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HPSJ Medi-Cal Formulary
HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 1 of 119 May 2015 THERAPUTIC CATEGORY Allergy DRUG CLASS: 1St Gen Antihistamine & Decongestant Combinations Brand Name Generic Name Formulation Strength Promethazine Vc Phenylephrine Hcl/Prometh Hcl Syrup 5‐6.25MG/5 Dimetapp Phenylephrine/Brompheniramine Solution 2.5‐1MG/5 Cardec Phenylephrine/Chlorpheniramine Drops 3.5‐1MG/ML CATEGORY Allergy PA S QL F AL P GL Restrictions (if applicable) Triaminic Cold & Allergy Pseudoephed/Chlorpheniramine Syrup 15‐1MG/5ML Wal‐Tap Pseudoephedrine/Brompheniramin Liquid 15‐1MG/5ML Allerfrim Pseudoephedrine/Triprolidine Syrup 30‐1.25/5 Genac Pseudoephedrine/Triprolidine Tablet 60MG‐2.5MG DRUG CLASS: 2Nd Gen Antihistamine & Decongestant Combinations Brand Name Generic Name Formulation Strength All Day Allergy‐D Cetirizine Hcl/Pseudoephedrine Tab Er 12H 5 MG‐120MG Allegra‐D 12 Hour Fexofenadine/Pseudoephedrine Tab Er 12H 60MG‐120MG Reserved for patients with treatment failure of both loratadine and cetirizine. Allegra‐D 24 Hour Fexofenadine/Pseudoephedrine Tab Er 24H 180‐240MG Reserved for patients with treatment failure of both loratadine and cetirizine. Allergy & Congestion Re Loratadine/Pseudoephedrine Tab Er 12H 5 MG‐120MG Tab Er 24H 10MG‐240MG Allergy‐Congestion Reli Loratadine/Pseudoephedrine DRUG CLASS: Adrenergic Agents,Catecholamines Brand Name Generic Name Formulation Strength Epinephrine Epinephrine Ampul 1 MG/ML(1) Adrenalin Chloride Epinephrine Vial 1 MG/ML(1) DRUG CLASS: Antihistamines ‐ 1St Generation Brand Name Generic Name Formulation Strength Ed Chlorped Jr Chlorpheniramine Maleate Syrup 2 MG/5 ML Chlor‐Trimeton Chlorpheniramine Maleate Tablet 4 MG Chlor‐Trimeton Allergy Chlorpheniramine Maleate Tablet Er 12 MG Clemastine Fumarate Clemastine Fumarate Syrup 0.67MG/5ML Tavist‐1 Clemastine Fumarate Tablet 1.34 MG Clemastine Fumarate Clemastine Fumarate Tablet 2.68 MG Cyproheptadine Hcl Cyproheptadine Hcl Syrup 4 MG/10 ML Cyproheptadine Hcl Cyproheptadine Hcl Tablet 4 MG Benadryl Diphenhydramine Hcl Capsule 25 MG Diphenhydramine Hcl Diphenhydramine Hcl Capsule 50 MG Diphenhydramine Hcl Diphenhydramine Hcl Elixir 12.5MG/5ML Benadryl Allergy Diphenhydramine Hcl Liquid 12.5MG/5ML Quenalin Diphenhydramine Hcl Syrup 12.5MG/5ML Benadryl Diphenhydramine Hcl Tab Chew 12.5 MG Children'S Allergy Relief Diphenhydramine Hcl Tab Rapdis 12.5 MG Benadryl Allergy Diphenhydramine Hcl Tablet 25 MG Diphenhist Diphenhydramine Hcl Tablet 50 MG CATEGORY Allergy PA S QL F AL P GL Restrictions (if applicable) CATEGORY Allergy PA S QL F AL P GL Restrictions (if applicable) CATEGORY Allergy PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 2 of 119 May 2015 Diphenhydramine Hcl Diphenhydramine Hcl Vial 50 MG/ML Hydroxyzine Hcl Hydroxyzine Hcl Syrup 10 MG/5 ML Hydroxyzine Hcl Hydroxyzine Hcl Tablet 10 MG Hydroxyzine Hcl Hydroxyzine Hcl Tablet 25 MG Hydroxyzine Hcl Hydroxyzine Hcl Tablet 50 MG Hydroxyzine Pamoate Hydroxyzine Pamoate Capsule 100 MG Vistaril Hydroxyzine Pamoate Capsule 25 MG Vistaril Hydroxyzine Pamoate Capsule 50 MG Promethazine Hcl Promethazine Hcl Syrup 6.25MG/5ML Promethazine Hcl Promethazine Hcl Tablet 12.5 MG Promethazine Hcl Promethazine Hcl Tablet 25 MG Tablet 50 MG Promethazine Hcl Promethazine Hcl DRUG CLASS: Antihistamines ‐ 2Nd Generation Brand Name Generic Name Formulation Strength Zyrtec Cetirizine Hcl Solution 1 MG/ML Cetirizine Hcl Cetirizine Hcl Solution 5 MG/5 ML Aller‐Tec Cetirizine Hcl Tablet 10 MG Cetirizine Hcl Cetirizine Hcl Tablet 5 MG Allegra Fexofenadine Hcl Oral Susp 30 MG/5 ML Reserved for patients with treatment failure of both loratadine and cetirizine. Allegra Odt Fexofenadine Hcl Tab Rapdis 30 MG Reserved for patients with treatment failure of both loratadine and cetirizine. Allegra Fexofenadine Hcl Tablet 180 MG Reserved for patients with treatment failure of both loratadine and cetirizine. Fexofenadine Hcl Fexofenadine Hcl Tablet 30 MG Reserved for patients with treatment failure of both loratadine and cetirizine. Allegra Fexofenadine Hcl Tablet 60 MG Reserved for patients with treatment failure of both loratadine and cetirizine. Wal‐Itin Loratadine Solution 5 MG/5 ML Tavist Nd Loratadine Tablet 10 MG DRUG CLASS: Histamine H2‐Receptor Inhibitors Brand Name Generic Name Formulation Strength Heartburn Relief Cimetidine Tablet 200 MG Cimetidine Cimetidine Tablet 300 MG Cimetidine Cimetidine Tablet 400 MG Cimetidine Cimetidine Tablet 800 MG Cimetidine Cimetidine Hcl Solution 300 MG/5ML Pepcid Famotidine Tablet 20 MG Pepcid Famotidine Tablet 40 MG Zantac Ranitidine Hcl Capsule 150 MG Ranitidine Hcl Ranitidine Hcl Capsule 300 MG Ranitidine Hcl Ranitidine Hcl Syrup 15 MG/ML CATEGORY Allergy PA S QL F AL P GL Restrictions (if applicable) CATEGORY Allergy PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 3 of 119 May 2015 Acid Reducer Ranitidine Hcl Tablet 150 MG Ranitidine Hcl Ranitidine Hcl Tablet 300 MG Acid Reducer Ranitidine Hcl Tablet 75 MG DRUG CLASS: Nasal Antihistamine Brand Name Generic Name Formulation Strength Astelin Azelastine Hcl Spray/Pump 137 MCG DRUG CLASS: Nasal Anti‐Inflammatory Steroids Brand Name Generic Name Formulation Strength Beconase Aq Beclomethasone Dipropionate Spray 42MCG St to 2 of the following: fluticasone, flunisolide, or nasacort otc Rhinocort Aqua Budesonide Spray/Pump 32MCG Rhinocort: 3rd line behind flonase and nasacort Rhinocort Aqua Budesonide Spray/Pump 32MCG Rhinocort: 3rd line behind flonase and nasacort Flunisolide Flunisolide Spray 25 MCG Flonase Fluticasone Propionate Spray Susp 50 MCG Nasonex Mometasone Furoate Spray/Pump 50 MCG Nasacort OTC Triamcinolone Acetonide Spray 55 MCG CATEGORY Allergy PA S QL F AL P GL Restrictions (if applicable) Step therapy to failure of an adequate trial of fluticasone or flunisolide nasal spray. CATEGORY Allergy PA S QL F AL P GL Restrictions (if applicable) Nasonex: 3rd line behind flonase and nasacort aq CATEGORY Allergy DRUG CLASS: Nasal Mast Cell Stabilizers Agents Brand Name Generic Name Formulation Strength Spray/Pump 5.2 MG Nasalcrom Cromolyn Sodium DRUG CLASS: Nose Preparations, Vasoconstrictors (Rx) Brand Name Generic Name Formulation Strength Adrenalin Chloride Epinephrine Hcl Solution 0.73611111111 DRUG CLASS: Nose Preparations, Vasoconstrictors(Otc) Brand Name Generic Name Formulation Strength Afrin Oxymetazoline Hcl Spray 0.0005 Little Noses Phenylephrine Hcl Drops 0.00125 Neo‐Synephrine Phenylephrine Hcl Drops 0.01 Neo‐Synephrine Phenylephrine Hcl Spray 0.0025 Neo‐Synephrine Phenylephrine Hcl Spray 0.005 Neo‐Synephrine Phenylephrine Hcl Spray 0.01 PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Allergy AL P GL Restrictions (if applicable) CATEGORY Allergy PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 4 of 119 May 2015 THERAPUTIC CATEGORY Cardiology, Anticoagulation CATEGORY Cardiology, Anticoagulation DRUG CLASS: Direct Factor Xa Inhibitors Brand Name Generic Name Formulation Strength Eliquis Apixaban Tablet 2.5 MG For afib: reserved for patients with non‐valvular afib with chads2 score >2. for dvt/pe: reserved for treatment failure/intolerance to warfarin for 2 months. for dvt/pe prevention: reserved for documented post‐hip/knee replacement. Eliquis Apixaban Tablet 5 MG For afib: reserved for patients with non‐valvular afib with chads2 score >2. for dvt/pe: reserved for treatment failure/intolerance to warfarin for 2 months. for dvt/pe prevention: reserved for documented post‐hip/knee replacement. Xarelto Rivaroxaban Tablet 10 MG For afib: reserved for patients with non‐valvular afib with chads2 score >2. for dvt/pe: reserved for treatment failure/intolerance to warfarin for 2 months. for dvt/pe prevention: reserved for documented post‐hip/knee replacement. Xarelto Rivaroxaban Tablet 15 MG For afib: reserved for patients with non‐valvular afib with chads2 score >2. for dvt/pe: reserved for treatment failure/intolerance to warfarin for 2 months. for dvt/pe prevention: reserved for documented post‐hip/knee replacement. Xarelto Rivaroxaban Tablet 20 MG For afib: reserved for patients with non‐valvular afib with chads2 score >2. for dvt/pe: reserved for treatment failure/intolerance to warfarin for 2 months. for dvt/pe prevention: reserved for documented post‐hip/knee replacement. DRUG CLASS: Heparin And Related Preparations Brand Name Generic Name Formulation Strength Lovenox Enoxaparin Sodium Syringe 100 MG/ML No pa is required if <= 10 days supply as bridge therapy. maximum of 2 syringes per day, 3 courses per 180 days. for longer duration, please fax prior auth to hpsj at (209)942‐6302 Lovenox Enoxaparin Sodium Syringe 120MG/.8ML No pa is required if <= 10 days supply as bridge therapy. maximum of 2 syringes per day, 3 courses per 180 days. for longer duration, please fax prior auth to hpsj at (209)942‐6302 Lovenox Enoxaparin Sodium Syringe 150 MG/ML No pa is required if <= 10 days supply as bridge therapy. maximum of 2 syringes per day, 3 courses per 180 days. for longer duration, please fax prior auth to hpsj at (209)942‐6302 Lovenox Enoxaparin Sodium Syringe 30MG/0.3ML No pa is required if <= 10 days supply as bridge therapy. maximum of 2 syringes per day, 3 courses per 180 days. for longer duration, please fax prior auth to hpsj at (209)942‐6302 Lovenox Enoxaparin Sodium Syringe 40MG/0.4ML No pa is required if <= 10 days supply as bridge therapy. maximum of 2 syringes per day, 3 courses per 180 days. for longer duration, please fax prior auth to hpsj at (209)942‐6302 Lovenox Enoxaparin Sodium Syringe 60MG/0.6ML No pa is required if <= 10 days supply as bridge therapy. maximum of 2 syringes per day, 3 courses per 180 days. for longer duration, please fax prior auth to hpsj at (209)942‐6302 PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Anticoagulation PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 5 of 119 May 2015 Lovenox Enoxaparin Sodium Syringe 80MG/0.8ML Heparin Flush Heparin Sod,Porcine‐0.9 % Nacl Kit 10 UNIT/ML Heparin Lock Heparin Sodium,Porcine Syringe 10 UNIT/ML Heparin Lock Heparin Sodium,Porcine Syringe 100/ML (1) Heparin Lock Heparin Sodium,Porcine Vial 10 UNIT/ML Heparin Lock Heparin Sodium,Porcine Vial 100/ML Heparin Sodium Heparin Sodium,Porcine Vial 1000/ML Heparin Sodium Heparin Sodium,Porcine Vial 10000/ML Heparin Sodium Heparin Sodium,Porcine Vial 20000/ML Heparin Sodium Heparin Sodium,Porcine Vial 5000/ML Heparin Flush Heparin Sodium,Porcine/Pf Syringe 10 UNIT/ML Heparin Flush Heparin Sodium,Porcine/Pf Syringe 100/ML (1) Heparin Flush Heparin Sodium,Porcine/Pf Syringe 200/2 ML Hep‐Lock Heparin Sodium,Porcine/Pf Vial 10 UNIT/ML Hep‐Lock Heparin Sodium,Porcine/Pf Vial 100/ML (1) DRUG CLASS: Oral Anticoagulants,Coumarin Type Brand Name Generic Name Formulation Strength Coumadin Warfarin Sodium Tablet 1 MG Coumadin Warfarin Sodium Tablet 10 MG Coumadin Warfarin Sodium Tablet 2 MG Coumadin Warfarin Sodium Tablet 2.5 MG Coumadin Warfarin Sodium Tablet 3 MG Coumadin Warfarin Sodium Tablet 4 MG Coumadin Warfarin Sodium Tablet 5 MG Coumadin Warfarin Sodium Tablet 6 MG Tablet 7.5 MG No pa is required if <= 10 days supply as bridge therapy. maximum of 2 syringes per day, 3 courses per 180 days. for longer duration, please fax prior auth to hpsj at (209)942‐6302 CATEGORY Cardiology, Anticoagulation PA S QL F PA S QL F AL P GL Restrictions (if applicable) Coumadin Warfarin Sodium DRUG CLASS: Platelet Aggregation Inhibitors Brand Name Generic Name Formulation Strength Aggrenox Aspirin/Dipyridamole Cpmp 12Hr 25MG‐200MG Cilostazol Cilostazol Tablet 100 MG Cilostazol Cilostazol Tablet 50 MG Clopidogrel Clopidogrel Bisulfate Tablet 75 MG Dipyridamole Dipyridamole Tablet 25 MG Dipyridamole Dipyridamole Tablet 50 MG Dipyridamole Dipyridamole Tablet 75 MG Effient Prasugrel Hcl Tablet 10 MG Reserved for patients status post stent placement or medical management of acute coronary syndrome for patients intolerant to plavix (clopidogrel) Effient Prasugrel Hcl Tablet 5 MG Reserved for patients status post stent placement or medical management of acute coronary syndrome for patients intolerant to plavix (clopidogrel) Effient Prasugrel Hcl Tablet 5 MG Reserved for patients status post stent placement or medical management of acute coronary syndrome for patients intolerant to plavix (clopidogrel) CATEGORY Cardiology, Anticoagulation AL P GL Restrictions (if applicable) Restricted to secondary cva prevention. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 6 of 119 May 2015 Brilinta Ticagrelor Tablet 90 MG DRUG CLASS: Thrombin Inhibitors,Selective,Direct, & Reversible Brand Name Generic Name Formulation Strength Pradaxa Dabigatran Etexilate Mesylate Capsule 150 MG Reserved for treatment failure or intolerance to clopidogrel. total asprin dose should not exceed 100mg/day concurrently. CATEGORY Cardiology, Anticoagulation PA S QL F AL P GL Restrictions (if applicable) For afib: reserved for patients with non‐valvular afib with chads2 score >2. for dvt/pe: reserved for treatment failure/intolerance to warfarin for 2 months. CATEGORY Cardiology, Anticoagulation DRUG CLASS: Thrombolytic Enzymes Brand Name Generic Name Formulation Strength Activase Alteplase Vial 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Activase Alteplase Vial 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Thrombopoietin Receptor Agonists Brand Name Generic Name Formulation Strength Promacta Eltrombopag Olamine Tablet 25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Promacta Eltrombopag Olamine Tablet 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Nplate Romiplostim Vial 250 MCG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Nplate Romiplostim Vial 500 MCG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Anticoagulation PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 7 of 119 May 2015 THERAPUTIC CATEGORY Cardiology, Hypertension DRUG CLASS: Ace Inhibitor/Thiazide & Thiazide‐Like Diuretic Brand Name Generic Name Formulation Strength Lotensin Hct Benazepril/Hydrochlorothiazide Tablet 10‐12.5MG Lotensin Hct Benazepril/Hydrochlorothiazide Tablet 20‐12.5 MG Lotensin Hct Benazepril/Hydrochlorothiazide Tablet 20‐25MG Lotensin Hct Benazepril/Hydrochlorothiazide Tablet 5‐6.25MG Captopril‐Hydrochlorot Captopril/Hydrochlorothiazide Tablet 25 MG‐15MG Captopril‐Hydrochlorot Captopril/Hydrochlorothiazide Tablet 25 MG‐25MG Captopril‐Hydrochlorot Captopril/Hydrochlorothiazide Tablet 50 MG‐15MG Captopril‐Hydrochlorot Captopril/Hydrochlorothiazide Tablet 50 MG‐25MG Enalapril‐Hydrochloroth Enalapril/Hydrochlorothiazide Tablet 10 MG‐25MG Enalapril‐Hydrochloroth Enalapril/Hydrochlorothiazide Tablet 5MG‐12.5MG Prinzide Lisinopril/Hydrochlorothiazide Tablet 10‐12.5MG Prinzide Lisinopril/Hydrochlorothiazide Tablet 20‐12.5 MG Lisinopril‐Hctz Lisinopril/Hydrochlorothiazide Tablet 20‐25MG CATEGORY Cardiology, Hypertension PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Hypertension DRUG CLASS: Alpha/Beta‐Adrenergic Blocking Agents Brand Name Generic Name Formulation Strength Coreg Carvedilol Tablet 12.5 MG Restricted to 2 tablets per day. Coreg Carvedilol Tablet 25 MG Restricted to 4 tablets per day. Coreg Carvedilol Tablet 3.125 MG Restricted to 2 tablets per day. Coreg Carvedilol Tablet 6.25 MG Restricted to 2 tablets per day. Labetalol Hcl Labetalol Hcl Tablet 100 MG Labetalol Hcl Labetalol Hcl Tablet 200 MG Labetalol Hcl Labetalol Hcl Tablet 300 MG DRUG CLASS: Alpha‐Adrenergic Blocking Agents Brand Name Generic Name Formulation Strength Cardura Doxazosin Mesylate Tablet 1 MG Cardura Doxazosin Mesylate Tablet 2 MG Cardura Doxazosin Mesylate Tablet 4 MG Cardura Doxazosin Mesylate Tablet 8 MG Minipress Prazosin Hcl Capsule 1 MG Minipress Prazosin Hcl Capsule 2 MG Minipress Prazosin Hcl Capsule 5 MG Terazosin Hcl Terazosin Hcl Capsule 1 MG Terazosin Hcl Terazosin Hcl Capsule 10 MG Hytrin Terazosin Hcl Capsule 2 MG Terazosin Hcl Terazosin Hcl Capsule 5 MG AL P GL Restrictions (if applicable) CATEGORY Cardiology, Hypertension PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 8 of 119 May 2015 CATEGORY Cardiology, Hypertension DRUG CLASS: Angiotensin Receptr Antg./Thiazide & Related Comb. Brand Name Generic Name Hyzaar Losartan/Hydrochlorothiazide Tablet 100‐12.5MG Hyzaar Losartan/Hydrochlorothiazide Tablet 100MG‐25MG Hyzaar Losartan/Hydrochlorothiazide Tablet 50‐12.5 MG Diovan Hct Valsartan/Hydrochlorothiazide Tablet 160‐12.5MG Reserved for heart failure patients intolerant of ace inhbiitors. Diovan Hct Valsartan/Hydrochlorothiazide Tablet 160‐25MG Reserved for heart failure patients intolerant of ace inhbiitors. Diovan Hct Valsartan/Hydrochlorothiazide Tablet 320‐12.5MG Reserved for heart failure patients intolerant of ace inhbiitors. Diovan Hct Valsartan/Hydrochlorothiazide Tablet 320MG‐25MG Reserved for heart failure patients intolerant of ace inhbiitors. Diovan Hct Valsartan/Hydrochlorothiazide Tablet 80‐12.5MG Reserved for heart failure patients intolerant of ace inhbiitors. Formulation Strength PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Hypertension DRUG CLASS: Beta‐Adrenergic Blocking Agents Brand Name Generic Name Formulation Strength Atenolol Atenolol Tablet 100 MG Atenolol Atenolol Tablet 25 MG Atenolol Atenolol Tablet 50 MG Kerlone Betaxolol Hcl Tablet 10 MG Kerlone Betaxolol Hcl Tablet 20 MG Bisoprolol Fumarate Bisoprolol Fumarate Tablet 10 MG Bisoprolol Fumarate Bisoprolol Fumarate Tablet 5 MG Metoprolol Succinate Metoprolol Succinate Tab Er 24H 100 MG Metoprolol Succinate Metoprolol Succinate Tab Er 24H 200 MG Metoprolol Succinate Metoprolol Succinate Tab Er 24H 25 MG Metoprolol Succinate Metoprolol Succinate Tab Er 24H 50 MG Lopressor Metoprolol Tartrate Tablet 100 MG Metoprolol Tartrate Metoprolol Tartrate Tablet 25 MG Lopressor Metoprolol Tartrate Tablet 50 MG Nadolol Nadolol Tablet 20 MG Nadolol Nadolol Tablet 40 MG Nadolol Nadolol Tablet 80 MG Bystolic Nebivolol Hcl Tablet 10 MG Reserved for intolerance or treatment failure of dose optimized metoprolol and carvedilol. restricted to 1 tablet per day Bystolic Nebivolol Hcl Tablet 2.5 MG Reserved for intolerance or treatment failure of dose optimized metoprolol and carvedilol. restricted to 1 tablet per day Bystolic Nebivolol Hcl Tablet 20 MG Reserved for intolerance or treatment failure of dose optimized metoprolol and carvedilol. restricted to 1 tablet per day Bystolic Nebivolol Hcl Tablet 5 MG Reserved for intolerance or treatment failure of dose optimized metoprolol and carvedilol. restricted to 1 tablet per day Pindolol Pindolol Tablet 10 MG Pindolol Pindolol Tablet 5 MG PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 9 of 119 May 2015 Innopran Xl Propranolol Hcl Cap Er 24H 120 MG Innopran Xl Propranolol Hcl Cap Er 24H 80 MG Inderal La Propranolol Hcl Cap Sa 24H 120 MG Inderal La Propranolol Hcl Cap Sa 24H 160 MG Propranolol Hcl Propranolol Hcl Cap Sa 24H 60 MG Inderal La Propranolol Hcl Cap Sa 24H 80 MG Propranolol Hcl Propranolol Hcl Solution 20 MG/5 ML Propranolol Hcl Propranolol Hcl Solution 40MG/5ML Propranolol Hcl Propranolol Hcl Tablet 10 MG Propranolol Hcl Propranolol Hcl Tablet 20 MG Propranolol Hcl Propranolol Hcl Tablet 40 MG Propranolol Hcl Propranolol Hcl Tablet 60 MG Propranolol Hcl Propranolol Hcl Tablet 80 MG Sotalol Sotalol Hcl Tablet 120 MG Sotalol Sotalol Hcl Tablet 160 MG Sotalol Sotalol Hcl Tablet 240 MG Sotalol Sotalol Hcl Tablet 80 MG Timolol Maleate Timolol Maleate Tablet 10 MG Timolol Maleate Timolol Maleate Tablet 20 MG Timolol Maleate Timolol Maleate Tablet 5 MG DRUG CLASS: Beta‐Adrenergic Blocking Agents/Thiazide & Related Brand Name Generic Name Formulation Strength Tenoretic 100 Atenolol/Chlorthalidone Tablet 100MG‐25MG Tenoretic 50 Atenolol/Chlorthalidone Tablet 50 MG‐25MG CATEGORY Cardiology, Hypertension PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Hypertension DRUG CLASS: Calcium Channel Blocking Agents Brand Name Generic Name Formulation Strength Amlodipine Besylate Amlodipine Besylate Tablet 10 MG Restricted to 1 tablet per day. Amlodipine Besylate Amlodipine Besylate Tablet 2.5 MG Restricted to 1 tablet per day. Amlodipine Besylate Amlodipine Besylate Tablet 5 MG Restricted to 1 tablet per day. Diltiazem Er Diltiazem Hcl Cap Er 12H 120 MG Diltiazem Er Diltiazem Hcl Cap Er 12H 60 MG Diltiazem Er Diltiazem Hcl Cap Er 12H 90 MG Diltiazem 24Hr Er Diltiazem Hcl Cap Er 24H 120 MG Diltiazem 24Hr Er Diltiazem Hcl Cap Er 24H 180 MG Diltiazem 24Hr Er Diltiazem Hcl Cap Er 24H 240 MG Diltiazem 24Hr Er Diltiazem Hcl Cap Er 24H 300 MG Cardizem Cd Diltiazem Hcl Cap Er 24H 360 MG Diltiazem Er Diltiazem Hcl Cap Er Deg 120 MG Diltiazem Er Diltiazem Hcl Cap Er Deg 180 MG Diltiazem Er Diltiazem Hcl Cap Er Deg 240 MG Diltiazem Er Diltiazem Hcl Capsule Er 120 MG Diltiazem Er Diltiazem Hcl Capsule Er 180 MG Diltiazem Er Diltiazem Hcl Capsule Er 240 MG AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 10 of 119 May 2015 Diltiazem Er Diltiazem Hcl Capsule Er 300 MG Diltiazem Er Diltiazem Hcl Capsule Er 360 MG Diltiazem Er Diltiazem Hcl Capsule Er 420MG Cardizem La Diltiazem Hcl Tab Er 24H 120 MG Cardizem La Diltiazem Hcl Tab Er 24H 180 MG Cardizem La Diltiazem Hcl Tab Er 24H 240 MG Cardizem La Diltiazem Hcl Tab Er 24H 300 MG Cardizem La Diltiazem Hcl Tab Er 24H 360 MG Cardizem La Diltiazem Hcl Tab Er 24H 420MG Diltiazem Hcl Diltiazem Hcl Tablet 120 MG Diltiazem Hcl Diltiazem Hcl Tablet 30 MG Diltiazem Hcl Diltiazem Hcl Tablet 60 MG Diltiazem Hcl Diltiazem Hcl Tablet 90 MG Plendil Felodipine Tab Er 24H 10 MG Plendil Felodipine Tab Er 24H 2.5 MG Plendil Felodipine Tab Er 24H 5 MG Procardia Nifedipine Capsule 10 MG Nifedipine Nifedipine Capsule 20 MG Procardia Xl Nifedipine Tab Er 24 30 MG Procardia Xl Nifedipine Tab Er 24 60 MG Procardia Xl Nifedipine Tab Er 24 90 MG Adalat Cc Nifedipine Tablet Er 30 MG Adalat Cc Nifedipine Tablet Er 60 MG Adalat Cc Nifedipine Tablet Er 90 MG Verelan Pm Verapamil Hcl Cap24H Pct 100 MG Verelan Pm Verapamil Hcl Cap24H Pct 200 MG Verelan Pm Verapamil Hcl Cap24H Pct 300 MG Verelan Verapamil Hcl Cap24H Pel 120 MG Verelan Verapamil Hcl Cap24H Pel 180 MG Verelan Verapamil Hcl Cap24H Pel 240 MG Verelan Verapamil Hcl Cap24H Pel 360 MG Calan Verapamil Hcl Tablet 120 MG Calan Verapamil Hcl Tablet 40 MG Calan Verapamil Hcl Tablet 80 MG Calan Sr Verapamil Hcl Tablet Er 120 MG Calan Sr Verapamil Hcl Tablet Er 180 MG Calan Sr Verapamil Hcl Tablet Er 240 MG DRUG CLASS: Hypotensives, Ace Inhibitors Brand Name Generic Name Formulation Strength Lotensin Benazepril Hcl Tablet 10 MG Lotensin Benazepril Hcl Tablet 20 MG Lotensin Benazepril Hcl Tablet 40 MG Lotensin Benazepril Hcl Tablet 5 MG Captopril Captopril Tablet 100 MG Captopril Captopril Tablet 12.5 MG Captopril Captopril Tablet 25 MG Captopril Captopril Tablet 50 MG Enalapril Maleate Enalapril Maleate Tablet 10 MG CATEGORY Cardiology, Hypertension PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 11 of 119 May 2015 Enalapril Maleate Enalapril Maleate Tablet 2.5 MG Enalapril Maleate Enalapril Maleate Tablet 20 MG Enalapril Maleate Enalapril Maleate Tablet 5 MG Prinivil Lisinopril Tablet 10 MG Lisinopril Lisinopril Tablet 2.5 MG Prinivil Lisinopril Tablet 20 MG Lisinopril Lisinopril Tablet 30 MG Lisinopril Lisinopril Tablet 40 MG Prinivil Lisinopril Tablet 5 MG Accupril Quinapril Hcl Tablet 10 MG Accupril Quinapril Hcl Tablet 20 MG Accupril Quinapril Hcl Tablet 40 MG Accupril Quinapril Hcl Tablet 5 MG Ramipril Ramipril Capsule 1.25 MG Restricted to 1 capsule per day. Ramipril Ramipril Capsule 10 MG Restricted to 2 capsules per day. Ramipril Ramipril Capsule 2.5 MG Restricted to 1 capsule per day. Ramipril Ramipril Capsule 5 MG Restricted to 1 capsule per day. CATEGORY Cardiology, Hypertension DRUG CLASS: Hypotensives,Angiotensin Receptor Antagonist Brand Name Generic Name Formulation Strength Avapro Irbesartan Tablet 150 MG Restricted to 1 tablet per day Avapro Irbesartan Tablet 300 MG Restricted to 1 tablet per day Avapro Irbesartan Tablet 75 MG Restricted to 1 tablet per day Cozaar Losartan Potassium Tablet 100 MG Cozaar Losartan Potassium Tablet 25 MG Cozaar Losartan Potassium Tablet 50 MG Diovan Valsartan Tablet 160 MG Reserved for heart failure patients intolerant of ace inhbiitors. Diovan Valsartan Tablet 320 MG Reserved for heart failure patients intolerant of ace inhbiitors. Diovan Valsartan Tablet 40 MG Reserved for heart failure patients intolerant of ace inhbiitors. Diovan Valsartan Tablet 80 MG Reserved for heart failure patients intolerant of ace inhbiitors. PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Hypertension DRUG CLASS: Hypotensives,Sympatholytic Brand Name Generic Name Formulation Strength Clonidine Clonidine Patch Tdwk 0.1MG/24HR PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 12 of 119 May 2015 Clonidine Clonidine Patch Tdwk 0.2MG/24HR Clonidine Clonidine Patch Tdwk 0.3MG/24HR Clonidine Hcl Clonidine Hcl Tablet 0.1 MG Clonidine Hcl Clonidine Hcl Tablet 0.2 MG Clonidine Hcl Clonidine Hcl Tablet 0.3 MG Guanfacine Hcl Guanfacine Hcl Tablet 1 MG Guanfacine Hcl Guanfacine Hcl Tablet 2 MG Methyldopa Methyldopa Tablet 250 MG Methyldopa Methyldopa Tablet 500 MG Methyldopa‐Hydrochlor Methyldopa/Hydrochlorothiazide Tablet 250MG‐15MG Methyldopa‐Hydrochlor Methyldopa/Hydrochlorothiazide Tablet 250MG‐25MG Formulation Strength CATEGORY Cardiology, Hypertension DRUG CLASS: Hypotensives,Vasodilators Brand Name Generic Name Hydralazine Hcl Hydralazine Hcl Tablet 10 MG Hydralazine Hcl Hydralazine Hcl Tablet 100 MG Hydralazine Hcl Hydralazine Hcl Tablet 25 MG Hydralazine Hcl Hydralazine Hcl Tablet 50 MG Minoxidil Minoxidil Tablet 10 MG Tablet 2.5 MG Minoxidil Minoxidil DRUG CLASS: Potassium Sparing Diuretics Brand Name Generic Name Formulation Strength Aldactone Spironolactone Tablet 100 MG Aldactone Spironolactone Tablet 25 MG Aldactone Spironolactone Tablet 50 MG Dyrenium Triamterene Capsule 100 MG Capsule 50 MG PA S QL F PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Hypertension AL P GL Restrictions (if applicable) Dyrenium Triamterene DRUG CLASS: Renin Inhibitor, Direct Brand Name Generic Name Formulation Strength Tekturna Aliskiren Hemifumarate Tablet 150 MG Step therapy to treatment failure of at least 3 formulary antihypertensives, including a thiazide, acei/arb and beta‐ blocker/calcium channel blocker Tekturna Aliskiren Hemifumarate Tablet 300 MG Step therapy to treatment failure of at least 3 formulary antihypertensives, including a thiazide, acei/arb and beta‐ blocker/calcium channel blocker CATEGORY Cardiology, Hypertension AL P GL Restrictions (if applicable) CATEGORY Cardiology, Hypertension DRUG CLASS: Thiazide And Related Diuretics Brand Name Generic Name Formulation Strength Chlorthalidone Chlorthalidone Tablet 25 MG Restricted to 1 tablet per day. Chlorthalidone Chlorthalidone Tablet 50 MG Restricted to 1 tablet per day. Hydrochlorothiazide Hydrochlorothiazide Capsule 12.5 MG Hydrochlorothiazide Hydrochlorothiazide Tablet 12.5 MG Hydrochlorothiazide Hydrochlorothiazide Tablet 25 MG Hydrochlorothiazide Hydrochlorothiazide Tablet 50 MG Metolazone Metolazone Tablet 10 MG Metolazone Metolazone Tablet 2.5 MG PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 13 of 119 May 2015 Metolazone Metolazone DRUG CLASS: Vasodilators,Coronary Tablet 5 MG Brand Name Generic Name Formulation Strength Dilatrate‐Sr Isosorbide Dinitrate Isosorbide Dinitrate Capsule Er 40 MG Isosorbide Dinitrate Tablet 10 MG Isosorbide Dinitrate Isosorbide Dinitrate Tablet 20 MG Isosorbide Dinitrate Isosorbide Dinitrate Tablet 30 MG Isordil Isosorbide Dinitrate Tablet 40 MG Isordil Isosorbide Dinitrate Tablet 5 MG Isosorbide Dinitrate Isosorbide Dinitrate Tablet Er 40 MG Imdur Isosorbide Mononitrate Tab Er 24H 120 MG Imdur Isosorbide Mononitrate Tab Er 24H 30 MG Imdur Isosorbide Mononitrate Tab Er 24H 60 MG Monoket Isosorbide Mononitrate Tablet 10 MG Monoket Isosorbide Mononitrate Tablet 20 MG Nitroglycerin Nitroglycerin Capsule Er 2.5 MG Nitroglycerin Nitroglycerin Capsule Er 6.5 MG Nitroglycerin Nitroglycerin Capsule Er 9 MG Nitro‐Bid Nitroglycerin Oint. (G) 0.02 Nitro‐Dur Nitroglycerin Patch Td24 0.1MG/HR Nitro‐Dur Nitroglycerin Patch Td24 0.2MG/HR Nitro‐Dur Nitroglycerin Patch Td24 0.3 MG/HR Nitro‐Dur Nitroglycerin Patch Td24 0.4MG/HR Nitro‐Dur Nitroglycerin Patch Td24 0.6MG/HR Nitro‐Dur Nitroglycerin Patch Td24 0.8MG/HR Nitrolingual Nitroglycerin Spray 400MCG/SPR Nitrostat Nitroglycerin Tab Subl 0.3 MG Nitrostat Nitroglycerin Tab Subl 0.4 MG Nitrostat Nitroglycerin Tab Subl 0.6 MG CATEGORY Cardiology, Hypertension PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Hypertension DRUG CLASS: Vasodilators,Peripheral Brand Name Generic Name Formulation Strength Ergoloid Mesylates Ergoloid Mesylates Tablet 1 MG AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 14 of 119 May 2015 THERAPUTIC CATEGORY Cardiology, Lipotropics CATEGORY Cardiology, Lipotropics DRUG CLASS: Antihyperlip.Hmg Coa Reduct Inhib&Cholest.Ab.Inhib. Brand Name Generic Name Formulation Strength Vytorin Ezetimibe/Simvastatin Tablet 10 MG‐10MG Reserved for uncontrolled hyperlipidemia despite compliant Alernatives: of (or intolerance to) dose optimized atorvastatin (lipitor) and rosuvastatin (crestor). Vytorin Ezetimibe/Simvastatin Tablet 10 MG‐20MG Reserved for uncontrolled hyperlipidemia despite compliant Alernatives: of (or intolerance to) dose optimized atorvastatin (lipitor) and rosuvastatin (crestor). Vytorin Ezetimibe/Simvastatin Tablet 10 MG‐40MG Reserved for uncontrolled hyperlipidemia despite compliant Alernatives: of (or intolerance to) dose optimized atorvastatin (lipitor) and rosuvastatin (crestor). Vytorin Ezetimibe/Simvastatin Tablet 10 MG‐80MG Reserved for uncontrolled hyperlipidemia despite compliant Alernatives: of (or intolerance to) dose optimized atorvastatin (lipitor) and rosuvastatin (crestor). PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Lipotropics DRUG CLASS: Antihyperlipidemic‐Hmg‐Coa Reductase Inhibitors Brand Name Generic Name Formulation Strength Lipitor Atorvastatin Calcium Tablet 10 MG Restricted to 30 tablets per month Lipitor Atorvastatin Calcium Tablet 20 MG Restricted to 30 tablets per month Lipitor Atorvastatin Calcium Tablet 40 MG Restricted to 30 tablets per month Lipitor Atorvastatin Calcium Tablet 80 MG Restricted to 30 tablets per month Lovastatin Lovastatin Tablet 10 MG Restricted to 1 tablet per day. Mevacor Lovastatin Tablet 20 MG Restricted to 1 tablet per day. Mevacor Lovastatin Tablet 40 MG Restricted to 2 tablets per day. Pravachol Pravastatin Sodium Tablet 10 MG Restricted to 1 tablet per day. Pravachol Pravastatin Sodium Tablet 20 MG Restricted to 1 tablet per day. Pravachol Pravastatin Sodium Tablet 40 MG Restricted to 2 tablets per day. Pravachol Pravastatin Sodium Tablet 80 MG Restricted to 1 tablet per day. PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 15 of 119 May 2015 Crestor Rosuvastatin Calcium Tablet 10 MG Reserved for treatment failure of compliant Alernatives: of atorvastatin 40mg/day. tablet splitting required for 5, 10, and 20mg doses. (e.g. for 20mg dose, Alernatives: 40mg tablets, 1/2 tab daily) Crestor Rosuvastatin Calcium Tablet 20 MG Reserved for treatment failure of compliant Alernatives: of atorvastatin 40mg/day. tablet splitting required for 5, 10, and 20mg doses. (e.g. for 20mg dose, Alernatives: 40mg tablets, 1/2 tab daily) Crestor Rosuvastatin Calcium Tablet 40 MG Reserved for treatment failure of compliant Alernatives: of atorvastatin 40mg/day. tablet splitting required for 5, 10, and 20mg doses. (e.g. for 20mg dose, Alernatives: 40mg tablets, 1/2 tab daily) Crestor Rosuvastatin Calcium Tablet 5 MG Reserved for treatment failure of compliant Alernatives: of atorvastatin 40mg/day. tablet splitting required for 5, 10, and 20mg doses. (e.g. for 20mg dose, Alernatives: 40mg tablets, 1/2 tab daily) Zocor Simvastatin Tablet 10 MG Restricted to 1 tablet per day Zocor Simvastatin Tablet 20 MG Restricted to 1 tablet per day Zocor Simvastatin Tablet 40 MG Restricted to 1 tablet per day Zocor Simvastatin Tablet 5 MG Restricted to 1 tablet per day Zocor Simvastatin Tablet 80 MG Restricted to 1 tablet per day Formulation Strength 4 G CATEGORY Cardiology, Lipotropics DRUG CLASS: Bile Salt Sequestrants Brand Name Generic Name Cholestyramine Cholestyramine (With Sugar) Powd Pack Cholestyramine Cholestyramine (With Sugar) Powder 4 G Cholestyramine Light Cholestyramine/Aspartame Powd Pack 4 G Cholestyramine Light Cholestyramine/Aspartame Powder 4 G Welchol Colesevelam Hcl Tablet 625 MG DRUG CLASS: Lipotropics Brand Name Generic Name Formulation Strength Zetia Ezetimibe Tablet 10 MG Reserved for persistent elevated ldl despite compliant Alernatives: of medium dose of formulary statins Fenofibrate Fenofibrate Tablet 160 MG Step therapy to treatment with statin. only 54mg, 67mg, 134mg 160mg and 200mg are covered strengths. consider gemfibrozil in isolated hypertriglyceridemia. Fenofibrate Fenofibrate Tablet 54 MG Step therapy to treatment with statin. only 54mg, 67mg, 134mg 160mg and 200mg are covered strengths. consider gemfibrozil in isolated hypertriglyceridemia. Fenofibrate Fenofibrate,Micronized Capsule 134MG Step therapy to treatment with statin. only 54mg, 67mg, 134mg 160mg and 200mg are covered strengths. consider gemfibrozil in isolated hypertriglyceridemia. PA S QL F AL P GL Restrictions (if applicable) Reserved for patients who are intolerant to 2 formulary statins. CATEGORY Cardiology, Lipotropics PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 16 of 119 May 2015 Fenofibrate Fenofibrate,Micronized Capsule 200 MG Step therapy to treatment with statin. only 54mg, 67mg, 134mg 160mg and 200mg are covered strengths. consider gemfibrozil in isolated hypertriglyceridemia. Fenofibrate Fenofibrate,Micronized Capsule 67 MG Step therapy to treatment with statin. only 54mg, 67mg, 134mg 160mg and 200mg are covered strengths. consider gemfibrozil in isolated hypertriglyceridemia. Lopid Gemfibrozil Tablet 600 MG Niaspan Niacin Tab Er 24H 1000 MG Niaspan Niacin Tab Er 24H 500 MG Niaspan Niacin Tab Er 24H 750 MG Niacor Niacin Tablet 500 MG Omega‐3 Acid Ethyl Esters Omega‐3 Acid Ethyl Esters Capsule 1 G Reserved for patients with elevated triglycerides >500 mg/dl despite dose‐optimized treatment with both a statin and fenofibrate. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 17 of 119 May 2015 THERAPUTIC CATEGORY Cardiology, Other CATEGORY Cardiology, Other DRUG CLASS: Antianginal & Anti‐Ischemic Agents,Non‐Hemodynamic Brand Name Generic Name Formulation Strength Ranexa Ranolazine Tab Er 12H 1000 MG Step therapy to treatment failure or intolerance to 3 formulary alternatives including a beta‐blocker, calcium channel blocker and long‐acting nitrate. Ranexa Ranolazine Tab Er 12H 500 MG Step therapy to treatment failure or intolerance to 3 formulary alternatives including a beta‐blocker, calcium channel blocker and long‐acting nitrate. PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Other DRUG CLASS: Antiarrhythmics Brand Name Generic Name Formulation Strength Cordarone Amiodarone Hcl Tablet 200 MG Norpace Disopyramide Phosphate Capsule 100 MG Norpace Disopyramide Phosphate Capsule 150 MG Norpace Cr Disopyramide Phosphate Capsule Er 100 MG Norpace Cr Disopyramide Phosphate Capsule Er 150 MG Multaq Dronedarone Hcl Tablet 400 MG Flecainide Acetate Flecainide Acetate Tablet 100 MG Flecainide Acetate Flecainide Acetate Tablet 150 MG Flecainide Acetate Flecainide Acetate Tablet 50 MG Mexiletine Hcl Mexiletine Hcl Capsule 150 MG Mexiletine Hcl Mexiletine Hcl Capsule 200 MG Mexiletine Hcl Mexiletine Hcl Capsule 250 MG Rythmol Sr Propafenone Hcl Cap Er 12H 225 MG Rythmol Sr Propafenone Hcl Cap Er 12H 325 MG Rythmol Sr Propafenone Hcl Cap Er 12H 425 MG Rythmol Propafenone Hcl Tablet 150 MG Rythmol Propafenone Hcl Tablet 225 MG Propafenone Hcl Propafenone Hcl Tablet 300 MG Quinidine Gluconate Quinidine Gluconate Tablet Er 324 MG Quinidine Gluconate Quinidine Gluconate Vial 80 MG/ML Quinidine Sulfate Quinidine Sulfate Tablet 200 MG Quinidine Sulfate Quinidine Sulfate Tablet 300 MG Tablet Er 300 MG Formulation Strength Quinidine Sulfate Quinidine Sulfate DRUG CLASS: Digitalis Glycosides Brand Name Generic Name Digoxin Digoxin Solution 50 MCG/ML Digoxin Digoxin Tablet 125 MCG Digoxin Digoxin Tablet 250 MCG DRUG CLASS: Electrolyte Depleters Brand Name Generic Name Formulation Strength Calcium Acetate Calcium Acetate Capsule 667 MG Calcium Acetate Calcium Acetate Tablet 667 MG PA S QL F AL P GL Restrictions (if applicable) Reserved for patients <55yo or failure of amiodarone with high risk of lung/eye disease and without congestive heart failure CATEGORY Cardiology, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 18 of 119 May 2015 Fosrenol Lanthanum Carbonate Tab Chew 1000 MG Third line therapy for patients with treatment failure of calcium acetate and sevelamer. Fosrenol Lanthanum Carbonate Tab Chew 500 MG Third line therapy for patients with treatment failure of calcium acetate and sevelamer. Renvela Sevelamer Carbonate Powd Pack 0.8 G Second line after phoslo (calcium acetate), unless on dialysis, corrected serum calcium > 10.2 mg/dl, or evidence of soft tissue calcification Renvela Sevelamer Carbonate Powd Pack 2.4 G Second line after phoslo (calcium acetate), unless on dialysis, corrected serum calcium > 10.2 mg/dl, or evidence of soft tissue calcification Sevelamer Carbonate Sevelamer Carbonate Tablet 800 MG Second line after phoslo (calcium acetate), unless on dialysis, corrected serum calcium > 10.2 mg/dl, or evidence of soft tissue calcification Renagel Sevelamer Hcl Tablet 400 MG Second line after phoslo (calcium acetate), unless on dialysis, corrected serum calcium > 10.2 mg/dl, or evidence of soft tissue calcification Renagel Sevelamer Hcl Tablet 800 MG Second line after phoslo (calcium acetate), unless on dialysis, corrected serum calcium > 10.2 mg/dl, or evidence of soft tissue calcification Sodium Polystyrene Sulf Sodium Polystyrene Sulfonate Enema 30G/120ML Sodium Polystyrene Sulf Sodium Polystyrene Sulfonate Oral Susp 15 G/60 ML Kayexalate Sodium Polystyrene Sulfonate Powder DRUG CLASS: Electrolyte Maintenance Brand Name Generic Name Formulation Strength Pedialyte Electrolyte,Oral Solution CATEGORY Cardiology, Other PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Other DRUG CLASS: Folic Acid Preparations Brand Name Generic Name Formulation Strength Folic Acid Folic Acid Tablet 0.4 MG Folic Acid Folic Acid Tablet 1 MG DRUG CLASS: Hemorrheologic Agents Brand Name Generic Name Formulation Strength Trental Pentoxifylline Tablet Er 400 MG DRUG CLASS: Iron Replacement Brand Name Generic Name Formulation Strength Iron Ferrous Sulfate Capsule Er 325(65) MG Fer‐In‐Sol Ferrous Sulfate Drops 15 MG/ML Ferrous Sulfate Ferrous Sulfate Liquid 300 MG/5ML Ferrous Sulfate Ferrous Sulfate Solution 220(44)/5 Ferrous Sulfate Ferrous Sulfate Tablet 325(65) MG Ferrous Sulfate Ferrous Sulfate Tablet Dr 324(65)MG Ferrous Sulfate Ferrous Sulfate Tablet Dr 325(65) MG Venofer Iron Sucrose Complex Vial 100 MG/5ML DRUG CLASS: Loop Diuretics Brand Name Generic Name AL P GL Restrictions (if applicable) CATEGORY Cardiology, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Other PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. CATEGORY Cardiology, Other Formulation Strength PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 19 of 119 May 2015 Bumetanide Bumetanide Tablet 0.5 MG Bumetanide Bumetanide Tablet 1 MG Bumex Bumetanide Tablet 2 MG Edecrin Ethacrynic Acid Tablet 25 MG Furosemide Furosemide Solution 10 MG/ML Furosemide Furosemide Solution 40MG/5ML Lasix Furosemide Tablet 20 MG Lasix Furosemide Tablet 40 MG Lasix Furosemide Tablet 80 MG Demadex Torsemide Tablet 10 MG Demadex Torsemide Tablet 100 MG Demadex Torsemide Tablet 20 MG Demadex Torsemide Tablet 5 MG DRUG CLASS: Magnesium Salts Replacement Brand Name Generic Name Formulation Strength Magox Magnesium Oxide Tablet 400 MG DRUG CLASS: Medical Supplies,Miscellaneous Brand Name Generic Name Formulation Strength Blood Pressure Kit Blood Pressure Kit Liquid Limited to 1 per lifetime, submit pa for lost/broken Blood Pressure Monitor Kit Blood Pressure Monitor Kit Liquid Limited to 1 per lifetime, submit pa for lost/broken Blood Pressure Test Kit‐ Blood Pressure Test Kit‐Large Cuff Large Cuff Liquid Limited to 1 per lifetime, submit pa for lost/broken Condoms‐Prem Lubricated Condoms Liquid Limited to 24 per month Kimono Microthin Condoms Condoms Liquid Limited to 100 per 30 days Fora Normal Control Solution Control Solution Liquid Limited to 1 per year Fora D20 Kit Glucometer Liquid Reserved for patients in the diabetes disease management program Fora V30A Kit Glucometer Liquid Limit 1 per 3 years Test N'Go Blood Glucose System Glucometer Liquid Reserved for patients in the diabetes disease management program Bd Microtainer Lancet 3 Lancets/Lancing Device Liquid Comfort Ez Lancets 21 Gauge Lancets/Lancing Device Liquid E‐Z Ject Lancets 33 Gaug Lancets/Lancing Device Liquid Fora Lancing Device Lancets/Lancing Device Liquid Limited to 1 per lifetime, submit pa for lost/broken Foracare Lancets 30 Gauge Lancets/Lancing Device Liquid Limited to 100 per 30 days Freestyle Lancets 28 Ga Lancets/Lancing Device Liquid CATEGORY Cardiology, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Other PA S QL F AL P GL Restrictions (if applicable) Limited to 100 per 30 days RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 20 of 119 May 2015 Freestyle Unistik 2 Misc Lancets/Lancing Device Liquid Optichamber Adult Mask‐Large Mask/Spacer Liquid Limited to 2 per year Vortex Vhc Frog Mask‐ Child Mask/Spacer Liquid Limited to 2 per year Bubbles The Fish Pedi Mask Mask/Spacer Liquid Limited to 1 per lifetime, submit pa for lost/broken Optichamber Diamond‐ Mask/Spacer Lg Msk Device Liquid Limited to 2 per year Optichamber Diamond‐ Mask/Spacer Med Msk Device Liquid Limited to 2 per year Optichamber Diamond‐ Mask/Spacer Sml Msk Device Liquid Limited to 2 per year Vortex Holding Chamber Mask/Spacer Liquid Limited to 2 per year Vortex Holding Chamber With Child Mask Mask/Spacer Liquid Limited to 2 per year Vortex Holding Mask/Spacer Chamber With Toddler Mask Liquid Limited to 2 per year Personal Best Full Rang Peak Flow meter Liquid Peak Air Peak Flow Meter Peak Flow meter Liquid Bd Insulin Pen Needle U Pen Needles Liquid Sharps Container Sharps Container Liquid Limited to 1 per 30 days Tablet Cutter Misc Tablet Cutter Misc Liquid Limited to 1 per year Strength Limited to 1 per lifetime, submit pa for lost/broken CATEGORY Cardiology, Other DRUG CLASS: Niacin Preparations Brand Name Generic Name Formulation Niacin Niacin Capsule Er 500 MG Niacin Niacin Tablet 100 MG Niacin Niacin Tablet 250 MG Niacin Niacin Tablet 50 MG Niacin Niacin Tablet 500 MG Slo‐Niacin Niacin Tablet Er 250 MG Niacin Niacin Tablet Er 500 MG DRUG CLASS: Potassium Replacement Brand Name Generic Name Formulation Strength Potassium Chloride Potassium Chloride Capsule Er 10 MEQ Potassium Chloride Potassium Chloride Capsule Er 8 MEQ Potassium Chloride Potassium Chloride Liquid 20MEQ/15ML Potassium Chloride Potassium Chloride Liquid 40MEQ/15ML Klor‐Con Potassium Chloride Packet 20 MEQ PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 21 of 119 May 2015 Klor‐Con Potassium Chloride Packet 25 MEQ Potassium Chloride Potassium Chloride Tab Er Prt 10 MEQ Klor‐Con M15 Potassium Chloride Tab Er Prt 15 MEQ Potassium Chloride Potassium Chloride Tab Er Prt 20 MEQ K‐Tab Er Potassium Chloride Tablet Er 10 MEQ K‐Tab Er Potassium Chloride Tablet Er 20 MEQ Tablet Er 8 MEQ Klor‐Con 8 Potassium Chloride DRUG CLASS: Potassium Sparing Diuretics In Combination Brand Name Generic Name Formulation Strength Aldactazide Spironolact/Hydrochlorothiazid Tablet 25 MG‐25MG Aldactazide Spironolact/Hydrochlorothiazid Tablet 50 MG‐50MG Dyazide Triamterene/Hydrochlorothiazid Capsule 37.5‐25 MG Triamterene‐Hctz Triamterene/Hydrochlorothiazid Capsule 50 MG‐25MG Maxzide‐25 Mg Triamterene/Hydrochlorothiazid Tablet 37.5‐25 MG Triamterene‐Hydrochlo Triamterene/Hydrochlorothiazid Tablet 75 MG‐50MG CATEGORY Cardiology, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Other DRUG CLASS: Sodium/Saline Preparations Brand Name Generic Name Formulation Strength Sodium Chloride 0.9 % Sodium Chloride IV Soln 0.009 Sodium Chloride 0.9 % Sodium Chloride Syringe 0.009 Sodium Chloride 0.9 % Sodium Chloride Vial 0.009 Strength PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cardiology, Other DRUG CLASS: Vitamin K Preparations Brand Name Generic Name Formulation Vitamin K Phytonadione Tablet 100 MCG Mephyton Phytonadione Tablet 5 MG AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 22 of 119 May 2015 THERAPUTIC CATEGORY CNS, ADHD CATEGORY CNS, ADHD DRUG CLASS: Adrenergics, Aromatic, Non‐Catecholamine Brand Name Generic Name Formulation Strength Dexedrine Dextroamphetamine Sulfate Capsule Er 10 MG Dexedrine Dextroamphetamine Sulfate Capsule Er 15 MG Dexedrine Dextroamphetamine Sulfate Capsule Er 5 MG Dextroamphetamine Su Dextroamphetamine Sulfate Tablet 10 MG Dextroamphetamine Su Dextroamphetamine Sulfate Tablet 5 MG Dextroamphetamine‐A Dextroamphetamine/Amphetamine Cap Er 24H 10 MG Dextroamphetamine‐A Dextroamphetamine/Amphetamine Cap Er 24H 15 MG Dextroamphetamine‐A Dextroamphetamine/Amphetamine Cap Er 24H 20 MG Dextroamphetamine‐A Dextroamphetamine/Amphetamine Cap Er 24H 25 MG Dextroamphetamine‐A Dextroamphetamine/Amphetamine Cap Er 24H 30 MG Dextroamphetamine‐A Dextroamphetamine/Amphetamine Cap Er 24H 5 MG Amphetamine Salt Com Dextroamphetamine/Amphetamine Tablet 10 MG Adderall PA S QL F AL P GL Restrictions (if applicable) Dextroamphetamine/Amphetamine Tablet 12.5 MG Amphetamine Salt Com Dextroamphetamine/Amphetamine Tablet 15 MG Amphetamine Salt Com Dextroamphetamine/Amphetamine Tablet 20 MG Amphetamine Salt Com Dextroamphetamine/Amphetamine Tablet 30 MG Amphetamine Salt Com Dextroamphetamine/Amphetamine Tablet 5 MG Adderall Dextroamphetamine/Amphetamine Tablet 7.5 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 10 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 20 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 30 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 30 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 40 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 50 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 50 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 60 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 70 MG Vyvanse Lisdexamfetamine Dimesylate Capsule 70 MG DRUG CLASS: Tx For Adhd ‐ Selective Alpha‐2A Receptor Agonist Brand Name Generic Name Formulation Strength Intuniv Guanfacine Hcl Tab Er 24H 1 MG Reserved for failure, intolerance or contraindication to stimulants (e.g., adderall xr, concerta, ritalin er/la) Intuniv Guanfacine Hcl Tab Er 24H 2 MG Reserved for failure, intolerance or contraindication to stimulants (e.g., adderall xr, concerta, ritalin er/la) Intuniv Guanfacine Hcl Tab Er 24H 3 MG Reserved for failure, intolerance or contraindication to stimulants (e.g., adderall xr, concerta, ritalin er/la) Intuniv Guanfacine Hcl Tab Er 24H 4 MG Reserved for failure, intolerance or contraindication to stimulants (e.g., adderall xr, concerta, ritalin er/la) DRUG CLASS: Tx For Attention Deficit‐Hyperact(Adhd)/Narcolepsy Brand Name Generic Name Formulation Strength CATEGORY CNS, ADHD PA S QL F AL P GL Restrictions (if applicable) CATEGORY CNS, ADHD PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 23 of 119 May 2015 Focalin Xr Dexmethylphenidate Hcl Cpbp 50‐50 10 MG Focalin Xr Dexmethylphenidate Hcl Cpbp 50‐50 15 MG Focalin Xr Dexmethylphenidate Hcl Cpbp 50‐50 20 MG Focalin Xr Dexmethylphenidate Hcl Cpbp 50‐50 25 MG Focalin Xr Dexmethylphenidate Hcl Cpbp 50‐50 30 MG Focalin Xr Dexmethylphenidate Hcl Cpbp 50‐50 35 MG Focalin Xr Dexmethylphenidate Hcl Cpbp 50‐50 40 MG Focalin Xr Dexmethylphenidate Hcl Cpbp 50‐50 5 MG Focalin Dexmethylphenidate Hcl Tablet 10 MG Focalin Dexmethylphenidate Hcl Tablet 2.5 MG Focalin Dexmethylphenidate Hcl Tablet 5 MG Daytrana Methylphenidate Patch Td24 10MG/9HR Restricted to patients with documented inability to swallow tablets or capsules. may consider ritalin la or adderall xr, which can be opened and sprinkled on food. Daytrana Methylphenidate Patch Td24 15MG/9HR Restricted to patients with documented inability to swallow tablets or capsules. may consider ritalin la or adderall xr, which can be opened and sprinkled on food. Daytrana Methylphenidate Patch Td24 20 MG/9 HR Restricted to patients with documented inability to swallow tablets or capsules. may consider ritalin la or adderall xr, which can be opened and sprinkled on food. Daytrana Methylphenidate Patch Td24 30MG/9HR Restricted to patients with documented inability to swallow tablets or capsules. may consider ritalin la or adderall xr, which can be opened and sprinkled on food. Methylphenidate Hcl Cd Methylphenidate Hcl Cpbp 30‐70 10 MG Methylphenidate Hcl Cd Methylphenidate Hcl Cpbp 30‐70 20 MG Methylphenidate Hcl Cd Methylphenidate Hcl Cpbp 30‐70 30 MG Methylphenidate Hcl Cd Methylphenidate Hcl Cpbp 30‐70 40 MG Methylphenidate Hcl Cd Methylphenidate Hcl Cpbp 30‐70 50 MG Methylphenidate Hcl Cd Methylphenidate Hcl Cpbp 30‐70 60 MG Ritalin La Methylphenidate Hcl Cpbp 50‐50 10 MG Ritalin La Methylphenidate Hcl Cpbp 50‐50 20 MG Ritalin La Methylphenidate Hcl Cpbp 50‐50 30 MG Ritalin La Methylphenidate Hcl Cpbp 50‐50 40 MG Methylphenidate Hcl Methylphenidate Hcl Solution 10 MG/5 ML Methylphenidate Hcl Methylphenidate Hcl Solution 5 MG/5 ML Methylin Methylphenidate Hcl Tab Chew 10 MG Methylin Methylphenidate Hcl Tab Chew 2.5 MG Methylin Methylphenidate Hcl Tab Chew 5 MG Methylphenidate Er Methylphenidate Hcl Tab Er 24 18 MG Methylphenidate Er Methylphenidate Hcl Tab Er 24 27 MG Methylphenidate Er Methylphenidate Hcl Tab Er 24 36 MG Methylphenidate Er Methylphenidate Hcl Tab Er 24 54 MG Ritalin Methylphenidate Hcl Tablet 10 MG Ritalin Methylphenidate Hcl Tablet 20 MG Ritalin Methylphenidate Hcl Tablet 5 MG Methylin Er Methylphenidate Hcl Tablet Er 10 MG Ritalin‐Sr Methylphenidate Hcl Tablet Er 20 MG RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 24 of 119 May 2015 THERAPUTIC CATEGORY CNS, Mental Health CATEGORY CNS, Mental Health DRUG CLASS: Alpha‐2 Receptor Antagonist Antidepressants Brand Name Generic Name Formulation Strength Remeron Mirtazapine Tab Rapdis 15 MG Reserved for patients with a documented inability to swallow tablets or capsules. limited to 1 tab per day Remeron Mirtazapine Tab Rapdis 30 MG Reserved for patients with a documented inability to swallow tablets or capsules. limited to 1 tab per day Remeron Mirtazapine Tab Rapdis 45 MG Reserved for patients with a documented inability to swallow tablets or capsules. limited to 1 tab per day Remeron Mirtazapine Tablet 15 MG Restricted to 1 tablet per day Remeron Mirtazapine Tablet 30 MG Restricted to 1 tablet per day Remeron Mirtazapine Tablet 45 MG Restricted to 1 tablet per day Mirtazapine Mirtazapine Tablet 7.5 MG Restricted to 1 tablet per day DRUG CLASS: Norepinephrine And Dopamine Reuptake Inhib (Ndris) Brand Name Generic Name Formulation Strength Budeprion Xl Bupropion Hcl Tab Er 24H 150 MG Budeprion Xl Bupropion Hcl Tab Er 24H 300 MG Bupropion Hcl Bupropion Hcl Tablet 100 MG Bupropion Hcl Bupropion Hcl Tablet 75 MG Budeprion Sr Bupropion Hcl Tablet Er 100 MG Budeprion Sr Bupropion Hcl Tablet Er 150 MG Bupropion Hcl Sr Bupropion Hcl Tablet Er 200 MG DRUG CLASS: Selective Serotonin Reuptake Inhibitor (Ssris) Brand Name Generic Name Formulation Strength Citalopram Hbr Citalopram Hydrobromide Solution 10 MG/5 ML Citalopram Hbr Citalopram Hydrobromide Tablet 10 MG Citalopram Hbr Citalopram Hydrobromide Tablet 20 MG Citalopram Hbr Citalopram Hydrobromide Tablet 40 MG Lexapro Escitalopram Oxalate Solution 5 MG/5 ML Escitalopram Oxalate Escitalopram Oxalate Tablet 10 MG Escitalopram Oxalate Escitalopram Oxalate Tablet 20 MG Escitalopram Oxalate Escitalopram Oxalate Tablet 5 MG Prozac Fluoxetine Hcl Capsule 10 MG Prozac Fluoxetine Hcl Capsule 20 MG Fluoxetine Hcl Fluoxetine Hcl Capsule 40 MG Prozac Fluoxetine Hcl Solution 20 MG/5 ML PA S QL F AL P GL Restrictions (if applicable) CATEGORY CNS, Mental Health PA S QL F AL P GL Restrictions (if applicable) CATEGORY CNS, Mental Health PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 25 of 119 May 2015 Fluvoxamine Maleate Fluvoxamine Maleate Tablet 100 MG Fluvoxamine Maleate Fluvoxamine Maleate Tablet 25 MG Fluvoxamine Maleate Fluvoxamine Maleate Tablet 50 MG Paxil Paroxetine Hcl Oral Susp 10 MG/5 ML Paxil Cr Paroxetine Hcl Tab Er 24H 12.5 MG Reserved for failure of 2 months of dose optimized paroxetine. limit 1 tab per day. Paxil Cr Paroxetine Hcl Tab Er 24H 25 MG Reserved for failure of 2 months of dose optimized paroxetine. limit 1 tab per day. Paxil Cr Paroxetine Hcl Tab Er 24H 37.5 MG Reserved for failure of 2 months of dose optimized paroxetine. limit 1 tab per day. Paxil Paroxetine Hcl Tablet 10 MG Restricted to 1 tablet per day. Paxil Paroxetine Hcl Tablet 20 MG Restricted to 1 tablet per day. Paxil Paroxetine Hcl Tablet 30 MG Restricted to 1 tablet per day. Paxil Paroxetine Hcl Tablet 40 MG Restricted to 1 tablet per day. Zoloft Sertraline Hcl Oral Conc 20 MG/ML Restricted to 10ml per day Zoloft Sertraline Hcl Tablet 100 MG Restricted to 2 tablets per day. Zoloft Sertraline Hcl Tablet 25 MG Restricted to 2 tablets per day. Zoloft Sertraline Hcl Tablet 50 MG Restricted to 2 tablets per day. Viibryd Vilazodone Hydrochloride Tablet 10 MG Reserved for treatment failure of two different dose optimized formulary antidepressants for 2 months each Viibryd Vilazodone Hydrochloride Tablet 20 MG Reserved for treatment failure of two different dose optimized formulary antidepressants for 2 months each Viibryd Vilazodone Hydrochloride Tablet 40 MG Reserved for treatment failure of two different dose optimized formulary antidepressants for 2 months each Brintellix Vortioxetine Hydrobromide Tablet 10 MG Reserved for treatment failure of two different dose optimized formulary antidepressants for 2 months each Brintellix Vortioxetine Hydrobromide Tablet 20 MG Reserved for treatment failure of two different dose optimized formulary antidepressants for 2 months each Brintellix Vortioxetine Hydrobromide Tablet 5 MG Reserved for treatment failure of two different dose optimized formulary antidepressants for 2 months each DRUG CLASS: Serotonin‐2 Antagonist/Reuptake Inhibitors (Saris) Brand Name Generic Name Formulation Strength Nefazodone Hcl Nefazodone Hcl Tablet 100 MG CATEGORY CNS, Mental Health PA S QL F AL P GL Restrictions (if applicable) Restricted to 90 tablets per 30 days. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 26 of 119 May 2015 Nefazodone Hcl Nefazodone Hcl Tablet 150 MG Restricted to 90 tablets per 30 days. Nefazodone Hcl Nefazodone Hcl Tablet 200 MG Restricted to 90 tablets per 30 days. Nefazodone Hcl Nefazodone Hcl Tablet 250 MG Restricted to 90 tablets per 30 days. Nefazodone Hcl Nefazodone Hcl Tablet 50 MG Restricted to 90 tablets per 30 days. Trazodone Hcl Trazodone Hcl Tablet 100 MG Trazodone Hcl Trazodone Hcl Tablet 150 MG Trazodone Hcl Trazodone Hcl Tablet 50 MG DRUG CLASS: Serotonin‐Norepinephrine Reuptake‐Inhib (Snris) Brand Name Generic Name Formulation Strength Pristiq Er Desvenlafaxine Succinate Tab Er 24H 100 MG Reserved for patients, with major depressive disorder, who are treatment failure of dose‐optimized effexor and cymbalta for 2 months each. Pristiq Er Desvenlafaxine Succinate Tab Er 24H 50 MG Reserved for patients, with major depressive disorder, who are treatment failure of dose‐optimized effexor and cymbalta for 2 months each. Cymbalta Duloxetine Hcl Capsule Dr 20 MG Reserved for failure of dose optimized venlafaxine, gabapentin, and/or tricyclic antidepressants (depending on diagnosis). Cymbalta Duloxetine Hcl Capsule Dr 30 MG Reserved for failure of dose optimized venlafaxine. limit of 2 caps per day. Cymbalta Duloxetine Hcl Capsule Dr 60 MG Reserved for failure of dose optimized venlafaxine. limit of 1 cap per day. Fetzima Levomilnacipran Hydrochloride Cap Sa 24H 120 MG Reserved for treatment failure of dose‐optimized venlafaxine and duloxetine for 2 months each Fetzima Levomilnacipran Hydrochloride Cap Sa 24H 20 MG Reserved for treatment failure of dose‐optimized venlafaxine and duloxetine for 2 months each Fetzima Levomilnacipran Hydrochloride Cap Sa 24H 40 MG Reserved for treatment failure of dose‐optimized venlafaxine and duloxetine for 2 months each Fetzima Levomilnacipran Hydrochloride Cap Sa 24H 80 MG Reserved for treatment failure of dose‐optimized venlafaxine and duloxetine for 2 months each Effexor Xr Venlafaxine Hcl Cap Er 24H 150 MG Restricted to 2 per day Effexor Xr Venlafaxine Hcl Cap Er 24H 37.5 MG Restricted to 2 per day Effexor Xr Venlafaxine Hcl Cap Er 24H 75 MG Restricted to 3 per day Effexor Venlafaxine Hcl Tablet 100 MG Restricted to 3 per day CATEGORY CNS, Mental Health PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 27 of 119 May 2015 Effexor Venlafaxine Hcl Tablet 25 MG Restricted to 3 per day Effexor Venlafaxine Hcl Tablet 37.5 MG Restricted to 3 per day Effexor Venlafaxine Hcl Tablet 50 MG Restricted to 3 per day Effexor Venlafaxine Hcl Tablet 75 MG Restricted to 3 per day DRUG CLASS: Tricyclic Antidepressants & Rel. Non‐Sel. Ru‐Inhib Brand Name Generic Name Formulation Amitriptyline Hcl Amitriptyline Hcl Tablet 10 MG Amitriptyline Hcl Amitriptyline Hcl Tablet 100 MG Amitriptyline Hcl Amitriptyline Hcl Tablet 150 MG Amitriptyline Hcl Amitriptyline Hcl Tablet 25 MG Amitriptyline Hcl Amitriptyline Hcl Tablet 50 MG Amitriptyline Hcl Amitriptyline Hcl Tablet 75 MG Norpramin Desipramine Hcl Tablet 10 MG Norpramin Desipramine Hcl Tablet 100 MG Norpramin Desipramine Hcl Tablet 150 MG Norpramin Desipramine Hcl Tablet 25 MG Norpramin Desipramine Hcl Tablet 50 MG Norpramin Desipramine Hcl Tablet 75 MG Doxepin Hcl Doxepin Hcl Capsule 10 MG Doxepin Hcl Doxepin Hcl Capsule 100 MG Doxepin Hcl Doxepin Hcl Capsule 150 MG Doxepin Hcl Doxepin Hcl Capsule 25 MG Doxepin Hcl Doxepin Hcl Capsule 50 MG Doxepin Hcl Doxepin Hcl Capsule 75 MG Doxepin Hcl Doxepin Hcl Oral Conc 10 MG/ML Tofranil Imipramine Hcl Tablet 10 MG Tofranil Imipramine Hcl Tablet 25 MG Tofranil Imipramine Hcl Tablet 50 MG Nortriptyline Hcl Nortriptyline Hcl Capsule 10 MG Nortriptyline Hcl Nortriptyline Hcl Capsule 25 MG Nortriptyline Hcl Nortriptyline Hcl Capsule 50 MG Nortriptyline Hcl Nortriptyline Hcl Capsule 75 MG Nortriptyline Hcl Nortriptyline Hcl Solution 10 MG/5 ML Strength CATEGORY CNS, Mental Health PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 28 of 119 May 2015 THERAPUTIC CATEGORY CNS, Migraine CATEGORY CNS, Migraine DRUG CLASS: Antimigraine Preparations Brand Name Generic Name Formulation Strength Axert Almotriptan Malate Tablet 12.5 MG 4th line after tx failure of imitrex, maxalt and amerge. for frequent HA >2 per month, prophylaxis with topamax, depakote, or beta blockers may be considered. restricted to 9 tabs/30 days. Axert Almotriptan Malate Tablet 6.25 MG 4th line after tx failure of imitrex, maxalt and amerge. for frequent HA >2 per month, prophylaxis with topamax, depakote, or beta blockers may be considered. restricted to 9 tabs/30 days. Relpax Eletriptan Hbr Tablet 20 MG 4th line after tx failure of imitrex, maxalt and amerge. for frequent HA >2 per month, prophylaxis with topamax, depakote, or beta blockers may be considered. restricted to 9 tabs/30 days. Relpax Eletriptan Hbr Tablet 40 MG 4th line after tx failure of imitrex, maxalt and amerge. for frequent HA >2 per month, prophylaxis with topamax, depakote, or beta blockers may be considered. restricted to 9 tabs/30 days. Ergomar Ergotamine Tartrate Tab Subl 2 MG Restricted to 1 fill per 30 days. for frequent headaches >2 attacks per month, prophylaxis with topamax, depakote or a beta blocker may be considered. Migergot Ergotamine Tartrate/Caffeine Supp.Rect 2‐100MG Restricted to 1 fill per 30 days. for frequent headaches >2 attacks per month, prophylaxis with topamax, depakote or a beta blocker may be considered. Ergotamine‐Caffeine Ergotamine Tartrate/Caffeine Tablet 1 MG‐100MG Restricted to 1 fill per 30 days. for frequent headaches >2 attacks per month, prophylaxis with topamax, depakote or a beta blocker may be considered. Midrin Isomethept/Dichlphn/Acetaminop Capsule 65‐100‐325 Limited to 1 fill per 30 days. for frequent headaches >2 attacks per month, prophylaxis with topamax, depakote or a beta blocker may be considered Naratriptan Hcl Naratriptan Hcl Tablet 1 MG 3rd line to treatment failure of imitrex and maxalt. for frequent headaches >2 attacks per month, prophylaxis should be considered. max of 9 per 30 days Naratriptan Hcl Naratriptan Hcl Tablet 2.5 MG 3rd line to treatment failure of imitrex and maxalt. for frequent headaches >2 attacks per month, prophylaxis should be considered. max of 9 per 30 days Maxalt Rizatriptan Benzoate Tablet 10 MG Restricted to 9 tablets per 30 days. for frequent headache > 2 attacks per month, prophylaxis should be considered Maxalt Rizatriptan Benzoate Tablet 5 MG Restricted to 9 tablets per 30 days. for frequent headache > 2 attacks per month, prophylaxis should be considered Imitrex Sumatriptan Spray 20 MG Reserved for patients unable to take oral meds (including odt). max 6/month. for frequent HA >2 attacks/month, prophylaxis with topamax/depakote/beta blocker may be considered PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 29 of 119 May 2015 Imitrex Sumatriptan Spray 5 MG Reserved for patients unable to take oral meds (including odt). max 6/month. for frequent HA >2 attacks/month, prophylaxis with topamax/depakote/beta blocker may be considered Sumatriptan Succinate Sumatriptan Succinate Tablet 100 MG Restricted to 9 tablets per 30 days. for frequent headache > 2 attacks per month, prophylaxis should be considered Sumatriptan Succinate Sumatriptan Succinate Tablet 25 MG Restricted to 9 tablets per 30 days. for frequent headache > 2 attacks per month, prophylaxis should be considered Sumatriptan Succinate Sumatriptan Succinate Tablet 50 MG Restricted to 9 tablets per 30 days. for frequent headache > 2 attacks per month, prophylaxis should be considered Zolmitriptan Odt Zolmitriptan Tab Rapdis 2.5 MG 3rd line after tx failure of imitrex and amerge. for frequent HA >2 per month, prophylaxis with topamax, depakote, or beta blockers may be considered. restricted to 9 tabs/30 days. Zolmitriptan Odt Zolmitriptan Tab Rapdis 5 MG 3rd line after tx failure of imitrex and amerge. for frequent HA >2 per month, prophylaxis with topamax, depakote, or beta blockers may be considered. restricted to 9 tabs/30 days. Zolmitriptan Zolmitriptan Tablet 2.5 MG 3rd line after tx failure of imitrex and amerge. for frequent HA >2 per month, prophylaxis with topamax, depakote, or beta blockers may be considered. restricted to 9 tabs/30 days. Zolmitriptan Zolmitriptan Tablet 5 MG 3rd line after tx failure of imitrex and amerge. for frequent HA >2 per month, prophylaxis with topamax, depakote, or beta blockers may be considered. restricted to 9 tabs/30 days. THERAPUTIC CATEGORY CNS, Muscle Relaxants CATEGORY CNS, Muscle Relaxants DRUG CLASS: Skeletal Muscle Relaxants Brand Name Generic Name Formulation Strength Baclofen Baclofen Tablet 10 MG Baclofen Baclofen Tablet 20 MG Cyclobenzaprine Hcl Cyclobenzaprine Hcl Tablet 10 MG Cyclobenzaprine Hcl Cyclobenzaprine Hcl Tablet 5 MG Dantrolene Sodium Dantrolene Sodium Capsule 100 MG Dantrolene Sodium Dantrolene Sodium Capsule 25 MG Dantrolene Sodium Dantrolene Sodium Capsule 50 MG Robaxin Methocarbamol Tablet 500 MG Robaxin‐750 Methocarbamol Tablet 750 MG Tizanidine Hcl Tizanidine Hcl Tablet 2 MG Tizanidine Hcl Tizanidine Hcl Tablet 4 MG PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 30 of 119 May 2015 THERAPUTIC CATEGORY CNS, Other CATEGORY CNS, Other DRUG CLASS: Agents To Treat Multiple Sclerosis Brand Name Generic Name Formulation Strength Tecfidera Dimethyl Fumarate Capsule Dr 120 MG Reserved for treatment failure to Avonex, betaseron, Rebif or Copaxone. Tecfidera Dimethyl Fumarate Capsule Dr 120‐240 MG Reserved for treatment failure to Avonex, betaseron, Rebif or Copaxone. Tecfidera Dimethyl Fumarate Capsule Dr 240 MG Reserved for treatment failure to Avonex, betaseron, Rebif or Copaxone. Gilenya Fingolimod Hcl Capsule 0.5 MG 2nd line tx for ms after treatment failure of Avonex/Rebif/Copaxone. must be prescribed by a neurologist, for verified dx of MS. restricted to Diplomat specialty pharmacy at 877‐319‐6337 Copaxone Glatiramer Acetate Syringe 20 MG/ML First line therapy for MS. must be prescribed by a neurologist, for verified diagnosis of MS. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Copaxone Glatiramer Acetate Syringe 40 MG/ML Reserved for multiple sclerosis prescribed by neurologist Avonex Pen Interferon Beta‐1A Pen Ij Kit 30MCG/.5ML Reserved for multiple sclerosis prescribed by neurologist Avonex Pen Interferon Beta‐1A Pen Injctr 30MCG/.5ML Reserved for multiple sclerosis prescribed by neurologist Avonex Interferon Beta‐1A Syringe 30MCG/.5ML First line therapy for MS. must be prescribed by a neurologist, for verified diagnosis of MS. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Avonex Interferon Beta‐1A Syringekit 30MCG/.5ML First line therapy for MS. must be prescribed by a neurologist, for verified diagnosis of MS. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Avonex Administration Interferon Beta‐1A/Albumin Pack Kit 30 MCG Reserved for multiple sclerosis prescribed by neurologist Rebif Interferon Beta‐1A/Albumin Syringe 22MCG/.5ML First line therapy for MS. must be prescribed by a neurologist, for verified diagnosis of MS. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Rebif Interferon Beta‐1A/Albumin Syringe 44MCG/.5ML First line therapy for MS. must be prescribed by a neurologist, for verified diagnosis of MS. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Rebif Interferon Beta‐1A/Albumin Syringe 8.8‐22(6) First line therapy for MS. must be prescribed by a neurologist, for verified diagnosis of MS. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Extavia Interferon Beta‐1B Kit 0.3 MG Reserved for multiple sclerosis prescribed by neurologist Extavia Interferon Beta‐1B Vial 0.3 MG First line therapy for MS. must be prescribed by a neurologist, for verified diagnosis of MS. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 31 of 119 May 2015 Aubagio Teriflunomide Tablet 14 MG 2nd line tx for ms after treatment failure of Avonex/Rebif/Copaxone. must be prescribed by a neurologist, for verified dx of MS. Aubagio Teriflunomide Tablet 7 MG 2nd line tx for ms after treatment failure of Avonex/Rebif/Copaxone. must be prescribed by a neurologist, for verified dx of MS. DRUG CLASS: Agts Tx Neuromusc Transmission Dis,Pot‐Chan Blkr Brand Name Generic Name Formulation Strength Ampyra Dalfampridine Tab Er 12H 10 MG DRUG CLASS: Alzheimer'S Therapy, Nmda Receptor Antagonists Brand Name Generic Name Formulation Strength Namenda Memantine Hcl Solution 10 MG/5 ML Reserved for patients with moderate‐to‐severe dementia of alzheimer's type, based on mmse score of 3‐ 14. Namenda Memantine Hcl Tab Ds Pk 5 MG‐10 MG Reserved for patients with moderate‐to‐severe dementia of alzheimer's type, based on mmse score of 3‐ 14. Namenda Memantine Hcl Tablet 10 MG Reserved for patients with moderate‐to‐severe dementia of alzheimer's type, based on mmse score of 3‐ 14. Namenda Memantine Hcl Tablet 5 MG Reserved for patients with moderate‐to‐severe dementia of alzheimer's type, based on mmse score of 3‐ 14. DRUG CLASS: Anti‐Alcoholic Preparations Brand Name Generic Name Formulation Strength Disulfiram Disulfiram Tablet 250 MG Disulfiram Disulfiram Tablet 500 MG CATEGORY CNS, Other PA S QL F AL P GL Restrictions (if applicable) Reserved for patients on disease modifying therapy who are ambulatory with a timed 25‐foot walk test between 8‐ 45 seconds. CATEGORY CNS, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY CNS, Other PA S QL F PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY CNS, Other DRUG CLASS: Anti‐Anxiety Drugs Brand Name Generic Name Formulation Strength Xanax Alprazolam Tablet 0.25 MG Xanax Alprazolam Tablet 0.5 MG Xanax Alprazolam Tablet 1 MG Xanax Alprazolam Tablet 2 MG Buspar Buspirone Hcl Tablet 10 MG Buspar Buspirone Hcl Tablet 15 MG Buspar Buspirone Hcl Tablet 30 MG Buspar Buspirone Hcl Tablet 5 MG Buspirone Hcl Buspirone Hcl Tablet 7.5 MG Librium Chlordiazepoxide Hcl Capsule 10 MG Librium Chlordiazepoxide Hcl Capsule 25 MG Librium Chlordiazepoxide Hcl Capsule 5 MG Lorazepam Intensol Lorazepam Oral Conc 2 MG/ML Lorazepam Lorazepam Tablet 0.5 MG Lorazepam Lorazepam Tablet 1 MG Lorazepam Lorazepam Tablet 2 MG AL P GL Restrictions (if applicable) CATEGORY CNS, Other DRUG CLASS: Anticonvulsants Brand Name Generic Name Formulation Strength Carbamazepine Carbamazepine Cpmp 12Hr 100 MG AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 32 of 119 May 2015 Carbamazepine Carbamazepine Cpmp 12Hr Carbamazepine Carbamazepine Cpmp 12Hr 200 MG 300 MG Tegretol Carbamazepine Oral Susp 100 MG/5ML Tegretol Carbamazepine Tab Chew 100 MG Tegretol Xr Carbamazepine Tab Er 12H 200 MG Tegretol Xr Carbamazepine Tab Er 12H 400 MG Tegretol Carbamazepine Tablet 200 MG Onfi Clobazam Tablet 10 MG Restricted to Alernatives: by neurologists only. Onfi Clobazam Tablet 20 MG Restricted to Alernatives: by neurologists only. Klonopin Clonazepam Tab Rapdis 0.125 MG Klonopin Clonazepam Tab Rapdis 0.25 MG Klonopin Clonazepam Tab Rapdis 0.5 MG Klonopin Clonazepam Tab Rapdis 1 MG Klonopin Clonazepam Tab Rapdis 2 MG Klonopin Clonazepam Tablet 0.5 MG Klonopin Clonazepam Tablet 1 MG Klonopin Clonazepam Tablet 2 MG Depakote Sprinkle Divalproex Sodium Cap Sprink 125 MG Depakote Er Divalproex Sodium Tab Er 24H 250 MG Depakote Er Divalproex Sodium Tab Er 24H 500 MG Depakote Divalproex Sodium Tablet Dr 125 MG Depakote Divalproex Sodium Tablet Dr 250 MG Depakote Divalproex Sodium Tablet Dr 500 MG Zarontin Ethosuximide Capsule 250 MG Zarontin Ethosuximide Solution 250 MG/5ML Restricted to Alernatives: by neurologists only. Felbatol Felbamate Tablet 400 MG Restricted to Alernatives: by neurologists only. Felbatol Felbamate Tablet 600 MG Neurontin Gabapentin Capsule 100 MG Neurontin Gabapentin Capsule 300 MG Neurontin Gabapentin Capsule 400 MG Neurontin Gabapentin Solution 250 MG/5ML Neurontin Gabapentin Tablet 600 MG Neurontin Gabapentin Tablet 800 MG Vimpat Lacosamide Solution 10 MG/ML Restricted to Alernatives: by neurologists only. Vimpat Lacosamide Tablet 100 MG Restricted to Alernatives: by neurologists only. Vimpat Lacosamide Tablet 150 MG Restricted to Alernatives: by neurologists only. Vimpat Lacosamide Tablet 200 MG Restricted to Alernatives: by neurologists only. Vimpat Lacosamide Tablet 50 MG Restricted to Alernatives: by neurologists only. Vimpat Lacosamide Vial 200MG/20ML Restricted to Alernatives: by neurologists only. Lamotrigine Lamotrigine Tablet 100 MG Lamotrigine Lamotrigine Tablet 150 MG Lamotrigine Lamotrigine Tablet 200 MG Lamotrigine Lamotrigine Tablet 25 MG Lamotrigine Lamotrigine Tb Chw Dsp 25 MG Lamotrigine Lamotrigine Tb Chw Dsp 5 MG Levetiracetam Levetiracetam Solution 100 MG/ML Levetiracetam Levetiracetam Solution 500 MG/5ML Restricted to Alernatives: by neurologists only. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 33 of 119 May 2015 Levetiracetam Er Levetiracetam Tab Er 24H Levetiracetam Er Levetiracetam Tab Er 24H 500 MG 750 MG Levetiracetam Levetiracetam Tablet 1000 MG Levetiracetam Levetiracetam Tablet 250 MG Levetiracetam Levetiracetam Tablet 500 MG Levetiracetam Levetiracetam Tablet 750 MG Levetiracetam Levetiracetam Vial 500 MG/5ML Celontin Methsuximide Capsule 300 MG Oxcarbazepine Oxcarbazepine Oral Susp 300 MG/5ML Oxcarbazepine Oxcarbazepine Tablet 150 MG Oxcarbazepine Oxcarbazepine Tablet 300 MG Oxcarbazepine Oxcarbazepine Tablet 600 MG Dilantin‐125 Phenytoin Oral Susp 125 MG/5ML Dilantin Phenytoin Tab Chew 50 MG Dilantin Phenytoin Sodium Extended Capsule 100 MG Phenytek Phenytoin Sodium Extended Capsule 200 MG Dilantin Phenytoin Sodium Extended Capsule 30 MG Phenytek Phenytoin Sodium Extended Capsule 300 MG Lyrica Pregabalin Capsule 100 MG Step therapy to treatment failure of a tricyclic antidepressant and gabapentin at dose larger than 1800mg/day for at least 8 weeks. Lyrica Pregabalin Capsule 150 MG Step therapy to treatment failure of a tricyclic antidepressant and gabapentin at dose larger than 1800mg/day for at least 8 weeks. Lyrica Pregabalin Capsule 200 MG Step therapy to treatment failure of a tricyclic antidepressant and gabapentin at dose larger than 1800mg/day for at least 8 weeks. Lyrica Pregabalin Capsule 225 MG Step therapy to treatment failure of a tricyclic antidepressant and gabapentin at dose larger than 1800mg/day for at least 8 weeks. Lyrica Pregabalin Capsule 25 MG Step therapy to treatment failure of a tricyclic antidepressant and gabapentin at dose larger than 1800mg/day for at least 8 weeks. Lyrica Pregabalin Capsule 300 MG Step therapy to treatment failure of a tricyclic antidepressant and gabapentin at dose larger than 1800mg/day for at least 8 weeks. Lyrica Pregabalin Capsule 50 MG Step therapy to treatment failure of a tricyclic antidepressant and gabapentin at dose larger than 1800mg/day for at least 8 weeks. Lyrica Pregabalin Capsule 75 MG Step therapy to treatment failure of a tricyclic antidepressant and gabapentin at dose larger than 1800mg/day for at least 8 weeks. Primidone Primidone Tablet 250 MG Primidone Primidone Tablet 50 MG Gabitril Tiagabine Hcl Tablet 12 MG Restricted to Alernatives: by neurologists only. Gabitril Tiagabine Hcl Tablet 16 MG Restricted to Alernatives: by neurologists only. Gabitril Tiagabine Hcl Tablet 2 MG Restricted to Alernatives: by neurologists only. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 34 of 119 May 2015 Gabitril Tiagabine Hcl Tablet 4 MG Topamax Topiramate Cap Sprink 15 MG Reserved for patients with documented inability to swallow tablets Topamax Topiramate Cap Sprink 25 MG Reserved for patients with documented inability to swallow tablets Topamax Topiramate Tablet 100 MG Topamax Topiramate Tablet 200 MG Topamax Topiramate Tablet 25 MG Topamax Topiramate Tablet 50 MG Depakene Valproic Acid Capsule 250 MG Depakene Valproic Acid (As Sodium Salt) Solution 250 MG/5ML Valproic Acid Valproic Acid (As Sodium Salt) Solution 250 MG/5ML Zonisamide Zonisamide Capsule 100 MG Restricted to Alernatives: by neurologists Zonisamide Zonisamide Capsule 25 MG Restricted to Alernatives: by neurologists Zonisamide Zonisamide Capsule 50 MG Restricted to Alernatives: by neurologists DRUG CLASS: Anti‐Narcolepsy & Anti‐Cataplexy,Sedative‐Type Agt Brand Name Generic Name Formulation Strength Xyrem Sodium Oxybate Solution 500 MG/ML Formulation Strength 5 MG CATEGORY CNS, Other PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. CATEGORY CNS, Other DRUG CLASS: Antiparkinsonism Drugs,Other Brand Name Generic Name Parlodel Bromocriptine Mesylate Capsule Parlodel Bromocriptine Mesylate Tablet 2.5 MG Parcopa Carbidopa/Levodopa Tab Rapdis 10MG‐100MG Parcopa Carbidopa/Levodopa Tab Rapdis 25MG‐100MG Parcopa Carbidopa/Levodopa Tab Rapdis 25MG‐250MG Sinemet 10‐100 Carbidopa/Levodopa Tablet 10MG‐100MG Sinemet 25‐100 Carbidopa/Levodopa Tablet 25MG‐100MG Sinemet 25‐250 Carbidopa/Levodopa Tablet 25MG‐250MG Sinemet Cr Carbidopa/Levodopa Tablet Er 25MG‐100MG Sinemet Cr Carbidopa/Levodopa Tablet Er 50MG‐200MG Pramipexole Dihydrochloride Pramipexole Di‐Hcl Tablet 0.125 MG Restricted to 60 tablets per month. please consolidate dose Pramipexole Dihydrochloride Pramipexole Di‐Hcl Tablet 0.25 MG Restricted to 60 tablets per month. please consolidate dose Pramipexole Dihydrochloride Pramipexole Di‐Hcl Tablet 0.5 MG Restricted to 60 tablets per month. please consolidate dose Pramipexole Dihydrochloride Pramipexole Di‐Hcl Tablet 0.75 MG Restricted to 60 tablets per month. please consolidate dose PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 35 of 119 May 2015 Pramipexole Dihydrochloride Pramipexole Di‐Hcl Tablet 1 MG Restricted to 60 tablets per month. please consolidate dose Pramipexole Dihydrochloride Pramipexole Di‐Hcl Tablet 1.5 MG Restricted to 60 tablets per month. please consolidate dose Azilect Rasagiline Mesylate Tablet 0.5 MG Restricted to Alernatives: by neurologists only. Azilect Rasagiline Mesylate Tablet 1 MG Restricted to Alernatives: by neurologists only. Requip Ropinirole Hcl Tablet 0.25 MG Restricted to 60 tablets per month. please consolidate dose Requip Ropinirole Hcl Tablet 0.5 MG Restricted to 60 tablets per month. please consolidate dose Requip Ropinirole Hcl Tablet 1 MG Restricted to 60 tablets per month. please consolidate dose Requip Ropinirole Hcl Tablet 2 MG Restricted to 60 tablets per month. please consolidate dose Requip Ropinirole Hcl Tablet 3 MG Restricted to 60 tablets per month. please consolidate dose Requip Ropinirole Hcl Tablet 4 MG Restricted to 60 tablets per month. please consolidate dose Requip Ropinirole Hcl Tablet 5 MG Restricted to 60 tablets per month. please consolidate dose Eldepryl Selegiline Hcl Capsule 5 MG Selegiline Hcl Selegiline Hcl Tablet 5 MG DRUG CLASS: Barbiturates Brand Name Generic Name Formulation Strength Phenobarbital Phenobarbital Elixir 20 MG/5 ML Phenobarbital Phenobarbital Tablet 100 MG Phenobarbital Phenobarbital Tablet 15 MG Phenobarbital Phenobarbital Tablet 16.2 MG Phenobarbital Phenobarbital Tablet 30 MG Phenobarbital Phenobarbital Tablet 32.4 MG Phenobarbital Phenobarbital Tablet 60 MG Phenobarbital Phenobarbital Tablet 64.8 MG Phenobarbital Phenobarbital Tablet 97.2MG DRUG CLASS: Cholinesterase Inhibitors Brand Name Generic Name Formulation Strength Donepezil Hcl Donepezil Hcl Tablet 10 MG Donepezil Hcl Donepezil Hcl Tablet 5 MG Regonol Pyridostigmine Bromide Ampul 5 MG/ML Mestinon CATEGORY CNS, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY CNS, Other Pyridostigmine Bromide Syrup 60 MG/5 ML Pyridostigmine Bromide Pyridostigmine Bromide Tablet 60 MG Mestinon Pyridostigmine Bromide Tablet Er 180 MG Exelon Rivastigmine Tartrate Capsule 1.5 MG PA S QL F AL P GL Restrictions (if applicable) Reserved for patients with mild‐moderate dementia of the alzheimer's type with a mmse score between 10 and 26. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 36 of 119 May 2015 Exelon Rivastigmine Tartrate Capsule 3 MG Reserved for patients with mild‐moderate dementia of the alzheimer's type with a mmse score between 10 and 26. Exelon Rivastigmine Tartrate Capsule 4.5 MG Reserved for patients with mild‐moderate dementia of the alzheimer's type with a mmse score between 10 and 26. Exelon Rivastigmine Tartrate Capsule 6 MG Reserved for patients with mild‐moderate dementia of the alzheimer's type with a mmse score between 10 and 26. CATEGORY CNS, Other DRUG CLASS: Fibromyalgia Agents,Serotonin‐Norepineph Ru Inhib Brand Name Generic Name Formulation Strength Savella Milnacipran Hcl Tablet 100 MG Step therapy to treatment failure of dose‐optimized venlafaxine for 2 months. Savella Milnacipran Hcl Tablet 12.5 MG Step therapy to treatment failure of dose‐optimized venlafaxine for 2 months. Savella Milnacipran Hcl Tablet 25 MG Step therapy to treatment failure of dose‐optimized venlafaxine for 2 months. Savella Milnacipran Hcl Tablet 50 MG Step therapy to treatment failure of dose‐optimized venlafaxine for 2 months. DRUG CLASS: Sedative‐Hypnotics,Non‐Barbiturate Brand Name Generic Name Formulation Strength Wal‐Som Diphenhydramine Hcl Capsule 50 MG Sleep Aid Diphenhydramine Hcl Tablet 25 MG Sominex Max Strength Diphenhydramine Hcl Tablet 50 MG Temazepam Temazepam Capsule 15 MG Restricted to 60 tabs/caps per 75 days to encourage as needed Alernatives: . please counsel on sleep hygiene. submit pa for patients in care facility or psychiatric conditions. Temazepam Temazepam Capsule 30 MG Restricted to 60 tabs/caps per 75 days to encourage as needed Alernatives: . please counsel on sleep hygiene. submit pa for patients in care facility or psychiatric conditions. Zaleplon Zaleplon Capsule 10 MG Restricted to 60 tabs/caps per 75 days to encourage as needed Alernatives: . please counsel on sleep hygiene. submit pa for patients in care facility or psychiatric conditions. Zaleplon Zaleplon Capsule 5 MG Restricted to 60 tabs/caps per 75 days to encourage as needed Alernatives: . please counsel on sleep hygiene. submit pa for patients in care facility or psychiatric conditions. Ambien Zolpidem Tartrate Tablet 10 MG Restricted to 60 tabs/caps per 75 days to encourage as needed Alernatives: . please counsel on sleep hygiene. submit pa for patients in care facility or psychiatric conditions. Ambien Zolpidem Tartrate Tablet 5 MG Restricted to 60 tabs/caps per 75 days to encourage as needed Alernatives: . please counsel on sleep hygiene. submit pa for patients in care facility or psychiatric conditions. DRUG CLASS: Tx For Attention Deficit‐Hyperact.(Adhd), Nri‐Type Brand Name Generic Name Formulation PA S QL F AL P GL Restrictions (if applicable) CATEGORY CNS, Other Strength PA S QL F AL P GL Restrictions (if applicable) CATEGORY CNS, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 37 of 119 May 2015 Strattera Atomoxetine Hcl Capsule 10 MG Step therapy to intolerance or treatment failure of stimulants (eg, concerta, ritalin sr/er or adderall xr). Strattera Atomoxetine Hcl Capsule 100 MG Step therapy to intolerance or treatment failure of stimulants (eg, concerta, ritalin sr/er or adderall xr). Strattera Atomoxetine Hcl Capsule 18 MG Step therapy to intolerance or treatment failure of stimulants (eg, concerta, ritalin sr/er or adderall xr). Strattera Atomoxetine Hcl Capsule 25 MG Step therapy to intolerance or treatment failure of stimulants (eg, concerta, ritalin sr/er or adderall xr). Strattera Atomoxetine Hcl Capsule 40 MG Step therapy to intolerance or treatment failure of stimulants (eg, concerta, ritalin sr/er or adderall xr). Strattera Atomoxetine Hcl Capsule 60 MG Step therapy to intolerance or treatment failure of stimulants (eg, concerta, ritalin sr/er or adderall xr). Strattera Atomoxetine Hcl Capsule 80 MG Step therapy to intolerance or treatment failure of stimulants (eg, concerta, ritalin sr/er or adderall xr). CATEGORY CNS, Other DRUG CLASS: Wakefulness‐Promoting Agents Brand Name Generic Name Formulation Strength Modafinil Modafinil Tablet 200 MG PA S QL F AL P GL Restrictions (if applicable) Reserved for narcolepsly treated by sleep specialist or pulmonologist RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 38 of 119 May 2015 THERAPUTIC CATEGORY Cough&Cold DRUG CLASS: 1St Gen Antihistamine‐Decongestant‐Analgesic Comb Brand Name Generic Name Non‐Aspirin Child'S Cold P‐Ephed Hcl/Acetaminophen/Cp Formulation Strength Tab Chew 7.5‐80‐0.5 CATEGORY Cough&Cold PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cough&Cold DRUG CLASS: 1St Gen Antihist‐Decon‐Nsaid,Cox Nonspec Brand Name Generic Name Formulation Strength Advil Chlorphen/Pseudoeph/Ibuprofen Tablet 2‐30‐200MG PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cough&Cold DRUG CLASS: Decongest‐Analgesic,Non‐Salicylate Comb. Brand Name Generic Name Formulation Daytime Sinus Relief Pseudoephedrine/Acetaminophen Capsule 30MG‐325MG Tavist Pseudoephedrine/Acetaminophen Tablet 30MG‐500MG DRUG CLASS: Decongestant Brand Name Generic Name Formulation Strength Sudafed Pe Phenylephrine Hcl Tablet 10 MG Nasal Decongestant Phenylephrine Hcl Tablet 5 MG Pediacare Pseudoephedrine Hcl Drops 9.4MG/ML Children'S Sudafed Pseudoephedrine Hcl Liquid 15 MG/5 ML Pseudoephedrine Hcl Pseudoephedrine Hcl Liquid 30 MG/5 ML Pseudoephedrine Hcl Pseudoephedrine Hcl Tablet 30 MG Pseudoephedrine Hcl Pseudoephedrine Hcl Tablet 60 MG Sudafed 12 Hour Pseudoephedrine Hcl Tablet Er 120 MG Tablet Er 120 MG Strength AL P GL Restrictions (if applicable) CATEGORY Cough&Cold 12 Hour Cold Relief Pseudoephedrine Sulfate DRUG CLASS: Decongestant‐Expectorant Combinations Brand Name Generic Name Formulation PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cough&Cold Strength Suphedrin Non‐Drying S Guaifenesin/Pseudoephedrne Hcl Capsule 200MG‐30MG Q‐Tussin Pe Guaifenesin/Pseudoephedrne Hcl Syrup 100‐30MG/5 Triaminic Guaifenesin/Pseudoephedrne Hcl Syrup 50‐15MG/5 Mucinex D Guaifenesin/Pseudoephedrne Hcl Tab Er 12H 1200‐120MG Mucinex D Guaifenesin/Pseudoephedrne Hcl Tab Er 12H 600MG‐60MG Congestac Guaifenesin/Pseudoephedrne Hcl Tablet 400MG‐60MG DRUG CLASS: Decongestant‐Nsaid, Cox Non‐Spec Comb. Brand Name Generic Name Formulation Strength Ibuprofen Cold Ibuprofen/Pseudoephedrine Hcl Oral Susp 100‐15MG/5 DRUG CLASS: Expectorants Brand Name Generic Name Formulation Strength Robitussin Guaifenesin Liquid 100 MG/5ML Diabetic Tussin Mucus R Guaifenesin Liquid 200 MG/5ML Organidin Nr Guaifenesin Tablet 200 MG Mucus Relief Guaifenesin Tablet Er 600 MG DRUG CLASS: Narcotic Antituss‐1St Gen. Antihistamine‐Decongest Brand Name Generic Name Formulation Strength Phenylhistine Dh P‐Ephed Hcl/Cod/Chlorphenir Liquid 30‐10‐2/5 AL P GL Restrictions (if applicable) CATEGORY Cough&Cold PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cough&Cold PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cough&Cold PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 39 of 119 May 2015 Phenergan Vc With Codeine Promethazine/Phenyleph/Codeine Syrup 6.25‐5‐10 DRUG CLASS: Narcotic Antituss‐Decongestant‐Expectorant Comb Brand Name Generic Name Formulation Strength Cheratussin Dac P‐Ephed Hcl/Codeine/Guaifen Syrup 30‐10‐100 DRUG CLASS: Narcotic Antitussive‐1St Generation Antihistamine Brand Name Generic Name Formulation Strength Promethazine‐Codeine Promethazine Hcl/Codeine Syrup 6.25‐10/5 DRUG CLASS: Narcotic Antitussive‐Anticholinergic Comb. Brand Name Generic Name Formulation Strength Hydromet Hydrocodone Bit/Homatrop Me‐Br Syrup 5‐1.5 MG/5 DRUG CLASS: Narcotic Antitussive‐Expectorant Combination Brand Name Generic Name Formulation Strength Guaifenesin‐Codeine Guaifenesin/Codeine Phosphate Liquid 100‐10MG/5 DRUG CLASS: Non‐Narc Antitus‐1St Gen Antihist‐Decon‐Analges Cb Brand Name Generic Name Formulation Strength Alka‐Seltzer Plus‐D Dm Hb/Pseudoephed/Acetamin/Cp Capsule 10‐30‐325 Tylenol Cold Dm Hb/Pseudoephed/Acetamin/Cp Tablet 15‐30‐325 Liquid 30‐12.5/30 Tylenol Cold & Flu Sever Dm/P‐Ephed/Acetaminoph/Doxylam CATEGORY Cough&Cold PA S QL F AL P GL Restrictions (if applicable) Restricted to 240 ml per fill , 4 fills in 365 days and over the age of 5 CATEGORY Cough&Cold PA S QL F AL P GL Restrictions (if applicable) Restricted to 240 ml per fill and 4 fills in 365 days. must be over 5. CATEGORY Cough&Cold DRUG CLASS: Non‐Narc Antituss‐1St Gen. Antihistamine‐Decongest Brand Name Generic Name Dimetapp Dm Brompheniram/Phenylephrine/Dm Solution 1‐2.5‐5/5 Cardec Dm Dm/Phenyleph/Chlorpheniramine Drops 3‐3.5‐1/ML Bromaline Dm D‐Methorphan Hb/P‐Epd Hcl/Bpm Elixir 5‐15‐1MG/5 Bio‐Dtuss Dmx D‐Methorphan Hb/P‐Epd Hcl/Bpm Liquid 20‐30‐1/5 Dimetane‐Dx D‐Methorphan Hb/P‐Epd Hcl/Bpm Syrup 10‐30‐2/5 Anaplex Dm D‐Methorphan Hb/P‐Epd Hcl/Bpm Syrup 30‐60‐4/5 Rescon‐Dm D‐Methorphan Hb/P‐Ephed Hcl/Cp Liquid 10‐30‐2/5 Pediacare Cough‐Cold D‐Methorphan Hb/P‐Ephed Hcl/Cp Liquid 5‐15‐1MG/5 M‐End Dm D‐Methorphan Hb/P‐Ephed Hcl/Cp Syrup 15‐15‐2/5 Formulation Restricted to 240 ml per fill and 4 fills in 365 days. must be over 5. Strength DRUG CLASS: Non‐Narc Antitussive‐1St Gen Antihistamine Comb. Brand Name Generic Name Formulation Strength Syrup 15‐6.25/5 Promethazine‐Dm D‐Methorphan Hb/Prometh Hcl DRUG CLASS: Non‐Narcotic Antituss‐Decongestant‐Expectorant Cmb Brand Name Generic Name Formulation Strength Tussin Cf Guaifenesin/Dm/Pseudoephedrine Syrup 100‐10‐30 Robitussin Cough & Col Guaifenesin/D‐Methorphan Hb/Pe Liquid 100‐10‐5MG PA S QL F AL P GL Restrictions (if applicable) Limited to 240ml per fill and 4 fills per year CATEGORY Cough&Cold PA S QL F AL P GL Restrictions (if applicable) Restricted to 240 ml per fill and 4 fills in 365 days. CATEGORY Cough&Cold PA S QL F PA S QL F PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cough&Cold AL P GL Restrictions (if applicable) CATEGORY Cough&Cold AL P GL Restrictions (if applicable) CATEGORY Cough&Cold AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 40 of 119 May 2015 DRUG CLASS: Non‐Narcotic Antitussive And Expectorant Comb. Brand Name Generic Name Formulation Coricidin Hbp Guaifenesin/Dextromethorphan Strength Capsule 200MG‐10MG Adult Robitussin Peak C Guaifenesin/Dextromethorphan Liquid 100‐10MG/5 Child Mucus Relief Coug Guaifenesin/Dextromethorphan Liquid 100‐5 MG/5 Robitussin Dm Max Guaifenesin/Dextromethorphan Liquid 200‐10MG/5 Scot‐Tussin Senior Guaifenesin/Dextromethorphan Liquid 200‐15MG/5 Neo‐Tuss Guaifenesin/Dextromethorphan Liquid 200‐30MG/5 Biospec Dmx Guaifenesin/Dextromethorphan Liquid 25‐15MG/5 Double Tussin Dm Guaifenesin/Dextromethorphan Liquid 300‐20MG/5 Robitussin‐Dm Cough Guaifenesin/Dextromethorphan Syrup 100‐10MG/5 Tussin Dm Guaifenesin/Dextromethorphan Syrup 100‐15MG/5 Mucus Dm Max Guaifenesin/Dextromethorphan Tab Er 12H 1200‐60MG Mucinex Dm Guaifenesin/Dextromethorphan Tab Er 12H 600MG‐30MG Mucus Relief Dm Guaifenesin/Dextromethorphan Tablet 400MG‐20MG DRUG CLASS: Non‐Narcotic Antitussive‐Decongestant Combinations Brand Name Generic Name Formulation Strength Pedia Relief Dextromethorphan/Pseudoephed Drops 2.5‐7.5/.8 Expectorant Max Streng Dextromethorphan/Pseudoephed Liquid 15‐30MG/5 DRUG CLASS: Non‐Narcotic Antitussive‐Decongestant‐Analgesic Cb Brand Name Generic Name Formulation Strength Drops 5‐15‐160MG Infant Non‐Asa Cold Dm/Pseudoephed/Acetaminophen DRUG CLASS: Nose Preparations, Vasoconstrictors(Otc) Brand Name Generic Name Formulation Strength Opcon‐A Naphazoline Hcl/Pheniramine Drops .0268‐.315 Naphcon‐A Naphazoline Hcl/Pheniramine Drops 0.025‐0.3% CATEGORY Cough&Cold PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cough&Cold PA S QL F PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Cough&Cold AL P GL Restrictions (if applicable) CATEGORY Cough&Cold AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 41 of 119 May 2015 THERAPUTIC CATEGORY Dental CATEGORY Dental DRUG CLASS: Fluoride Preparations Brand Name Generic Name Formulation Strength Prevident 5000 Plus Sodium Fluoride Cream (G) 0.011 Fluoritab Sodium Fluoride Drops 0.125/DROP Fluorabon Sodium Fluoride Drops 0.25MG/0.6 Fluoritab Sodium Fluoride Drops 0.25MG/DRP Luride Sodium Fluoride Drops 0.5 MG/ML Fluor‐A‐Day Sodium Fluoride Drops 2.5 MG/ML Prevident Sodium Fluoride Gel (Gram) 0.011 Prevident 5000 Sodium Fluoride Gel (Ml) 0.011 Prevident Sodium Fluoride Paste (Ml) 0.011 Phos‐Flur Sodium Fluoride Solution 0.0002 Prevident Sodium Fluoride Solution 0.002 Luride Sodium Fluoride Tab Chew 0.25(0.55) Luride Sodium Fluoride Tab Chew 0.5(1.1)MG Luride Sodium Fluoride Tab Chew 1MG(2.2MG) Fluor‐A‐Day Sodium Fluoride/Xylitol Tab Chew 0.25(0.55) Fluor‐A‐Day Sodium Fluoride/Xylitol Tab Chew 0.5(1.1)MG Fluor‐A‐Day Sodium Fluoride/Xylitol Tab Chew 1MG(2.2MG) PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 42 of 119 May 2015 THERAPUTIC CATEGORY Dermatology CATEGORY Dermatology DRUG CLASS: Acne Agents,Systemic Brand Name Generic Name Formulation Strength Accutane Isotretinoin Capsule 10 MG Step therapy to failing 2 formulary alternatives: benzoyl peroxide, topical retinoids, topical antibiotics or oral antibiotics. Accutane Isotretinoin Capsule 20 MG Step therapy to failing 2 formulary alternatives: benzoyl peroxide, topical retinoids, topical antibiotics or oral antibiotics. Claravis Isotretinoin Capsule 30 MG Step therapy to failing 2 formulary alternatives: benzoyl peroxide, topical retinoids, topical antibiotics or oral antibiotics. Accutane Isotretinoin Capsule 40 MG Step therapy to failing 2 formulary alternatives: benzoyl peroxide, topical retinoids, topical antibiotics or oral antibiotics. DRUG CLASS: Acne Agents,Topical Brand Name Generic Name Formulation Strength Aczone Dapsone Gel (Gram) 0.05 PA S QL F AL P GL Restrictions (if applicable) CATEGORY Dermatology PA S QL F AL P GL Restrictions (if applicable) Reserved for treatment failure to tretinoin/adapalene and clindamycin/erythromycin concurrently with benzoyl peroxide CATEGORY Dermatology DRUG CLASS: Antiperspirants Brand Name Generic Name Formulation Strength Drysol Aluminum Chloride Solution 0.2 PA S QL F AL P GL Restrictions (if applicable) Limited to 1 fill per month CATEGORY Dermatology DRUG CLASS: Antipsoriatic Agents,Systemic Brand Name Generic Name Formulation Strength Acitretin Acitretin Capsule 10 MG Restricted to Alernatives: by dermatologists only. Acitretin Acitretin Capsule 25 MG Restricted to Alernatives: by dermatologists only. Cosentyx Syringe Secukinumab Syringe 150 MG/ML Psoriasis: reserved for treatment failure to adalimumab/etanercept and infliximab. must be prescribed by dermatologist or rheumatologist. PA S QL F AL P GL Restrictions (if applicable) CATEGORY Dermatology DRUG CLASS: Antipsoriatics Agents Brand Name Generic Name Formulation Strength Drithocreme Hp Anthralin Cream (G) 0.01 Dovonex Calcipotriene Cream (G) 5e‐005 St to 1 fill of medium/high‐potency topical corticosteroids within the last 30 days. must be prescribed by dermatologist. Calcipotriene Calcipotriene Oint. (G) 5e‐005 St to 1 fill of medium/high‐potency topical corticosteroids within the last 30 days. must be prescribed by dermatologist. Calcipotriene Calcipotriene Solution 5e‐005 St to 1 fill of medium/high‐potency topical corticosteroids within the last 30 days. must be prescribed by dermatologist. Tazorac Tazarotene Cream (G) 0.0005 Psoriasis: st to medium/high‐potency corticosteroids within the last 30 days//acne: treatment failure to tretinoin and adapalene + bpo. must be prescribed by dermatologist. limit 30g per month PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 43 of 119 May 2015 Tazorac Tazarotene Cream (G) 0.001 Psoriasis: st to medium/high‐potency corticosteroids within the last 30 days//acne: treatment failure to tretinoin and adapalene + bpo. must be prescribed by dermatologist. limit 30g per month Tazorac Tazarotene Gel (Gram) 0.0005 Psoriasis: st to medium/high‐potency corticosteroids within the last 30 days//acne: treatment failure to tretinoin and adapalene + bpo. must be prescribed by dermatologist. limit 30g per month Tazorac Tazarotene Gel (Gram) 0.001 Psoriasis: st to medium/high‐potency corticosteroids within the last 30 days//acne: treatment failure to tretinoin and adapalene + bpo. must be prescribed by dermatologist. limit 30g per month DRUG CLASS: Antiseborrheic Agents Brand Name Generic Name Formulation Strength Selseb Selenium Sulfide Shampoo 0.0225 Selenium Sulfide Selenium Sulfide Suspension 0.025 Shampoo 0.01 Formulation Strength CATEGORY Dermatology Dandruff Shampoo Selenium Sulfide/Aloe Vera DRUG CLASS: Emollients Brand Name Generic Name Lac‐Hydrin Ammonium Lactate Cream (G) 0.12 Amlactin Ammonium Lactate Kit 12%‐12% Lac‐Hydrin 5 Ammonium Lactate Lotion 0.05 Lac‐Hydrin Ammonium Lactate Lotion 0.12 Hand Cream Glycerin Cream (G) Glycerin Glycerin Liquid Wibi Glycerin Lotion Glycerin Glycerin Solution 0.995 Lactinol‐E Lactic Acid Cream (G) 0.1 Lotion 0.1 PA S QL F PA S QL F PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Dermatology Lactinol Lactic Acid DRUG CLASS: Irritants/Counter‐Irritants Brand Name Generic Name Formulation Strength Capsaicin Capsaicin Cream (G) 0.00025 Muscle Relief Capsaicin Cream (G) 0.00075 High Potency Capsaicin Capsaicin Cream (G) 0.001 Strength AL P GL Restrictions (if applicable) CATEGORY Dermatology AL P GL Restrictions (if applicable) CATEGORY Dermatology DRUG CLASS: Keratolytics Brand Name Generic Name Formulation Panoxyl Benzoyl Peroxide Bar 0.1 Panoxyl‐4 Benzoyl Peroxide Cleanser 0.04 Benzoyl Peroxide Benzoyl Peroxide Cleanser 0.05 Benzoyl Peroxide Benzoyl Peroxide Cleanser 0.06 Panoxyl Benzoyl Peroxide Cleanser 0.1 Acne Treatment Benzoyl Peroxide Cream (G) 0.1 Brevoxyl‐4 Benzoyl Peroxide Gel (Gram) 0.04 Benzoyl Peroxide Benzoyl Peroxide Gel (Gram) 0.05 Desquam‐X Benzoyl Peroxide Gel (Gram) 0.1 Benzoyl Peroxide Benzoyl Peroxide Lotion 0.05 Benzoyl Peroxide Benzoyl Peroxide Lotion 0.1 Condylox Podofilox Gel (Gram) 0.005 AL P GL Restrictions (if applicable) Limited to 3.5g per 30 days RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 44 of 119 May 2015 Podofilox Podofilox Solution 0.005 X‐Seb T Pearl Salicylic Acid/Coal Tar Shampoo Formulation Strength Tablet 0.1 MG DRUG CLASS: Mineralocorticoids Brand Name Generic Name Fludrocortisone Acetate Fludrocortisone Acetate Limited to 3.5g per 30 days CATEGORY Dermatology PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Dermatology DRUG CLASS: Neuromuscular Blocking Agents Brand Name Generic Name Formulation Strength Botox Onabotulinumtoxina Vial 100 UNIT AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Dermatology DRUG CLASS: Protectives Brand Name Generic Name Formulation Strength Calamine Calamine Lotion Calamine Calamine/Zinc Oxide Lotion DRUG CLASS: Topical Antifungal/Antiinflammatory,Steriod Agent Brand Name Generic Name Formulation Strength Lotrisone Clotrimazole/Betamethasone Dip Cream (G) 1 %‐0.05 % PA S QL F AL P GL Restrictions (if applicable) CATEGORY Dermatology PA S QL F AL P GL Restrictions (if applicable) Restricted to 45g per 30 days CATEGORY Dermatology DRUG CLASS: Topical Anti‐Inflammatory Steroidal Brand Name Generic Name Formulation Beta‐Val Betamethasone Valerate Cream (G) 0.001 Beta‐Val Betamethasone Valerate Lotion 0.001 Betamethasone Valerat Betamethasone Valerate Oint. (G) 0.001 Clobetasol Propionate Clobetasol Propionate Cream (G) 0.0005 Quantity limit of 60g per 90 days per p&t dermatologist recommendation due to high systemic absorption and hpa axis supression Clobetasol Propionate Clobetasol Propionate Oint. (G) 0.0005 Quantity limit of 60g per 90 days per p&t dermatologist recommendation due to high systemic absorption and hpa axis supression Cormax Clobetasol Propionate Solution 0.0005 Quantity limit of 60g per 90 days per p&t dermatologist recommendation due to high systemic absorption and hpa axis supression Desonide Desonide Cream (G) 0.0005 Desonide Desonide Lotion 0.0005 Desonide Desonide Strength Oint. (G) 0.0005 Fluocinolone Acetonide Fluocinolone Acetonide Cream (G) 0.0001 Fluocinolone Acetonide Fluocinolone Acetonide Cream (G) 0.00025 Fluocinolone Acetonide Fluocinolone Acetonide Oil 0.0001 Fluocinolone Acetonide Fluocinolone Acetonide Oint. (G) 0.00025 Fluocinolone Acetonide Fluocinolone Acetonide Solution 0.0001 Fluocinonide Fluocinonide Cream (G) 0.0005 Fluocinonide Fluocinonide Gel (Gram) 0.0005 Fluocinonide Fluocinonide Oint. (G) 0.0005 Fluocinonide Fluocinonide Solution 0.0005 Dermolate Anti‐Itch Hydrocortisone Cream (G) 0.005 PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 45 of 119 May 2015 Cortaid Hydrocortisone Cream (G) 0.01 Hytone Hydrocortisone Cream (G) 0.025 Hydrocortisone Hydrocortisone Lotion 0.01 Aquanil Hc Hydrocortisone Lotion 0.01 Hydrocortisone Hydrocortisone Lotion 0.025 Hydrocortisone Hydrocortisone Oint. (G) 0.005 Hydrocortisone Hydrocortisone Oint. (G) 0.01 Hydrocortisone Hydrocortisone Oint. (G) 0.025 Hydrocortisone Acetate Hydrocortisone Acetate Cream (G) 0.005 Hydrocortisone Acetate Hydrocortisone Acetate Cream (G) 0.01 Cortaid Hydrocortisone Acetate Oint. (G) 0.01 Hydrocortisone‐Aloe Hydrocortisone/Aloe Vera Cream (G) 0.01 Elocon Mometasone Furoate Cream (G) 0.001 Elocon Mometasone Furoate Oint. (G) 0.001 Triamcinolone Acetonid Triamcinolone Acetonide Cream (G) 0.00025 Triamcinolone Acetonid Triamcinolone Acetonide Cream (G) 0.001 Triamcinolone Acetonid Triamcinolone Acetonide Cream (G) 0.005 Triamcinolone Acetonid Triamcinolone Acetonide Lotion 0.00025 Triamcinolone Acetonid Triamcinolone Acetonide Lotion 0.001 Triamcinolone Acetonid Triamcinolone Acetonide Oint. (G) 0.00025 Trianex Triamcinolone Acetonide Oint. (G) 0.0005 Triamcinolone Acetonid Triamcinolone Acetonide Oint. (G) 0.001 Triamcinolone Acetonid Triamcinolone Acetonide Oint. (G) 0.005 CATEGORY Dermatology DRUG CLASS: Topical Anti‐Inflammatory, Nsaids Brand Name Generic Name Formulation Strength Pennsaid Diclofenac Sodium Drops 0.015 Step therapy to failure of 3 different nsaids (including meloxicam or etodolac) unless over 65 or at high risk for gi events. Voltaren Diclofenac Sodium Gel (Gram) 0.01 Step therapy to failure of 3 different nsaids (including meloxicam or etodolac) unless over 65 or at high risk for gi events. DRUG CLASS: Topical Immunosuppressive Agents Brand Name Generic Name Formulation Strength Elidel Pimecrolimus Cream (G) 0.01 Step therapy to medium potency corticosteroids (triamcinolone 0.5%, betamethasone valerate 0.1% or fluocinolone 0.025% for 30 days Protopic Tacrolimus Oint. (G) 0.0003 Step therapy to medium potency corticosteroids (triamcinolone 0.5%, betamethasone valerate 0.1% or fluocinolone 0.025% for 30 days Protopic Tacrolimus Oint. (G) 0.0003 Step therapy to medium potency corticosteroids (triamcinolone 0.5%, betamethasone valerate 0.1% or fluocinolone 0.025% for 30 days Protopic Tacrolimus Oint. (G) 0.001 Step therapy to medium potency corticosteroids (triamcinolone 0.5%, betamethasone valerate 0.1% or fluocinolone 0.025% for 30 days Protopic Tacrolimus Oint. (G) 0.001 Step therapy to medium potency corticosteroids (triamcinolone 0.5%, betamethasone valerate 0.1% or fluocinolone 0.025% for 30 days PA S QL F AL P GL Restrictions (if applicable) CATEGORY Dermatology PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 46 of 119 May 2015 CATEGORY Dermatology DRUG CLASS: Topical Sulfonamides Brand Name Generic Name Formulation Strength Rosanil Cleanser Sulfacetamide Sodium/Sulfur Cleanser 10‐5%(W/W) PA S QL F AL P GL Restrictions (if applicable) Limited to 1 fill per 23 days CATEGORY Dermatology DRUG CLASS: Topical/Mucous Membr./Subcut. Enzymes Brand Name Generic Name Formulation Strength Xenaderm Trypsin/Balsam Peru/Castor Oil Oint. (G) 90 U‐87/G PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. CATEGORY Dermatology DRUG CLASS: Vitamin A Derivatives Brand Name Generic Name Formulation Strength Adapalene Adapalene Cream (G) 0.001 Restricted to Alernatives: by patients <= 35yo. over 35 will require clinic notes, prior Alernatives: of topical antibiotics and benzoyl peroxide or prescribed by dermatologist. Adapalene Adapalene Gel (Gram) 0.001 Restricted to Alernatives: by patients <= 35yo. over 35 will require clinic notes, prior Alernatives: of topical antibiotics and benzoyl peroxide or prescribed by dermatologist. Differin Adapalene Gel (Gram) 0.003 Restricted to Alernatives: by patients <= 35yo. over 35 will require clinic notes, prior Alernatives: of topical antibiotics and benzoyl peroxide or prescribed by dermatologist. Differin Adapalene Lotion 0.001 Restricted to Alernatives: by patients <= 35yo. over 35 will require clinic notes, prior Alernatives: of topical antibiotics and benzoyl peroxide or prescribed by dermatologist. Retin‐A Tretinoin Cream (G) 0.00025 Restricted to Alernatives: by patients <= 35yo. over 35 will require clinic notes, prior Alernatives: of topical antibiotics and benzoyl peroxide or prescribed by dermatologist. Retin‐A Tretinoin Cream (G) 0.0005 Restricted to Alernatives: by patients <= 35yo. over 35 will require clinic notes, prior Alernatives: of topical antibiotics and benzoyl peroxide or prescribed by dermatologist. Retin‐A Tretinoin Cream (G) 0.001 Restricted to Alernatives: by patients <= 35yo. over 35 will require clinic notes, prior Alernatives: of topical antibiotics and benzoyl peroxide or prescribed by dermatologist. Retin‐A Tretinoin Gel (Gram) 0.0001 Restricted to Alernatives: by patients <= 35yo. over 35 will require clinic notes, prior Alernatives: of topical antibiotics and benzoyl peroxide or prescribed by dermatologist. Retin‐A Tretinoin Gel (Gram) 0.00025 Restricted to Alernatives: by patients <= 35yo. over 35 will require clinic notes, prior Alernatives: of topical antibiotics and benzoyl peroxide or prescribed by dermatologist. PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 47 of 119 May 2015 THERAPUTIC CATEGORY Diabetes CATEGORY Diabetes DRUG CLASS: Antihypergly, (Dpp‐4) Inhibitor & Biguanide Comb. Brand Name Generic Name Formulation Strength Jentadueto Linagliptin/Metformin Hcl Tablet 2.5‐1000MG Restricted to maximum of 2 tablets per day. Jentadueto Linagliptin/Metformin Hcl Tablet 2.5‐500 MG Restricted to maximum of 2 tablets per day. Jentadueto Linagliptin/Metformin Hcl Tablet 2.5‐850 MG Restricted to maximum of 2 tablets per day. Kombiglyze Xr Saxagliptin Hcl/Metformin Hcl Tbmp 24Hr 2.5‐1000MG Restricted to 1 tablet per day. Kombiglyze Xr Saxagliptin Hcl/Metformin Hcl Tbmp 24Hr 5 MG‐500MG Restricted to 1 tablet per day (5/500 and 5/1000mg formulations) Kombiglyze Xr Saxagliptin Hcl/Metformin Hcl Tbmp 24Hr 5MG‐1000MG Restricted to 1 tablet per day. Janumet Sitagliptin Phos/Metformin Hcl Tablet 50‐1000 MG Restricted to 2 tablets per day. Janumet Sitagliptin Phos/Metformin Hcl Tablet 50MG‐500MG Restricted to 2 tablets per day. Janumet Xr Sitagliptin Phos/Metformin Hcl Tbmp 24Hr 100‐1000MG Restricted to 1 tablet per day. Janumet Xr Sitagliptin Phos/Metformin Hcl Tbmp 24Hr 50‐1000 MG Restricted to 2 tablets per day. Janumet Xr Sitagliptin Phos/Metformin Hcl Tbmp 24Hr 50MG‐500MG Restricted to 2 tablets per day. DRUG CLASS: Antihypergly,Incretin Mimetic(Glp‐1 Recep.Agonist) Brand Name Generic Name Formulation Strength Byetta Exenatide Pen Injctr 10MCG/0.04 Step therapy to inadequate response to an adequate trial of metformin (unless intolerant or contraindicated) for patients with hba1c < 9%. Byetta Exenatide Pen Injctr 5MCG/0.02 Step therapy to inadequate response to an adequate trial of metformin (unless intolerant or contraindicated) for patients with hba1c < 9%. Bydureon Exenatide Microspheres Vial 2 MG Reserved for patients concurrently on metformin with hba1c <9% Victoza 2‐Pak Liraglutide Pen Injctr 0.6MG/0.1 Step therapy to inadequate response to an adequate trial of metformin (unless intolerant or contraindicated) for patients with hba1c < 9% and who have failed byetta. DRUG CLASS: Antihyperglycemic, Amylin Analog‐Type Brand Name Generic Name Formulation PA S QL F AL P GL Restrictions (if applicable) CATEGORY Diabetes PA S QL F AL P GL Restrictions (if applicable) CATEGORY Diabetes Strength PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 48 of 119 May 2015 Symlinpen 60 Pramlintide Acetate Pen Injctr 1500/1.5ML DRUG CLASS: Antihyperglycemic, Dpp‐4 Inhibitors Brand Name Generic Name Formulation Strength Tradjenta Linagliptin Tablet 5 MG Step therapy to inadequate response to an adequate trial of metformin (unless intolerant or contraindicated). Onglyza Saxagliptin Hcl Tablet 2.5 MG Step therapy to metformin. standard dosing is 5mg daily unless ckd. for 2.5mg/day, please submit recent renal function tests showing impairment. Onglyza Saxagliptin Hcl Tablet 5 MG Step therapy to metformin. standard dosing is 5mg daily unless ckd. for 2.5mg/day, please submit recent renal function tests showing impairment. Januvia Sitagliptin Phosphate Tablet 100 MG St to metformin (metformin er if gi upset). Januvia Sitagliptin Phosphate Tablet 25 MG Step therapy to metformin. standard dosing is 100mg daily unless ckd. for 50mg/day and lower, please submit recent renal function tests showing impairment. Januvia Sitagliptin Phosphate Tablet 50 MG Step therapy to metformin. standard dosing is 100mg daily unless ckd. for 50mg/day and lower, please submit recent renal function tests showing impairment. CATEGORY Diabetes PA S QL F AL P GL Restrictions (if applicable) CATEGORY Diabetes DRUG CLASS: Blood Sugar Diagnostics Brand Name Generic Name Formulation Strength Ascensia Elite Blood Sugar Diagnostic Strip DRUG CLASS: Hyperglycemics Brand Name Generic Name Glucagon Emergency Kit Glucagon,Human Recombinant Reserved for patients concurrently on metformin with hba1c <9% PA S QL F AL P GL Restrictions (if applicable) Limited to 100 per 30 days CATEGORY Diabetes Formulation Strength Kit 1 MG DRUG CLASS: Hypogly, Insulin‐Rel Stim. & Biguanide (N‐S) Comb. Brand Name Generic Name Formulation Strength Glucovance Glyburide/Metformin Hcl Tablet 1.25‐250MG Glucovance Glyburide/Metformin Hcl Tablet 2.5‐500 MG Glucovance Glyburide/Metformin Hcl Tablet 5 MG‐500MG DRUG CLASS: Hypogly, Insul‐Resp. Enhancer & Biguanide Comb. Brand Name Generic Name PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Diabetes AL P GL Restrictions (if applicable) CATEGORY Diabetes Formulation Strength Pioglitazone‐Metformin Pioglitazone Hcl/Metformin Hcl Tablet 15MG‐500MG PA S QL F AL P GL Restrictions (if applicable) Restricted to a maximum of 2 tablets per day. Pioglitazone‐Metformin Pioglitazone Hcl/Metformin Hcl Tablet 15MG‐850MG Restricted to a maximum of 2 tablets per day. Actoplus Met Xr Pioglitazone Hcl/Metformin Hcl Tbmp 24Hr 15‐1000 MG Restricted to a maximum of 2 tablets per day. Actoplus Met Xr Pioglitazone Hcl/Metformin Hcl Tbmp 24Hr 30‐1000 MG Restricted to a maximum of 2 tablets per day. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 49 of 119 May 2015 CATEGORY Diabetes DRUG CLASS: Hypoglycemics, Alpha‐Glucosidase Inhib Type (N‐S) Brand Name Generic Name Formulation Strength Precose Acarbose Tablet 100 MG Precose Acarbose Tablet 25 MG Precose Acarbose Tablet 50 MG DRUG CLASS: Hypoglycemics, Biguanide Type (Non‐Sulfonylureas) Brand Name Generic Name Formulation Strength Metformin Hcl Er Metformin Hcl Tab Er 24 500 MG Restricted to 5 tablets per day. Glucophage Xr Metformin Hcl Tab Er 24H 500 MG Restricted to 5 tablets per day Glucophage Xr Metformin Hcl Tab Er 24H 750 MG Restricted to 3 tablets per day Glucophage Metformin Hcl Tablet 1000 MG Restricted to 75 per 30 days Glucophage Metformin Hcl Tablet 500 MG Restricted to 5 tablets per day Glucophage Metformin Hcl Tablet 850 MG Restricted to 3 tablets per day PA S QL F AL P GL Restrictions (if applicable) CATEGORY Diabetes PA S QL F AL P GL Restrictions (if applicable) CATEGORY Diabetes DRUG CLASS: Hypoglycemics, Insulin‐Release Stimulant Type Brand Name Generic Name Formulation Strength Chlorpropamide Chlorpropamide Tablet 100 MG Chlorpropamide Chlorpropamide Tablet 250 MG Amaryl Glimepiride Tablet 1 MG Amaryl Glimepiride Tablet 2 MG Amaryl Glimepiride Tablet 4 MG Glucotrol Xl Glipizide Tab Er 24 10 MG Glucotrol Xl Glipizide Tab Er 24 2.5 MG Glucotrol Xl Glipizide Tab Er 24 5 MG Glucotrol Glipizide Tablet 10 MG Glucotrol Glipizide Tablet 5 MG Diabeta Glyburide Tablet 1.25 MG Micronase Glyburide Tablet 2.5 MG Micronase Glyburide Tablet 5 MG DRUG CLASS: Hypoglycemics, Insulin‐Response Enhancer (N‐S) Brand Name Generic Name Formulation Strength Pioglitazone Hcl Pioglitazone Hcl Tablet 15 MG Step therapy to inadequate response to an adequate trial of metformin, unless intolerant or contraindicated. Pioglitazone Hcl Pioglitazone Hcl Tablet 30 MG Step therapy to inadequate response to an adequate trial of metformin, unless intolerant or contraindicated. PA S QL F AL P GL Restrictions (if applicable) CATEGORY Diabetes PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 50 of 119 May 2015 Pioglitazone Hcl Pioglitazone Hcl Tablet 45 MG Step therapy to inadequate response to an adequate trial of metformin, unless intolerant or contraindicated. DRUG CLASS: Insulins Brand Name Generic Name Formulation Strength Humulin 70‐30 Hum Insulin Nph/Reg Insulin Hm Vial 70‐30/ML Novolog Insulin Aspart Vial 100/ML Lantus Insulin Glargine,Hum.Rec.Anlog Vial 100/ML Apidra Insulin Glulisine Vial 100/ML Humalog Insulin Lispro Vial 100/ML Humalog Mix 75‐25 Insulin Npl/Insulin Lispro Vial 75‐25/ML Afrezza Insulin Regular, Human Cart W/Dev 4 UNIT Reserved for treatment failures of two dose‐optimized rapid‐acting injectable insulin (3 months each), given patient tested normal fev1 at baseline. to be Alernatives: d concurrently with basal insulin. Afrezza Insulin Regular, Human Cart W/Dev 4 UNIT(30) Reserved for treatment failures of two dose‐optimized rapid‐acting injectable insulin (3 months each), given patient tested normal fev1 at baseline. to be Alernatives: d concurrently with basal insulin. Afrezza Insulin Regular, Human Cart W/Dev 4 UNIT(60) Reserved for treatment failures of two dose‐optimized rapid‐acting injectable insulin (3 months each), given patient tested normal fev1 at baseline. to be Alernatives: d concurrently with basal insulin. Humulin R Insulin Regular, Human Vial 100/ML Novolog Mix 70‐30 Insuln Asp Prt/Insulin Aspart Vial 70‐30/ML Vial 100/ML CATEGORY Diabetes PA S QL F AL P GL Restrictions (if applicable) Humulin N Nph, Human Insulin Isophane DRUG CLASS: Sodium‐Gluc Cotransport 2 (Sglt2) Inhib Brand Name Generic Name Formulation Strength Invokana Canagliflozin Tablet 100 MG Step therapy to an adequate trial of metformin Invokana Canagliflozin Tablet 300 MG Step therapy to an adequate trial of metformin Farxiga Dapagliflozin Propanediol Tablet 10 MG Step therapy to metformin, and invokana or jardiance. a trial of metformin er is required if intolerance is gi‐ related. Farxiga Dapagliflozin Propanediol Tablet 5 MG Step therapy to metformin, and invokana or jardiance. a trial of metformin er is required if intolerance is gi‐ related. Jardiance Empagliflozin Tablet 10 MG Step therapy to an adequate trial of metformin, unless intolerant/contraindicated. a trial of metformin er is required if intolerance is gi‐related. Jardiance Empagliflozin Tablet 25 MG Step therapy to an adequate trial of metformin, unless intolerant/contraindicated. a trial of metformin er is required if intolerance is gi‐related. DRUG CLASS: Urine Acetone Test Aids Brand Name Generic Name Formulation Strength Ketone Urine Acetone Test,Strips Strip DRUG CLASS: Urine Glucose Test Aids Brand Name Generic Name Formulation Strength Diastix Reagent Urine Glucose Test,Strip Strip CATEGORY Diabetes PA S QL F AL P GL Restrictions (if applicable) CATEGORY Diabetes PA S QL F AL P GL Restrictions (if applicable) Restricted to 100 per 30 days. CATEGORY Diabetes PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 51 of 119 May 2015 Clinitest Reagent Urine Glucose Test,Tablet DRUG CLASS: Urine Glucose/Acetone Test Aids,Strips Tablet Brand Name Generic Name Formulation Strength Keto‐Diastix Reagent Urine Gluc‐Acet Comb.Tst,Strip Strip CATEGORY Diabetes PA S QL F AL P GL Restrictions (if applicable) THERAPUTIC CATEGORY Ear CATEGORY Ear DRUG CLASS: Ear Preparations, Misc. Anti‐Infectives Brand Name Generic Name Formulation Strength Vosol Acetic Acid Solution 0.02 Borofair Acetic Acid/Aluminum Acetate Drops 0.02 Vosol Hc Acetic Acid/Hydrocortisone Drops 2 %‐1 % DRUG CLASS: Ear Preparations,Antibiotics Brand Name Generic Name PA S QL F AL P GL Restrictions (if applicable) CATEGORY Ear Formulation Strength Neomycin‐Polymyxin‐H Neomycin/Polymyxin B Sulf/Hc Drops Susp 3.5‐10K‐1 Neomycin‐Polymyxin‐H Neomycin/Polymyxin B Sulf/Hc Solution 3.5‐10K‐1 Drops 0.003 Ofloxacin Ofloxacin DRUG CLASS: Ear Preparations,Local Anesthetics Brand Name Generic Name Formulation Strength A‐B Otic Antipyrine/Benzocaine Drops 5.4 %‐1.4% PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Ear AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 52 of 119 May 2015 THERAPUTIC CATEGORY Endocrinology CATEGORY Endocrinology DRUG CLASS: Adrenocorticotrophic Hormones Brand Name Generic Name Formulation Strength Cortrosyn Cosyntropin Vial 0.25 MG PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Endocrinology DRUG CLASS: Androgenic Agents Brand Name Generic Name Formulation Strength Vogelxo Testosterone Gel (Gram) 50 MG (1%) Reserved for hypogonadism as evidenced by testosterone levels Androgel Testosterone Gel Md Pmp 1.25G (1%) Reserved for hypogonadism as evidenced by testosterone levels Androgel Testosterone Gel Md Pmp 1.25G (1%) Reserved for hypogonadism as evidenced by testosterone levels. formulary products: androgel and depo‐testosterone only. please submit testosterone lab results to hpsj. Androgel Testosterone Gel Packet 25MG(1%) Reserved for hypogonadism as evidenced by testosterone levels. formulary products: androgel and depo‐testosterone only. please submit testosterone lab results to hpsj. Androgel Testosterone Gel Packet 50 MG (1%) Reserved for hypogonadism as evidenced by testosterone levels. formulary products: androgel and depo‐testosterone only. please submit testosterone lab results to hpsj. Depo‐Testosterone Testosterone Cypionate Vial 100 MG/ML Reserved for hypogonadism as evidenced by testosterone levels. formulary products: androgel and depo‐testosterone only. please submit testosterone lab results to hpsj. Depo‐Testosterone Testosterone Cypionate Vial 200 MG/ML Reserved for hypogonadism as evidenced by testosterone levels. formulary products: androgel and depo‐testosterone only. please submit testosterone lab results to hpsj. DRUG CLASS: Antithyroid Preparations Brand Name Generic Name Formulation Strength Methimazole Methimazole Tablet 10 MG Methimazole Methimazole Tablet 5 MG Tablet 50 MG PA S QL F AL P GL Restrictions (if applicable) CATEGORY Endocrinology PA S QL F PA S QL F AL P GL Restrictions (if applicable) Propylthiouracil Propylthiouracil DRUG CLASS: Bone Resorption Inhibitors Brand Name Generic Name Formulation Strength Prolia Denosumab Syringe 60 MG/ML Reserved for diganosis of osteoporosis and failure of 2 bisphosphonates or fracture on bisphosphonate therapy. 1 fill per 180 days Reclast Zoledronic Acid Infus. Btl 5 MG/100ML Reserved for patients unable to swallow tablets. 1 fill per 365 days DRUG CLASS: Growth Hormones Brand Name Generic Name CATEGORY Endocrinology AL P GL Restrictions (if applicable) CATEGORY Endocrinology Formulation Strength PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 53 of 119 May 2015 Nutropin Aq Somatropin Cartridge 10 MG/2 ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Nutropin Aq Somatropin Cartridge 10 MG/2 ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy at 877‐319‐6337 Omnitrope Somatropin Cartridge 10MG/1.5ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Humatrope Somatropin Cartridge 12 MG Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Cartridge 12 MG/ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Nutropin Aq Somatropin Cartridge 20 MG/2 ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Nutropin Aq Somatropin Cartridge 20 MG/2 ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy at 877‐319‐6337 Humatrope Somatropin Cartridge 24 MG Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Norditropin Somatropin Cartridge 5 MG/1.5ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Nutropin Aq Nuspin Somatropin Cartridge 5 MG/2 ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Cartridge 5 MG/ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Humatrope Somatropin Cartridge 6 MG Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Saizen Somatropin Cartridge 8.8 MG/1.5 Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Norditropin Nordiflex Somatropin Pen Injctr 10MG/1.5ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Norditropin Nordiflex Somatropin Pen Injctr 15MG/1.5ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 54 of 119 May 2015 Norditropin Nordiflex Somatropin Pen Injctr 30 MG/3 ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Norditropin Nordiflex Somatropin Pen Injctr 5 MG/1.5ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 0.2MG/0.25 Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 0.4MG/0.25 Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 0.6MG/0.25 Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 0.8MG/0.25 Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 1.2MG/0.25 Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 1.4MG/0.25 Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 1.6MG/0.25 Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 1.8MG/0.25 Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 1MG/0.25ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Genotropin Somatropin Syringe 2MG/0.25ML Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Serostim Somatropin Vial 4 MG Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy at 877‐319‐6337 Humatrope Somatropin Vial 5 MG Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Serostim Somatropin Vial 5 MG Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy at 877‐319‐6337 RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 55 of 119 May 2015 Omnitrope Somatropin Vial 5.8 MG Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy Serostim Somatropin Vial 6 MG Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy at 877‐319‐6337 Serostim Somatropin Vial 8.8 MG Reserved for children with documented growth home deficiency, turner syndrome, prader‐willi syndrome, small for gestational age. restricted to Diplomat specialty pharmacy at 877‐319‐6337 DRUG CLASS: Lhrh(Gnrh)Agnst Pit.Sup‐Central Precocious Puberty Brand Name Generic Name Formulation Strength Lupron Depot‐Ped Leuprolide Acetate Kit 11.25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Lupron Depot‐Ped Leuprolide Acetate Kit 15 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Lupron Depot‐Ped Leuprolide Acetate Kit 7.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Lupron Depot‐Ped Leuprolide Acetate Syringekit 11.25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Thyroid Function Diagnostic Agents Brand Name Generic Name Formulation Strength Thyrogen Thyrotropin Alfa Vial 1.1 MG DRUG CLASS: Thyroid Hormones Brand Name Generic Name Formulation Strength Synthroid Levothyroxine Sodium Tablet 100 MCG Synthroid Levothyroxine Sodium Tablet 112 MCG Synthroid Levothyroxine Sodium Tablet 125 MCG Synthroid Levothyroxine Sodium Tablet 137 MCG Synthroid Levothyroxine Sodium Tablet 150 MCG Synthroid Levothyroxine Sodium Tablet 175MCG Synthroid Levothyroxine Sodium Tablet 200 MCG Synthroid Levothyroxine Sodium Tablet 25 MCG Synthroid Levothyroxine Sodium Tablet 300 MCG Synthroid Levothyroxine Sodium Tablet 50 MCG Synthroid Levothyroxine Sodium Tablet 75 MCG Synthroid Levothyroxine Sodium Tablet 88 MCG Liothyronine Sodium Liothyronine Sodium Tablet 25 MCG Liothyronine Sodium Liothyronine Sodium Tablet 5 MCG Liothyronine Sodium Liothyronine Sodium Tablet 50 MCG Armour Thyroid Thyroid,Pork Tablet 120 MG Armour Thyroid Thyroid,Pork Tablet 15 MG Armour Thyroid Thyroid,Pork Tablet 180 MG Armour Thyroid Thyroid,Pork Tablet 240 MG Armour Thyroid Thyroid,Pork Tablet 30 MG CATEGORY Endocrinology PA S QL F AL P GL Restrictions (if applicable) CATEGORY Endocrinology PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Endocrinology PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 56 of 119 May 2015 Armour Thyroid Thyroid,Pork Tablet 300 MG Armour Thyroid Thyroid,Pork Tablet 60 MG Armour Thyroid Thyroid,Pork Tablet 90 MG THERAPUTIC CATEGORY Enzyme CATEGORY Enzyme DRUG CLASS: Metabolic Disease Enzyme Replacement, Fabry'S Dx Brand Name Generic Name Formulation Strength Fabrazyme Agalsidase Beta Vial 35 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Fabrazyme Agalsidase Beta Vial 5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Metabolic Dx Enzyme Replace, Mucopolysaccharidosis Brand Name Generic Name Formulation Strength Aldurazyme Laronidase Vial 2.9 MG/5ML PA S QL F AL P GL Restrictions (if applicable) CATEGORY Enzyme PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 57 of 119 May 2015 THERAPUTIC CATEGORY Eye CATEGORY Eye DRUG CLASS: Artificial Tears Brand Name Generic Name Formulation Strength Refresh Liquigel Carboxymethylcellulose Sodium Drp Lq Gel 0.01 Tears Naturale‐Ii Dextran 70/Hypromellose Drops Artificial Tears Dextran 70/Hypromellose Drops 0.1%‐0.3% Advanced Eye Relief Glycerin/Propylene Glycol Drops 0.3%‐1% Refresh P.M. Petrolat,Wht/Min Oil/Sod Chl Oint. (G) Teargen Polyvinyl Alcohol Drops 0.014 Systane Propylene Glycol/Peg 400 Drops 0.3 %‐0.4% DRUG CLASS: Carbonic Anhydrase Inhibitors Brand Name Generic Name Formulation Strength Acetazolamide Acetazolamide Capsule Er 500 MG Acetazolamide Acetazolamide Tablet 125 MG Acetazolamide Acetazolamide Tablet 250 MG Methazolamide Methazolamide Tablet 25 MG Methazolamide Methazolamide Tablet 50 MG DRUG CLASS: Eye Antibiotic‐Corticoid Combinations Brand Name Generic Name Formulation Strength Pred‐G Gentamicin/Prednisol Ac Drops Susp 0.3%‐1% Pred‐G Gentamicin/Prednisol Ac Oint. (G) 0.3‐0.6% Maxitrol Neo/Polymyx B Sulf/Dexameth Drops Susp 0.001 Maxitrol Neo/Polymyx B Sulf/Dexameth PA S QL F AL P GL Restrictions (if applicable) CATEGORY Eye PA S QL F AL P GL Restrictions (if applicable) CATEGORY Eye Oint. (G) 3.5‐10K‐.1 Neomycin‐Bacitracin‐Po Neomy Sulf/Bacitrac Zn/Poly/Hc Oint. (G) 3.5‐10K‐1 Cortisporin Neomycin/Polymyxin B Sulf/Hc Drops Susp 3.5‐10K‐10 Tobradex Tobramycin/Dexamethasone Drops Susp 0.3 %‐0.1% Tobradex Tobramycin/Dexamethasone Oint. (G) 0.3 %‐0.1% DRUG CLASS: Eye Antihistamines Brand Name Generic Name Formulation Strength Refresh Ketotifen Fumarate Drops 0.00025 Refresh Ketotifen Fumarate Drops 0.00025 Patanol Olopatadine Hcl Drops 0.001 PA S QL F AL P GL Restrictions (if applicable) CATEGORY Eye PA S QL F AL P GL Restrictions (if applicable) Limited to 10 ml per 30 days. Step therapy to treatment failure of visine‐a and alaway CATEGORY Eye DRUG CLASS: Eye Antiinflammatory Agents Brand Name Generic Name Formulation Strength Maxidex Dexamethasone Drops Susp 0.001 Dexamethasone Sodiu Dexamethasone Sod Phosphate Drops 0.001 Voltaren Diclofenac Sodium Drops 0.001 Fml Fluorometholone Drops Susp 0.001 Fml Forte Fluorometholone Drops Susp 0.0025 Fml S.O.P. Fluorometholone Oint. (G) 0.001 Ocufen Flurbiprofen Sodium Drops 0.0003 Acular Ls Ketorolac Tromethamine Drops 0.004 PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 58 of 119 May 2015 Acular Ketorolac Tromethamine Drops 0.005 Pred Mild Prednisolone Acetate Drops Susp 0.0012 Omnipred Prednisolone Acetate Drops Susp 0.01 Prednisolone Sodium P Prednisolone Sod Phosphate Drops 0.01 Vexol Rimexolone Drops Susp 0.01 CATEGORY Eye DRUG CLASS: Eye Antivirals Brand Name Generic Name Formulation Strength Drops 0.01 Viroptic Trifluridine DRUG CLASS: Eye Local Anesthetics Brand Name Generic Name Formulation Strength Drops 0.005 PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Eye Alcaine Proparacaine Hcl DRUG CLASS: Eye Sulfonamides Brand Name Generic Name Formulation Strength Sulfamide Sulfacetamide Sodium Drops 0.1 Sulfacetamide Sodium Sulfacetamide Sodium Oint. (G) 0.1 AL P GL Restrictions (if applicable) CATEGORY Eye Sulfacetamide‐Predniso Sulfacetamide/Prednisolone Sp Drops 10 %‐0.23% Blephamide Sulfacetm Na/Prednisol Ac Drops Susp 10 %‐0.2 % Blephamide S.O.P. Sulfacetm Na/Prednisol Ac Oint. (G) 10 %‐0.2 % DRUG CLASS: Eye Vasoconstrictors (Rx Only) Brand Name Generic Name Formulation Strength Albalon Naphazoline Hcl Drops 0.001 Mydfrin Phenylephrine Hcl Drops 0.025 Drops 0.1 PA S QL F AL P GL Restrictions (if applicable) CATEGORY Eye Phenylephrine Hcl Phenylephrine Hcl DRUG CLASS: Miotics/Other Intraoc. Pressure Reducers Brand Name Generic Name Formulation Iopidine Apraclonidine Hcl Droperette 0.01 Iopidine Apraclonidine Hcl Drops 0.005 Betaxolol Hcl Betaxolol Hcl Drops 0.005 Betoptic S Betaxolol Hcl Drops Susp 0.0025 Lumigan Bimatoprost Drops 0.0001 Alphagan P Brimonidine Tartrate Drops 0.001 Alphagan P Brimonidine Tartrate Drops 0.0015 Brimonidine Tartrate Brimonidine Tartrate Drops 0.002 Combigan Brimonidine Tartrate/Timolol Drops 0.2%‐0.5% Azopt Brinzolamide Drops Susp 0.01 Miostat Carbachol Vial 0.0001 Carteolol Hcl Carteolol Hcl Drops 0.01 Trusopt Dorzolamide Hcl Drops 0.02 Cosopt Dorzolamide Hcl/Timolol Maleat Drops 22.3‐6.8/1 Phospholine Iodide Echothiophate Iodide Drops 0.00125 Xalatan Latanoprost Drops 5e‐005 Betagan Levobunolol Hcl Drops 0.005 Optipranolol Metipranolol Drops 0.003 Pilocarpine Hcl Pilocarpine Hcl Drops 0.01 Pilocarpine Hcl Pilocarpine Hcl Drops 0.02 Pilocarpine Hcl Pilocarpine Hcl Drops 0.04 Betimol Timolol Drops 0.005 PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Eye Strength AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 59 of 119 May 2015 Timoptic Timolol Maleate Drops 0.0025 Timoptic Timolol Maleate Drops 0.005 Timoptic‐Xe Timolol Maleate Sol‐Gel 0.0025 Timoptic‐Xe Timolol Maleate Sol‐Gel 0.005 Timoptic Ocudose Timolol Maleate/Pf Droperette 0.0025 Timoptic Ocudose Timolol Maleate/Pf Droperette 0.005 CATEGORY Eye DRUG CLASS: Mydriatics Brand Name Generic Name Formulation Strength Atropine Sulfate Atropine Sulfate Drops 0.01 Atropine Sulfate Atropine Sulfate Oint. (G) 0.01 Cyclogyl Cyclopentolate Hcl Drops 0.005 Cyclogyl Cyclopentolate Hcl Drops 0.01 Cyclogyl Cyclopentolate Hcl Drops 0.02 Isopto Homatropine Homatropine Hbr Drops 0.05 Isopto Hyoscine Scopolamine Hydrobromide Drops 0.0025 Tropicamide Tropicamide Drops 0.005 Mydriacyl Tropicamide Drops 0.01 DRUG CLASS: Ophthalmic Antibiotics Brand Name Generic Name Formulation Strength Bacitracin Bacitracin Oint. (G) 500 UNIT/G Bacitracin‐Polymyxin Bacitracin/Polymyxin B Sulfate Oint. (G) 500‐10K/G Ciloxan Ciprofloxacin Hcl Drops 0.003 Erythromycin Erythromycin Base Oint. (G) 5 MG/G Garamycin Gentamicin Sulfate Drops 0.003 Gentamicin Sulfate Gentamicin Sulfate Oint. (G) 0.003 Vigamox Moxifloxacin Hcl Drops 0.005 Step therapy to treatment failure of ofloxacin or ciprofloxacin opthalmic suspension in the last 90 days. Moxeza Moxifloxacin Hcl Drops Visc 0.005 Step therapy to treatment failure of ofloxacin or ciprofloxacin opthalmic suspension in the last 90 days. PA S QL F AL P GL Restrictions (if applicable) CATEGORY Eye Neomycin‐Bacitracin‐Po Neomy Sulf/Bacitra/Polymyxin B Oint. (G) 3.5MG‐400 Neomycin‐Polymyxin‐G Neomycin/Polymyxn B/Gramicidin Drops 1.75MG‐10K Ocuflox Ofloxacin Drops 0.003 Polytrim Polymyxin B Sulf/Trimethoprim Drops 10000‐1/ML Tobrex Tobramycin Drops 0.003 Tobrex Tobramycin Oint. (G) 0.003 DRUG CLASS: Ophthalmic Anti‐Inflammatory Immunomodulator‐Type Brand Name Generic Name Formulation Strength Restasis Cyclosporine Droperette 0.0005 DRUG CLASS: Ophthalmic Mast Cell Stabilizers Brand Name Generic Name Formulation Strength Cromolyn Sodium Cromolyn Sodium Drops 0.04 PA S QL F AL P GL Restrictions (if applicable) CATEGORY Eye PA S QL F AL P GL Restrictions (if applicable) Reserved for patients who have failed ophthalmic lubricants in the last 6 months. CATEGORY Eye PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Eye DRUG CLASS: Topical Antifungals Brand Name Generic Name Formulation Strength Natacyn Natamycin Drops Susp 0.05 AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 60 of 119 May 2015 THERAPUTIC CATEGORY GI, GERD CATEGORY GI, GERD DRUG CLASS: Antacids Brand Name Generic Name Formulation Strength Calcium Carbonate Calcium Carbonate Tablet 260MG(648) Maalox Mag Hydrox/Al Hydrox/Simeth Oral Susp 200‐200‐20 Alamag Plus Mag Hydrox/Al Hydrox/Simeth Oral Susp 200‐225‐25 Maalox Maximum Stren Mag Hydrox/Al Hydrox/Simeth Oral Susp 400‐400‐40 Gelusil Mag Hydrox/Al Hydrox/Simeth Tab Chew 200‐200‐25 DRUG CLASS: Proton‐Pump Inhibitors Brand Name Generic Name Formulation Strength Kapidex Dexlansoprazole Cap Dr Bp 30 MG St to two first line ppi (omep/pantop/lansop), nexium otc, and rabeprazole Dexilant Dexlansoprazole Cap Dr Bp 60 MG St to two first line ppi (omep/pantop/lansop), nexium otc, and rabeprazole Nexium 24h OTC Esomeprazole Magnesium Capsule Dr 20 MG Nexium otc is reserved for documentation of treatment failure of 2 (two) dose‐optimized first line agents (omeprazole 40mg or higher, pantoprazole 40mg or higher, lansoprazole 60mg or higher). Prevacid 24Hr Lansoprazole Capsule Dr 15 MG Lansoprazole Lansoprazole Capsule Dr 30 MG First‐Lansoprazole Lansoprazole Susp Recon 3 MG/ML Omeprazole Omeprazole Capsule Dr 20 MG Omeprazole Omeprazole Capsule Dr 40 MG Omeprazole+Syrspend Sf Alka Omeprazole Susp Recon 2 MG/ML Restricted to children under 13 years old or documented inability to swallot tablets or capsules Omeprazole+Syrspend Sf Alka Omeprazole Susp Recon 2 MG/ML Restricted to children under 13 years old or documented inability to swallot tablets or capsules Pantoprazole Sodium Pantoprazole Sodium Tablet Dr 20 MG Pantoprazole Sodium Pantoprazole Sodium Tablet Dr 40 MG Rabeprazole Sodium Rabeprazole Sodium Tablet Dr 20 MG PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, GERD PA S QL F AL P GL Restrictions (if applicable) Restricted to children under 13 years old or documented inability to swallot tablets or capsules St to two first line ppi (omeprazole/pantoprzole/lansoprazole) and nexium otc RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 61 of 119 May 2015 THERAPUTIC CATEGORY GI, Other CATEGORY GI, Other DRUG CLASS: Ammonia Inhibitors Brand Name Generic Name Formulation Strength Lactulose Lactulose Solution 10 G/15 ML DRUG CLASS: Amyotrophic Lateral Sclerosis Agents Brand Name Generic Name Formulation Strength Rilutek Riluzole Tablet 50 MG QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other DRUG CLASS: Anticholinergics/Antispasmodics Brand Name Generic Name Formulation Strength Dicyclomine Hcl Dicyclomine Hcl Capsule 10 MG Dicyclomine Hcl Dicyclomine Hcl Solution 10 MG/5 ML Dicyclomine Hcl Dicyclomine Hcl Tablet 20 MG DRUG CLASS: Antidiarrheals Brand Name Generic Name Formulation Strength Kaopectate Bismuth Subsalicylate Oral Susp 262MG/15ML Maalox Bismuth Subsalicylate Oral Susp 525MG/15ML Stomach Relief Bismuth Subsalicylate Tab Chew 262 MG Soothe Bismuth Subsalicylate Tablet 262 MG Lomotil Diphenoxylate Hcl/Atropine Liquid 2.5‐.025/5 Lomotil Diphenoxylate Hcl/Atropine Tablet 2.5‐.025MG Loperamide Loperamide Hcl Capsule 2 MG Imodium A‐D Loperamide Hcl Liquid 1 MG/5 ML Loperamide Loperamide Hcl Liquid 1MG/7.5ML Imodium A‐D Loperamide Hcl Tablet 2 MG Paregoric Paregoric Liquid 2 MG/5 ML DRUG CLASS: Anti‐Flam. Interleukin‐1 Receptor Antagonist Brand Name Generic Name Formulation Strength Kineret Anakinra Syringe 100MG/0.67 DRUG CLASS: Antiflatulents Brand Name Generic Name Formulation Strength Simethicone Simethicone Drops Susp 40MG/0.6ML AL P GL Restrictions (if applicable) CATEGORY GI, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY GI, Other PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other DRUG CLASS: Anti‐Ulcer Preparations Brand Name Generic Name Formulation Strength Cytotec Misoprostol Tablet 100 MCG Cytotec Misoprostol Tablet 200 MCG Sucralfate Sucralfate Oral Susp 1 G/10 ML Sucralfate Sucralfate Tablet 1 G DRUG CLASS: Belladonna Alkaloids Brand Name Generic Name Formulation Strength Levsin Hyoscyamine Sulfate Drops 0.125MG/ML Levsin Hyoscyamine Sulfate Elixir 125MCG/5ML Tab Er 12H 0.375 MG Hyoscyamine Sulfate Er Hyoscyamine Sulfate PA S AL P GL Restrictions (if applicable) CATEGORY GI, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 62 of 119 May 2015 Hyomax‐Dt Hyoscyamine Sulfate Tab Mphase Anaspaz Hyoscyamine Sulfate Tab Rapdis 0.125‐0.25 0.125 MG Hyoscyamine Sulfate Hyoscyamine Sulfate Tab Subl 0.125 MG Hyoscyamine Sulfate Hyoscyamine Sulfate Tablet 0.125 MG Belladonna‐Phenobarbi Phenobarb/Hyoscy/Atropine/Scop Elixir 16.2MG/5ML Belladonna‐Phenobarbi Phenobarb/Hyoscy/Atropine/Scop Tablet 16.2 MG CATEGORY GI, Other DRUG CLASS: Bile Salts Brand Name Generic Name Formulation Strength Ursodiol Ursodiol Capsule 300 MG Ursodiol Ursodiol Tablet 250 MG Ursodiol Ursodiol Tablet 500 MG DRUG CLASS: Chronic Inflam. Colon Dx, 5‐A‐Salicylat,Rectal Tx Brand Name Generic Name Formulation Strength Mesalamine Mesalamine Enema 4 G/60 ML Canasa Mesalamine Supp.Rect 1000 MG DRUG CLASS: Drug Tx‐Chronic Inflam. Colon Dx,5‐Aminosalicylat Brand Name Generic Name Formulation Strength Colazal Balsalazide Disodium Capsule 750 MG Delzicol Mesalamine Capsule Dr 400 MG Step therapy to treatment failure of balsalazide, sulfasalazine, or mesalamine enema for 3 months for induction or maintenance. Pentasa Mesalamine Capsule Er 250 MG Pa required. reserved for induction of remission in ileal disease. Pentasa Mesalamine Capsule Er 500 MG Pa required. reserved for induction of remission in ileal disease. DRUG CLASS: Drugs To Tx Chronic Inflamm. Disease Of Colon Brand Name Generic Name Formulation Strength Cimzia Certolizumab Pegol Kit 400 MG Reserved for pregnant patients with RA who are unable to discontinue biologic therapy during pregnancy. Cimzia Certolizumab Pegol Syringekit 400MG/2ML Reserved for pregnant patients with RA who are unable to discontinue biologic therapy during pregnancy. for crohn's disease, it is 3rd line behind remicade and humira. Cimzia Certolizumab Pegol Syringekit 400MG/2ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Remicade Infliximab Vial 100 MG For RA, it is step therapy to treatment failure of enbrel or humira. for crohn's disease, Reserved for severe disease non‐responsive to corticosteroids or immunosupressants. PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other PA S QL F AL P GL Restrictions (if applicable) Reserved for patients unable to administer mesalamine enema. CATEGORY GI, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other DRUG CLASS: Glucocorticoids Brand Name Generic Name Formulation Strength Entocort EC Budesonide Capdr ‐ Er 3 MG DRUG CLASS: Hemorrhoidal Prep,Anti‐Infam Steriods/Local Anesth Brand Name Generic Name Formulation Strength Analpram Hc Hydrocortisone/Pramoxine Cream/Appl 1 %‐1 % Analpram Hc Hydrocortisone/Pramoxine Cream/Appl 2.5 %‐1 % Proctofoam‐Hc Hydrocortisone/Pramoxine Foam 1 %‐1 % PA S QL F AL P GL Restrictions (if applicable) Reserved for induction of remission in those intolerant to conventional glucoorticoids for up to 90 days of therapy. CATEGORY GI, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 63 of 119 May 2015 CATEGORY GI, Other DRUG CLASS: Hemorrhoidal Preparations Brand Name Generic Name Hemorrhoidal Phenylephrine Hcl Supp.Rect 0.0025 Proctofoam Pramoxine Hcl Foam 0.01 DRUG CLASS: Intestinal Motility Stimulants Brand Name Generic Name Formulation Strength Metoclopramide Hcl Metoclopramide Hcl Solution 5 MG/5 ML Reglan Metoclopramide Hcl Tablet 10 MG Reglan Metoclopramide Hcl Tablet 5 MG Formulation Strength PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other DRUG CLASS: Laxatives And Cathartics Brand Name Generic Name Formulation Strength Ex‐Lax Bisacodyl Tablet 5 MG Doxidan Bisacodyl Tablet Dr 5 MG Stool Softener Docusate Sodium Capsule 100 MG Docusate Sodium Docusate Sodium Capsule 250 MG Col‐Rite Docusate Sodium Capsule 50 MG Docusate Sodium Docusate Sodium Liquid 50 MG/5 ML Pedia‐Lax Stool Softene Docusate Sodium Syrup 50 MG/15ML Docusate Sodium Docusate Sodium Syrup 60 MG/15ML Dok Docusate Sodium Tablet 100 MG Kristalose Lactulose Packet 10 G Kristalose Lactulose Packet 20 G Lactulose Lactulose Solution 10 G/15 ML Lactulose Lactulose Solution 10 G/15 ML Lactulose Lactulose Solution 20 G/30 ML Amitiza Lubiprostone Capsule 24MCG Step therapy to treatment failure to senna, pysllium, and miralax. restricted to 60 per 30 days. Amitiza Lubiprostone Capsule 8 MCG Step therapy to treatment failure to senna, pysllium, and miralax. restricted to 60 per 30 days. Magnesium Citrate Magnesium Citrate Solution Ex‐Lax Milk Of Magnesi Magnesium Hydroxide Oral Susp 400 MG/5ML Osmoprep Naphos M‐B M‐H/Na Phos,Di‐Ba Tablet 1.5 G Golytely Peg 3350/Na Sulf,Bicarb,Cl/Kcl Powd Pack 227.1‐21.5 Peg‐3350 And Electrolyt Peg 3350/Na Sulf,Bicarb,Cl/Kcl Soln Recon 236‐22.74G Colyte With Flavor Pack Peg 3350/Na Sulf,Bicarb,Cl/Kcl Soln Recon 240‐22.72G Clearlax Polyethylene Glycol 3350 Powder 17G/DOSE Clearlax Polyethylene Glycol 3350 Powder 17G/DOSE Konsyl Psyllium Husk (With Sugar) Powd Pack 3.4 G Wal‐Mucil Psyllium Husk (With Sugar) Powder 3.4 G/7 G Wal‐Mucil Psyllium Husk/Aspartame Powder 3.4G/5.8G Hydrocil Instant Psyllium Seed Packet Konsyl Psyllium Seed Powder Genfiber Psyllium Seed (With Dextrose) Powder Genfiber Psyllium Seed (With Sugar) Powder AL P GL Restrictions (if applicable) Restricted to 1054g per 30 days. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 64 of 119 May 2015 Metamucil Psyllium Seed (With Sugar) Wafer Senna Sennosides Capsule 8.6 MG Senexon Sennosides Syrup 8.8MG/5ML Ex‐Lax Sennosides Tab Chew 15 MG Ex‐Lax Sennosides Tablet 15 MG Laxative Sennosides Tablet 17.2MG Ex‐Lax Maximum Relief Sennosides Tablet 25 MG Natural Senna Laxative Sennosides Tablet 8.6 MG Senna S Sennosides/Docusate Sodium Tablet 8.6MG‐50MG Soln Recon 420G Trilyte With Flavor Pack Sodium Chloride/Nahco3/Kcl/Peg CATEGORY GI, Other DRUG CLASS: Laxatives, Local/Rectal Brand Name Generic Name Formulation Strength Bisacodyl Bisacodyl Enema 10MG/30ML Bisacodyl Bisacodyl Supp.Rect 10 MG Adult Glycerin Glycerin Supp.Rect ADULT Pedia‐Lax Glycerin Supp.Rect PEDIATRIC DRUG CLASS: Pancreatic Enzymes Brand Name Generic Name Formulation Strength Pancreaze Lipase/Protease/Amylase Capsule Dr 10.5K‐25K Zenpep Lipase/Protease/Amylase Capsule Dr 10‐34‐55K Creon Lipase/Protease/Amylase Capsule Dr 12K‐38K‐60 Zenpep Lipase/Protease/Amylase Capsule Dr 15‐51‐82K Pancreaze Lipase/Protease/Amylase Capsule Dr 16.8‐40‐70 Zenpep Lipase/Protease/Amylase Capsule Dr 20‐68‐109K Pancreaze Lipase/Protease/Amylase Capsule Dr 21‐37‐61K Creon Lipase/Protease/Amylase Capsule Dr 24‐76‐120K Zenpep Lipase/Protease/Amylase Capsule Dr 25‐85‐136K Creon Lipase/Protease/Amylase Capsule Dr 36‐114‐180 Creon Lipase/Protease/Amylase Capsule Dr 3‐9.5‐15K Zenpep Lipase/Protease/Amylase Capsule Dr 3K‐10K‐16K Pancreaze Lipase/Protease/Amylase Capsule Dr 4.2K‐10K Pancrelipase 5,000 Lipase/Protease/Amylase Capsule Dr 5K‐17K‐27K Creon Lipase/Protease/Amylase Capsule Dr 6K‐19K‐30K DRUG CLASS: Parasympathetic Agents Brand Name Generic Name Formulation Strength Bethanechol Chloride Bethanechol Chloride Tablet 10 MG Bethanechol Chloride Bethanechol Chloride Tablet 25 MG Bethanechol Chloride Bethanechol Chloride Tablet 5 MG Bethanechol Chloride Bethanechol Chloride Tablet 50 MG Formulation Strength DRUG CLASS: Rectal Preparations Brand Name Generic Name Procto‐Kit Hydrocortisone QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other PA S QL F PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY GI, Other Cream/Appl 0.025 Hydrocortisone Acetate Hydrocortisone Acetate Supp.Rect 25 MG Hemril Supp.Rect 30 MG Hydrocortisone Acetate PA S DRUG CLASS: Rectal/Lower Bowel Prep.,Glucocort. (Non‐Hemorr) Brand Name Generic Name Formulation Strength Hydrocortisone Hydrocortisone Enema 100MG/60ML AL P GL Restrictions (if applicable) CATEGORY GI, Other AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 65 of 119 May 2015 Cortifoam Hydrocortisone Acetate DRUG CLASS: Topical Local Anesthetics Foam/Appl 0.1 Brand Name Generic Name Formulation Strength Linzess Linaclotide Capsule 145 MCG Reserved for treatment failure of properly titrated and regularly scheduled dosing of polyethylene glycol for 2 months and 2 other laxatives Linzess Linaclotide Capsule 290 MCG Reserved for treatment failure of properly titrated and regularly scheduled dosing of polyethylene glycol for 2 months and 2 other laxatives CATEGORY GI, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 66 of 119 May 2015 THERAPUTIC CATEGORY Infection, Hepatitis CATEGORY Infection, Hepatitis DRUG CLASS: Hepatitis B Treatment Agents Brand Name Generic Name Formulation Strength Adefovir Dipivoxil Adefovir Dipivoxil Tablet 10 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Baraclude Entecavir Tablet 0.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Baraclude Entecavir Tablet 1 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Epivir Hbv Lamivudine Tablet 100 MG Tyzeka Telbivudine Tablet 600 MG DRUG CLASS: Hepatitis C Treatment Agents Brand Name Generic Name Formulation Strength Viekira Pak Ombita/Paritap/Riton/Dasabuvir Tab Ds Pk 12.5‐75‐50 Reserved for hepatitis c patients who meet dhcs treatment policy criteria Pegasys Proclick Peginterferon Alfa‐2A Pen Injctr 180MCG/0.5 Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Pegasys Peginterferon Alfa‐2A Syringe 180MCG/0.5 Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Pegasys Peginterferon Alfa‐2A Vial 180MCG/ML Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Pegintron Redipen Peginterferon Alfa‐2B Pen Ij Kit 120MCG/0.5 Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Pegintron Redipen Peginterferon Alfa‐2B Pen Ij Kit 150MCG/0.5 Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Pegintron Redipen Peginterferon Alfa‐2B Pen Ij Kit 50 MCG/0.5 Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Pegintron Redipen Peginterferon Alfa‐2B Pen Ij Kit 80MCG/0.5 Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Rebetol Ribavirin Capsule 200 MG Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Rebetol Ribavirin Solution 40 MG/ML Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Copegus Ribavirin Tablet 200 MG Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Ribavirin Ribavirin Tablet 400 MG Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Infection, Hepatitis PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 67 of 119 May 2015 Ribavirin Ribavirin Tablet 600 MG Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . Olysio Simeprevir Sodium Capsule 150 MG Reserved for severe hcv infection as evidenced by genotype and fibrosis score. restricted to Diplomat specialty pharmacy Sovaldi Sofosbuvir Tablet 400 MG Reserved for severe hcv infection as evidenced by genotype and fibrosis score. restricted to Diplomat specialty pharmacy THERAPUTIC CATEGORY Infection, HIV DRUG CLASS: Antivirals, Hiv‐Specific, Nucleoside Analog, Rti Brand Name Generic Name Formulation Strength Videx Ec Didanosine Capsule Dr 125 MG Videx Ec Didanosine Capsule Dr 200 MG Videx Ec Didanosine Capsule Dr 250 MG Videx Ec Didanosine Capsule Dr 400 MG Videx Didanosine Soln Recon FNL10MG/ML Retrovir Zidovudine Capsule 100 MG Retrovir Zidovudine Syrup 10 MG/ML Zidovudine Zidovudine Tablet 300 MG Retrovir Zidovudine Vial 10 MG/ML CATEGORY Infection, HIV PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 68 of 119 May 2015 THERAPUTIC CATEGORY Infection, Other CATEGORY Infection, Other DRUG CLASS: 2Nd Gen. Anaerobic Antiprotozoal‐Antibacterial Brand Name Generic Name Formulation Strength Tinidazole Tinidazole Tablet 250 MG Step therapy to treatment failure or intolerance to metronidazole within last 30 days. Tinidazole Tinidazole Tablet 500 MG Step therapy to treatment failure or intolerance to metronidazole within last 30 days. Formulation Strength PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other DRUG CLASS: Absorbable Sulfonamides Brand Name Generic Name Sulfamethoxazole‐Trim Sulfamethoxazole/Trimethoprim Tablet 400MG‐80MG Sulfamethoxazole‐Trim Sulfamethoxazole/Trimethoprim Tablet 800‐160 MG DRUG CLASS: Aminoglycosides Brand Name Generic Name Formulation Strength Gentamicin Sulfate Gentamicin Sulfate Vial 40 MG/ML Neomycin Sulfate Neomycin Sulfate Tablet 500 MG Tobi Tobramycin In 0.225% Nacl Ampul‐Neb 300 MG/5ML PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other DRUG CLASS: Anaerobic Antiprotozoal‐Antibacterial Agents Brand Name Generic Name Formulation Strength Flagyl Metronidazole Tablet 250 MG Flagyl Metronidazole Tablet 500 MG DRUG CLASS: Anthelmintics Brand Name Generic Name Formulation Strength Albenza Albendazole Tablet 200 MG Household Lice Control Piperonyl Butoxide/Pyrethrins Spray Licide Piperonyl Butoxide/Pyrethrins Spray 1 %‐0.2 % Reese Pinworm Pyrantel Pamoate Oral Susp 50 MG/ML Formulation Strength PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) Restricted to 2 tablets per 180 days. for larger quantity, please submit pa CATEGORY Infection, Other DRUG CLASS: Antifungal Agents Brand Name Generic Name Clotrimazole Clotrimazole Troche 10 MG Diflucan Fluconazole Susp Recon 10 MG/ML Diflucan Fluconazole Susp Recon 40 MG/ML Diflucan Fluconazole Tablet 100 MG Diflucan Fluconazole Tablet 150 MG Diflucan Fluconazole Tablet 200 MG Diflucan Fluconazole Tablet 50 MG Ancobon Flucytosine Capsule 250 MG PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 69 of 119 May 2015 Ancobon Flucytosine Capsule 500 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sporanox Itraconazole Capsule 100 MG Restricted to Alernatives: by id, transplant, onychomycosis (after terbinafine), or candidiasis (after fluconazole). Ketoconazole Ketoconazole Tablet 200 MG Reserved for treatment failure or intolerance to other systemic antifungal medications. Noxafil Posaconazole Oral Susp 200 MG/5ML Restricted to Alernatives: by id or transplant specialists. restricted to specialty pharmacy Noxafil Posaconazole Tablet Dr 100 MG Restricted to Alernatives: by id or transplant specialists. Terbinafine Hcl Terbinafine Hcl Tablet 250 MG Restricted to 1 tablet per day and 3 fills per year. Vfend Voriconazole Tablet 200 MG Restricted to Alernatives: for treatment failure of fluconazole for aspergillosis or candidiasis Vfend Voriconazole Tablet 50 MG Restricted to Alernatives: for treatment failure of fluconazole for aspergillosis or candidiasis CATEGORY Infection, Other DRUG CLASS: Antifungal Antibiotics Brand Name Generic Name Formulation Strength Cancidas Caspofungin Acetate Vial 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Cancidas Caspofungin Acetate Vial 70 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Gris‐Peg Griseofulvin Ultramicrosize Tablet 125 MG Gris‐Peg Griseofulvin Ultramicrosize Tablet 250 MG Grifulvin V Griseofulvin, Microsize Oral Susp 125 MG/5ML Grifulvin V Griseofulvin, Microsize Tablet 500 MG Nystatin Nystatin Oral Susp 100000/ML Nystatin Nystatin Powder(Ea) 150MM UNIT Nystatin Nystatin Powder(Ea) 500MM UNIT Nystatin Nystatin Powder(Ea) 50MM UNIT Mycostatin Nystatin Tablet 500K UNIT PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other DRUG CLASS: Antileprotics Brand Name Generic Name Formulation Strength Dapsone Dapsone Tablet 100 MG Dapsone Dapsone Tablet 25 MG Thalomid Thalidomide Capsule 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Thalomid Thalidomide Capsule 150 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Thalomid Thalidomide Capsule 200 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Thalomid Thalidomide Capsule 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 70 of 119 May 2015 CATEGORY Infection, Other DRUG CLASS: Antimalarial Drugs Brand Name Generic Name Formulation Strength Malarone Atovaquone/Proguanil Hcl Tablet 250‐100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Malarone Atovaquone/Proguanil Hcl Tablet 62.5‐25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Chloroquine Phosphate Chloroquine Phosphate Tablet 250 MG Aralen Phosphate Chloroquine Phosphate Tablet 500 MG Plaquenil Hydroxychloroquine Sulfate Tablet 200 MG Lariam Mefloquine Hcl Tablet 250 MG Primaquine Primaquine Phosphate Tablet 26.3 MG Daraprim Pyrimethamine Tablet 25 MG DRUG CLASS: Anti‐Mycobacterium Agents Brand Name Generic Name Formulation Strength Myambutol Ethambutol Hcl Tablet 100 MG Myambutol Ethambutol Hcl Tablet 400 MG Trecator Ethionamide Tablet 250 MG Isoniazid Isoniazid Solution 50 MG/5 ML Isoniazid Isoniazid Tablet 100 MG Isoniazid Isoniazid Tablet 300 MG Pyrazinamide Pyrazinamide Tablet 500 MG PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other DRUG CLASS: Antiprotozoal Drugs,Miscellaneous Brand Name Generic Name Formulation Strength Mepron Atovaquone Oral Susp 750 MG/5ML AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Infection, Other DRUG CLASS: Antitubercular Antibiotics Brand Name Generic Name Formulation Strength Seromycin Cycloserine Capsule 250 MG Rifadin Rifampin Capsule 150 MG Rifadin Rifampin Capsule 300 MG Rifamate Rifampin/Isoniazid Capsule 300‐150 MG DRUG CLASS: Antiviral Monoclonal Antibodies Brand Name Generic Name Formulation Strength Synagis Palivizumab Vial 100 MG/ML Reserved for high risk pediatric patients based on current guidelines. Synagis Palivizumab Vial 50MG/0.5ML Reserved for high risk pediatric patients based on current guidelines. PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other DRUG CLASS: Antivirals, General Brand Name Generic Name Formulation Strength Acyclovir Acyclovir Capsule 200 MG Zovirax Acyclovir Oral Susp 200 MG/5ML Acyclovir Acyclovir Tablet 400 MG Acyclovir Acyclovir Tablet 800 MG PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 71 of 119 May 2015 Tamiflu Oseltamivir Phosphate Capsule 30 MG Restricted to 2 fills in 6 months. maximum of 120ml (liquid), 20 caps (30mg) or 10 caps (75mg) per fill. Tamiflu Oseltamivir Phosphate Capsule 45 MG Restricted to 2 fills in 6 months. maximum of 120ml (liquid), 20 caps (30mg) or 10 caps (75mg) per fill. Tamiflu Oseltamivir Phosphate Capsule 75 MG Restricted to 2 fills in 6 months. maximum of 120ml (liquid), 20 caps (30mg) or 10 caps (75mg) per fill. Tamiflu Oseltamivir Phosphate Susp Recon 6 MG/ML Restricted to 2 fills in 6 months. maximum of 120ml (liquid), 20 caps (30mg) or 10 caps (75mg) per fill. Virazole Ribavirin Vial‐Neb 6G Valcyte Valganciclovir Hcl Tablet 450 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Relenza Zanamivir Blst W/Dev 5 MG Limited to 2 fills in 6 months. CATEGORY Infection, Other DRUG CLASS: Cephalosporins ‐ 1St Generation Brand Name Generic Name Formulation Strength Cephalexin Cephalexin Capsule 250 MG Cephalexin Cephalexin Capsule 500 MG Cephalexin Cephalexin Susp Recon 125 MG/5ML Cephalexin Cephalexin Susp Recon 250 MG/5ML Cephalexin Cephalexin Tablet 250 MG Cephalexin Cephalexin Tablet 500 MG DRUG CLASS: Cephalosporins ‐ 2Nd Generation Brand Name Generic Name Formulation Strength Cefaclor Cefaclor Capsule 250 MG Cefaclor Cefaclor Capsule 500 MG Cefaclor Cefaclor Susp Recon 125 MG/5ML Cefaclor Cefaclor Susp Recon 250 MG/5ML Cefaclor Cefaclor Susp Recon 375 MG/5ML Ceftin Cefuroxime Axetil Tablet 250 MG Ceftin Cefuroxime Axetil Tablet 500 MG DRUG CLASS: Cephalosporins ‐ 3Rd Generation Brand Name Generic Name Formulation Strength Omnicef Cefdinir Capsule 300 MG Step therapy to 1 course of generic first line antibiotics within the last 90 days. Omnicef Cefdinir Susp Recon 125 MG/5ML Step therapy to 1 course of generic first line antibiotics within the last 90 days. Omnicef Cefdinir Susp Recon 250 MG/5ML Step therapy to 1 course of generic first line antibiotics within the last 90 days. DRUG CLASS: Chemotherapeutics, Antibacterial, Misc. Brand Name Generic Name Formulation Strength Hiprex Methenamine Hippurate Tablet 1 G Mandelamine Methenamine Mandelate Tablet 1 G Mandelamine Methenamine Mandelate Tablet 500 MG PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 72 of 119 May 2015 Primsol Trimethoprim Solution 50 MG/5 ML Trimethoprim Trimethoprim Tablet 100 MG DRUG CLASS: Drug Tx‐Chronic Inflam. Colon Dx,5‐Aminosalicylat Brand Name Generic Name Formulation Strength Azulfidine Sulfasalazine Tablet 500 MG Azulfidine Sulfasalazine Tablet Dr 500 MG DRUG CLASS: Hepatitis C Treatment Agents Brand Name Generic Name Formulation Strength Harvoni Ledipasvir/Sofosbuvir Tablet 90MG‐400MG DRUG CLASS: Immunomodulators Brand Name Generic Name Formulation Strength Proleukin Aldesleukin Vial 22MM UNIT Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Imiquimod Imiquimod Cream Pack 0.05 Limited to 12 packets per dispensing and treatment for a maximum of 16 weeks. Intron A Interferon Alfa‐2B,Recomb. Vial 10MM UNIT Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Intron A Interferon Alfa‐2B,Recomb. Vial 10MM/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Intron A Interferon Alfa‐2B,Recomb. Vial 18MM UNIT Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Intron A Interferon Alfa‐2B,Recomb. Vial 50MM UNIT Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Intron A Interferon Alfa‐2B,Recomb. Vial 6MMUNIT/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Alferon N Interferon Alfa‐N3 Vial 5MMUNIT/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. Actimmune Interferon Gamma‐1B,Recomb. Vial 100MCG/0.5 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) Reserved for members with a diagnosis of hepatitis c who meet the california department of health care services (dhcs) requirements for Alernatives: . CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other DRUG CLASS: Immunosuppressives Brand Name Generic Name Formulation Strength Azasan Azathioprine Tablet 100 MG Azathioprine Azathioprine Tablet 50 MG Azasan Azathioprine Tablet 75 MG Gengraf Cyclosporine, Modified Capsule 100 MG Gengraf Cyclosporine, Modified Capsule 25 MG Cyclosporine Modified Cyclosporine, Modified Capsule 50 MG Gengraf Cyclosporine, Modified Solution 100 MG/ML Zortress Everolimus Tablet 0.25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Zortress Everolimus Tablet 0.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 73 of 119 May 2015 Zortress Everolimus Tablet 0.75 MG Cellcept Mycophenolate Mofetil Capsule 250 MG Cellcept Mycophenolate Mofetil Susp Recon 200 MG/ML Cellcept Mycophenolate Mofetil Tablet 500 MG Myfortic Mycophenolate Sodium Tablet Dr 180 MG Myfortic Mycophenolate Sodium Tablet Dr 360 MG Rapamune Sirolimus Solution 1 MG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Rapamune Sirolimus Tablet 0.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Rapamune Sirolimus Tablet 1 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Rapamune Sirolimus Tablet 2 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Prograf Tacrolimus Ampul 5 MG/ML Hecoria Tacrolimus Capsule 0.5 MG Hecoria Tacrolimus Capsule 1 MG Capsule 5 MG Hecoria Tacrolimus DRUG CLASS: Lincosamides Brand Name Generic Name Formulation Strength Cleocin Hcl Clindamycin Hcl Capsule 150 MG Cleocin Hcl Clindamycin Hcl Capsule 300 MG Cleocin Hcl Clindamycin Hcl Capsule 75 MG Cleocin Palmitate Clindamycin Palmitate Hcl Soln Recon 75 MG/5 ML Strength Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Infection, Other PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other DRUG CLASS: Macrolides Brand Name Generic Name Formulation Zithromax Azithromycin Packet 1 G Zmax Pediatric Azithromycin Sus Er Rec 2 G/60 ML Zithromax Azithromycin Susp Recon 100 MG/5ML Zithromax Azithromycin Susp Recon 200 MG/5ML Zithromax Azithromycin Tablet 250 MG Zithromax Azithromycin Tablet 500 MG Zithromax Azithromycin Tablet 600 MG Biaxin Clarithromycin Susp Recon 250 MG/5ML Clarithromycin Clarithromycin Tablet 250 MG Clarithromycin Clarithromycin Tablet 500 MG Erythromycin Erythromycin Base Capsule Dr 250 MG Pce Erythromycin Base Tab Part 333 MG Pce Erythromycin Base Tab Part 500 MG Erythromycin Erythromycin Base Tablet 250 MG Erythromycin Erythromycin Base Tablet 500 MG Ery‐Tab Erythromycin Base Tablet Dr 250 MG Ery‐Tab Erythromycin Base Tablet Dr 333 MG Ery‐Tab Erythromycin Base Tablet Dr 500 MG Eryped 200 Erythromycin Ethylsuccinate Susp Recon 200 MG/5ML AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 74 of 119 May 2015 Erythromycin Ethylsucci Erythromycin Ethylsuccinate Tablet 400 MG Erythrocin Stearate Erythromycin Stearate Tablet 250 MG DRUG CLASS: Monoclonal Antibody‐Human Interleukin 12/23 Inhib Brand Name Generic Name Formulation Strength Stelara Ustekinumab Syringe 45MG/0.5ML Second line agent after treatment failure of humira or enbrel, or remicade or simponi. Stelara Ustekinumab Syringe 90 MG/ML Second line agent after treatment failure of humira or enbrel, or remicade or simponi. CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other DRUG CLASS: Nitrofuran Derivatives Brand Name Generic Name Formulation Strength Nitrofurantoin Nitrofurantoin Oral Susp 25 MG/5 ML Nitrofurantoin Nitrofurantoin Macrocrystal Capsule 100 MG Macrodantin Nitrofurantoin Macrocrystal Capsule 25 MG Nitrofurantoin Nitrofurantoin Macrocrystal Capsule 50 MG Macrobid Nitrofurantoin Monohyd/M‐Cryst Capsule 100 MG PA S QL F AL P GL Restrictions (if applicable) Reserved for infections resistant to all first line antibiotics as proven by urine culture and sensitivity. submit culture/sensitivity to hpsj for review. CATEGORY Infection, Other DRUG CLASS: Oxazolidinones Brand Name Generic Name Formulation Strength Zyvox Linezolid Tablet 600 MG DRUG CLASS: Penicillins Brand Name Generic Name Formulation Strength Amoxicillin Amoxicillin Capsule 250 MG Amoxil Amoxicillin Capsule 500 MG Amoxicillin Amoxicillin Susp Recon 125 MG/5ML Amoxicillin Amoxicillin Susp Recon 200 MG/5ML Amoxil Amoxicillin Susp Recon 250 MG/5ML Amoxil Amoxicillin Susp Recon 400 MG/5ML Amoxicillin Amoxicillin Tab Chew 125 MG Amoxicillin Amoxicillin Tab Chew 250 MG Amoxicillin Amoxicillin Tablet 500 MG Amoxicillin Amoxicillin Tablet 875 MG Amox Tr‐Potassium Cla Amoxicillin/Potassium Clav Susp Recon 200‐28.5/5 Augmentin Amoxicillin/Potassium Clav Susp Recon 400‐57MG/5 Augmentin Es‐600 Amoxicillin/Potassium Clav Susp Recon 600‐42.9/5 Augmentin Amoxicillin/Potassium Clav Tablet 250‐125 MG Augmentin Amoxicillin/Potassium Clav Tablet 500‐125 MG Augmentin Amoxicillin/Potassium Clav Tablet 875‐125 MG Ampicillin Trihydrate Ampicillin Trihydrate Capsule 250 MG Ampicillin Trihydrate Ampicillin Trihydrate Capsule 500 MG Ampicillin Trihydrate Ampicillin Trihydrate Susp Recon 125 MG/5ML Ampicillin Trihydrate Ampicillin Trihydrate Susp Recon 250 MG/5ML Dicloxacillin Sodium Dicloxacillin Sodium Capsule 250 MG Dicloxacillin Sodium Dicloxacillin Sodium Capsule 500 MG PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 75 of 119 May 2015 Penicillin V Potassium Penicillin V Potassium Soln Recon Penicillin V Potassium Penicillin V Potassium Soln Recon 125 MG/5ML 250 MG/5ML Penicillin V Potassium Penicillin V Potassium Tablet 250 MG Penicillin V Potassium Penicillin V Potassium Tablet 500 MG DRUG CLASS: Quinolones Brand Name Generic Name Formulation Strength Cipro Ciprofloxacin Sus Mc Rec 250 MG/5ML Cipro Ciprofloxacin Sus Mc Rec 500 MG/5ML Ciprofloxacin Hcl Ciprofloxacin Hcl Tablet 100 MG Limited to 28 tablets per month Cipro Ciprofloxacin Hcl Tablet 250 MG Limited to 28 tablets per month Cipro Ciprofloxacin Hcl Tablet 500 MG Cipro Ciprofloxacin Hcl Tablet 750 MG Levaquin Levofloxacin Solution 250MG/10ML Restricted to patients 18 and older, maximum of 14 tablets or 280 ml per month. Levofloxacin Levofloxacin Solution 250MG/10ML Restricted to patients 18 and older, maximum of 14 tablets or 280 ml per month. Levaquin Levofloxacin Tablet 250 MG Restricted to patients 18 and older, maximum of 14 tablets or 280 ml per month. Levaquin Levofloxacin Tablet 500 MG Restricted to patients 18 and older, maximum of 14 tablets or 280 ml per month. Levaquin Levofloxacin Tablet 750 MG Restricted to patients 18 and older, maximum of 14 tablets or 280 ml per month. CATEGORY Infection, Other DRUG CLASS: Rifamycins And Related Derivative Antibiotics Brand Name Generic Name Formulation Strength Xifaxan Rifaximin Tablet 550 MG PA S QL F AL P GL Restrictions (if applicable) Restricted to 300 ml per month (for 250mg/5ml suspension) or 150 ml per month (500mg/5ml suspension). CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) Step therapy to treatment failure of compliant Alernatives: of lactulose CATEGORY Infection, Other DRUG CLASS: Rosacea Agents, Topical Brand Name Generic Name Formulation Strength Metronidazole Metronidazole Cream (G) 0.0075 Noritate Metronidazole Cream (G) 0.01 Metronidazole Metronidazole Gel (Gram) 0.0075 Metrogel Metronidazole Gel (Gram) 0.01 Lotion 0.0075 Metronidazole Metronidazole DRUG CLASS: Tetracyclines Brand Name Generic Name Formulation Strength Vibramycin Doxycycline Hyclate Capsule 100 MG PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 76 of 119 May 2015 Doxycycline Hyclate Doxycycline Hyclate Capsule 50 MG Vibra‐Tabs Doxycycline Hyclate Tablet 100 MG Doxycycline Monohydra Doxycycline Monohydrate Capsule 100 MG Doxycycline Monohydra Doxycycline Monohydrate Capsule 50 MG Minocycline Hcl Minocycline Hcl Capsule 100 MG Minocycline Hcl Minocycline Hcl Capsule 50 MG Capsule 75 MG Minocycline Hcl Minocycline Hcl DRUG CLASS: Topical Antibiotics Brand Name Generic Name Formulation Strength Bacitracin Bacitracin Oint. (G) 500 UNIT/G Bacitracin Bacitracin Packet 500 UNIT/G Bacitracin Zinc Bacitracin Zinc Oint. (G) 500 UNIT/G Bacitracin Zinc Bacitracin Zinc Packet 500 UNIT/G Polysporin Bacitracin/Polymyxin B Sulfate Oint. (G) 500‐10K/G Polysporin Bacitracin/Polymyxin B Sulfate Packet Cleocin T Clindamycin Phosphate Gel (Gram) 0.01 Cleocin T Clindamycin Phosphate Lotion 0.01 Cleocin T Clindamycin Phosphate Med. Swab 0.01 Cleocin T Clindamycin Phosphate Solution 0.01 Erythromycin Erythromycin Base/Ethanol Gel (Gram) 0.02 Ery Erythromycin Base/Ethanol Med. Swab 0.02 Erythromycin Erythromycin Base/Ethanol Solution 0.02 Gentamicin Sulfate Gentamicin Sulfate Cream (G) 0.001 Gentamicin Sulfate Gentamicin Sulfate Oint. (G) 0.001 Bactroban Mupirocin Oint. (G) 0.02 Neosporin Neomy Sulf/Bacitrac Zn/Poly Oint. (G) 3.5‐400‐5K Neosporin Plus Neomy Sulf/Polymyx B Sulf/Pram Cream (G) 3.5‐10K‐10 Neosporin Plus Neomycn/Baci Zn/Pmyx Bs/Pramox Oint. (G) 3.5‐10K‐10 DRUG CLASS: Topical Antibiotics/Antiinflammatory,Steroidal Brand Name Generic Name Formulation Strength Cortisporin Neomycin/Bacitra/Polymyxin/Hc Oint. (G) 0.01 Cream (G) 0.005 Strength CATEGORY Infection, Other Cortisporin Neomycin/Polymyxin B Sulf/Hc DRUG CLASS: Topical Antifungals Brand Name Generic Name Formulation Desenex Clotrimazole Cream (G) 0.01 Clotrimazole Clotrimazole Solution 0.01 Econazole Nitrate Econazole Nitrate Cream (G) 0.01 Ketoconazole Ketoconazole Cream (G) 0.02 Nizoral A‐D Ketoconazole Shampoo 0.01 Ketoconazole Ketoconazole Shampoo 0.02 Micatin Miconazole Nitrate Aero Powd 0.02 Micatin Miconazole Nitrate Cream (G) 0.02 Fungoid Tincture Miconazole Nitrate Kit 0.02 Aloe Vesta Miconazole Nitrate Oint. (G) 0.02 Desenex Miconazole Nitrate Spray 0.02 Fungoid Tincture Miconazole Nitrate Tincture 0.02 Nystatin Nystatin Cream (G) 100000/G Nystatin Nystatin Oint. (G) 100000/G PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 77 of 119 May 2015 Nystop Powder 100000/G Nystatin‐Triamcinolone Nystatin/Triamcin Nystatin Cream (G) 100000‐0.1 Nystatin‐Triamcinolone Nystatin/Triamcin Oint. (G) 100000‐0.1 Desenex Terbinafine Hcl Cream (G) 0.01 Jock Itch Tolnaftate Aero Powd 0.01 Lamisil Af Defense Tolnaftate Cream (G) 0.01 Medi‐First Anti‐Fungal Tolnaftate Packet 0.01 Lamisil Af Tolnaftate Powder 0.01 Tolnaftate Tolnaftate Solution 0.01 DRUG CLASS: Topical Antiparasitics Brand Name Generic Name Formulation Strength Ulesfia Benzyl Alcohol Lotion 0.05 Eurax Crotamiton Cream (G) 0.1 Eurax Crotamiton Lotion 0.1 Sklice Ivermectin Lotion 0.005 Reserved for treatment failure of ulesfia 5% and ovide in the last 30 days. note ulesfia and ovide step therapy to 2 fills of permethrin lotion. Malathion Malathion Lotion 0.005 Step therapy to 2 fills of permethrin1% in the last 30 days. restricted to 60 ml per 90 days. Elimite Permethrin Cream (G) 0.05 Lice Treatment Permethrin Liquid 0.01 Rid Piperonyl Butoxide/Pyrethrins Kit Lice Treatment Piperonyl Butoxide/Pyrethrins Liquid Lice Treatment Piperonyl Butoxide/Pyrethrins Liquid 4%‐0.33% Lice Killing Piperonyl Butoxide/Pyrethrins Shampoo 4%‐0.33% Spinosad Spinosad Suspension 0.009 CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) Step therapy to failure of at least 2 documented courses of permethrin in the last 30 days. Reserved for treatment failure of ulesfia 5% and ovide in the last 30 days. note ulesfia and ovide step therapy to 2 fills of permethrin lotion. CATEGORY Infection, Other DRUG CLASS: Topical Sulfonamides Brand Name Generic Name Formulation Strength Cream (G) 0.01 Silver Sulfadiazine Silver Sulfadiazine DRUG CLASS: Vaginal Antibiotics Brand Name Generic Name Formulation Strength Cleocin Clindamycin Phosphate Cream/Appl 0.02 Cleocin Clindamycin Phosphate Supp.Vag 100 MG Vandazole Metronidazole Gel W/Appl 0.0075 PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Infection, Other DRUG CLASS: Vaginal Antifungals Brand Name Generic Name Formulation Strength Gyne‐Lotrimin Clotrimazole Cream/Appl 0.01 Gyne‐Lotrimin Clotrimazole Cream/Appl 0.02 Miconazole 3 Miconazole Nitrate Cmb Pf Crm 200 MG‐2 % Monistat 7 Miconazole Nitrate Cream/Appl 0.02 Monistat 3 Miconazole Nitrate Cream/Appl 0.04 Monistat 3 Miconazole Nitrate Crm/Pf App 0.04 Miconazole 1 Miconazole Nitrate Kit 1200MG‐2% Monistat 3 Miconazole Nitrate Kit 200 MG‐2 % Monistat 7 Miconazole Nitrate Supp.Vag 100 MG AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 78 of 119 May 2015 Terazol 7 Terconazole Cream/Appl 0.004 Terazol 3 Terconazole Cream/Appl 0.008 Terazol 3 Terconazole Supp.Vag 80 MG Vagistat‐1 Tioconazole Oin/Pf App 0.065 DRUG CLASS: Vancomycin And Derivatives Brand Name Generic Name Formulation Strength Vancomycin Hcl Vancomycin Hcl Capsule 125 MG CATEGORY Infection, Other PA S QL F AL P GL Restrictions (if applicable) Reserved for clostridium difficile infections as evidenced by c. diff toxin assay or c. diff dna pcr THERAPUTIC CATEGORY Miscellaneous CATEGORY Miscellaneous DRUG CLASS: C1 Esterase Inhibitors Brand Name Generic Name Formulation Strength Cinryze C1 Esterase Inhibitor Vial 500 (5 ML) Formulation Strength DRUG CLASS: Dental Aids And Preparations Brand Name Generic Name PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Miscellaneous Chlorhexidine Gluconat Chlorhexidine Gluconate Mouthwash 0.0012 Triamcinolone Acetonid Triamcinolone Acetonide Paste (G) 0.001 PA S QL F AL P GL Restrictions (if applicable) CATEGORY Miscellaneous DRUG CLASS: Irrigants Brand Name Generic Name Formulation Strength Acetic Acid Acetic Acid Irrig Soln 0.0025 Neomycin‐Polymyxin B Neomy Sulf/Polymyxin B Sulfate Ampul 40‐200K/ML Sodium Chloride Sodium Chloride Irrig Solution Irrig Soln 0.009 Water Water For Irrigation,Sterile Irrig Soln PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 79 of 119 May 2015 THERAPUTIC CATEGORY Nutrition CATEGORY Nutrition DRUG CLASS: Anorexic Agents Brand Name Generic Name Formulation Strength Phentermine Hcl Phentermine Hcl Capsule 15 MG Documentation of exercise, dietary counseling, and comorbidities is required. Phentermine Hcl Phentermine Hcl Capsule 30 MG Documentation of exercise, dietary counseling, and comorbidities is required. Phentermine Hcl Phentermine Hcl Capsule 37.5 MG Documentation of exercise, dietary counseling, and comorbidities is required. Phentermine Hcl Phentermine Hcl Tablet 37.5 MG Documentation of exercise, dietary counseling, and comorbidities is required. Formulation Strength Calcium Replacement Brand Name Generic Name Parva‐Cal 500 Calcium Carb &Gluconate/Vit D2 Tablet 500 MG‐200 Calci‐Mix Calcium Carbonate Capsule 500(1250) Calcium Carbonate Calcium Carbonate Oral Susp 500 MG/5ML Calci‐Chew Calcium Carbonate Tab Chew 500(1250) Calcium Carbonate Calcium Carbonate Tablet 500(1250) Caltrate 600 Calcium Carbonate Tablet 600 MG Oyster Shell Calcium W‐ Calcium Carbonate/Vitamin D2 Tablet 250 MG‐125 Oyst‐Cal‐D Calcium Carbonate/Vitamin D3 Tablet 250 MG‐125 Calcium 500 + Vitamin Calcium Carbonate/Vitamin D3 Tablet 500 MG‐125 Os‐Cal 500+D3 Calcium Carbonate/Vitamin D3 Tablet 500 MG‐200 Calcium 500 + Vit D Calcium Carbonate/Vitamin D3 Tablet 500 MG‐400 Calcium 600 + Vit D Calcium Carbonate/Vitamin D3 Tablet 600 MG‐200 Calcium 600 + Vit D Calcium Carbonate/Vitamin D3 Tablet 600 MG‐400 Caltrate 600 + D Calcium Carbonate/Vitamin D3 Tablet 600 MG‐800 DRUG CLASS: Metabolic Deficiency Agents Brand Name Generic Name Formulation Strength Carnitor Sf Levocarnitine Solution 100 MG/ML Levocarnitine Levocarnitine Tablet 330 MG Levocarnitine Levocarnitine (With Sugar) Solution 100 MG/ML DRUG CLASS: Multivitamin Preparations Brand Name Generic Name Formulation Strength Surbex W‐C B Complex With Vitamin C Tablet Chewable‐Vite Multivitamin Tab Chew Formulation Strength Tri‐Vit With Fluoride‐Iro Fluoride/Iron/Vit A,C&D Drops 0.25 MG/ML Fruity Chews Tab Chew Pediatric Vitamin Preparations Brand Name Generic Name Multivitamin QL F AL P GL Restrictions (if applicable) CATEGORY Nutrition DRUG CLASS: DRUG CLASS: PA S PA S QL F AL P GL Restrictions (if applicable) CATEGORY Nutrition PA S QL F AL P GL Restrictions (if applicable) CATEGORY Nutrition PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Nutrition AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 80 of 119 May 2015 Cerovite Jr Multivitamin W/Iron, Minerals Tab Chew Centrum Kids Multivitamins With Iron Tab Chew Polyvitamin With Iron Ped Multivit #46/Iron Sulfate Drops 1500‐10/ML Tri‐Vitamin With Fluori Ped Mv A,C,D3 #21 W‐Fluoride Drops 0.25 MG/ML Tri‐Vitamin With Fluori Ped Mv A,C,D3 #21 W‐Fluoride Drops 0.5 MG/ML Multivitamins With Fluo Pedi M.Vit No.17 With Fluoride Tab Chew 0.25 MG Multivitamins With Fluo Pedi M.Vit No.17 With Fluoride Tab Chew 0.5 MG Multivitamins With Fluo Pedi M.Vit No.17 With Fluoride Tab Chew 1 MG Tri‐Vitamin Pedi Multivits A,C,&D3 No.21 Drops 1500‐35/ML Multivitamins W‐Fluori Pedi Mv #75/Fluoride/Iron Drops 0.25‐10/ML Multivitamins With Fluo Pedi Mvi No.12/Sodium Fluoride Tab Chew 0.25 MG Multivitamins With Fluo Pedi Mvi No.12/Sodium Fluoride Tab Chew 0.5 MG Multivitamins With Fluo Pedi Mvi No.12/Sodium Fluoride Tab Chew 1 MG Multivitamins With Fluo Pedi Mvi No.16 With Fluoride Tab Chew 0.5 MG Poly‐Vitamin Pediatric Multivit Comb No.20 Drops 1500‐400/1 Tri‐Vi‐Sol Vit A Palmitate/Vit C/Vit D3 Drops 750‐35/ML Formulation Strength CATEGORY Nutrition DRUG CLASS: Prenatal Vitamin Preparations Brand Name Generic Name Se‐Natal 19 Pnv No.118/Iron Fumarate/Fa Tab Chew 29 MG‐1 MG Vol‐Plus Pnv With Ca,No.71/Iron/Fa Tablet 27 MG‐1 MG Prenatal Plus Pnv With Ca,No.72/Iron,Carb/Fa Tablet 29 MG‐1 MG Prenatal Plus Pnv With Ca,No.72/Iron/Fa Tablet 27 MG‐1 MG Prenatal Low Iron Pnv With Ca,No.74/Iron/Fa Tablet 27 MG‐1 MG Se‐Natal 90 Pnv/Ferrous Fumarate/Doss/Fa Tablet Er 90‐50‐1MG Materna Pnv/Ferrous Fumarate/Fa/Se Tablet 27 MG‐1 MG Mynatal Pnv/Iron,Carbonyl/Docusate/Fa Tablet 90‐50‐1MG Prenatal Multivitamins Pnv95/Ferrous Fumarate/Fa Tablet 28MG‐0.8MG Tricare Prenatal #103/Iron Fumarate/Fa Tablet 27 MG‐1 MG Vol‐Tab Rx Prenatal Vit #76/Iron,Carb/Fa Tablet 29 MG‐1 MG Triadvance Prenatal Vit 15/Iron Cb/Fa/Dss Tablet 90‐1‐50 MG Co‐Natal Fa Prenatal Vit No.78/Iron/Fa Tablet 29 MG‐1 MG Prenatal Prenatal Vit#96/Ferrous Fum/Fa Tablet 27MG‐0.8MG Prenatal S Prenatal Vit/Iron Fumarate/Fa Tablet 27MG‐0.8MG Classic Prenatal Prenatal Vit/Iron Fumarate/Fa Tablet 28MG‐0.8MG Prenatal 1‐1 Prenatal Vit/Iron Fumarate/Fa Tablet 65 MG‐1 MG O‐Cal Fa Prenatal Vit/Iron Fumarate/Fa Tablet 66‐1MG Natalvit Prenatal Vit/Iron Fumarate/Fa Tablet 75‐1MG Trinatal Rx 1 Prenatal Vit27&Calcium/Iron/Fa Tablet 60 MG‐1 MG P‐D Natal Plus Prenatal Vits W‐Ca,Fe,Fa(<1Mg) Tablet Obstetrix Ec Pv W‐O Cal/Fe,Carbonyl/Doss/Fa Tablet Dr 29‐50‐1MG Tablet 27 MG‐1 MG M‐Vit Pv W‐O Cal/Ferrous Fumarate/Fa DRUG CLASS: Protein Replacement Brand Name Generic Name Formulation Strength L‐Carnitine Levocarnitine Tablet 500 MG DRUG CLASS: Vitamin B Preparations Brand Name Generic Name Formulation Strength Dialyvite 3000 Fa/Vit Bcomp&C/Se/Min Aa/Zn Tablet 3MG‐15MG Dialyvite 800‐Ultra D Fa/Vit Bcomp&C/Zinc/Vitamin D3 Tablet 0.8MG‐2000 PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Nutrition AL P GL Restrictions (if applicable) CATEGORY Nutrition PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 81 of 119 May 2015 Nephro‐Vite Folic Acid/Vitamin B Comp W‐C Tablet 0.8 MG Supervite Lysine Hcl/Vit B Comp/Fa/Zinc Liquid 1000‐1‐75 Formulation Strength 100 MG CATEGORY Nutrition DRUG CLASS: Vitamin B1 Preparations Brand Name Generic Name Vitamin B‐1 Thiamine Hcl Tablet Vitamin B‐1 Thiamine Hcl Tablet 50 MG Vitamin B‐1 Thiamine Mononitrate Tablet 100 MG Formulation Strength PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Nutrition DRUG CLASS: Vitamin B12 Preparations Brand Name Generic Name Vitamin B‐12 Cyanocobalamin (Vitamin B‐12) Tablet 1000 MCG Hydroxocobalamin Hydroxocobalamin Vial 1000MCG/ML DRUG CLASS: Vitamin B6 Preparations Brand Name Generic Name Formulation Strength Vitamin B‐6 Pyridoxine Hcl Tablet 100 MG Pyridoxine Hcl Pyridoxine Hcl Tablet 25 MG Vitamin B‐6 Pyridoxine Hcl Tablet 50 MG AL P GL Restrictions (if applicable) CATEGORY Nutrition PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 82 of 119 May 2015 THERAPUTIC CATEGORY Oncology CATEGORY Oncology DRUG CLASS: Alkylating Agents Brand Name Generic Name Formulation Strength Hexalen Altretamine Capsule 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Myleran Busulfan Tablet 2 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Busulfex Busulfan Vial 60 MG/10ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Bicnu Carmustine Vial 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Leukeran Chlorambucil Tablet 2 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Cyclophosphamide Cyclophosphamide Capsule 25 MG Cyclophosphamide Cyclophosphamide Capsule 50 MG Hydrea Hydroxyurea Capsule 500 MG Ceenu Lomustine Capsule 10 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Ceenu Lomustine Capsule 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Ceenu Lomustine Capsule 40 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Alkeran Melphalan Tablet 2 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Eloxatin Oxaliplatin Vial 100MG/20ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Eloxatin Oxaliplatin Vial 50 MG/10ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Temodar Temozolomide Capsule 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Temodar Temozolomide Capsule 140 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Temodar Temozolomide Capsule 180 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Temodar Temozolomide Capsule 20 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Temodar Temozolomide Capsule 250 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 83 of 119 May 2015 Temodar Temozolomide Capsule 5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Temodar Temozolomide Vial 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Antiandrogenic Agents Brand Name Generic Name Formulation Strength Bicalutamide Bicalutamide Tablet 50 MG Flutamide Flutamide Capsule 125 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Nilandron Nilutamide Tablet 150 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology DRUG CLASS: Anti‐Arthritic And Chelating Agents Brand Name Generic Name Formulation Cuprimine Penicillamine Capsule 250 MG Depen Penicillamine Tablet 250 MG DRUG CLASS: Anti‐Cd20 (B Lymphocyte) Monoclonal Antibody Brand Name Generic Name Formulation Strength Rituxan Rituximab Vial 10 MG/ML DRUG CLASS: Antiemetic/Antivertigo Agents Brand Name Generic Name Formulation Strength Emend Aprepitant Cap Ds Pk 125MG‐80MG Reserved for patients who are receiving highly emetogenic chemotherapy or for post‐operative naAlernatives: a and vomiting that is treatment failure of ondansetron. Emend Aprepitant Capsule 125 MG Reserved for patients who are receiving highly emetogenic chemotherapy or for post‐operative naAlernatives: a and vomiting that is treatment failure of ondansetron. Emend Aprepitant Capsule 40 MG Reserved for patients who are receiving highly emetogenic chemotherapy or for post‐operative naAlernatives: a and vomiting that is treatment failure of ondansetron. Emend Aprepitant Capsule 80 MG Reserved for patients who are receiving highly emetogenic chemotherapy or for post‐operative naAlernatives: a and vomiting that is treatment failure of ondansetron. Anzemet Dolasetron Mesylate Tablet 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Anzemet Dolasetron Mesylate Tablet 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Marinol Dronabinol Capsule 10 MG Restricted to patients with anorexia/weight loss due to aids or chemotherapy who have failed ondansetron, emend and/or dexamethasone Marinol Dronabinol Capsule 2.5 MG Restricted to patients with anorexia/weight loss due to aids or chemotherapy who have failed ondansetron, emend and/or dexamethasone Strength PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) Second‐line agent after treatment failure of enbrel or humira or remicade or simponi. CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 84 of 119 May 2015 Marinol Dronabinol Capsule 5 MG Restricted to patients with anorexia/weight loss due to aids or chemotherapy who have failed ondansetron, emend and/or dexamethasone Sancuso Granisetron Patch Tdwk 3.1MG/24HR Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Meclizine Hcl Meclizine Hcl Tab Chew 25 MG Antivert Meclizine Hcl Tablet 12.5 MG Dramamine Ii Meclizine Hcl Tablet 25 MG Ondansetron Odt Ondansetron Tab Rapdis 4 MG Restricted to 60 tablets per 30 days. Ondansetron Odt Ondansetron Tab Rapdis 8 MG Restricted to 60 tablets per 30 days. Ondansetron Hcl Ondansetron Hcl Tablet 4 MG Restricted to 60 tablets per 30 days. Ondansetron Hcl Ondansetron Hcl Tablet 8 MG Restricted to 60 tablets per 30 days. Aloxi Palonosetron Hcl Vial 0.25MG/5ML Prochlorperazine Malea Prochlorperazine Maleate Supp.Rect 25 MG Prochlorperazine Malea Prochlorperazine Maleate Tablet 10 MG Prochlorperazine Malea Prochlorperazine Maleate Tablet 5 MG Promethazine Hcl Promethazine Hcl Supp.Rect 12.5 MG Promethazine Hcl Promethazine Hcl Supp.Rect 25 MG Promethazine Hcl Promethazine Hcl Trimethobenzamide Hcl Trimethobenzamide Hcl Supp.Rect 50 MG Capsule 300 MG CATEGORY Oncology DRUG CLASS: Antimetabolites Brand Name Generic Name Formulation Strength Xeloda Capecitabine Tablet 150 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Xeloda Capecitabine Tablet 500 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Mercaptopurine Mercaptopurine Tablet 50 MG Methotrexate Methotrexate Sodium Tablet 2.5 MG Methotrexate Sodium Methotrexate Sodium/Pf Vial 25 MG/ML Alimta Pemetrexed Disodium Vial 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Alimta Pemetrexed Disodium Vial 500 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Tabloid Thioguanine Tablet 40 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Antineoplast Egf Receptor Blocker Rcmb Mc Antibody Brand Name Generic Name Formulation Strength Erbitux Cetuximab Vial 200MG/0.1L PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 85 of 119 May 2015 CATEGORY Oncology DRUG CLASS: Antineoplastic ‐ Aromatase Inhibitors Brand Name Generic Name Formulation Anastrozole Anastrozole Tablet 1 MG Aromasin Exemestane Tablet 25 MG Tablet 2.5 MG Strength PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Letrozole Letrozole DRUG CLASS: Antineoplastic ‐ Mtor Kinase Inhibitors Brand Name Generic Name Formulation Strength Afinitor Everolimus Tablet 10 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Afinitor Everolimus Tablet 2.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Afinitor Everolimus Tablet 5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Afinitor Everolimus Tablet 7.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology DRUG CLASS: Antineoplastic ‐ Topoisomerase I Inhibitors Brand Name Generic Name Formulation Strength Hycamtin Topotecan Hcl Capsule 0.25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Hycamtin Topotecan Hcl Capsule 1 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Antineoplastic Immunomodulator Agents Brand Name Generic Name Formulation Strength Revlimid Lenalidomide Capsule 10 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Revlimid Lenalidomide Capsule 15 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Revlimid Lenalidomide Capsule 2.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Revlimid Lenalidomide Capsule 20 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Revlimid Lenalidomide Capsule 25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Revlimid Lenalidomide Capsule 5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology DRUG CLASS: Antineoplastic Lhrh(Gnrh) Agonist,Pituitary Suppr. Brand Name Generic Name Formulation Strength Zoladex Goserelin Acetate Implant 10.8MG PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 86 of 119 May 2015 Zoladex Goserelin Acetate Implant 3.6 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Supprelin La Histrelin Ac Kit 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Leuprolide Acetate Leuprolide Acetate Kit 1 MG/0.2ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Eligard Leuprolide Acetate Syringe 22.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Eligard Leuprolide Acetate Syringe 30 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Eligard Leuprolide Acetate Syringe 45 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Eligard Leuprolide Acetate Syringe 7.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Lupron Depot Leuprolide Acetate Syringekit 22.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Lupron Depot Leuprolide Acetate Syringekit 30 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Lupron Depot Leuprolide Acetate Syringekit 7.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Trelstar Triptorelin Pamoate Syringe 11.25/2ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Trelstar Triptorelin Pamoate Syringe 3.75MG/2ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Antineoplastic Systemic Enzyme Inhibitors Brand Name Generic Name Formulation Strength Velcade Bortezomib Vial 3.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sprycel Dasatinib Tablet 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sprycel Dasatinib Tablet 140 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sprycel Dasatinib Tablet 20 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sprycel Dasatinib Tablet 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sprycel Dasatinib Tablet 70 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sprycel Dasatinib Tablet 80 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 87 of 119 May 2015 Tarceva Erlotinib Hcl Tablet 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Tarceva Erlotinib Hcl Tablet 150 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Tarceva Erlotinib Hcl Tablet 25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Gleevec Imatinib Mesylate Tablet 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Gleevec Imatinib Mesylate Tablet 400 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Tykerb Lapatinib Ditosylate Tablet 250 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Tasigna Nilotinib Hcl Capsule 200 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Nexavar Sorafenib Tosylate Tablet 200 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sutent Sunitinib Malate Capsule 12.5 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sutent Sunitinib Malate Capsule 25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Sutent Sunitinib Malate Capsule 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Oncology DRUG CLASS: Antineoplastics,Histone Deacetylase Inhibitors,Hdis Brand Name Generic Name Formulation Strength Zolinza Vorinostat Capsule 100 MG DRUG CLASS: Antineoplastics,Miscellaneous Brand Name Generic Name Formulation Strength Elspar Asparaginase Vial 10000 UNIT Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Docefrez Docetaxel Vial 20 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Docefrez Docetaxel Vial 80 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Etoposide Etoposide Capsule 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Etopophos Etoposide Phosphate Vial 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Lysodren Mitotane Tablet 500 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 88 of 119 May 2015 Mitoxantrone Hcl Mitoxantrone Hcl Vial 2 MG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Abraxane Paclitaxel Protein‐Bound Vial 100 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Matulane Procarbazine Hcl Capsule 50 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Vesanoid Tretinoin Capsule 10 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Appetite Stim. For Anorexia,Cachexia,Wasting Synd. Brand Name Generic Name Formulation Strength Megestrol Acetate Megestrol Acetate Oral Susp 400MG/10ML Megace Megestrol Acetate Oral Susp 400MG/10ML DRUG CLASS: Chemotherapy Rescue/Antidote Agents Brand Name Generic Name Formulation Strength Leucovorin Calcium Leucovorin Calcium Tablet 10 MG Leucovorin Calcium Leucovorin Calcium Tablet 15 MG Leucovorin Calcium Leucovorin Calcium Tablet 25 MG Tablet 5 MG CATEGORY Oncology PA S QL F PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology AL P GL Restrictions (if applicable) Leucovorin Calcium Leucovorin Calcium DRUG CLASS: Hematinics,Other Brand Name Generic Name Formulation Strength Procrit Epoetin Alfa Vial 10000/ML Restricted to patients with hgb <9 g/dl without iron deficiency. restricted to Diplomat specialty pharmacy. procrit is formulary esa Epogen Epoetin Alfa Vial 2000/ML Restricted to patients with hgb <9 g/dl without iron deficiency. restricted to Diplomat specialty pharmacy. procrit is formulary esa Epogen Epoetin Alfa Vial 20000/2ML Restricted to patients with hgb <9 g/dl without iron deficiency. restricted to Diplomat specialty pharmacy. procrit is formulary esa Procrit Epoetin Alfa Vial 20000/ML Restricted to patients with hgb <9 g/dl without iron deficiency. restricted to Diplomat specialty pharmacy. procrit is formulary esa Epogen Epoetin Alfa Vial 3000/ML Restricted to patients with hgb <9 g/dl without iron deficiency. restricted to Diplomat specialty pharmacy. procrit is formulary esa Epogen Epoetin Alfa Vial 4000/ML Restricted to patients with hgb <9 g/dl without iron deficiency. restricted to Diplomat specialty pharmacy. procrit is formulary esa Procrit Epoetin Alfa Vial 40000/ML Restricted to patients with hgb <9 g/dl without iron deficiency. restricted to Diplomat specialty pharmacy. procrit is formulary esa DRUG CLASS: Hyperuricemia Tx ‐ Urate‐Oxidase Enzyme‐Type Brand Name Generic Name Formulation Strength Elitek Rasburicase Vial 1.5 MG Elitek Rasburicase Vial 7.5 MG CATEGORY Oncology AL P GL Restrictions (if applicable) CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 89 of 119 May 2015 CATEGORY Oncology DRUG CLASS: Leukocyte (Wbc) Stimulants Brand Name Generic Name Formulation Strength Neupogen Filgrastim Syringe 300MCG/0.5 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Neupogen Filgrastim Syringe 480MCG/0.8 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Neupogen Filgrastim Vial 300 MCG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Neupogen Filgrastim Vial 480MCG/1.6 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Neulasta Pegfilgrastim Syringe 6MG/0.6ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Lhrh(Gnrh) Agonist Analog Pituitary Suppressants Brand Name Generic Name Formulation Strength Lupron Depot Leuprolide Acetate Syringekit 11.25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Lupron Depot Leuprolide Acetate Syringekit 3.75 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Synarel Nafarelin Acetate Spray 2 MG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology DRUG CLASS: Lhrh(Gnrh) Antagonist,Pituitary Suppressant Agents Brand Name Generic Name Formulation Strength Cetrotide Cetrorelix Acetate Kit 0.25 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Ganirelix Acetate Ganirelix Acetate Syringe 250MCG/0.5 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Metallic Poison,Agents To Treat Brand Name Generic Name Formulation Strength Exjade Deferasirox Tab Disper 125 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Exjade Deferasirox Tab Disper 250 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Exjade Deferasirox Tab Disper 500 MG Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) CATEGORY Oncology DRUG CLASS: Platelet Proliferation Stimulants Brand Name Generic Name Formulation Strength Neumega Oprelvekin Vial 5 MG DRUG CLASS: Steroid Antineoplastics Brand Name Generic Name PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Oncology Formulation Strength PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 90 of 119 May 2015 Emcyt Estramustine Phosphate Sodium Capsule 140 MG Megestrol Acetate Megestrol Acetate Tablet 20 MG Megestrol Acetate Megestrol Acetate Tablet 40 MG DRUG CLASS: Topical Antineoplastic & Premalignant Lesion Agnts Brand Name Generic Name Formulation Strength Carac Fluorouracil Cream (G) 0.005 Fluoroplex Fluorouracil Cream (G) 0.01 Efudex Fluorouracil Cream (G) 0.05 Efudex Fluorouracil Solution 0.02 Efudex Fluorouracil Solution 0.05 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Oncology PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 91 of 119 May 2015 THERAPUTIC CATEGORY Osteoporosis DRUG CLASS: Bone Formation Stim. Agents ‐ Parathyroid Hormone Brand Name Generic Name Formulation Strength Forteo Teriparatide Pen Injctr 20MCG/DOSE CATEGORY Osteoporosis PA S QL F AL P GL Restrictions (if applicable) Reserved for treatment of osteoporosis as evidenced by documented t‐score <‐2.5 in patients with treatment failure to 1 year of prolia with calcium supplementation. CATEGORY Osteoporosis DRUG CLASS: Bone Resorption Inhibitors Brand Name Generic Name Formulation Strength Fosamax Alendronate Sodium Tablet 10 MG Restricted to 4 tablets per month (35mg and 70mg) or 30 tablets per month (5mg, 10mg and 40mg) Fosamax Alendronate Sodium Tablet 35 MG Restricted to 4 tablets per month (35mg and 70mg) or 30 tablets per month (5mg, 10mg and 40mg) Fosamax Alendronate Sodium Tablet 40 MG Restricted to 4 tablets per month (35mg and 70mg) or 30 tablets per month (5mg, 10mg and 40mg) Fosamax Alendronate Sodium Tablet 5 MG Restricted to 4 tablets per month (35mg and 70mg) or 30 tablets per month (5mg, 10mg and 40mg) Fosamax Alendronate Sodium Tablet 70 MG Restricted to 4 tablets per month (35mg and 70mg) or 30 tablets per month (5mg, 10mg and 40mg) Miacalcin Calcitonin,Salmon,Synthetic Spray/Pump 200/SPRAY Reserved as last‐line therapy for treatment failure/intolerance to all other formulary agents. Boniva Ibandronate Sodium Tablet 150 MG Step therapy to an adequate trial or intolerance to alendronate. restricted to 1 tablet per month Boniva Ibandronate Sodium Tablet 150 MG Step therapy to an adequate trial or intolerance to alendronate. restricted to 1 tablet per month. Actonel Risedronate Sodium Tablet 150 MG Step therapy to intolerance or treatment failure of alendronate and ibandronate. restricted to 1 tablet per 30 days. Actonel Risedronate Sodium Tablet 30 MG Step therapy to intolerance or treatment failure of alendronate and ibandronate. restricted to 4 tablets per 30 days. Actonel Risedronate Sodium Tablet 35 MG Step therapy to intolerance or treatment failure of alendronate and ibandronate. restricted to 4 tablets per 30 days. Actonel Risedronate Sodium Tablet 5 MG Step therapy to intolerance or treatment failure of alendronate and ibandronate. restricted to 30 tablets per 30 days. DRUG CLASS: Hyperparathyroid Tx Agents ‐ Vitamin D Analog‐Type Brand Name Generic Name Formulation Strength PA S QL F AL P GL Restrictions (if applicable) CATEGORY Osteoporosis PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 92 of 119 May 2015 Zemplar Paricalcitol Capsule 1 MCG Reserved for patients who have failed calcitriol Zemplar Paricalcitol Capsule 2 MCG Reserved for patients who have failed calcitriol Zemplar Paricalcitol Capsule 4MCG Reserved for patients who have failed calcitriol DRUG CLASS: Selective Estrogen Receptor Modulators (Serm) Brand Name Generic Name Formulation Strength Tamoxifen Citrate Tamoxifen Citrate Tablet 10 MG Tamoxifen Citrate Tamoxifen Citrate Tablet 20 MG Fareston Toremifene Citrate Tablet 60 MG CATEGORY Osteoporosis PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Osteoporosis DRUG CLASS: Vitamin D Preparations Brand Name Generic Name Formulation Strength Calcijex Calcitriol Ampul 1 MCG/ML Calcitriol Calcitriol Capsule 0.25 MCG Calcitriol Calcitriol Capsule 0.5 MCG Rocaltrol Calcitriol Solution 1 MCG/ML Vitamin D3 Cholecalciferol (Vitamin D3) Capsule 400 UNIT D‐Vi‐Sol Cholecalciferol (Vitamin D3) Drops 400/ML Vitamin D Cholecalciferol (Vitamin D3) Tablet 1000 UNIT Vitamin D3 Cholecalciferol (Vitamin D3) Tablet 400 UNIT Drisdol Ergocalciferol (Vitamin D2) Capsule 50000 UNIT Drisdol Ergocalciferol (Vitamin D2) Drops 8000/ML Vitamin D Ergocalciferol (Vitamin D2) Tablet 400 UNIT PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 93 of 119 May 2015 THERAPUTIC CATEGORY Pain Management, Chronic CATEGORY Pain Management, Chronic DRUG CLASS: Analgesic/Antipyretics, Salicylates Brand Name Generic Name Formulation Strength Aspirin Aspirin Supp.Rect 300 MG Aspirin Aspirin Supp.Rect 600 MG Aspirin Aspirin Tab Chew 81 MG Aspirin Aspirin Tablet 325 MG Aspirin Aspirin Tablet 500 MG Aspirin Ec Aspirin Tablet Dr 325 MG Ecotrin Aspirin Tablet Dr 500 MG Aspirin Ec Aspirin Tablet Dr 650 MG Aspirin Ec Aspirin PA S QL F AL P GL Restrictions (if applicable) Tablet Dr 81 MG Choline Mag Trisalicylat Choline Sal/Mag Salicylate Liquid 500 MG/5ML Salflex Salsalate Tablet 500 MG Salflex Salsalate Tablet 750 MG DRUG CLASS: Analgesics,Narcotics Brand Name Generic Name Formulation Strength Codeine Sulfate Codeine Sulfate Tablet 15 MG Codeine Sulfate Codeine Sulfate Tablet 30 MG Codeine Sulfate Codeine Sulfate Tablet 60 MG Fentanyl Fentanyl Patch Td72 100 MCG/HR Step therapy to treatment failure of adequate dose of or intolerance to ms contin or unable to take medications by mouth. Fentanyl Fentanyl Patch Td72 12 MCG/HR Step therapy to treatment failure of adequate dose of or intolerance to ms contin or unable to take medications by mouth. Fentanyl Fentanyl Patch Td72 25MCG/HR Step therapy to treatment failure of adequate dose of or intolerance to ms contin or unable to take medications by mouth. Fentanyl Fentanyl Patch Td72 50MCG/HR Step therapy to treatment failure of adequate dose of or intolerance to ms contin or unable to take medications by mouth. Fentanyl Fentanyl Patch Td72 75MCG/HR Step therapy to treatment failure of adequate dose of or intolerance to ms contin or unable to take medications by mouth. Hydrocodone‐ Acetaminophen Hydrocodone/Acetaminophen Solution 2.5‐167/5 Restricted to 946ml per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, (ms contin, methadone) may be considered. Hydrocodone‐ Acetaminophen Hydrocodone/Acetaminophen Solution 7.5‐325/15 Restricted to 946ml per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, (ms contin, methadone) may be considered. Hydrocodone‐ Acetaminophen Hydrocodone/Acetaminophen Tablet 10MG‐325MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, (ms contin, methadone) may be considered. Hydrocodone‐ Acetaminophen Hydrocodone/Acetaminophen Tablet 5 MG‐325MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, (ms contin, methadone) may be considered. CATEGORY Pain Management, Chronic PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 94 of 119 May 2015 Hydrocodone‐ Acetaminophen Hydrocodone/Acetaminophen Tablet 7.5‐325MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, (ms contin, methadone) may be considered. Hydromorphone Hcl Hydromorphone Hcl Tablet 2 MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, (ms contin, methadone) may be considered. Hydromorphone Hcl Hydromorphone Hcl Tablet 4 MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, (ms contin, methadone) may be considered. Hydromorphone Hcl Hydromorphone Hcl Tablet 8 MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, (ms contin, methadone) may be considered. Levorphanol Tartrate Levorphanol Tartrate Tablet 2 MG Meperidine Hcl Meperidine Hcl Solution 50 MG/5 ML Demerol Meperidine Hcl Tablet 100 MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, e.g. ms contin, methadone may be considered. Demerol Meperidine Hcl Tablet 50 MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, e.g. ms contin, methadone may be considered. Methadone Hcl Methadone Hcl Oral Conc 10 MG/ML Methadone Hcl Methadone Hcl Solution 10 MG/5 ML Methadone Hcl Methadone Hcl Solution 5 MG/5 ML Dolophine Hcl Methadone Hcl Tablet 10 MG Dolophine Hcl Methadone Hcl Tablet 5 MG Diskets Methadone Hcl Tablet Sol 40 MG Morphine Sulfate Morphine Sulfate Solution 10 MG/5 ML Morphine Sulfate Morphine Sulfate Solution 100 MG/5ML Morphine Sulfate Morphine Sulfate Solution 20 MG/5 ML Morphine Sulfate Morphine Sulfate Supp.Rect 10 MG Restricted to 120/month, for chronic pain req. >120, Alernatives: ms contin or methadone. Morphine Sulfate Morphine Sulfate Supp.Rect 20 MG Restricted to 120/month, for chronic pain req. >120, Alernatives: ms contin or methadone. Morphine Sulfate Morphine Sulfate Supp.Rect 30 MG Restricted to 120/month, for chronic pain req. >120, Alernatives: ms contin or methadone. Morphine Sulfate Morphine Sulfate Supp.Rect 5 MG Restricted to 120/month, for chronic pain req. >120, Alernatives: ms contin or methadone. Morphine Sulfate Morphine Sulfate Tablet 15 MG Restricted to 120/month, for chronic pain req. >120, Alernatives: ms contin or methadone. Morphine Sulfate Morphine Sulfate Tablet 30 MG Restricted to 120/month, for chronic pain req. >120, Alernatives: ms contin or methadone. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 95 of 119 May 2015 Morphine Sulfate Er Morphine Sulfate Tablet Er 100 MG Restricted to 3 tabs per day, consolidate dose or submit pa if not possible Morphine Sulfate Er Morphine Sulfate Tablet Er 15 MG Restricted to 3 tabs per day, consolidate dose or submit pa if not possible Morphine Sulfate Er Morphine Sulfate Tablet Er 200 MG Restricted to 3 tabs per day, consolidate dose or submit pa if not possible Morphine Sulfate Er Morphine Sulfate Tablet Er 30 MG Restricted to 3 tabs per day, consolidate dose or submit pa if not possible Morphine Sulfate Er Morphine Sulfate Tablet Er 60 MG Restricted to 3 tabs per day, consolidate dose or submit pa if not possible Oxycodone Hcl Oxycodone Hcl Capsule 5 MG Oxycodone ir: restricted to 120 tabs per 30 days, for chronic pain req. >120, Alernatives: ms contin Oxycodone Hcl Oxycodone Hcl Oral Conc 20 MG/ML Oxycodone Hcl Oxycodone Hcl Solution 5 MG/5 ML Oxycodone Hcl Oxycodone Hcl Tablet 10 MG Oxycodone ir: restricted to 120 tabs per 30 days, for chronic pain req. >120, Alernatives: ms contin Oxycodone Hcl Oxycodone Hcl Tablet 15 MG Oxycodone ir: restricted to 120 tabs per 30 days, for chronic pain req. >120, Alernatives: ms contin Oxycodone Hcl Oxycodone Hcl Tablet 20 MG Oxycodone ir: restricted to 120 tabs per 30 days, for chronic pain req. >120, Alernatives: ms contin Oxycodone Hcl Oxycodone Hcl Tablet 30 MG Oxycodone ir: restricted to 120 tabs per 30 days, for chronic pain req. >120, Alernatives: ms contin Oxycodone Hcl Oxycodone Hcl Tablet 5 MG Oxycodone ir: restricted to 120 tabs per 30 days, for chronic pain req. >120, Alernatives: ms contin Oxycodone Hcl‐ Acetaminophen Oxycodone Hcl/Acetaminophen Tablet 10MG‐325MG Restricted to 120 tabs/caps per 30 days. Oxycodone Hcl‐ Acetaminophen Oxycodone Hcl/Acetaminophen Tablet 10MG‐325MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, e.g. ms contin, methadone may be considered. Oxycodone‐ Acetaminophen Oxycodone Hcl/Acetaminophen Tablet 5 MG‐325MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, e.g. ms contin, methadone may be considered. Oxycodone‐Acetaminop Oxycodone Hcl/Acetaminophen Tablet 5 MG‐325MG Oxycodone‐ Acetaminophen Tablet 5 MG‐325MG Oxycodone Hcl/Acetaminophen Restricted to 120 tabs/caps per 30 days. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 96 of 119 May 2015 Oxycodone‐ Acetaminophen Oxycodone Hcl/Acetaminophen Tablet 7.5‐325MG Restricted to 120 tabs/caps per 30 days. Oxycodone‐ Acetaminophen Oxycodone Hcl/Acetaminophen Tablet 7.5‐325MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, e.g. ms contin, methadone may be considered. Ultram Tramadol Hcl Tablet 50 MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, e.g. ms contin, methadone may be considered. DRUG CLASS: Nsaids, Cyclooxygenase 2 Inhibitor ‐ Type Brand Name Generic Name Formulation Strength Celebrex Celecoxib Capsule 100 MG Step therapy to failure of 3 different nsaids (including meloxicam or etodolac) unless over 65 or at high risk for gi events. Celebrex Celecoxib Capsule 200 MG Step therapy to failure of 3 different nsaids (including meloxicam or etodolac) unless over 65 or at high risk for gi events. Celebrex Celecoxib Capsule 400 MG Step therapy to failure of 3 different nsaids (including meloxicam or etodolac) unless over 65 or at high risk for gi events. Celebrex Celecoxib Capsule 50 MG Step therapy to failure of 3 different nsaids (including meloxicam or etodolac) unless over 65 or at high risk for gi events. DRUG CLASS: Nsaids, Cyclooxygenase Inhibitor ‐ Type Brand Name Generic Name Formulation Strength Cataflam Diclofenac Potassium Tablet 50 MG Voltaren‐Xr Diclofenac Sodium Tab Er 24H 100 MG Diclofenac Sodium Diclofenac Sodium Tablet Dr 50 MG Voltaren Diclofenac Sodium Tablet Dr 75 MG Lodine Etodolac Capsule 200 MG Etodolac Etodolac Capsule 300 MG Etodolac Etodolac Tablet 400 MG Etodolac Etodolac Tablet 500 MG Indomethacin Indomethacin Capsule 25 MG Indomethacin Indomethacin Capsule 50 MG Indomethacin Indomethacin Capsule Er 75 MG Indocin Indomethacin Oral Susp 25 MG/5 ML Indomethacin Indomethacin Supp.Rect 50 MG Nabumetone Nabumetone Tablet 500 MG Nabumetone Nabumetone Tablet 750 MG CATEGORY Pain Management, Chronic PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pain Management, Chronic PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 97 of 119 May 2015 THERAPUTIC CATEGORY Pain Management, General CATEGORY Pain Management, General DRUG CLASS: Analgesic/Antipyretics,Non‐Salicylate Brand Name Generic Name Formulation Strength Mapap Acetaminophen Capsule 500 MG Acetaminophen Acetaminophen Drops 100 MG/ML Q‐Pap Acetaminophen Drops 80MG/0.8ML Infant'S Pain Relief Acetaminophen Drops Susp 100 MG/ML Tylenol Acetaminophen Drops Susp 80MG/0.8ML Acetaminophen Acetaminophen Elixir 160 MG/5ML Child Triaminic Fever Re Acetaminophen Liquid 160 MG/5ML Acetaminophen Acetaminophen Liquid 500 MG/5ML Tylenol Extra Strength Acetaminophen Liquid 500MG/15ML Children'S Tylenol Acetaminophen Oral Susp 160 MG/5ML Acetaminophen Acetaminophen Solution 160 MG/5ML Acetaminophen Acetaminophen Supp.Rect 120 MG Acetaminophen Acetaminophen Supp.Rect 325 MG Acetaminophen Acetaminophen Supp.Rect 650 MG Feverall PA S QL F AL P GL Restrictions (if applicable) Acetaminophen Supp.Rect 80 MG Acetaminophen Junior S Acetaminophen Tab Chew 160 MG Children'S Pain Reliever Acetaminophen Tab Chew 80 MG Jr. Tylenol Meltaways Acetaminophen Tab Rapdis 160 MG Children'S Tylenol Melt Acetaminophen Tab Rapdis 80 MG Pain Relief Acetaminophen Tablet 325 MG Tylenol Extra Strength Acetaminophen Tablet 500 MG Tylenol Arthritis Acetaminophen Tablet Er 650 MG DRUG CLASS: Nsaids, Cyclooxygenase Inhibitor ‐ Type Brand Name Generic Name Formulation Strength Infant'S Ibuprofen Ibuprofen Drops Susp 50 MG/1.25 Children'S Motrin Ibuprofen Oral Susp 100 MG/5ML Motrin Ibuprofen Tab Chew 100 MG Motrin Ibuprofen Tablet 100 MG Motrin Ib Ibuprofen Tablet 200 MG Ibuprofen Ibuprofen Tablet 400 MG Ibuprofen Ibuprofen Tablet 600 MG Ibuprofen Ibuprofen Tablet 800 MG Meloxicam Meloxicam Tablet 15 MG Restricted to 1 tablet per day. Meloxicam Meloxicam Tablet 7.5 MG Restricted to 2 tablets per day. Naprosyn Naproxen Oral Susp 125 MG/5ML Naprosyn Naproxen Tablet 250 MG Naprosyn Naproxen Tablet 375 MG Naprosyn Naproxen Tablet 500 MG Ec‐Naprosyn Naproxen Tablet Dr 500 MG CATEGORY Pain Management, General PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 98 of 119 May 2015 Sulindac Sulindac Tablet 150 MG Clinoril Sulindac Tablet 200 MG RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 99 of 119 May 2015 THERAPUTIC CATEGORY Pain Management, Other DRUG CLASS: Analgesic, Salicylate, Barbiturate,&Xanthine Cmb Brand Name Generic Name Formulation Strength Butalbital‐Aspirin‐ Caffeine Butalbital/Aspirin/Caffeine Capsule 50‐325‐40 CATEGORY Pain Management, Other PA S QL F AL P GL Restrictions (if applicable) Restricted to 30 tabs/caps per 30 days. for frequent headache > 2 attacks per month, prophylaxis should be considered CATEGORY Pain Management, Other DRUG CLASS: Analgesic,Non‐Salicylate,Barbiturate,&Xanthine Cmb Brand Name Generic Name Formulation Strength Esgic Butalb/Acetaminophen/Caffeine Capsule 50‐325‐40 Restricted to 30 tabs/caps per 30 days. for frequent headache > 2 attacks per month, prophylaxis should be considered Butalbital‐ Acetaminophen‐Caffe Butalb/Acetaminophen/Caffeine Tablet 50‐325‐40 Restricted to 30 tabs/caps per 30 days. for frequent headache > 2 attacks per month, prophylaxis should be considered DRUG CLASS: Antinflammatory, Sel.Costim.Mod.,T‐Cell Inhibitor Brand Name Generic Name Formulation Strength Orencia Abatacept Syringe 125 MG/ML Reserved as a third‐line agent after treatment failure of (1) enbrel or humira or remicade or simponi and (2) rituxan. Orencia Abatacept/Maltose Vial 250 MG Reserved as a third‐line agent after treatment failure of (1) enbrel or humira or remicade or simponi and (2) rituxan. PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pain Management, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pain Management, Other DRUG CLASS: Antiseptics,General Brand Name Generic Name Formulation Strength Alcohol Prep Pads Alcohol Antiseptic Pads Med. Pad PA S QL F AL P GL Restrictions (if applicable) Restricted to 100 per 30 days. CATEGORY Pain Management, Other DRUG CLASS: Colchicine Brand Name Generic Name Formulation Strength Colchicine Colchicine Tablet 0.6 MG Tablet 0.5‐500MG PA S QL F AL P GL Restrictions (if applicable) Reserved for acute gout attack. max 15 tabs/month. bill as 15 tabs for 30 ds. Alernatives: allopurinol for prevention, meloxicam/indomethacin for pain, colcrys for attack. Probenecid‐Colchicine Colchicine/Probenecid DRUG CLASS: Hyperuricemia Tx ‐ Purine Inhibitors Brand Name Generic Name Formulation Strength Allopurinol Allopurinol Tablet 100 MG Allopurinol Allopurinol Tablet 300 MG Uloric Febuxostat Tablet 40 MG Reserved for patients who are allergic to allopurinol Uloric Febuxostat Tablet 80 MG Reserved for patients who are allergic to allopurinol CATEGORY Pain Management, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pain Management, Other DRUG CLASS: Local Anesthetics Brand Name Generic Name Formulation Strength Anbesol Benzocaine Gel (Gram) 0.1 Hurricaine Benzocaine Gel (Gram) 0.2 Orasep Benzocaine/Menth/Cetylpyrd Cl Spray 2‐0.5‐0.1% PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 100 of 119 May 2015 Lidocaine Hcl Lidocaine Hcl Jel (Ml) Lidocaine Hcl Lidocaine Hcl Jel/Pf App 0.02 0.02 Lidocaine Hcl Viscous Lidocaine Hcl Solution 0.02 Lidocaine Hcl Lidocaine Hcl Solution 40 MG/ML DRUG CLASS: Narc.&Non‐Sal.Analgesic,Barbiturate &Xanthine Cmb Brand Name Generic Name Formulation Strength Butalb‐Caff‐ Acetaminoph‐Codein Butalbit/Acetamin/Caff/Codeine Capsule 50‐325‐30 DRUG CLASS: Narcotic Analgesic & Non‐Salicylate Analgesic Comb Brand Name Generic Name Formulation Strength Acetaminophen‐ Codeine Acetaminophen With Codeine Solution 120‐12MG/5 Restricted to 240 ml per fill and 946 ml per month Acetaminophen‐ Codeine Acetaminophen With Codeine Tablet 300MG‐15MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, e.g. ms contin, methadone may be considered. Tylenol‐Codeine No.3 Acetaminophen With Codeine Tablet 300MG‐30MG Restricted to 120 tabs/caps per 30 days. for chronic pain requiring > 120/month, long‐acting opioids, e.g. ms contin, methadone may be considered. Tylenol‐Codeine No.4 Acetaminophen With Codeine Tablet 300MG‐60MG Restricted to 120 tabs/caps per 30 days. CATEGORY Pain Management, Other PA S QL F AL P GL Restrictions (if applicable) Restricted to 30 tabs/caps per 30 days. for frequent headache > 2 attacks per month, prophylaxis should be considered CATEGORY Pain Management, Other PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pain Management, Other DRUG CLASS: Topical Local Anesthetics Brand Name Generic Name Formulation Strength Lidocaine Lidocaine Adh. Patch 5%(700MG) Reserved for patients with peripheral neuropathy and treatment failure of 2 conventional treatments (e.g. tca, snri, gabapentin). Lidocaine‐Prilocaine Lidocaine/Prilocaine Cream (G) 2.5 %‐2.5% Restricted to 30g per fill and 1 fill per 30 days Sarna Sensitive Pramoxine Hcl Lotion 0.01 Summer'S Eve Pramoxine Hcl Towelette 0.01 DRUG CLASS: Uricosuric Agents Brand Name Generic Name Formulation Strength Probenecid Probenecid Tablet 500 MG PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pain Management, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 101 of 119 May 2015 THERAPUTIC CATEGORY Pain Mgmt, Chronic CATEGORY Pain Mgmt, Chronic DRUG CLASS: Analgesics,Narcotics Brand Name Generic Name Formulation Strength Oxycontin Oxycodone Hcl Tab Er 12H 10 MG Oxycontin step to failure of ms contin and fentanyl patch, restricted to 2 tabs per day. Oxycontin Oxycodone Hcl Tab Er 12H 15 MG Oxycontin step to failure of ms contin and fentanyl patch, restricted to 2 tabs per day. Oxycontin Oxycodone Hcl Tab Er 12H 20 MG Oxycontin step to failure of ms contin and fentanyl patch, restricted to 2 tabs per day. Oxycontin Oxycodone Hcl Tab Er 12H 30 MG Oxycontin step to failure of ms contin and fentanyl patch, restricted to 2 tabs per day. Oxycontin Oxycodone Hcl Tab Er 12H 40 MG Oxycontin step to failure of ms contin and fentanyl patch, restricted to 2 tabs per day. Oxycontin Oxycodone Hcl Tab Er 12H 60 MG Oxycontin step to failure of ms contin and fentanyl patch, restricted to 2 tabs per day. Oxycontin Oxycodone Hcl Tab Er 12H 80 MG Oxycontin step to failure of ms contin and fentanyl patch, restricted to 2 tabs per day. PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 102 of 119 May 2015 THERAPUTIC CATEGORY Pulmonary, Asthma/COPD CATEGORY Pulmonary, Asthma/COPD DRUG CLASS: Anaphylaxis Therapy Agents Brand Name Generic Name Formulation Strength Epipen Jr Epinephrine Auto Injct 0.15MG/0.3 Auvi‐Q Epinephrine Auto Injct 0.3MG/0.3 PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pulmonary, Asthma/COPD DRUG CLASS: Beta‐Adrenergic Agents Brand Name Generic Name Formulation Strength Proventil Hfa Albuterol Sulfate Hfa Aer Ad 90 MCG Ventolin: max 2 inhalers/month and 7/6 months. for uncontrolled asthma, standard of care is ics +/‐ laba (flovent, qvar, advair) Albuterol Sulfate Albuterol Sulfate Solution 5 MG/ML Restricted to 40 ml in 30 days Albuterol Sulfate Albuterol Sulfate Syrup 2 MG/5 ML Restricted to 240 ml per month. for uncontrolled asthma, standard of care is ics +/‐ laba (flovent, qvar, advair) Albuterol Sulfate Albuterol Sulfate Vial‐Neb 0.63MG/3ML Restricted to 375 ml per month. for uncontrolled asthma, standard of care is ics +/‐ laba (flovent, qvar, advair) Albuterol Sulfate Albuterol Sulfate Vial‐Neb 1.25MG/3ML Restricted to 375 ml per month. for uncontrolled asthma, standard of care is ics +/‐ laba (flovent, qvar, advair) Albuterol Sulfate Albuterol Sulfate Vial‐Neb 2.5 MG/0.5 Limited to 375ml per 30 days Albuterol Sulfate Albuterol Sulfate Vial‐Neb 2.5 MG/3ML Restricted to 375 ml per month. for uncontrolled asthma, standard of care is ics +/‐ laba (flovent, qvar, advair) Foradil Formoterol Fumarate Cap W/Dev 12 MCG Concurrent Alernatives: of inhaled corticosteroids is required. restricted to 1 inhaler per month. Foradil Formoterol Fumarate Cap W/Dev 12 MCG Concurrent Alernatives: of inhaled corticosteroids is required. restricted to 1 inhaler per month. Levalbuterol Hcl Levalbuterol Hcl Vial‐Neb 0.31MG/3ML Step therapy to intolerance to albuterol. formulary rescue inhaler is ventolin hfa with dose counter Levalbuterol Hcl Levalbuterol Hcl Vial‐Neb 0.63MG/3ML Step therapy to intolerance to albuterol. formulary rescue inhaler is ventolin hfa with dose counter Levalbuterol Concentrate Levalbuterol Hcl Vial‐Neb 1.25MG/0.5 Step therapy to intolerance to albuterol. formulary rescue inhaler is ventolin hfa with dose counter Levalbuterol Hcl Levalbuterol Hcl Vial‐Neb 1.25MG/3ML Step therapy to intolerance to albuterol. formulary rescue inhaler is ventolin hfa with dose counter AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 103 of 119 May 2015 Xopenex Hfa Levalbuterol Tartrate Hfa Aer Ad 45 MCG Step therapy to intolerance to albuterol. formulary rescue inhaler is ventolin hfa with dose counter Serevent Diskus Salmeterol Xinafoate Blst W/Dev 50 MCG Concurrent Alernatives: of inhaled corticosteroids is required. restricted to 1 inhaler per month. DRUG CLASS: Beta‐Adrenergic And Anticholinergic Combinations Brand Name Generic Name Formulation Strength Ipratropium‐Albuterol Ipratropium/Albuterol Sulfate Ampul‐Neb 0.5‐3MG/3 Restricted to 375 ml per 30 days Combivent Respimat Ipratropium/Albuterol Sulfate Mist Inhal 20‐100 MCG Restricted to 1 inhaler per 30 days. CATEGORY Pulmonary, Asthma/COPD PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pulmonary, Asthma/COPD DRUG CLASS: Beta‐Adrenergics And Glucocorticoids Combination Brand Name Generic Name Formulation Strength Symbicort Budesonide/Formoterol Fumarate Hfa Aer Ad 160‐4.5MCG Restricted to 1 inhaler per 30 days. Symbicort Budesonide/Formoterol Fumarate Hfa Aer Ad 80‐4.5 MCG Restricted to 1 inhaler per 30 days. Advair Diskus Fluticasone/Salmeterol Blst W/Dev 100‐50 MCG Restricted to 1 inhaler per 30 days. Advair Diskus Fluticasone/Salmeterol Blst W/Dev 250‐50 MCG Restricted to 1 inhaler per 30 days. Advair Diskus Fluticasone/Salmeterol Blst W/Dev 500‐50 MCG Restricted to 1 inhaler per 30 days. Advair Hfa Fluticasone/Salmeterol Hfa Aer Ad 115‐21MCG Restricted to 1 inhaler per 30 days. Advair Hfa Fluticasone/Salmeterol Hfa Aer Ad 230‐21MCG Restricted to 1 inhaler per 30 days. Advair Hfa Fluticasone/Salmeterol Hfa Aer Ad 45‐21MCG Restricted to 1 inhaler per 30 days. Dulera Mometasone/Formoterol Hfa Aer Ad 100‐5 MCG Restricted to 1 inhaler per 30 days. Dulera Mometasone/Formoterol Hfa Aer Ad 200‐5 MCG Restricted to 1 inhaler per 30 days. DRUG CLASS: Corticosteroids (Respiratory Tract) Brand Name Generic Name Formulation Strength Qvar Beclomethasone Dipropionate Aer W/Adap 40 MCG Qvar: restricted to 1 inhaler per 30 days. Qvar Beclomethasone Dipropionate Aer W/Adap 80 MCG Qvar: restricted to 1 inhaler per 30 days. PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pulmonary, Asthma/COPD PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 104 of 119 May 2015 Pulmicort Flexhaler Budesonide Aer Pow Ba 180 MCG Restricted to 1 inhaler per 30 days. Budesonide Budesonide Ampul‐Neb 0.25MG/2ML Pulmicort: restricted to patients <=4 years old. max 120 ml/month. for patients over 4, Alernatives: flovent or qvar with spacer and mask. Budesonide Budesonide Ampul‐Neb 0.25MG/2ML Pulmicort: restricted to patients <=4 years old. max 120 ml/month. for patients over 4, Alernatives: flovent or qvar with spacer and mask. Budesonide Budesonide Ampul‐Neb 0.5 MG/2ML Pulmicort: restricted to patients <=4 years old. max 120 ml/month. for patients over 4, Alernatives: flovent or qvar with spacer and mask. Budesonide Budesonide Ampul‐Neb 0.5 MG/2ML Pulmicort: restricted to patients <=4 years old. max 120 ml/month. for patients over 4, Alernatives: flovent or qvar with spacer and mask. Pulmicort Budesonide Ampul‐Neb 1 MG/2 ML Pulmicort: restricted to patients <=4 years old. max 120 ml/month. for patients over 4, Alernatives: flovent or qvar with spacer and mask. Pulmicort Budesonide Ampul‐Neb 1 MG/2 ML Pulmicort: restricted to patients <=4 years old. max 120 ml/month. for patients over 4, Alernatives: flovent or qvar with spacer and mask. Flovent Hfa Fluticasone Propionate Aer W/Adap 110 MCG Restricted to 1 inhaler per 30 days. Flovent Hfa Fluticasone Propionate Aer W/Adap 220 MCG Restricted to 1 inhaler per 30 days. Flovent Hfa Fluticasone Propionate Aer W/Adap 44 MCG Restricted to 1 inhaler per 30 days. Flovent Diskus Fluticasone Propionate Blst W/Dev 100 MCG Restricted to 1 inhaler per 30 days. Flovent Diskus Fluticasone Propionate Blst W/Dev 250 MCG Restricted to 1 inhaler per 30 days. Flovent Diskus Fluticasone Propionate Blst W/Dev 50 MCG Restricted to 1 inhaler per 30 days. Asmanex Mometasone Furoate Aer Pow Ba 110MCG(30) Restricted to patients under 12 yrs old Asmanex Mometasone Furoate Aer Pow Ba 220MCG 120 Asmanex: restricted to 1 inhaler per 30 days. Asmanex Mometasone Furoate Aer Pow Ba 220MCG(60) Asmanex: restricted to 1 inhaler per 30 days. CATEGORY Pulmonary, Asthma/COPD DRUG CLASS: General Bronchodilator Agents Brand Name Generic Name Formulation Strength Tudorza Pressair Aclidinium Bromide Aer Pow Ba 400 MCG PA S QL F AL P GL Restrictions (if applicable) Reserved for patients with diagnosis of copd with gold stage 2 airflow limitation as proven by pulmonary function testing. restricted to 1 inhaler per month. RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 105 of 119 May 2015 Atrovent Hfa Ipratropium Bromide Hfa Aer Ad 17MCG Ipratropium Bromide Spiriva Spiriva Respimat Restricted to 2 inhalers per 30 days. Ipratropium Bromide Solution 0.2 MG/ML Tiotropium Bromide Cap W/Dev 18 MCG Reserved for patient with at least stage ii (moderate) copd confirmed by pulmonary function testing. Tiotropium Bromide Mist Inhal 2.5 MCG Reserved for patient with at least stage ii (moderate) copd confirmed by pulmonary function testing. Formulation Strength CATEGORY Pulmonary, Asthma/COPD DRUG CLASS: Glucocorticoids Brand Name Generic Name Cortisone Acetate Cortisone Acetate Tablet 25 MG Dexamethasone Intens Dexamethasone Drops 1 MG/ML Dexamethasone Dexamethasone Elixir 0.5 MG/5ML Dexamethasone Dexamethasone Solution 0.5 MG/5ML Dexpak Dexamethasone Tab Ds Pk 1.5MG (51) Dexamethasone Dexamethasone Tablet 0.5 MG Dexamethasone Dexamethasone Tablet 0.75 MG Dexamethasone Dexamethasone Tablet 1 MG Dexamethasone Dexamethasone Tablet 1.5 MG Dexamethasone Dexamethasone Tablet 2 MG Dexamethasone Dexamethasone Tablet 4 MG Dexamethasone Dexamethasone Tablet 6 MG Dexamethasone Sodiu Dexamethasone Sod Phosphate Vial 10 MG/ML Cortef Hydrocortisone Tablet 10 MG Cortef Hydrocortisone Tablet 20 MG Cortef Hydrocortisone Tablet 5 MG Medrol Methylprednisolone Tab Ds Pk 4 MG Medrol Methylprednisolone Tablet 16 MG Medrol Methylprednisolone Tablet 2 MG Medrol Methylprednisolone Tablet 32 MG Medrol Methylprednisolone Tablet 4 MG Medrol Methylprednisolone Tablet 8 MG Prednisolone Prednisolone Solution 15 MG/5 ML Prednisolone Prednisolone Tablet 5 MG Prednisolone Sodium P Prednisolone Sod Phosphate Solution 15 MG/5 ML Prednisolone Sodium P Prednisolone Sod Phosphate Solution 5 MG/5 ML Prednisone Intensol Prednisone Oral Conc 5 MG/ML Prednisone Prednisone Solution 5 MG/5 ML Sterapred Prednisone Tab Ds Pk 5 MG Prednisone Prednisone Tablet 1 MG Prednisone Prednisone Tablet 10 MG Prednisone Prednisone Tablet 2.5 MG Prednisone Prednisone Tablet 20 MG Prednisone Prednisone Tablet 5 MG Prednisone Prednisone Tablet 50 MG Aristospan Triamcinolone Hexacetonide Vial 20 MG/ML PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 106 of 119 May 2015 DRUG CLASS: Leukocyte Adhesion Inhib,Alpha4‐Mediat Igg4K Mc Ab Brand Name Generic Name Formulation Strength Tysabri Natalizumab Vial 300MG/15ML CATEGORY Pulmonary, Asthma/COPD PA S QL F AL P GL Restrictions (if applicable) Reserved as 3rd line therapy for ms behind [1] betaseron / Avonex / Rebif / Copaxone, and [2] gilenya or aubagio due to increased risk of developing progressive multifocal leukoencephalopathy (pml). CATEGORY Pulmonary, Asthma/COPD DRUG CLASS: Leukotriene Receptor Antagonists Brand Name Generic Name Formulation Strength Singulair Montelukast Sodium Gran Pack 4 MG Restricted to 1 tablet per day Singulair Montelukast Sodium Tab Chew 4 MG Restricted to 1 tablet per day Singulair Montelukast Sodium Tab Chew 5 MG Restricted to 1 tablet per day Singulair Montelukast Sodium Tablet 10 MG Restricted to 1 tablet per day DRUG CLASS: Monoclonal Antibodies To Immunoglobulin E(Ige) Brand Name Generic Name Formulation Strength Xolair Omalizumab Vial 150 MG PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pulmonary, Asthma/COPD PA S QL F AL P GL Restrictions (if applicable) Documenation of IgE levels, FEV1, Alernatives: of oral and inhaled corticosteroids , and immunotherapy is required. CATEGORY Pulmonary, Asthma/COPD DRUG CLASS: Phosphodiesterase‐4 (Pde4) Inhibitors Brand Name Generic Name Formulation Strength Daliresp Roflumilast Tablet 500 MCG PA S QL F AL P GL Restrictions (if applicable) Reserved for patients with stage iii copd who have persistent symptoms despite compliant Alernatives: of ics/laba and spiriva CATEGORY Pulmonary, Asthma/COPD DRUG CLASS: Xanthines Brand Name Generic Name Formulation Strength Cafcit Caffeine Citrated Solution 60 MG/3 ML Theo‐24 Theophylline Anhydrous Cap Er 24H 100 MG Theo‐24 Theophylline Anhydrous Cap Er 24H 200 MG Theo‐24 Theophylline Anhydrous Cap Er 24H 300 MG Theo‐24 Theophylline Anhydrous Cap Er 24H 400 MG Theophylline Theophylline Anhydrous Elixir 80 MG/15ML Elixophyllin Theophylline Anhydrous Elixir 80 MG/15ML Theophylline Theophylline Anhydrous Solution 80 MG/15ML Theophylline Anhydrou Theophylline Anhydrous Tab Er 12H 100 MG Theophylline Anhydrou Theophylline Anhydrous Tab Er 12H 200 MG Theophylline Anhydrou Theophylline Anhydrous Tab Er 12H 300 MG Theochron Theophylline Anhydrous Tab Er 12H 450 MG Theophylline Theophylline Anhydrous Tablet Er 400 MG Theophylline Theophylline Anhydrous Tablet Er 600 MG PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 107 of 119 May 2015 THERAPUTIC CATEGORY Pulmonary, Other CATEGORY Pulmonary, Other DRUG CLASS: Anticholinergics,Quaternary Ammonium Brand Name Generic Name Formulation Strength Glycopyrrolate Glycopyrrolate Tablet 1 MG Glycopyrrolate Glycopyrrolate Tablet 2 MG Glycopyrrolate Glycopyrrolate Vial 0.2 MG/ML Tablet 15 MG Propantheline Bromide Propantheline Bromide PA S QL F PA S QL F PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pulmonary, Other DRUG CLASS: Antitussives,Non‐Narcotic Brand Name Generic Name Formulation Strength Tessalon Perle Benzonatate Capsule 100 MG Benzonatate Benzonatate Capsule 200 MG Adult Robitussin Dextromethorphan Hbr Syrup 15 MG/5 ML Robitussin Pediatric Cou Dextromethorphan Hbr Syrup 7.5 MG/5ML Strength AL P GL Restrictions (if applicable) CATEGORY Pulmonary, Other DRUG CLASS: General Inhalation Agents Brand Name Generic Name Formulation Sodium Chloride Sodium Chloride For Inhalation Vial‐Neb 0.009 Sodium Chloride Sodium Chloride For Inhalation Vial‐Neb 0.03 Sodium Chloride Sodium Chloride For Inhalation Vial‐Neb 0.07 Sodium Chloride Sodium Chloride For Inhalation Vial‐Neb 0.1 Formulation Strength AL P GL Restrictions (if applicable) CATEGORY Pulmonary, Other DRUG CLASS: Mast Cell Stabilizers Brand Name Generic Name Cromolyn Sodium Cromolyn Sodium Ampul‐Neb 20 MG/2 ML Cromolyn Sodium Cromolyn Sodium Solution 20 MG/ML AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy CATEGORY Pulmonary, Other DRUG CLASS: Mucolytics Brand Name Generic Name Formulation Strength Acetylcysteine Acetylcysteine Vial 100 MG/ML Acetylcysteine Acetylcysteine Vial 200 MG/ML Pulmozyme Dornase Alfa Solution 1 MG/ML PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. CATEGORY Pulmonary, Other DRUG CLASS: Pulm.Anti‐Htn,Sel.C‐Gmp Phosphodiesterase T5 Inhib Brand Name Generic Name Formulation Strength Revatio Sildenafil Citrate Tablet 20 MG Reserved for patients with a confirmed diagnosis of pulmonary arterial hypertension (PAH). Adcirca Tadalafil Tablet 20 MG 2nd‐line for tx failure after revatio. DRUG CLASS: Pulmonary Anti‐Htn, Endothelin Receptor Antagonist Brand Name Generic Name Formulation Strength Letairis Ambrisentan Tablet 10 MG PA S QL F AL P GL Restrictions (if applicable) CATEGORY Pulmonary, Other PA S QL F AL P GL Restrictions (if applicable) Reserved for patients with ipah class ii with failure of sildenafil/tadalafil or ipah class iii RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 108 of 119 May 2015 Letairis Ambrisentan Tablet 5 MG Reserved for patients with ipah class ii with failure of sildenafil/tadalafil or ipah class iii Tracleer Bosentan Tablet 125 MG Reserved for patients with ipah class ii with failure of sildenafil/tadalafil or ipah class iii Tracleer Bosentan Tablet 62.5 MG Reserved for patients with ipah class ii with failure of sildenafil/tadalafil or ipah class iii DRUG CLASS: Pulmonary Antihypertensives, Prostacyclin‐Type Brand Name Generic Name Formulation Strength Veletri Epoprostenol Sodium (Arginine) Vial 0.5 MG 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Veletri Epoprostenol Sodium (Arginine) Vial 1.5 MG 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Flolan Epoprostenol Sodium (Glycine) Vial 0.5 MG 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Flolan Epoprostenol Sodium (Glycine) Vial 1.5 MG 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Ventavis Iloprost Tromethamine Ampul‐Neb 10 MCG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. Ventavis Iloprost Tromethamine Ampul‐Neb 20 MCG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. Tyvaso Treprostinil Ampul‐Neb 1.74MG/2.9 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Remodulin Treprostinil Sodium Vial 1 MG/ML 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Remodulin Treprostinil Sodium Vial 10 MG/ML 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Remodulin Treprostinil Sodium Vial 2.5 MG/ML 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Remodulin Treprostinil Sodium Vial 5 MG/ML 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Tyvaso Treprostinil/Neb Accessories Ampul‐Neb 1.74MG/2.9 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. Tyvaso Treprostinil/Nebulizer/Accesor Ampul‐Neb 1.74MG/2.9 3rd‐line for tx failure after revatio and Adcirca/Tracleer/Letairis. CATEGORY Pulmonary, Other PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 109 of 119 May 2015 THERAPUTIC CATEGORY Renal CATEGORY Renal DRUG CLASS: Calcimimetic,Parathyroid Calcium Enhancer Brand Name Generic Name Formulation Strength Sensipar Cinacalcet Hcl Tablet 30 MG Step therapy to patients with secondary hyperparathyroidism with bipth > 200 pg/ml despite compliant Alernatives: of phosphate binders. restricted to Diplomat pharmacy. Sensipar Cinacalcet Hcl Tablet 60 MG Step therapy to patients with secondary hyperparathyroidism with bipth > 200 pg/ml despite compliant Alernatives: of phosphate binders. restricted to Diplomat pharmacy. Sensipar Cinacalcet Hcl Tablet 90 MG Step therapy to patients with secondary hyperparathyroidism with bipth > 200 pg/ml despite compliant Alernatives: of phosphate binders. restricted to Diplomat pharmacy. Formulation Strength Sodium Citrate & Citric Citric Acid/Sodium Citrate Solution 334‐500MG K‐Phos Neutral Phosphorus #1 Tablet 250 MG Urocit‐K Potassium Citrate Tablet Er 10 MEQ Urocit‐K Potassium Citrate Tablet Er 5 MEQ DRUG CLASS: Urinary Ph Modifiers Brand Name Generic Name PA S QL F AL P GL Restrictions (if applicable) CATEGORY Renal PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 110 of 119 May 2015 THERAPUTIC CATEGORY Rheumatology CATEGORY Rheumatology DRUG CLASS: Alkylating Agents Brand Name Generic Name Formulation Strength Droxia Hydroxyurea Capsule 200 MG Droxia Hydroxyurea Capsule 300 MG Droxia Hydroxyurea Capsule 400 MG PA S QL F PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Rheumatology DRUG CLASS: Anti‐Arthritic, Folate Antagonist Agents Brand Name Generic Name Formulation Strength Tab Ds Pk 2.5 MG AL P GL Restrictions (if applicable) Methotrexate Methotrexate Sodium DRUG CLASS: Anti‐Inflammatory Tumor Necrosis Factor Inhibitor Brand Name Generic Name Formulation Strength Humira Adalimumab Pen Ij Kit 40MG/0.8ML Reserved for severe RA, psoriasis, or crohn's disesase. humira is prefered over enbrel for psoriasis. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Humira Adalimumab Syringekit 20MG/0.4ML Reserved for severe RA, psoriasis, or crohn's disesase. humira is prefered over enbrel for psoriasis. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Humira Adalimumab Syringekit 40MG/0.8ML Reserved for severe RA, psoriasis, or crohn's disesase. humira is prefered over enbrel for psoriasis. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Enbrel Etanercept Pen Injctr 50 MG/ML Enbrel Etanercept Syringe 25MG/0.5ML Reserved for severe RA or psoriasis, or psoriatic arthritis. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Enbrel Etanercept Syringe 50 MG/ML Reserved for severe RA or psoriasis, or psoriatic arthritis. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Enbrel Etanercept Vial 25 MG Reserved for severe RA or psoriasis, or psoriatic arthritis. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337 Simponi Golimumab Pen Injctr 100 MG/ML Step therapy to treatment failure of enbrel or humira. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337. Simponi Golimumab Pen Injctr 50MG/0.5ML Step therapy to treatment failure of enbrel or humira. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337. Simponi Golimumab Syringe 100 MG/ML Step therapy to treatment failure of enbrel or humira. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337. Simponi Golimumab Syringe 50MG/0.5ML Step therapy to treatment failure of enbrel or humira. restricted to Diplomat specialty pharmacy at 877‐319‐ 6337. DRUG CLASS: Anti‐Inflammatory, Pyrimidine Synthesis Inhibitor Brand Name Generic Name Formulation Strength Arava Leflunomide Tablet 10 MG Arava Leflunomide Tablet 20 MG DRUG CLASS: Anti‐Inflammatory/Antiarthritics Agents, Misc. Brand Name Generic Name Formulation Strength CATEGORY Rheumatology AL P GL Restrictions (if applicable) CATEGORY Rheumatology PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Rheumatology AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 111 of 119 May 2015 Hyalgan Hyaluronate Sodium Syringe 10 MG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Orthovisc Hyaluronate Sodium Syringe 30 MG/2 ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Hyalgan Hyaluronate Sodium Vial 10 MG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Synvisc Hylan G‐F 20 Syringe 16MG/2ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Synvisc‐One Hylan G‐F 20 Syringe 48 MG/6 ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy DRUG CLASS: Disease‐Modifying Antirheumatic Agents Brand Name Generic Name Formulation Strength Otezla Apremilast Tablet 30 MG Pso/psa: reserved for treatment failure to 2 of the following: dmard, topical corticosteroids, or phototherapy. must be prescribed by rheumatologist or dermatologist. Xeljanz Tofacitinib Citrate Tablet 5 MG Reserved as 4th line for severe RA after treatment failure or intolerance to 1st line (enbrel/humira), 2nd line (simponi/remicade), and 3rd line (orencia/rituxan) therapy. DRUG CLASS: Gold Salts Brand Name Generic Name Formulation Strength Ridaura Auranofin Capsule 3 MG CATEGORY Rheumatology PA S QL F AL P GL Restrictions (if applicable) CATEGORY Rheumatology PA S QL F AL P GL Restrictions (if applicable) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. CATEGORY Rheumatology DRUG CLASS: Interleukin‐6 (Il‐6) Receptor Inhibitors Brand Name Generic Name Formulation Strength Actemra Tocilizumab Syringe 162 MG/0.9 3rd line after humira/enbrel and rituxan Actemra Tocilizumab Vial 200MG/10ML 3rd line after humira/enbrel and rituxan Actemra Tocilizumab Vial 400MG/20ML 3rd line after humira/enbrel and rituxan Actemra Tocilizumab Vial 80 MG/4 ML 3rd line after humira/enbrel and rituxan PA S QL F AL P GL Restrictions (if applicable) THERAPUTIC CATEGORY Topical Nasal And Otic Prepartions CATEGORY Topical Nasal And Otic Prepartions DRUG CLASS: Nasal Anti‐Inflammatory Steroids Brand Name Generic Name Formulation Strength Veramyst Fluticasone Furoate Spray Susp 27.5 MCG PA S QL F AL P GL Restrictions (if applicable) Reserved for Alernatives: in 2‐4 year olds with treatment failure to nasacort otc (triamcinolone) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 112 of 119 May 2015 THERAPUTIC CATEGORY Urology CATEGORY Urology DRUG CLASS: Antidiuretic And Vasopressor Hormones Brand Name Generic Name Formulation Strength Ddavp Desmopressin Acetate Tablet 0.1 MG Step therapy to failing a 3‐month trial of behavioral therapy with bed‐wetting alarm. the nasal spray is no longer recommended due to hyponatremia risk. Ddavp Desmopressin Acetate Tablet 0.2 MG Step therapy to failing a 3‐month trial of behavioral therapy with bed‐wetting alarm. the nasal spray is no longer recommended due to hyponatremia risk. DRUG CLASS: Benign Prostatic Hypertrophy/Micturition Agents Brand Name Generic Name Uroxatral Alfuzosin Hcl Tab Er 24H 10 MG Proscar Finasteride Tablet 5 MG Tamsulosin Hcl Tamsulosin Hcl Cap Er 24H 0.4 MG Formulation Strength PA S QL F AL P GL Restrictions (if applicable) CATEGORY Urology PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Urology DRUG CLASS: Beta‐3‐Adrenergic Agonists Brand Name Generic Name Formulation Strength Myrbetriq Mirabegron Tab Er 24H 25 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr Myrbetriq Mirabegron Tab Er 24H 50 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr DRUG CLASS: Urinary Tract Analgesic Agents Brand Name Generic Name Formulation Strength Elmiron Pentosan Polysulfate Sodium Capsule 100 MG AL P GL Restrictions (if applicable) CATEGORY Urology PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Urology DRUG CLASS: Urinary Tract Anesthetic/Analgesic Agnt (Azo‐Dye) Brand Name Generic Name Formulation Strength Phenazopyridine Hcl Phenazopyridine Hcl Tablet 100 MG Phenazopyridine Hcl Phenazopyridine Hcl Tablet 200 MG DRUG CLASS: Urinary Tract Antispasmodic, M(3) Selective Antag. Brand Name Generic Name Formulation Strength Enablex Darifenacin Hydrobromide Tab Er 24H 15 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr Enablex Darifenacin Hydrobromide Tab Er 24H 7.5 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr Vesicare Solifenacin Succinate Tablet 10 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr Vesicare Solifenacin Succinate Tablet 5 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr AL P GL Restrictions (if applicable) CATEGORY Urology PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 113 of 119 May 2015 CATEGORY Urology DRUG CLASS: Urinary Tract Antispasmodic/Antiincontinence Agent Brand Name Generic Name Formulation Strength Toviaz Fesoterodine Fumarate Tab Er 24H 4 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr Toviaz Fesoterodine Fumarate Tab Er 24H 8 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr Gelnique Oxybutynin Gel Md Pmp 28MG/0.92G Restricted to 1 pump unit per 30 days Gelnique Oxybutynin Chloride Gel Packet 0.1 Step therapy to intolerance or treatment failure of oxybutynin immediate‐release (within last 180 days) or patients over 65 years of age. Oxybutynin Chloride Oxybutynin Chloride Syrup 5 MG/5 ML Oxybutynin Chloride Er Oxybutynin Chloride Tab Er 24 10 MG Step therapy to intolerance or treatment failure of oxybutynin immediate‐release (within last 180 days) or patients over 65 years of age. Oxybutynin Chloride Er Oxybutynin Chloride Tab Er 24 15 MG Step therapy to intolerance or treatment failure of oxybutynin immediate‐release (within last 180 days) or patients over 65 years of age. Oxybutynin Chloride Er Oxybutynin Chloride Tab Er 24 5 MG Step therapy to intolerance or treatment failure of oxybutynin immediate‐release (within last 180 days) or patients over 65 years of age. Oxybutynin Chloride Oxybutynin Chloride Tablet 5 MG Detrol La Tolterodine Tartrate Cap Er 24H 2 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr Detrol La Tolterodine Tartrate Cap Er 24H 4 MG Step to intolerance or treatment failure of: 1) oxybutynin immediate‐release (except those over 65); 2) oxybutynin extended‐release, and; 3) sanctura xr Sanctura Xr Trospium Chloride Cap Er 24H 60 MG Third line agent, reserved for intolerance or treatment failure of oxybutynin immediate‐release (unless over 65) and oxybutynin extended release within the last 365 days. PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 114 of 119 May 2015 THERAPUTIC CATEGORY Vaccines CATEGORY Vaccines DRUG CLASS: Antisera Brand Name Generic Name Formulation Strength Cytogam Cytomegalovirus Immune Glob Vial 50 MG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Hepagam B Hepatitis B Immun Glob/Maltose Vial >312/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Hepagam B Hepatitis B Immun Glob/Maltose Vial >312/ML(5) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Hyperhep B S‐D Hepatitis B Immune Globulin Syringe 220 UNIT/1 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Hyperhep B S‐D Hepatitis B Immune Globulin Vial 220/ML (5) Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Flebogamma Immune Globulin,Gamma(Igg) Vial 0.05 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Gammagard Liquid Immune Globulin,Gamma(Igg) Vial 0.1 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Gammagard S‐D Immune Globulin,Gamma(Igg) Vial 10 G Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Carimune Nf Nanofiltered Immune Globulin,Gamma(Igg) Vial 12G Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Gamastan S‐D Immune Globulin,Gamma(Igg) Vial 15 %‐18 % Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Gammagard S‐D Immune Globulin,Gamma(Igg) Vial 2.5 G Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Gammagard S‐D Immune Globulin,Gamma(Igg) Vial 5 G Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Carimune Nf Nanofiltered Immune Globulin,Gamma(Igg) Vial 6G Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Atgam Lymphocyte Immune Globulin Ampul 50 MG/ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Hyperrab S‐D Rabies Immune Globulin/Pf Vial 150 UNIT/1 Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Rhogam Ultra‐Filtered Plus Rho(D) Immune Globulin Syringe 1500 UNIT Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Rhophylac Rho(D) Immune Globulin Syringe 1500/2 ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 115 of 119 May 2015 Micrhogam Ultra‐ Filtered Plus Rho(D) Immune Globulin Syringe 250 UNIT Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Winrho Sdf Rho(D) Immune Globulin/Maltose Vial 1500/1.3ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Winrho Sdf Rho(D) Immune Globulin/Maltose Vial 15000/13ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Winrho Sdf Rho(D) Immune Globulin/Maltose Vial 2500/2.2ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy Winrho Sdf Rho(D) Immune Globulin/Maltose Vial 5000/4.4ML Approval is determined by medical necessity criteria. fax pa form and supporting info to hpsj at 209‐762‐4704. restricted to specialty pharmacy RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 116 of 119 May 2015 THERAPUTIC CATEGORY Wellness CATEGORY Wellness DRUG CLASS: Fat Absorption Decreasing Agents Brand Name Generic Name Formulation Strength Xenical Orlistat Capsule 120 MG DRUG CLASS: Prenatal Vitamin Preparations Brand Name Generic Name Formulation Strength Trimesis Rx Pnv W‐O Iron/Fa/Calcium/B6/B12 Tbmp 24Hr 1‐200‐75 DRUG CLASS: Smoking Deterrent Agents (Ganglionic Stim,Others) Brand Name Generic Name Formulation Strength Nicotrol Nicotine Cartridge 10 MG Limited to two 3‐month courses of any smoking cessation agent per 365 days. Nicotine Patch Nicotine Patch Dysq 21‐14‐7MG Limited to two 3‐month courses of any smoking cessation agent per 365 days. Nicotine Patch Nicotine Patch Td24 11MG/24HR Limited to two 3‐month courses of any smoking cessation agent per 365 days. Nicotine Patch Nicotine Patch Td24 14MG/24HR Limited to two 3‐month courses of any smoking cessation agent per 365 days. Nicotine Patch Nicotine Patch Td24 21 MG/24HR Limited to two 3‐month courses of any smoking cessation agent per 365 days. Nicotine Patch Nicotine Patch Td24 22 MG/24HR Limited to two 3‐month courses of any smoking cessation agent per 365 days. Nicotine Patch Nicotine Patch Td24 7MG/24HR Limited to two 3‐month courses of any smoking cessation agent per 365 days. Nicotrol Ns Nicotine Spray 10 MG/ML Limited to two 3‐month courses of any smoking cessation agent per 365 days. Thrive Nicotine Nicotine Polacrilex Gum 2 MG Limited to two 3‐month courses of any smoking cessation agent per 365 days. Thrive Nicotine Nicotine Polacrilex Gum 4 MG Limited to two 3‐month courses of any smoking cessation agent per 365 days. Nicotine Lozenge Nicotine Polacrilex Lozenge 2 MG Limited to two 3‐month courses of any smoking cessation agent per 365 days. Nicotine Lozenge Nicotine Polacrilex Lozenge 4 MG Limited to two 3‐month courses of any smoking cessation agent per 365 days. DRUG CLASS: Smoking Deterrent‐Nocotinic Recept.Partial Agonist Brand Name Generic Name Formulation Strength Chantix Varenicline Tartrate Tab Ds Pk 0.5(11)‐1 Limited to two 3‐month courses of any smoking cessation agent per 365 days. Chantix Varenicline Tartrate Tablet 0.5 MG Limited to two 3‐month courses of any smoking cessation agent per 365 days. Chantix Varenicline Tartrate Tablet 1 MG Limited to two 3‐month courses of any smoking cessation agent per 365 days. PA S QL F AL P GL Restrictions (if applicable) Documentation of exercise, dietary counseling, and comorbidities is required. CATEGORY Wellness PA S QL F AL P GL Restrictions (if applicable) CATEGORY Wellness PA S QL F AL P GL Restrictions (if applicable) CATEGORY Wellness PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 117 of 119 May 2015 THERAPUTIC CATEGORY Women's Health CATEGORY Women's Health DRUG CLASS: Contraceptives, Intravaginal, Systemic Brand Name Generic Name Formulation Strength Nuvaring Etonogestrel/Ethinyl Estradiol Vag Ring .12‐.015MG PA S QL F AL P GL Restrictions (if applicable) Restricted to females CATEGORY Women's Health DRUG CLASS: Contraceptives,Injectable Brand Name Generic Name Formulation Strength Depo‐Provera Medroxyprogesterone Acetate Syringe 150 MG/ML Depo‐Provera Medroxyprogesterone Acetate Vial 150 MG/ML PA S QL F AL P GL Restrictions (if applicable) Restricted to females Restricted to females CATEGORY Women's Health DRUG CLASS: Contraceptives,Intravaginal Brand Name Generic Name Formulation Strength Vcf Nonoxynol 9 Film 0.28 Restricted to females Delfen Contraceptive Nonoxynol 9 Foam/Appl 0.125 Restricted to females Conceptrol Nonoxynol 9 Gel/Pf App 0.04 Restricted to females Gynol Ii Extra Strength Nonoxynol 9 Jelly/Appl 0.03 PA S QL F AL P GL Restrictions (if applicable) Restricted to females CATEGORY Women's Health DRUG CLASS: Contraceptives,Oral Brand Name Generic Name Formulation Strength Desogen Desogestrel‐Ethinyl Estradiol Tablet 0.15‐0.03 Cyclessa Desogestrel‐Ethinyl Estradiol Tablet 7 DAYS X 3 Restricted to females Kelnor 1‐35 Ethynodiol D‐Ethinyl Estradiol Tablet 1 MG‐35MCG Restricted to females Zovia 1‐50E Ethynodiol D‐Ethinyl Estradiol Tablet 1 MG‐50MCG Restricted to females Next Choice Levonorgestrel Tablet 0.75 MG Restricted to 2 per 30 days and 4 fills per year Next Choice Levonorgestrel Tablet 0.75 MG Restricted to females Plan B One‐Step Levonorgestrel Tablet 1.5 MG Restricted to 2 per 30 days and 4 fills per year Plan B One‐Step Levonorgestrel Tablet 1.5 MG Restricted to females Plan B One‐Step Levonorgestrel Tablet 1.5 MG Restricted to females Plan B One‐Step Levonorgestrel Tablet 1.5 MG Restricted to 2 per 30 days and 4 fills per year Levonorgestrel‐Eth Estr Levonorgestrel‐Ethin Estradiol Tablet 0.1‐0.02 Restricted to females Levonorgestrel‐Eth Estr Levonorgestrel‐Ethin Estradiol Tablet 0.15‐0.03 Restricted to females Enpresse Levonorgestrel‐Ethin Estradiol Tablet 40334 Restricted to females Micronor Norethindrone Tablet 0.35 MG Restricted to females Junel Norethindrone Ac‐Eth Estradiol Tablet 1.5‐0.03MG Restricted to females Norethindron‐Ethinyl Es Norethindrone Ac‐Eth Estradiol Tablet 1MG‐20MCG Restricted to females Junel Fe Norethindrone‐E.Estradiol‐Iron Tablet 1.5‐30(21) Restricted to females Norethin‐Eth Estra Ferr Norethindrone‐E.Estradiol‐Iron Tablet 1MG‐20(21) Restricted to females Ovcon‐35 Norethindrone‐Ethinyl Estrad Tablet 0.4‐0.035 Restricted to females Modicon Norethindrone‐Ethinyl Estrad Tablet 0.5‐0.035 Restricted to females Ortho‐Novum Norethindrone‐Ethinyl Estrad Tablet 1 MG‐35MCG Restricted to females Aranelle Norethindrone‐Ethinyl Estrad Tablet 38542 Restricted to females PA S QL F AL P GL Restrictions (if applicable) Restricted to females RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 118 of 119 May 2015 Necon Norethindrone‐Ethinyl Estrad Tablet 42288 Ortho‐Novum Norethindrone‐Ethinyl Estrad Tablet 7 DAYS X 3 Restricted to females Restricted to females Ortho‐Novum Norethindrone‐Mestranol Tablet 1 MG‐50MCG Restricted to females Ortho‐Cyclen Norgestimate‐Ethinyl Estradiol Tablet 0.25‐0.035 Restricted to females Ortho Tri‐Cyclen Norgestimate‐Ethinyl Estradiol Tablet 7DAYSX3 28 Restricted to females Ortho Tri‐Cyclen Lo Norgestimate‐Ethinyl Estradiol Tablet 7DAYSX3 LO Restricted to females Lo‐Ovral‐28 Norgestrel‐Ethinyl Estradiol Tablet 0.3‐0.03MG Restricted to females Ogestrel Norgestrel‐Ethinyl Estradiol Tablet 0.5 MG‐50 Restricted to females Ella Ulipristal Acetate Tablet 30 MG Restricted to women and 1 per 30 days and 2 per year Ella Ulipristal Acetate Tablet 30 MG Restricted to women and 1 per 30 days and 2 per year DRUG CLASS: Contraceptives,Transdermal Brand Name Generic Name Formulation Strength Ortho Evra Norelgestromin/Ethin.Estradiol Patch Tdwk 150‐35/24H CATEGORY Women's Health PA S QL F AL P GL Restrictions (if applicable) Restricted to females CATEGORY Women's Health DRUG CLASS: Estrogen/Androgen Combinations Brand Name Generic Name Formulation Strength Estratest H.S. Estrogen,Ester/Me‐Testosterone Tablet 0.625‐1.25 Estratest Estrogen,Ester/Me‐Testosterone Tablet 1.25‐2.5MG DRUG CLASS: Estrogenic Agents Brand Name Generic Name Formulation Strength Vivelle‐Dot Estradiol Patch Tdsw .025MG/24H Vivelle‐Dot Estradiol Patch Tdsw .0375MG/24 Vivelle‐Dot Estradiol Patch Tdsw .075MG/24H Vivelle‐Dot Estradiol Patch Tdsw 0.05MG/24H Vivelle‐Dot Estradiol Patch Tdsw 0.1MG/24HR Estradiol Estradiol Patch Tdwk .025MG/24H Estradiol Estradiol Patch Tdwk .0375MG/24 Estradiol Estradiol Patch Tdwk .075MG/24H Estradiol Estradiol Patch Tdwk 0.05MG/24H Estradiol Estradiol Patch Tdwk 0.06MG/24H Estradiol Estradiol Patch Tdwk 0.1MG/24HR Menostar Estradiol Patch Tdwk 14MCG/24HR Estradiol Estradiol Tablet 0.5 MG Estradiol Estradiol Tablet 1 MG Estradiol Estradiol Tablet 2 MG Climara Pro Estradiol/Levonorgestrel Patch Tdwk 45‐15/24H Prempro Estrogen,Con/M‐Progest Acet Tablet 0.3‐1.5MG Prempro Estrogen,Con/M‐Progest Acet Tablet 0.45‐1.5MG Premphase Estrogen,Con/M‐Progest Acet Tablet 0.625 (14) Prempro Estrogen,Con/M‐Progest Acet Tablet 0.625‐2.5 Prempro Estrogen,Con/M‐Progest Acet Tablet 0.625‐5 MG Premarin Estrogens, Conjugated Tablet 0.3 MG Premarin Estrogens, Conjugated Tablet 0.45MG Premarin Estrogens, Conjugated Tablet 0.625 MG Premarin Estrogens, Conjugated Tablet 0.9 MG PA S QL F AL P GL Restrictions (if applicable) CATEGORY Women's Health PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions. HPSJ Medi‐Cal Formulary Print Date: 8/25/2015 Page 119 of 119 May 2015 Premarin Estrogens, Conjugated Tablet Menest Estrogens,Esterified Tablet 1.25 MG 0.3 MG Menest Estrogens,Esterified Tablet 0.625 MG Menest Estrogens,Esterified Tablet 1.25 MG Menest Estrogens,Esterified Tablet 2.5 MG Ogen Estropipate Tablet 0.75 MG Ogen Estropipate Tablet 1.5 MG Ogen Estropipate Tablet 3 MG Jinteli Norethindrone Ac‐Eth Estradiol Tablet 1MG‐5MCG DRUG CLASS: Oxytocics Brand Name Generic Name Formulation Strength Methergine Methylergonovine Maleate Tablet 0.2 MG CATEGORY Women's Health PA S QL F PA S QL F AL P GL Restrictions (if applicable) CATEGORY Women's Health DRUG CLASS: Pregnancy Facilitating/Maintaining Agent,Hormonal Brand Name Generic Name Formulation Strength First‐Progesterone Vgs 100 Progesterone Supp.Vag 100 MG Reserved for pregnancy with history of pre‐term birth, short cervix, or history of 3 consecutive miscarriages First‐Progesterone Vgs 200 Progesterone Supp.Vag 200 MG Reserved for pregnancy with history of pre‐term birth, short cervix, or history of 3 consecutive miscarriages Crinone Progesterone,Micronized Gel/Pf App 0.08 Reserved for pregnancy with history of pre‐term birth, short cervix, or history of 3 consecutive miscarriages. DRUG CLASS: Progestational Agents Brand Name Generic Name Formulation Strength Makena Hydroxyprogesterone Caproate Vial 250 MG/ML Provera Medroxyprogesterone Acetate Tablet 10 MG Provera Medroxyprogesterone Acetate Tablet 2.5 MG Provera Medroxyprogesterone Acetate Tablet 5 MG Depo‐Provera Medroxyprogesterone Acetate Vial 400 MG/ML Norethindrone Acetate Norethindrone Acetate Tablet 5 MG Progesterone Progesterone Vial 50 MG/ML Reserved for women with >3 consecutive miscarriages, >= 1 previous preterm delivery or a short cervix after 16 weeks. Prometrium Progesterone,Micronized Capsule 100 MG Reserved for pregnancy with history of pre‐term birth, short cervix, or history of 3 consecutive miscarriages Prometrium Progesterone,Micronized Capsule 200 MG Reserved for pregnancy with history of pre‐term birth, short cervix, or history of 3 consecutive miscarriages AL P GL Restrictions (if applicable) CATEGORY Women's Health PA S QL F AL P GL Restrictions (if applicable) Reserved for history of pre‐term birth between 20‐36 weeks CATEGORY Women's Health DRUG CLASS: Vaginal Estrogen Preparations Brand Name Generic Name Formulation Strength Estrace Estradiol Cream/Appl 0.0001 Vagifem Estradiol Tablet 10 MCG Premarin Estrogens, Conjugated Cream/Appl 0.625 MG/G PA S QL F AL P GL Restrictions (if applicable) RESTRICTION KEY PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | FL = Fill Limit | AL = Age Limit | PL = Provider Restriction | GL = Gender Limit This formulary printout is current as of 8/25/2015 . Formulary change are made in February, May, September, and November. HPSJ occasionally makes corrections or updates out of the usual cycle in certain situations. Please contact HPSJ if there are any questions.
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