN
2
2
PA
PA
TABS
SOLN
SOLN
1
2
2
GEL
INST
SUPP
1
1
1
QL
QL
QL
QL
QL
PA
QL
QL
PA
PA
PA
PA
QL
QL
QL
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
FIRST-PROGESTERONE VGS 200
COMPOUNDING KIT
FIRST-PROGESTERONE VGS 25 COMPOUNDING
KIT
FIRST-PROGESTERONE VGS 400
COMPOUNDING KIT
FIRST-PROGESTERONE VGS 50 COMPOUNDING
KIT
medroxyprogesterone acetate
norethindrone acetate
progesterone
Somatotropin Agonists and Antagonists
GENOTROPIN MINIQUICK
GENOTROPIN
HUMATROPE
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX PEN
NUTROPIN AQ NUSPIN 10
NUTROPIN AQ NUSPIN 20
NUTROPIN AQ NUSPIN 5
NUTROPIN
OMNITROPE
OMNITROPE
SAIZEN CLICK.EASY
SAIZEN
SEROSTIM
TEV-TROPIN
ZORBTIVE
Thyroid and Antithyroid Agents
ARMOUR THYROID
levothyroxine sodium
liothyronine sodium
methimazole
np thyroid 30
np thyroid 60
np thyroid 90
propylthiouracil
Miscellaneous Therapeutic Agents
5-alpha-Reductase Inhibitors
AVODART
finasteride
Alcohol Deterrents
disulfiram
Antidotes
SUPP
1
SUPP
1
SUPP
1
SUPP
1
TABS
TABS
CAPS
1
1
1
SOLR
SOLR
SOLR
SOLN
SOLN
SOLN
SOLN
SOLN
SOLR
SOLN
SOLR
SOLR
SOLR
SOLR
SOLR
SOLR
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
TABS
TABS
TABS
TABS
TABS
TABS
TABS
TABS
1
1
1
1
1
1
1
1
CAPS
TABS
2
1
TABS
1
QL
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
leucovorin calcium
Antigout Agents
allopurinol
COLCRYS
ULORIC
Bone Resorption Inhibitors
ACTONEL
alendronate sodium
ALENDRONATE SODIUM
alendronate sodium
ATELVIA
BINOSTO
ETIDRONATE DISODIUM
FOSAMAX PLUS D
ibandronate sodium
risedronate sodium
SKELID
Cariostatic Agents
denta 5000 plus
fluor-a-day
fluoridex daily defense
fluoritab
FLURA-DROPS
LOZI-FLUR
ludent
neutral sodium fluoride
PREVIDENT 5000 BOOSTER PLUS
sodium fluoride
sodium fluoride
Complement Inhibitors
FIRAZYR
Disease-modifying Antirheumatic Drugs
ENBREL SURECLICK
ENBREL
ENBREL
HUMIRA PEN
HUMIRA PEN-PSORIASIS STARTER
HUMIRA
leflunomide
Immunomodulatory Agents
ACTIMMUNE
AVONEX PEN
AVONEX
BETASERON
TABS
2
TABS
TABS
TABS
1
1
2
TABS
TABS
SOLN
TABS
TBEC
TBEF
TABS
TABS
TABS
TABS
TABS
2
1
2
2
2
1
2
2
2
2
2
CREA
SOLN
GEL
CHEW
SOLN
LOZG
CHEW
SOLN
PSTE
CHEW
SOLN
1
1
1
1
1
1
1
1
1
1
1
SOLN
2
PA
SOAJ
KIT
SOSY
KIT
KIT
KIT
TABS
2
2
2
2
2
2
1
PA
PA
PA
PA
PA
PA
SOLN
KIT
KIT
KIT
2
2
2
2
PA
QL
QL
PA
PA
QL
PA
PA
PA
QL
PA
PA
QL
ST
PA
PA
QL
PA
PA
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
COPAXONE
EXTAVIA
GILENYA
REBIF REBIDOSE TITRATION PACK
REBIF REBIDOSE
REBIF TITRATION PACK
REBIF
THALOMID
Immunosuppressive Agents
azathioprine
CELLCEPT
cyclosporine modified
cyclosporine modified
cyclosporine
hecoria
mycophenolate mofetil
mycophenolate mofetil
mycophenolic acid dr
RAPAMUNE
SANDIMMUNE
sirolimus
tacrolimus
ZORTRESS
Other Miscellaneous Therapeutic Agents
AMPYRA
CARNITOR SF
fish oil
levocarnitine
ORFADIN
SENSIPAR
ZAVESCA
Protective Agents
MESNEX
Oxytocics
KIT
KIT
CAPS
SOLN
SOLN
SOLN
SOLN
CAPS
2
2
2
2
2
2
2
1
TABS
SUSR
CAPS
SOLN
CAPS
CAPS
CAPS
TABS
TBEC
SOLN
SOLN
TABS
CAPS
TABS
1
2
1
2
2
1
1
1
2
2
2
2
1
2
TB12
SOLN
CAPS
SOLN
CAPS
TABS
CAPS
2
1
1
1
2
1
2
TABS
2
methylergonovine maleate
Respiratory Tract Agents
Anti-inflammatory Agents
cromolyn sodium
cromolyn sodium
montelukast sodium
montelukast sodium
montelukast sodium
ZYFLO CR
TABS
1
CONC
NEBU
CHEW
PACK
TABS
TB12
1
1
1
1
1
2
PA
PA
PA
PA
PA
PA
PA
QL
PA
QL
PA
PA
QL
QL
QL
PA
PA
PA
PA
QL
PA
PA
QL
PA
QL
PA
PA
QL
QL
QL
QL
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
ZYFLO
Antitussives
benzonatate
cheratussin dac
dextromethorphan polistirex
diabetic tussin maximum strength
guaifenesin/codeine
guaifenesin-dm
neotuss
pedia relief cough/cold
PROMETHAZINE VC/CODEINE
promethazine/codeine
promethazine-dm
REZIRA
Expectorants
guaifenesin er
guaifenesin
MUCINEX D
tussin
Mucolytic Agents
PULMOZYME
sodium chloride
Phosphodiesterase Type 4 Inhibitors
DALIRESP
Vasodilating Agents
ADEMPAS
LETAIRIS
TYVASO REFILL
TYVASO STARTER
Skin and Mucous Membrane Preparations
Anti-infectives
ABREVA
acne medication 5
acyclovir
ALCOHOL PREPS
AVC
AZOLEN TINCTURE
bacitracin zinc
bacitracin/neomycin/polymyxin
bacitracin
benzoyl peroxide wash
benzoyl peroxide
bp wash
CENTANY
TABS
2
PA
CAPS
SOLN
LQCR
LIQD
SOLN
SYRP
LIQD
LIQD
SYRP
SYRP
SYRP
SOLN
1
1
1
1
1
1
1
1
1
1
1
2
PA
TB12
TABS
TB12
SYRP
1
1
1
1
SOLN
NEBU
2
1
PA
TABS
2
PA
TABS
TABS
SOLN
SOLN
2
2
2
2
PA
PA
PA
PA
CREA
GEL
OINT
MISC
CREA
SOLN
OINT
OINT
OINT
LIQD
GEL
LIQD
OINT
1
1
2
1
1
1
1
1
1
1
1
1
1
QL
PA
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Dosage Form
ciclopirox olamine
CLEOCIN
clindamycin phosphate
clindamycin phosphate
clindamycin phosphate
clindamycin phosphate
clindamycin phosphate
clindamycin phosphate
clotrimazole/betamethasone dipropionate
clotrimazole
clotrimazole
clotrimazole
double antibiotic
econazole nitrate
erythromycin/benzoyl peroxide
erythromycin
erythromycin
GYNAZOLE-1
GYNE-LOTRIMIN 3
ketoconazole
ketoconazole
ketodan
LAVOCLEN-4 CREAMY WASH
lice killing maximum strength
lice treatment creme rinse
lotrimin af deodorant powder
lotrimin af
malathion
metronidazole vaginal
metronidazole
metronidazole
metronidazole
metronidazole
miconazole 3 combo pack
MICONAZOLE 3
miconazole 7
miconazole 7
miconazole nitrate
NORITATE
nystatin
nystatin
nystatin
PACNEX MX
permethrin
CREA
SUPP
CREA
GEL
LOTN
SOLN
SWAB
FOAM
CREA
CREA
SOLN
TROC
OINT
CREA
GEL
GEL
SOLN
CREA
CREA
CREA
SHAM
FOAM
LIQD
SHAM
LIQD
AERP
POWD
LOTN
GEL
CREA
GEL
LOTN
GEL
KIT
SUPP
CREA
SUPP
CREA
CREA
CREA
OINT
POWD
LIQD
CREA
Drug Requirements
Tier
/ Limits
1
1
1
1
1
1
1
2
1
1
1
1
1
1
2
1
1
1
1
1
1
2
1
1
1
1
1
2
1
1
1
1
2
1
1
1
1
1
2
1
1
1
1
1
QL
PA
QL
QL
QL
PA
PA
PA
QL
QL
QL
QL
ST
PA
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
permethrin
pr benzoyl peroxide wash
RELAGARD
selenium sulfide
SELENIUM SULFIDE
SPINOSAD
ssd
sulfacetamide sodium
terbinafine hcl
terconazole
terconazole
tioconazole-1
tolnaftate
XOLEGEL
ZOVIRAX
Anti-inflammatory Agents
anucort-hc
ANUSOL-HC
augmented betamethasone dipropionate
augmented betamethasone dipropionate
augmented betamethasone dipropionate
augmented betamethasone dipropionate
betamethasone dipropionate
betamethasone dipropionate
betamethasone valerate
betamethasone valerate
CORTIFOAM
desoximetasone
fluocinolone acetonide
fluocinonide
fluocinonide
fluocinonide
fluticasone propionate
gnp hydro-lotion
halobetasol propionate
hydrocortisone
hydrocortisone
hydrocortisone
hydrocortisone
mometasone furoate
mometasone furoate
mometasone furoate
nystatin/triamcinolone
nystatin/triamcinolone
LOTN
LIQD
GEL
LOTN
SHAM
SUSP
CREA
SUSP
CREA
CREA
SUPP
OINT
CREA
GEL
CREA
1
1
1
1
2
2
1
2
1
1
1
1
1
2
2
SUPP
CREA
CREA
GEL
LOTN
OINT
LOTN
OINT
CREA
LOTN
FOAM
CREA
CREA
GEL
OINT
SOLN
CREA
LOTN
OINT
CREA
ENEM
LOTN
OINT
CREA
OINT
SOLN
CREA
OINT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA
PA
PA
QL
QL
PA
PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
proctozone-hc
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
triamcinolone acetonide
TRIANEX
Antipruritics and Local Anesthetics
benadryl itch stopping
lidocaine hcl jelly
lidocaine/prilocaine
lidocaine
phenazopyridine hcl
PROCTOFOAM HC
vagicream
VAGISIL MAXIMUM STRENGTH
Astringents
ALUMINUM ACETATE
hypercare
Cell Stimulants and Proliferants
tretinoin
tretinoin
Emollients, Demulcents, and Protectants
ammonium lactate
ammonium lactate
BENGAY ULTRA STRENGTH
hydrophor
lac-hydrin five
lactic acid
minerin
Keratolytic Agents
avar cleanser
bp 10-1
prascion fc
ra wart remover
salicylic acid
se 10-5 ss
sodium sulfacetamide/sulfur wash
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur
SSS 10-4
CREA
CREA
LOTN
OINT
PSTE
OINT
1
1
1
1
1
1
GEL
GEL
CREA
OINT
TABS
FOAM
CREA
CREA
1
1
1
1
1
1
1
1
SOLN
SOLN
1
1
QL
CREA
GEL
1
1
QL
QL
CREA
LOTN
CREA
OINT
LOTN
LOTN
CREA
1
1
1
1
1
1
1
EMUL
EMUL
PADS
SOLN
SOLN
CREA
LIQD
CREA
FOAM
LIQD
LOTN
PADS
SUSP
FOAM
2
2
2
1
1
2
2
2
2
2
2
2
2
2
QL
QL
QL
QL
QL
QL
PA
PA
PA
QL
QL
PA
PA
PA
PA
PA
PA
PA
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
urea
Keratoplastic Agents
COAL TAR
Skin and Mucous Membrane Agents, Misc
acitretin
adapalene
adapalene
AZELEX
BEDSIDE-CARE PERINEAL WASH
calcipotriene
calcipotriene
CALCITRIOL
capsaicin hp
CONDYLOX
DIFFERIN
ELIDEL
fluorouracil
imiquimod
k-y lubricating jelly
PERIFRESH PERINEAL CLEANSER
podofilox
PROSHIELD SPRAY CLEANSER
PROTOPIC
RESTORE SILVER DRESSING 4"X4" NONADHESIVE
RESTORE SILVER DRESSING ROPE 12"
SALONPAS
TAZORAC
TAZORAC
trixaicin hp
TRIXAICIN
Smooth Muscle Relaxants
Genitourinary Smooth Muscle Relaxants
ENABLEX
GELNIQUE
oxybutynin chloride er
oxybutynin chloride
oxybutynin chloride
tolterodine tartrate er
tolterodine tartrate
VESICARE
Respiratory Smooth Muscle Relaxants
theophylline cr
theophylline er
CREA
1
SOLN
1
CAPS
CREA
GEL
CREA
LIQD
CREA
OINT
OINT
CREA
GEL
LOTN
CREA
CREA
CREA
GEL
LIQD
SOLN
LIQD
OINT
PADS
2
2
2
2
1
2
2
2
1
1
2
2
1
1
1
1
1
1
2
1
MISC
PTCH
CREA
GEL
CREA
CREA
1
1
2
2
1
1
TB24
GEL
TB24
SYRP
TABS
CP24
TABS
TABS
2
2
2
1
1
2
2
2
TB12
TB12
1
1
QL
PA
QL
ST
QL PA ST
PA
QL
QL
QL
QL
ST
ST
ST
PA
QL
QL
QL
ST
QL
ST
QL
PA
PA
PA
PA
QL
ST
PA
PA
PA
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Dosage Form
theophylline er
TB24
theophylline
SOLN
Vitamins
Multivitamin Preparations
AQUADEKS
CHEW
ATABEX EC
TBEC
BAL-CARE DHA ESSENTIAL
MISC
BAL-CARE DHA
MISC
CAVAN-EC SOD DHA
MISC
centrum kids complete
CHEW
CENTRUM SILVER
TABS
CENTRUM SPECIALIST PRENATAL
MISC
chewable vite childrens
CHEW
childrens chewable vitamins/iron
CHEW
CITRANATAL 90 DHA
MISC
CITRANATAL B-CALM
MISC
CITRANATAL DHA
MISC
CITRANATAL HARMONY
CAPS
COMPLETE NATAL DHA
MISC
COMPLETE PRENATAL MULTIVITAMIN/PRENATALMISC
DHA
COMPLETENATE
CHEW
COMPLETE-RF PRENATAL
TABS
daily vite
TABS
dialyvite 800/ultra d
TABS
dialyvite 800
TABS
dialyvite
TABS
DUET DHA 400
MISC
DUET DHA 400EC
MISC
DUET DHA 430
MISC
DUET DHA 430EC
MISC
DUET DHA BALANCED
MISC
ELITE OB WITH DHA
CAPS
ELITE-OB 400
CAPS
ELITE-OB
TABS
EXTRA-VIRT PLUS DHA
CAPS
EZFE FORTE
CAPS
flintstones complete
CHEW
FOCALGIN-B
TABS
FOLBECAL
TABS
FOLCAPS OMEGA 3
CAPS
FOLIVANE-OB
CAPS
FOLIVANE-PRX DHA NF
CAPS
GESTICARE DHA
MISC
Drug Requirements
Tier
/ Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Dosage Form
HEMENATAL OB + DHA
HEMENATAL OB
INATAL ULTRA
KPN PRENATAL
L-METHYLFOLATE PNV DHA
MACNATAL CN DHA
MARNATAL-F
multi vitamin/fluoride
multi-delyn
multivitamin with fluoride
multi-vitamin/fluoride/iron
multivitamin/fluoride
multi-vitamin/fluoride
multi-vitamin/fluoride
mvc-fluoride
MYNATAL ULTRACAPLET
MYNATAL
MYNATAL-Z
MYNATE 90 PLUS
mynephrocaps
NATACHEW
NATAFORT
NATALVIRT CA
NATALVIT
NATELLE ONE
NATELLE-EZ
nephronex
NESTABS DHA
NESTABS
NEXA PLUS
OB COMPLETE 400
OB COMPLETE ONE
OB COMPLETE PETITE
OB COMPLETE PREMIER
OB COMPLETE/DHA
OB COMPLETE
OBSTETRIX DHA
OBSTETRIX EC
OBTREX
O-CAL FA
O-CAL PRENATAL
OCUVITE LUTEIN
ocuvite
one daily plus minerals
MISC
TABS
TABS
TABS
CAPS
CAPS
CAPS
CHEW
LIQD
CHEW
SOLN
CHEW
CHEW
SOLN
CHEW
TABS
CAPS
TABS
TBCR
CAPS
CHEW
TABS
MISC
TABS
CAPS
TABS
TABS
MISC
TABS
CAPS
CAPS
CAPS
CAPS
TABS
CAPS
CHEW
MISC
TABS
TABS
TABS
TABS
CAPS
TABS
TABS
Drug Requirements
Tier
/ Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Dosage Form
ONE-A-DAY WOMENS PRENATAL
PAIRE OB
PERRY PRENATAL
PNV FOLIC ACID + IRON MULTIVITAMIN
PNV-DHA+DOCUSATE
PNV-OMEGA
poly vitamin
POLY-VI-SOL/IRON
POLY-VI-SOL
poly-vitamin drops
poly-vitamin/iron drops
polyvitamin/iron
polyvitamin/iron
polyvitamin
PR NATAL 400 EC
PR NATAL 400
PR NATAL 430 EC
PR NATAL 430
PREFERAOB ONE
PRENA1 CHEW/QUATREFOLIC
PRENA1/QUATREFOLIC
PRENAISSANCE BALANCE
PRENAPLUS
PRENATA
PRENATABS RX
PRENATAL 1
PRENATAL 19
PRENATAL 19
PRENATAL FORMULA A-FREE
PRENATAL LOW IRON
PRENATAL MULTI +DHA
PRENATAL MULTIVITAMIN + DHA
PRENATAL PLUS IRON
PRENATAL VITAMINS PLUS
PRENATAL VITAMINS
PRENATAL
PRENATAL-U
PRENATE DHA
PRENATE ELITE
PRENATE ESSENTIAL
PRENATE MINI
PRENATE
PREQUE 10
PROTECT PLUS
MISC
MISC
CAPS
TABS
CAPS
CAPS
CHEW
SOLN
SOLN
SOLN
SOLN
CHEW
SOLN
SOLN
MISC
MISC
MISC
MISC
CAPS
CHEW
CAPS
CAPS
TABS
CHEW
TABS
CAPS
CHEW
TABS
TABS
TABS
CAPS
MISC
TABS
TABS
TABS
TABS
CAPS
CAPS
TABS
CAPS
CAPS
CHEW
TABS
LIQD
Drug Requirements
Tier
/ Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Name
Dosage Form
PROTECTNATAL
PUREFE OB PLUS
RELNATE DHA
rena-vite rx
SELECT-OB
SE-TAN DHA
STROVITE FORTE
STUART PRENATAL + DHA
TARON-BC
TARON-C DHA
TARON-PREX
thera
thera-m
THERANATAL COMPLETE
theratrum complete
THEREMS-M
TRI RX
TRIADVANCE
TRICARE PRENATAL DHA ONE
TRINATAL GT
TRINATE
TRIVEEN-ONE
TRIVEEN-PRX RNF
TRIVEEN-TEN
TRI-VI-SOL/IRON
TRI-VIT/FLUORIDE/IRON
tri-vit/fluoride
tri-vitamin/fluoride
tri-vitamin
ULTIMATECARE ONE NF
VENATAL-FA
vic-forte
VINATE AZ
VINATE CALCIUM
VINATE CARE
VINATE IC
VINATE II
VINATE M
VINATE ONE
VINATE PN CARE
VIRT-SELECT
vita-bee/c
VITAFOL-OB
VITAMEDMD PLUS RX/QUATRE FOLIC
TBEC
CAPS
CAPS
TABS
CHEW
CAPS
TABS
MISC
MISC
CAPS
CAPS
TABS
TABS
MISC
TABS
TABS
TABS
TABS
CAPS
TABS
TABS
CAPS
CAPS
TABS
SOLN
SOLN
SOLN
SOLN
SOLN
CAPS
TABS
CAPS
TABS
TABS
CHEW
CAPS
TABS
TABS
TABS
TABS
CAPS
TABS
TABS
MISC
Drug Requirements
Tier
/ Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
San Francisco Health Plan Medi-Cal Formulary
AS OF NOVEMBER 2014
Drug Requirements
Tier
/ Limits
Drug Name
Dosage Form
VITASPIRE
VP-ERA OB PLUS
VP-PNV-DHA
ZATEAN-CH
ZATEAN-PN DHA
ZATEAN-PN
ZINGIBER
Vitamin A
vitamin a
Vitamin B Complex
B-1
cyanocobalamin
folic acid
niacin tr
niacin
NIACOR
pyridoxine hcl
vitamin b-1
vitamin b-12 cr
vitamin b-12
Vitamin C
ascorbic acid
c-500
vitamin c
Vitamin D
calcitriol
calcitriol
d 400
d3
doxercalciferol
vitamin d-1000
vitamin d
vitamin d
VITAMIN D3 400
vitamin d3
vitamin d3
Vitamin K Activity
MEPHYTON
TABS
TABS
CAPS
CAPS
CAPS
TABS
TABS
1
1
1
1
1
1
1
CAPS
1
TABS
SOLN
TABS
TBCR
TABS
TABS
TABS
TABS
TBCR
TABS
1
1
1
1
1
1
1
1
1
1
TABS
CHEW
TABS
1
1
1
CAPS
SOLN
CHEW
CAPS
CAPS
TABS
CAPS
TABS
CAPS
CAPS
TABS
1
2
1
1
2
1
1
1
1
1
1
TABS
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
QL
ST

Similar documents

2016 Drug Formulary for Qualified Health Plans

2016 Drug Formulary for Qualified Health Plans Our drug formulary applies to drugs used in an outpatient setting. It does not include medication administered in the doctor’s office or while in the hospital. These are known as medical drugs. Not...

More information