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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 [email protected] 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 [email protected]. 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
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