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Transcript
I. INTRODUCTION 1. This Preferred Drug List (PDL) was updated as of 3/31/2017. It is subject to change without notice. If you choose to print out/photocopy the PDL, please refer to the CCHP website for the most up to date version before making prescribing decisions. You will need Acrobat Reader to download the PDL. You may wish to bookmark the URL below for both the CCHP PDL and the “Medication Prior Authorization Request” form: http://cchealth.org/health_plan/pdl.php 2. To search this PDL: in addition to referring to the Table of Contents and Index, use “Control F” or the binoculars icon, and type in the drug name. 3. For Prior Authorization forms please call 925-957-7260 (option 2). The Medication Prior Authorization form is also available from the website address listed in #1 above. The PDL is a listing of “Preferred” first line drugs. If you have clinical reasons to choose a second line agent, please provide complete clinical information to expedite the processing of your Medication Prior Authorization Request. 4. This is only a listing of preferred medications. Listing in the PDL is not a guarantee of payment. There are many different levels of coverage and members should refer to their “Evidence of Coverage” (EOC) for information about co-pays, and exclusions to coverage for their specific situation. Most Over The Counter (OTC) medication is not covered, except where specified. Medication Supplies and Devices are not included in this list. II. OVERVIEW 1. All CCHP members and recipients of County health programs are subject to the PDL protocols. 2. A PDA-enabled version is available at the ePocrates web site: http://www.epocrates.com (choose < ePocrates Rx Formulary >). Follow these instructions to add the CCHP formulary to your epocrates user profile: a. Go to www.epocrates.com. b. Click on "My Account" in the top right. c. Sign in with your Epocrates username and password, if needed. d. Click on "Edit Formularies." e. Follow the on screen instructions to select and download formularies or to remove formularies. i. For the ‘Select State’ filter, click California ii. For the ‘Select Category’ filter, click Health Plan iii. Choose the Contra Costa Healthplan formulary; click the ‘Add’ button iv. Click the "Done" button when you've finished. f. Update your device, and the formularies on your mobile device will be changed accordingly. g. If you have any questions about the installation or use of Epocrates, please contact Epocrates Customer Support at [email protected] or at (800)230-2150. 1 3. Prior authorization (PA) Requests: All prior authorizations will be evaluated based upon CCHP PA criteria created by the health plan, and approved through Pharmacy and Therapeutics (P&T) committee. In instances where specific criteria do not exist, FDA indications, peer reviewed literature, and national guidelines (such as IDSA, NCCN, AACE, etc.) will be used for evaluation. All cases outside of the guidelines and PA criteria that require determination of medical necessity will be forwarded to the medical director for review. a. Urgent PAs are processed within 4 hours if the clinical information is complete. For an emergency medication during off hours pharmacists can give up to a 5 day supply (at their discretion) before receiving the PA approval. We will monitor Urgent PA requests to make sure they are appropriately urgent. b. Routine PAs are processed as quickly as possible. The usual reason for a delay is lack of adequate clinical information. We will call, page or fax you if we receive a prescription for a non-preferred drug without adequate medical justification. If you do not provide medical necessity for a non-preferred drug or if we do not hear back from you within five business days, the Rx may be modified or denied. 4. C1 (Code 1) are non-preferred drugs with criteria that can be satisfied without a PA. Some criteria such as “tried and failed <drug name> Rx” can be written on the prescription. Other criteria, such as “under 12 years old”, can be identified by the pharmacist. 5. Basic Health Care (BHC) patients must use the following Walgreens pharmacies to fill their prescriptions: 24-hour Pharmacy Location Walgreens Store #4026 2900 North Main Street Walnut Creek, CA 94596 925-933-0307 (PHONE) 925-933-0559 (FAX) Pharmacy Locations (alpha by City) Walgreens Store #4724 3416 Deer Valley Road Antioch, CA 94531 Walgreen Store #13026 2700 Willow Pass Road Bay Point, CA 94565 Walgreens Store #6871 4520 Balfour Road Brentwood, CA 94513 Walgreens Store #9978 6570 Lone Tree Way Brentwood, CA 94513 Walgreens Store #2112 5437 Clayton Road Clayton, CA 94517 Walgreens Store #3164 1800 Concord Ave Concord, CA 94520 Walgreens Store #15003 1990 Monument Blvd Concord, CA 94520 Walgreens Store #3770 11565 San Pablo Ave El Cerrito, CA 94530 Walgreens Store #4049 3630 San Pablo Dam Road El Sobrante, CA 94803 925-978-8000 (PHONE) 925-978-4209 (FAX) 925-709-0317 (PHONE) 925-709-0527 (FAX) 925-513-4055 (PHONE) 925-516-9544 (FAX) 925-240-6043 (PHONE) 925-240-6134 (FAX) 925-672-1334 (PHONE) 925-672-0587 (FAX) 925-674-9477 (PHONE) 925-674-9258 (FAX) 925-689-7812 (PHONE) 925-246-9861 (FAX) 510-234-9300 (PHONE) 510-234-8986 (FAX) 510-758-1294 (PHONE) Walgreens Store #6101 3655 Alhambra Ave Martinez, CA 94553 Walgreens Store #11614 2750 Pinole Valley Road Pinole, CA 94564 Walgreens Store #7376 2901 Railroad Ave Pittsburg, CA 94565 Walgreens Store #5864 721 Gregory Lane Pleasant Hill, CA 94523 Walgreens Store #2506 1150 MacDonald Ave Richmond, CA 94801 Walgreens Store #15947 13613 San Pablo Ave San Pablo, CA 94806 Walgreens Store #4491 15650 San Pablo Ave San Pablo, CA 94806 Walgreen Store #13796 14280 San Pablo Ave San Pablo, CA 94806 925-372-0337 (PHONE) 925-372-6018 (FAX) 510-222-9422 (PHONE) 510-222-9428 (FAX) 925-439-8575 (PHONE) 925-439-1558 (FAX) 925-944-1592 (PHONE) 925-944-5976 (FAX) 510-236-5748 (PHONE) 510-236-5267 (FAX) 510-233-9467 (PHONE) 510-233-8467 (FAX) 510-243-1100 (PHONE) 510-243-0527 (FAX) 510-730-7000 (PHONE) 510-730-7006 (FAX) 510-758-6192 (FAX) Thank you for providing cost-effective high quality health care! 2 CCHP pharmacy locations (Contra Costa County – alpha by City) PerformRx Pharmacies (Farmacias de PerformRx) Community Provider Network For the location of PerformRx Pharmacies outside of Contra Costa County call 1-877-234-4269 Para encontrar la ubicación de Farmacias Perform Rx fuera del Condado de Contra Costa llame al 877-2344269 Rite-Aid #5913 Walgreens ALAMO EL CERRITO 1905 Monument 4520 Balfour Rd. Rite-Aid #5907 Walgreens Blvd. Brentwood, CA 130-A Alamo Plaza 11565 San Pablo Av Concord, CA 94520 925-516-8614 Alamo, CA 94507 El Cerrito, CA 94530 925-680-2845 925-820-1233 510-234-9300 Walgreens Sycamore Medical 6570 Lone Tree Way ANTIOCH Pharmacy EL SOBRANTE Brentwood, CA 2485 High School Rite-Aid #5908 925-240-6043 Park Rexal 20 East 18th St. Ave., Pharmacy Antioch, CA 94509 Ste 114 Rite-Aid #5935 3716 San Pablo Dam 925-757-7161 Concord, CA 94520 580 Bailey Rd. Rd. 925-682-5600 Brentwood, CA El Sobrante, CA Rite-Aid #5909 925-458-0955 94803 3353 Deer Valley Rd. Walgreens 510-223-1321 Antioch, CA 94509 1800 Concord Ave 925-757-3390 Concord, CA 94520 CLAYTON Walgreens 925-674-9477 Walgreens 3630 San Pablo Dam Rite Aid #6356 5437 Clayton Rd Rd 4100 Lone Tree Way Walgreens Clayton, CA 94517 El Sobrante, CA Antioch, CA 94509 1990 Monument Blvd 925-672-1356 94803 925-522-0150 Concord, CA 94520 510-758-2365 925-689-7812 CONCORD Walgreens Bacon-East 3416 Deer Valley Rd Solano Pharmacy HERCULES Pharmacy Antioch, CA 94509 2172 Solano Way Rite Aid #5923 2425 East Street 925-978-8000 Concord, CA 94520 1560 Sycamore Ave. Concord, CA 94520 925-332-5141 Hercules, CA 94547 925-687-0565 510-799-1252 BAYPOINT Walgreens 2700 Willow Pass Rd. Bay Point, CA 94565 925-709-0317 BRENTWOOD Walgreens 2271 Balfour Rd. Brentwood, CA 925-626-3491 DANVILLE Diablo Professional Pharmacy 2700 Grant St. Concord, CA 94520 925-674-2637 Danville Pharmacy MARTINEZ 905 San Ramon Valley Blvd Rite-Aid #5927 1165 Arnold Drive Martinez, CA 94553 925-372-0945 Danville, CA 94526 925-820-4603 Oak Grove Pharmacy 785 Oak Grove Rd. Concord, CA 94518 925-681-1823 Walgreens 611 San Ramon Valley Blvd Danville, CA 94526 925-743-0166 3 Walgreens 3655 Alhambra Ave Martinez, Ca 94553 925-372-0337 OAKLEY 925-439-8575 Rite-Aid #5931 2555 Main St. Oakley, CA 94561 925-625-7440 PLEASANT HILL ORINDA Medicine Shoppe 282 Village Square Orinda, CA 94563 925-254-1211 Rite-Aid #5933 27 Orinda Way Orinda, CA 94563 925-253-1904 PINOLE Whitecross Professional Pharmacy 2160 Appian Way Pinole, CA 94564 510-724-2333 Walgreens 2750 Pinole Valley Road Pinole, Ca 94564 510-222-9422 PITTSBURG City Center Pharmacy 1270 East Leland Rd. #102 Pittsburg, CA 94565 925-432-9770 Rite-Aid #5935 580 Bailey Rd. Pittsburg, CA 94565 925-458-0955 Walgreens 2901 Railroad Ave Pittsburg, CA 94565 Vale Road Pharmacy 2023 Vale Rd. San Pablo, CA 94806 510-232-2377 Medical Arts Pharmacy 2100 Monument Blvd. Pleasant Hill, CA 94523 925-685-0147 Walgreens 15650 San Pablo Ave San Pablo, CA 94806 510-243-1100 Rite-Aid #5915 2140 Contra Costa Blvd. Pleasant Hill, CA 94523 925-691-0164 Walgreens 13613 San Pablo Ave San Pablo, CA 94806 510-233-9467 Walgreens 2455 San Pablo Dam Rd. San Pablo, CA 94806 510-235-0810 Walgreens 721 Gregory Lane Pleasant Hill, CA 94523 925-944-1592 SAN RAMON RICHMOND San Ramon Custom Care Pharmacy 124 Market Place San Ramon, CA 94583 925-830-0555 Central Pharmacy 2300 MacDonald Ave. Richmond, CA 94801 510-234-4381 Civic Center Pharmacy 2729 MacDonald Ave. Richmond, CA 94804 510-234-5023 Rite-Aid Pharmacy #5940 3207 Crow Canyon Place San Ramon, CA 94583 925-866-0505 Walgreens 1150 McDonald Ave Richmond, CA 94801 510-236-5748 Walgreens 21001 San Ramon Vly Blvd SAN PABLO San Ramon, CA 94583 925-803-0893 Brookvale Medical Center 2101 Vale Rd Ste 100 San Pablo, CA 94806 510-235-4443 4 WALNUT CREEK Advance Medical Pharmacy 112 La Casa Via, Ste 100 Walnut Creek, CA 94598 925-939-6311 Ridgecrest Pharmacy 1844 San Miguel Dr., #105 Walnut Creek, CA 94596 925-937-6800 Rite-Aid #5947 1997 Tice Valley Blvd. Walnut Creek, CA 94596 925-932-0568 Rite-Aid #5948 1526 Palos Verdes Mall Walnut Creek, CA 94596 925-939-8378 Walgreens 2923 Ygnacio Valley Rd Walnut Creek, CA 94598 925-256-7230 Walgreens 2900 N. Main St. Walnut Creek, CA 94596 925-933-0307 Preferred Drug List (PDL) - Table of Contents Page Number ANTINEOPLASTICS ...........................................................................................................................................9 ENDOCRINE SYSTEM MEDICATIONS ..........................................................................................................10 Androgens ..................................................................................................................................................10 Glucocorticoids..........................................................................................................................................10 Mineralocorticoids ....................................................................................................................................10 Diabetic Medications .................................................................................................................................10 Medications to Treat Hypoglycemia ..........................................................................................................11 Medications to Treat Of Osteoporosis .......................................................................................................11 Miscellaneous Bisphosphonates ................................................................................................................12 Estrogens ...................................................................................................................................................12 Estrogens/Progestin combinations ............................................................................................................12 Selective Estrogen Receptor Modulators...................................................................................................12 Oral Contraceptives...................................................................................................................................12 Non-Oral Contraceptives...........................................................................................................................13 OB/GYN Medications ................................................................................................................................13 Oxytocics ....................................................................................................................................................13 Progestins ..................................................................................................................................................13 Estrogen/Androgen Combinations.............................................................................................................13 Gout Medications.......................................................................................................................................13 Thyroid Medications ..................................................................................................................................13 Miscellaneous Endocrine Agents ...............................................................................................................13 GASTROINTESTINAL MEDICATIONS ............................................................................................................14 Ammonia Detoxicants ................................................................................................................................14 Antispasmodics ..........................................................................................................................................14 Anti-Ulcer Medications .............................................................................................................................14 Antidiarrheal Preparations .......................................................................................................................14 Digestive Enzymes .....................................................................................................................................15 5 Medications for Nausea & Vomiting .........................................................................................................15 Medications for Bowel Disease .................................................................................................................15 Miscellaneous Gastrointestinal Medications ............................................................................................15 GENITOURINARY TRACT MEDICATIONS ....................................................................................................16 Gall Stone Stabilizing Agents ....................................................................................................................16 Medications For The Urinary Tract ..........................................................................................................16 Misc Medications: (Phosphodiesterase Inhibitors) ...................................................................................16 HEART AND BLOOD PRESSURE MEDICATIONS ........................................................................................16 Angiotensin Converting Enzyme Inhibitors ...............................................................................................16 Angiotensin II Receptor Blockers ..............................................................................................................17 Angiotensin Converting Enzyme Inhibitor/Diuretic Combinations ...........................................................17 Antiarrhythmics .........................................................................................................................................17 Beta Blockers .............................................................................................................................................17 Calcium Channel Blockers ........................................................................................................................18 Carbonic Anhydrase Inhibitors .................................................................................................................18 Centrally Acting Antihypertensives ...........................................................................................................18 Cholesterol Lowering Drugs .....................................................................................................................19 Diuretics ....................................................................................................................................................19 MEDICATIONS AFFECTING THE BLOOD ....................................................................................................19 Anticoagulants ...........................................................................................................................................19 Hematopoetic .............................................................................................................................................20 Antiplatelets ...............................................................................................................................................20 Misc. Cardiovascular Drugs .....................................................................................................................20 Medication For Angina..............................................................................................................................20 Vasopressor ...............................................................................................................................................21 MEDICATIONS FOR EYES, EAR, NOSE & THROAT .....................................................................................21 Anti-Inflammatory Medications For The Eyes ..........................................................................................21 GLAUCOMA MEDICATIONS ..........................................................................................................................21 Beta Blockers .............................................................................................................................................21 Alpha-2 Adrenergic Agonist ......................................................................................................................21 Carbonic Anhydrase Inhibitors .................................................................................................................21 Prostaglandins ...........................................................................................................................................21 OPHTHALMIC MEDICATIONS .......................................................................................................................21 6 Other Treatments for Glaucoma ................................................................................................................21 Ophthalmic Anti-infectives ........................................................................................................................22 Ophthalmic Anti-infective Combinations ..................................................................................................22 Ophthalmic Anti-Allergic Medications ......................................................................................................22 Other Ophthalmic Medications .................................................................................................................23 Medications For The Ear...........................................................................................................................23 Medications For The Nose.........................................................................................................................24 Medications For The Throat And Mouth ...................................................................................................24 MEDICATIONS THAT AFFECT THE NERVOUS SYSTEM ............................................................................24 Antianxiety Medications ............................................................................................................................24 Anticonvulsants ..........................................................................................................................................24 Antidepressants ..........................................................................................................................................25 Anti-Mania .................................................................................................................................................26 Anti-Psychotic Medications .......................................................................................................................26 MISCELLANEOUS MEDICATIONS AFFECTING THE BRAIN .....................................................................26 Parkinson’s Medications ...........................................................................................................................27 Sedative/Hypnotics ....................................................................................................................................27 Stimulants ..................................................................................................................................................27 MEDICATIONS TO TREAT INFECTIONS.......................................................................................................28 Antibiotics ..................................................................................................................................................28 Bacterial Vaccines .....................................................................................................................................29 Antimalarials .............................................................................................................................................29 Anti-Parasitic Medications ........................................................................................................................29 Immunizations ............................................................................................................................................29 Antituberculosis Medications ....................................................................................................................29 ANTIRETROVIRALS .........................................................................................................................................30 Anti-HIV Medications, CCR5 Co-Receptor Antagonists ...........................................................................30 Anti-HIV Medications, Fusion Inhibitors ..................................................................................................30 Anti-HIV Medications, Integrase Strand Transfer Inhibitors....................................................................30 Anti-HIV Medications, Non-Nucleoside Reverse Transcriptase Inhibitors ..............................................30 Anti-HIV Medications, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors and Single-Tablet Regimens ............................................................................................................................................................30 Anti-HIV Medications, Protease Inhibitors ...............................................................................................31 Misc. Antiviral Medications.......................................................................................................................31 7 Oral Antifungals ........................................................................................................................................31 Other Oral Anti-Infective Medications ......................................................................................................31 Vaginal Anti-Infectives ..............................................................................................................................32 IMMUNOLOGICAL AGENTS...........................................................................................................................32 ANALGESICS/PAIN/RHEUMATIC MEDICATIONS .......................................................................................32 Anti-Inflammatory Medications (NSAIDS) ................................................................................................32 Anti-Rheumatic Medications .....................................................................................................................33 Migraine Medications ................................................................................................................................33 Analgesics ..................................................................................................................................................33 Opiate Antagonists.....................................................................................................................................35 Carved-out for Medi-Cal members ....................................................................................................................35 Skeletal Muscle Relaxants .........................................................................................................................35 NUTRITION .......................................................................................................................................................35 Electrolytes ................................................................................................................................................35 Vitamins and Minerals ...............................................................................................................................35 Phosphate Binding Medications ................................................................................................................36 RESPIRATORY DRUGS ....................................................................................................................................36 Antihistamine/Decongestants ....................................................................................................................36 Antihistamines............................................................................................................................................36 Cough Medications ....................................................................................................................................37 Medications For Asthma & COPD ............................................................................................................37 Mucolytic Agent .........................................................................................................................................38 SKIN MEDICATIONS (TOPICAL)....................................................................................................................38 Acne Medications.......................................................................................................................................38 Topical Antiparasitics/Anti-helmintic ........................................................................................................39 Other Topical Medications ........................................................................................................................39 Topical Immunomodulator ........................................................................................................................40 Topical Antifungal .....................................................................................................................................40 Topical Coricosteroids ..............................................................................................................................40 Grade 1 (Very High Potency) ....................................................................................................................40 Grade 2 (High Potency).............................................................................................................................40 Grade 3 (Medium Potency) .......................................................................................................................40 Grade 4 (Low Potency) ..............................................................................................................................41 INDEX................................................................................................................................................................42 8 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES ANTINEOPLASTICS Alkylating Agents Melphalan ALKERAN PA Lomustine CEENU PA Cyclophosphamide CYTOXAN PA Altretamine HEXALEN PA Chlorambucil LEUKERAN PA Procarbazine MATULANE PA Busulfan MYLERAN PA Temozolomide TEMODAR PA Denosumab XGEVA PA: trial and failure of Zometa (zoledronic acid) Lenalidomide REVLIMID PA Thalidomide THALOMID PA Antiangiogenic Agents Antiestrogens/Modifiers Estramustine EMCYT Toremifene FARESTON Antimetabolites Hydroxyurea DROXIA, HYDREA Thioguanine TABLOID Capecitabine XELODA PA Ruxolitinib JAKAFI PA Metyrosine DEMSER Phenoxybenzamine DIBENZYLINE Mesna MESNEX Etoposide ETOPOPHOS Vorinostat ZOLINZA Other Antineoplastics PA PA 3 Generation Aromatase Inhibitors rd Anastrozole ARIMIDEX Exemestane AROMASIN Letrozole FEMARA Molecular Target Inhibitors Imatinib GLEEVEC PA Gefitinib IRESSA PA Sorafenib NEXAVAR PA Dasatinib SPRYCEL PA Sunitinib SUTENT PA Erlotinib TARCEVA PA Nilotinib TASIGNA PA Lapatinib TYKERB PA HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 9 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Androgens Testolactone TESLAC HORMONAL AGENTS, ADRENAL SUPPRESANT Mitotane LYSODREN HORMONAL AGENTS; SUPPRESSANT Antiandrogens Abiraterone Acetate ZYTIGA Bicalutamide CASODEX Flutamide FLUTAMIDE Nilutamide NILANDRON PA IMMUNOLOGICAL AGENTS Immune Suppressants Mycophenolate mofetil Mycophenolic acid Cyclosporine Modified Tacrolimus Sirolimus Cyclosporine non-modified CELLCEPT MYFORTIC NEORAL , GENGRAF PROGRAF RAPAMUNE SANDIMMUNE ENDOCRINE SYSTEM MEDICATIONS Androgens Testosterone Cypionate (Injection) DEPO-TESTOSTERONE (inj) Testosterone Enanthate (Injection) TESTOSTERONE (inj) Testosterone Buccal STRIANT PA Testosterone Gel ANDROGEL PA Testosterone Patch ANDRODERM PA Glucocorticoids Dexamethasone DECADRON Hydrocortisone CORTEF Methylprednisolone MEDROL Prednisolone DELTA-CORTEF Prednisolone syrup PRELONE, ORAPRED Prednisone ORASONE Growth Hormones Growth hormone HUMATROPE® SEROSTIM® ZORBTIVE® GENOTROPIN® NORDITROPIN® NORDITROPIN FLEXPRO® NORDITROPIN NORDIFLEX® NUTROPIN® NUTROPIN AQ® NUTROPIN AQ NUSPIN® OMNITROPE® SAIZEN® TEV-TROPIN® ZOMACTON PA Mineralocorticoids Fludrocortisone FLORINEF Diabetic Medications Acarbose PA: Tried and failed OR contraindications to a sulfonylurea or metformin. Claim processes at the point of sale when PA criteria met. PRECOSE BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 10 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES ST: Tried and failed or contraindications to metformin ST: Tried and failed OR contraindications to metformin. ST: Tried and failed OR contraindications to Metformin PA: Trial of metformin AND Januvia AND insulin AND Victoza Albiglutide TANZEUM Canagliflozin INVOKANA Canagliflozin/metformin INVOKAMET Exenatide BYETTA Glimepiride AMARYL Glimepiride/Pioglitazone DUETACT Glipizide Glucose Monitor GLUCOTROL TRUETRACK, TRUETEST Diabetic Test Strips TRUETRACK, TRUEMETRIX Glyburide DIABETA/MICRONASE Insulin basal HUMULIN N, HUMULIN R, HUMULIN 50/50, HUMULIN 70/30 Insulin lispro HUMALOG Insulin aspart NOVOLOG Insulin glulisine APIDRA QL: 3000 units monthly (3 vials or 2 boxes of pens) Insulin detemir LEVEMIR QL: 3000 units monthly (3 vials or 2 boxes of pens) Insulin glargine LANTUS QL: 3000 units monthly (3 vials or 2 boxes of pens) Liraglutide VICTOZA PA: Trial of metformin AND Januvia AND insulin Metformin GLUCOPHAGE Metformin ER GLUCOPHAGE XR Metformin/Glipizide METAGLIP PA: Tried and failed separate agents Metformin/Glyburide GLUCOVANCE PA: Tried and failed separate agents Metformin/Pioglitazone ACTOPLUS Miglitol GLYSET Nateglinide STARLIX PA: Tried and failed preferred alternatives PA: Tried and failed OR contraindications to a sulfonylurea or metformin. PA: Tried and failed OR contraindications to a sulfonylurea or metformin. C1: Qty must = dose of self injection PA: Consider separate glimepiride and pioglitazone QL: Quanity Limit:150 test strips per 30 days if insulin dependent or gestational diabetes. 100 strips per 90 days if non-insulin dependent. QL: 12 vials/30days PA: Documented recent trial and failure to insulin glulisine (Apidra) PA: Documented recent trial and failure to insulin glulisine (Apidra) Needles & Syringes Pioglitazone ACTOS Pioglitazone/Metformin ACTOSPLUS MET PA: Consider separate pioglitazone and metformin Pramlintide SYMLIN Repaglinide PRANDIN Sitagliptin JANUVIA Sitagliptin/Metformin JANUMET PA: Tried and failed preferred alternatives PA: Tried and failed OR contraindications to a sulfonylurea or metformin. ST: Tried and failed OR contraindications to a sulfonylurea or metformin. PA: Tried and failed OR contraindications to a sulfonylurea or metformin. Claim processes at the point of sale when PA criteria met. Tolazamide TOLINASE Tolbutamide ORINASE Medications to Treat Hypoglycemia Glucagon HCl GLUCAGON Medications to Treat Of Osteoporosis Alendronate FOSAMAX Denosumab PROLIA Calcitonin-Salmon MIACALCIN NASAL SPRAY PA: Trial/failure OR contraindication to alendronate AND zolendronic acid BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 11 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Ibandronate BONIVA Raloxifene EVISTA Risedronate ACTONEL Zolendronic Acid ZOMETA, RECLAST NOTES PA QL: limit #1/30 days C1: Postmenopausal woman who has been on estrogen for 10 years OR any postmenopausal woman with an increased risk for breast cancer OR tried and failed or any contraindications/intolerance to estrogen PA PA: Tried and failed OR contraindications to at least one oral bisphosphonate Miscellaneous Bisphosphonates Etidronate Disodium C1: Restricted to hypercalcemia of malignancy. Choose other bisphosphonates for Paget’s disease of the bone if not contraindicated. DIDRONEL Estrogens Conjugated Estrogens (Tablet, Vaginal Cream) PREMARIN (TABLET, VAGINAL CREAM) Esterified Estrogens MENEST Estradiol acetate FEMRING Estradiol ESTRING Estradiol (Tablet, Vaginal Cream) ESTINYL, ESTRACE (Tablet, Vaginal Cream) Estradiol (Vaginal Tablet). VAGIFEM (VAGINAL TABLET) Estradiol, transdermal CLIMARA (TRANSDERMAL) Estradiol, transdermal VIVELLE-DOT, ESTRADERM, ALORA Estrogen, conjugated PREMARIN Estrogen, conjugated synthetic CENESTIN Estropipate OGEN PA: Tried and failed OR contraindications to at least one preferred alternative PA: Tried and failed OR contraindications to at least one preferred alternative ST: trial of Climara PA: Tried and failed OR contraindications to at least one preferred alternative PA: Tried and failed OR contraindications to at least one preferred alternative Estrogens/Progestin combinations Conjugated Estrogens/Medroxy Progesterone PREMPRO/PREMPHASE Estradiol/Levonorgestrel, transdermal CLIMARA-PRO Estradiol/Norethindrone, transdermal COMBIPATCH Ethinyl Estradiol/Norethindrone acetate FEMHRT Estradiol/Norgestimate PREFEST PA: Tried and failed OR contraindications to at least one preferred alternative ST: trial of Climara or Premphase or Prempro PA: Tried and failed OR contraindications to at least one preferred alternative PA: Tried and failed OR contraindications to at least one preferred alternative Selective Estrogen Receptor Modulators Tamoxifen NOLVADEX Oral Contraceptives Ethinyl Estradiol/Desogestrel VELIVET, CAZIANT, DESOGEN, MIRCETTE Ethinyl Estradiol/Drospirenone YASMIN, GIANVI, VESTURA, LORYNA Ethinyl Estradiol/Drospirenone/Levomefolate BEYAZ, SAFYRAL Ethinyl Estradiol/Ethynodiol Ethinyl Estradiol/Levonorgestrel DEMULEN 1/35, DEMULEN 1/50 ALESSE, NOREDETTE, TRI-LEVLEN, JOLESSA, QUARTETTE PA: Tried and failed OR contraindications to at least three preferred alternatives Ethinyl Estradiol/Levonorgestrel SEASONALE Ethinyl Estradiol/Levonorgestrel LYBREL, AMETHIA, CAMRESE LO LOESTRIN FE 1/20, LOESTRIN FE 1.5/30, LOESTRIN 24 FE, LO MINASTRIN FE, MINASTRIN 24 FE, LO LOESTRIN FE, FEMCON FE, ESTROSTEP FE ORTHONOVUM 1/35, ORTHO NOVUM 7/7/7, ORTHO NOVUM 10/11, OVCON 35, TRI- Ethinyl Estradiol/Norethindrone/Iron Ethinyl Estradiol/Norethindrone BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 12 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES NORINYL PA Ethinyl Estradiol/Norethindrone OVCON 50 Ethinyl Estradiol/Norgestimate ORTHO CYCLEN, ORTHO TRI-CYCLEN Estradiol/Norgestrel LO OVRAL Estradiol Valerate/Dienogest NATAZIA Ethinyl Estradiol/Norgestrel OVRAL Mestranol/Norethindrone ORTHONOVUM 1/50 Norethindrone MICRONOR Non-Oral Contraceptives Ethinyl Estradiol/Etonogestrel NUVARING Ethinyl Estradiol/Norelgestromin ORTHO EVRA SPERMICIDAL FOAM/JELLY/FILM/GEL, VAGINAL SPONGE, CONDOMS, CERVICAL CAP, DIAPHRAGM Barrier contraceptives OB/GYN Medications Prenatal Vitamins PRENATAL, PRENATAL FORTE, PRENAVITE, PRENATAL RX Formulary for females > 13 years < 45 years Prenatal Vitamins with DHA PRENATAL MULTI+DHA 27-800-228mg, PRENATAL VITAMIN+DHA Formulary for females > 13 years < 45 years Methylergonorine METHERGINE QL: 7 day maximum; 28 tabs per 7 days Ulipristal ELLA QL: 1 tablet monthly; 6 fills per year Oxytocics Progestins Levonorgestrel NEXT CHOICE ONE-DOSE, PLAN B Medroxyprogesterone Acetate PROVERA, DEPO-PROVERA Norethindrone Acetate AYGESTIN Progesterone, oral micronized PROMETRIUM ST: trial of medroxyprogesterone Progesterone, transdermal PROGESTERONE TD PA: Tried and failed preferred alternatives Estrogen/Androgen Combinations Esterified Estrogens/ Methyltestosterone ESTRATEST Gout Medications Allopurinol ZYLOPRIM Colchicine COLCRYS Colchicine/Probenecid COL-PROBENECID Probenecid BENEMID QL: 15 tabs per dispense every 60 days PA: > 15 tabs requires concurrent allopurinol Thyroid Medications Levothyroxine SYNTHROID Liothyronine CYTOMEL Liotrix THYROLAR Methimazole TAPAZOLE Propylthiouracil PTU Thyroid dessicated ARMOUR THYROID, NATURE-THROID Miscellaneous Endocrine Agents Cabergoline DOSTINEX Desmopressin Acetate DDAVP Teriparatide FORTEO Formulary: Tablets for patients 6 years of age and older. PA: Nasal Spray, Rhinal Tube, and Injection. PA: Tried and failed or contraindications to preferred alternatives. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 13 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES GASTROINTESTINAL MEDICATIONS Ammonia Detoxicants Lactulose CEPHULAC Antispasmodics Belladonna Alkaloids/Phenobarbital DONNATAL Clinidium/Chlordiazepoxide LIBRAX Darifenacin ENABLEX Dicyclomine BENTYL Diphenoxylate/Atropine LOMOTIL Ergotamine/Belladonna/Phenobarbital BELLERGAL-S Flavoxate URIPAS Hyoscyamine LEVSIN Hyoscyamine Sulfate CR LEVSINEX Metoclopramide REGLAN PEG Solution COLYTE Propantheline PRO-BANTHINE PA: Urology consult, approvable for one year for the DIAGNOSIS of urinary incontinence when at least one preferred alternative listed on the PDL has been tried and failed. Omeprazole Magnesium PRILOSEC Only packet for oral suspension requires PA Pantoprazole PROTONIX Lansoprazole PREVACID Only packet for oral suspension requires PA Solutab is formulary for 9 and younger or unable to take oral medications Cimetidine TAGAMET Dexlansoprazole DEXILANT Esomeprazole NEXIUM Famotidine PEPCID Lansoprazole (OTC version) PREVACID 24HR OTC Misoprostol CYTOTEC Omeprazole/Sodium Bicarbonate ZEGERID OTC Rabeprazole ACIPHEX Ranitidine ZANTAC Sucralfate CARAFATE PA: Urology consult PA: Tried and failed OR contraindications to preferred alternatives Anti-Ulcer Medications PA: PA: Trial/failure OR contraindication to omeprazole, pantoprazole, lansoprazole and rabeprazole PA: PA: Trial/failure OR contraindication to omeprazole, pantoprazole, lansoprazole and rabeprazole B: OTC Chewables and OTC Tablets A: Rx formulary PA: PA: Trial/failure OR contraindications to omeprazole, pantoprazole, lansoprazole and rabeprazole B: B A: Tablets only. Capsules are not covered Antidiarrheal Preparations Diphenoxylate/Atropine LOMOTIL Loperamide (2 mg capsules, 1mg/5mL liquid) IMODIUM Laxatives Linaclotide LINZESS Lubiprostone AMITIZA Polyethylene Glycol 3350 oral powder GLYCOLAX, Miralax OTC Sorbitol 70% solution SORBITOL PA: Tried and failed OR contraindications to preferred alternatives PA: Tried and failed OR contraindications to preferred alternatives A: OTC formulation. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 14 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Digestive Enzymes Amylase/ Lipase/ Protease CREON, ZENPEP Medications for Nausea & Vomiting Aprepitant EMEND PA Prevention of nausea/vomiting secondary to chemotherapy in Cancer patients only Dronabinol MARINOL PA: Restricted to use in cancer patients or the treatment of anorexia associated with weight loss in patients with AIDs Fosaprepitant EMEND PA Granisetron KYTRIL Granisetron SANCUSO Meclizine ANTIVERT Ondansetron ZOFRAN, ZOFRAN ODT Palonosetron ALOXI PA: Restricted to treatment with emetogenic chemotherapy or radiation therapy AND documented trial and failure with therapeutic doses or intolerance to ondansetron (Zofran). QL: 12 tablets/30 days, not to exceed 3 months PA: Trial and failure of oral granisetron AND palonosetron PA: Tried and failed ondansetron of 16mg PO (8mg IV) AND used for anti-nausea for highly emetogenic (>90% emesis risk) chemotherapy Prochlorperazine Promethazine PHENERGAN Scopolamine patch TRANSDERM-SCOP Trimethobenzamide TIGAN Phenergan suppositories PA: Trial and failure of at least two (2) preferred medications Medications for Bowel Disease Azathioprine IMURAN Hydrocortisone Acetate Rectal CORTIFOAM Hydrocortisone ANUSOL-HC CREAM, SUPP. Mercaptopurine (6M-P) PURINETHOL Miscellaneous Gastrointestinal Medications Aluminum Hydroxide Gel Aluminum Hydroxide, Magnesium Hydroxide, and Simethicone Balsalazide AMPHOGEL B MYLANTA B Bisacodyl DULCOLAX B Bismuth Subsalicylate PEPTO-BISMOL M Calcium Carbonate/Magnesium Carbonate MYLANTA B Docusate Sodium COLACE M Hydrocortisone Retention Enema CORTENEMA Infliximab REMICADE PA Magnesium Citrate CITRATE OF MAGNESIA B Mesalamine PENTASA, DELZICOL, ASACOL HD Mesalamine Enema CANASA (ENEMA) Mesalamine Supp ROWASA (SUPPOSITORY) Olsalazine DIPENTUM PEG 3350 Solution COLYTE Pilocarpine 5mg tablet SALAGEN Sennosides SENNA COLAZAL M BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 15 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Sennosides-docusate SENNA-S Sulfasalazine AZULFIDINE NOTES GENITOURINARY TRACT MEDICATIONS Gall Stone Stabilizing Agents Ursodiol ACTIGALL Medications For The Urinary Tract Alfuzosin ER UROXATRAL Bethanechol URECHOLINE Doxazosin Mesylate CARDURA Methenamine/Methylene Blue Atropine URISED Finasteride 5mg tablet PROSCAR Nitrofurantoin FURADANTIN Nitrofurantoin/Nitrofurantoin Macrocrystals MACROBID Nitrofurantoin Macrocrystals MACRODANTIN Oxybutynin IR DITROPAN Oxybutynin XL DITROPAN XL Oxybutynin, Transdermal OXYTROL Phenazopyridine PYRIDIUM Pentosan ELMIRON Prazosin MINIPRESS Solifenacin VESICARE Tamsulosin FLOMAX Terazosin HYTRIN Tolterodine DETROL, DETROL LA Trimethoprim TRIMPEX PA: Tried and failed or contraindicated to alphaadrenergic antagonists 5mg, 10mg, 25mg formulary PA: 50mg strength only Propecia (finasteride 1mg) non-formulary PA: Tried and failed OR contraindications to at least one preferred alternative, including oxybutynin immediate release PA: Tried and failed OR contraindications to oxybutynin immediate release PA: Tried and failed immediate release (IR) oxybutynin. Claim pays on-line contingent upon trial of IR oxybutynin. PA required if criteria not met. Misc Medications: (Phosphodiesterase Inhibitors) *ED Medications are not a covered product for Medi-Cal members or BHC recipients; quantity limits and PA required for commercial members. *PA required for all members when used for conditions other than ED (such as pulmonary arterial hypertension). PA: Questionnaire/PA form must be completed. Sildenafil VIAGRA (Form available on-line: www.CCHealth.org or call CCHP (925) 313-6008. Limit: 3 tablets/30 days. PA for PAH, generic sildenafil preferred Tadalafil CIALIS, ADCIRCA Vardenafil LEVITRA Alprostadil MUSE, CAVERJECT PA PA: Questionnaire/PA form must be completed. (Form available on-line: www.CCHealth.org or call CCHP (925) 313-6008. HEART AND BLOOD PRESSURE MEDICATIONS Angiotensin Converting Enzyme Inhibitors Benazepril LOTENSIN Captopril CAPOTEN Enalapril VASOTEC Enalapril/HCTZ VASARETIC Fosinopril MONOPRIL PA: Tried and failed OR contraindications to preferred alternatives PA: Tried and failed OR contraindications to BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 16 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES preferred alternatives Lisinopril ZESTRIL , PRINIVIL Moexipril UNIVASC Perindopril ACEON Quinapril ACCUPRIL Ramipril ALTACE Trandolapril MAVIK PA: Tried and failed OR contraindications to Lisinopril or enalapril PA: Tried and failed OR contraindications to Lisinopril or enalapril PA: Tried and failed OR contraindications to Lisinopril or enalapril PA: Tried and failed OR contraindications to Lisinopril or enalapril Angiotensin II Receptor Blockers Losartan COZAAR Olmesartan BENICAR Telmisartan MICARDIS PA: Tried and failed OR contraindications to formulary angiotensin converting enzyme inhibitors or losartan.Claim pays at point-of-sale when PA criteria met. PA: Tried and failed OR contraindications to formulary angiotensin converting enzyme inhibitors or losartan. Claim pays at point-of-sale when PA criteria met. Angiotensin Converting Enzyme Inhibitor/Diuretic Combinations Benazepril/HCTZ LOTENSIN HCT Lisinopril/HCTZ ZESTORETIC, PRINZIDE Angiotensin II Receptor Blocker/Diuretic Combinations Losartan/HCTZ HYZAAR Olmesartan/HCTZ BENICAR HCT Telmisartan/HCTZ MICARDIS HCT PA: Tried and failed OR contraindications to formulary angiotensin converting enzyme inhibitors or losartan or losartan/HCTZ. Claim pays at point-of-sale when PA criteria met. PA: Tried and failed OR contraindications to formulary angiotensin converting enzyme inhibitors or losartan or losartan/HCTZ. Claim pays at point-of-sale when PA criteria met. Angiotensin II Receptor Blocker Combinations Valsartan/Sacubitril PA ENTRESTO Antiarrhythmics Amiodarone CORDARONE Digoxin LANOXIN Disopyramide NORPACE, NORPACE CR Dofetilide TIKOSYN Dronedarone MULTAQ Flecainide TAMBOCOR Mexitiline MEXITIL Procainamide PRONESTYL, PRONESTYL SR Propafenone RYTHMOL, RYTHMOL SR Quinidine Gluconate QUINAGLUTE Quinidine Sulfate QUINIDINE SULFATE Sotalol BETAPACE Sotalol AF BETAPACE AF PA: Prescribed by cardiologist Beta Blockers Acebutolol SECTRAL Atenolol TENORMIN BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 17 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Bisoprolol ZEBETA Carvedilol COREG Labetalol TRANDATE, NORMODYNE Metoprolol Succinate TOPROL XL Metoprolol Tartrate LOPRESSOR Nadolol CORGARD Pindolol VISKEN Propranolol INDERAL Propanolol LA INDERAL LA PA: Coreg CR PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Tried and failed OR contraindications to at least one preferred alternative. Beta Blocker/Diuretic Combinations Atenolol/Chlorthalidone TENORETIC Bisoprolol/HCTZ ZIAC Propranolol/HCTZ INDERIDE Calcium Channel Blockers Amlodipine NORVASC Amlodipine-Benazepril LOTREL Diltiazem CARDIZEM, CARTIA XT Diltiazem CR DILACOR XR, CARDIZEM CD Diltiazem ER, Diltiazem SR CARDIZEM LA, CARDIZEM SR, DILT XR Felodipine PLENDIL Isradipine DYNACIRC Isradipine CR DYNACIRC CR Nicardipine CARDENE Nicardipine SR CARDENE SR Nifedipine ADALAT, PROCARDIA Nifedipine SR, ER ADALAT CC, PROCARDIA XL, AFEDITAB, NIFEDICAL XL, NIFEDIAC CC Nimodipine NIMOTOP PA: Tried and failed OR contraindications to at least one preferred alternative Nisoldipine SULAR PA: Tried and failed OR contraindications to at least one preferred alternative Verapamil CALAN Verapamil SR CALAN SR, ISOPTIN SR PA: : Tried and failed OR contraindications to the two products separately AND at least one preferred alternative PA: Required for Tiazac equivalent. PA: Tried and failed OR contraindications to at least one preferred alternative PA: Required for Dynacirc CR. PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Nifedipine extended release (generic Adalat CC or Procardia XL) is on formulary. Prior authorization required for immediate release formulation. Carbonic Anhydrase Inhibitors Acetazolamide DIAMOX, DIAMOX SEQUELS Centrally Acting Antihypertensives Clonidine CATAPRES Guanfacine TENEX Guanfacine ER INTUNIV Methyldopa ALDOMET Minoxidil tablets LONITEN PA: Tried and failed OR contraindications to preferred alternatives including guanfacine IR Topical solution is a plan exclusion. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 18 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME Reserpine BRAND NAME NOTES SERPASIL Cholesterol Lowering Drugs Lovastatin MEVACOR Pravastatin PRAVACHOL Simvastatin ZOCOR Atorvastatin LIPITOR Cholestyramine QUESTRAN Cholestyramine Light QUESTRAN LIGHT Colestipol COLESTID Ezetimibe ZETIA Fenofibrate LOFIBRA Fluvastatin LESCOL Gemfibrozil LOPID Niacin NIACIN B: OTC Niacin formulations. PA: Niaspan Niacin/Lovastatin ADVICOR PA: Tried and failed OR contraindications to at least one preferred alternative Nicotinic Acid SR SLO-NIACIN Omega-3-acid ethyl esters LOVAZA PA: generic omega-3-acid ethyl esters preferred Simvastatin/Niacin SIMCOR Rosuvastatin CRESTOR PA PA: Tried and failed OR contraindications to at least one preferred alternative ST: simvastatin or atorvastatin or lovastatin trial, or concurrent ritonavir therapy (due to interactions with other statins) PA: Tried and failed maximum doses of formulary statins Formulary if patient trialed any statin or gemfibrozil 54mg, 160mg tabs 67mg, 134mg, 200mg caps PA: Trial/failure OR contraindication to pravastatin, simvastatin, and atorvastatin Diuretics Amiloride MIDAMOR Amiloride/HCTZ MODURETIC Bumetanide BUMEX Chlorthalidone HYGROTON Eplerenone INSPRA Furosemide LASIX Hydrochlorothiazide HYDRODIURIL Indapamide LOZOL Metolazone ZAROXOLYN Spironolactone ALDACTONE Spironolactone/HCTZ ALDACTAZIDE Triamterene DYRENIUM Triamterene/HCTZ DYAZIDE, MAXZIDE Torsemide DEMADEX PA: Tried and failed OR contraindications to Spironolactone PA MEDICATIONS AFFECTING THE BLOOD Anticoagulants Dabigatran PRADAXA PA Enoxaparin LOVENOX Rivaroxaban XARELTO Apixaban ELIQUIS QL: 14 syringes twice per 6 months QL: 10mg 30 tablets per fill, 15mg 42 tablets per fill, 20mg 30 tablets per fill (per 30 days) QL: 2.5mg 60 tablets per 30 days, 5mg 60 tablets per 30 days BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 19 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME Warfarin BRAND NAME NOTES COUMADIN Hematopoietic PA: Anemia CRF zidovudine-treated patients chemotherapy-treated patients Appropriate quantity approved for 3 months at a time if patient has one of the above Diagnosis, and a) Hemoglobin<10g/dL OR HCT<30% (or rolling 90 day average HCT<36%) and b) Patient on iron or iron studies labs are nml (i.e., has adequate iron stores) Transferrin saturation should be at least 20%; ferritin at least 100 ng/ml. Erythropoietin (Epoetin Alfa) EPOGEN, PROCRIT Darbopoetin ARANESP Filgrastim NEUPOGEN PA Filgrastim-sndz ZARXIO PA Pegfilgrastim NEULASTA PA: Trial and failure of filgrastim (Neupogen) or filgrastim-sndz (Zarxio) Antiplatelets Clopidogrel PLAVIX Dipyridamole PERSANTINE Dipyridamole/Aspirin AGGRENOX Aspirin BAYER, ST. JOSEPH Anagrelide AGRYLIN Ticagrelor BRILINTA Misc. Cardiovascular Drugs Cilostazol Pentoxifylline PA: Tried and failed or contraindications to preferred alternatives, including clopidogrel PLETAL TRENTAL Medication For Angina Hydralazine APRESOLINE Isosorbide Dinitrate ISORDIL TITRADOSE Isosorbide Dinitrate SR DILATRATE-SR, ISOCHRON Isosorbide Mononitrate IMDUR, ISMO, MONOKET Nitroglycerin NITROSTAT Nitroglycerin (ointment) NITROL-BID (Ointment) Nitroglycerin (patch) NITRO-DUR (Patch) Nitroglycerin SR (Capsule) NITRO-BID (Capsule) Ranolazine ER RANEXA PA: : Tried and failed OR contraindications to at least two preferred alternatives Vasodilators PA: : Tried and failed OR contraindications to at least one preferred alternative PA: : Tried and failed OR contraindications to at least one preferred alternative Ambrisentan LETAIRIS Bosentan TRACLEER Doxazosin CARDURA Hydralazine APRESOLINE Iloprost VENTAVIS PA Macitentan OPSUMIT PA: : Tried and failed OR contraindications to at least one preferred alternative Minoxidil LONITEN Prazosin MINIPRESS BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 20 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES PA Selexipag UPTRAVI Terazosin HYTRIN Treprostinil TYVASO PA EPIPEN, EPIPEN JR QL: 2 pens per 180 days Vasopressor Epinephrine MEDICATIONS FOR EYES, EAR, NOSE & THROAT Anti-Inflammatory Medications For The Eyes Dexamethasone DECADRON, Fluorometholone FLAREX, FML LIQUIFILM, FLUR-OP, FML FORTE Ketorolac OPHTH ACULAR, ACULAR LS, ACULAR PF, Prednisolone acetate ECONOPRED PLUS, PRED FORTE, PRED-MILD, Prednisolone sodium AK-PRED, INFLAMASE FORTE, GLAUCOMA MEDICATIONS Beta Blockers Betaxolol PA: Tried and failed OR contraindications to at least one preferred alternative. Indicated for treatment of ocular HTN and chronic openangle glaucoma. May be used as an add-on therapy. BETOPTIC, BETOPTIC S Metipranolol OPTIPRANOLOL Levobunolol AKBETA , BETAGAN Timolol Hemihydrate BETIMOL Timolol Maleate TIMOPTIC, TIMOPTIC XE Alpha-2 Adrenergic Agonist Brimonidine ALPHAGAN P Brimonidine Tartrate ALPHAGAN PA: Tried and failed OR Contraindications to at least one preferred alternative.. Carbonic Anhydrase Inhibitors Acetazolamide DIAMOX, DIAMOX SEQUELS Brinzolamide AZOPT Dorzolamide TRUSOPT Dorzolamide/timolol XE COSOPT XE Methazolamide NEPTAZANE PA: Tried and failed OR contraindications to at least one preferred alternative. Elevated IOP in patients with ocular HTN or open-angle glaucoma. Prostaglandins PA: Tried and failed OR contraindications to at least one preferred alternative. Bimatoprost LUMIGAN Latanoprost XALATAN Travaprost TRAVATAN, TRAVATAN Z PA: Tried and failed OR contraindications to at least one preferred alternative. OPHTHALMIC MEDICATIONS Other Treatments for Glaucoma Carbachol ISOPTO-CARBACHOL Dipivefrin AKPRO, PROPINE, Echothiophate Iodide PHOSPHOLINE IODIDE Pilocarpine ISOPTO CARPINE, PILOCAR, PILOPINE HS BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 21 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Ophthalmic Anti-infectives Bacitracin optthalmic AK-TRACIN Ciprofloxacin CILOXAN Erythromycin ILOTYCIN OPHTH OINT Gatifloxacin ZYMAR Gentamicin GENOPTIC. GENOPTIC S.O.P. Moxifloxacin VIGAMOX Ofloxacin OCUFLOX Sulfacetamide BLEPH 10, SODIUM SULAMYD Tobramycin TOBREX Trifluridine VIROPTIC PA: Tried and failed OR contraindications to at least two preferred alternatives PA: Ophthalmologists exempt Ophthalmic Anti-infective Combinations Bacitracin/ Polymyxin B Sultate POLYSPORIN OINTMENT Gentamicin/Prednisolone Neomycin Sultate, Polymyxin B Sulfate, Bacitracin Neomycin Sulfate/Polymyxin B Sulfate/Bacitracin/ Hydrocortisone Neomycin Sulfate/Polymyxin B Sulfate/Gramicidin Neomycin Sulfate, Polymyxin B Sulfate, Dexamethasone Neomycin Sulfate/Polymyxin B Sulfate/Prednisolone Neomy, Polym, Bac PRED-G, PRED-G SOP Neo/Poly/Prednisolone Neomycin Sulfate,Polymyxin B Sulfate,Hydrocortizone Polymyxin B Sulfate/TMP POLY-PRED Sulfacetamide/Prednisolone (ointment) BLEPHAMIDE, BLEPHAMIDE S.O.P. Tobramycin Sulfate/Dexamethasone TOBRADEX NEOSPORIN OPHTH OINT CORTISPORIN OPHTH OINTMENT NEOSPORIN OPHTH SOLUTION MAXITROL OINTMENT & SUSP POLY-PRED NEOSPORIN OPHTH OINT CORTISPORIN OPHTH SUSP POLYTRIM Ophthalmic Anti-Allergic Medications Azelastine HCl OPTIVAR Cromolyn CROLOM Epinastine HCl ELESTAT Emedastine Difumarate EMADINE Ketotifen furmarate ALAWAY OTC, ZADITOR OTC Lodoxamide ALOMIDE Naphazoline HCl NAPHCON PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindications to Alaway OTC or Zaditor OTC AND THEN Pataday or Patanol. For members without OTC coverage, tried and failed OR contraindications to Crolom AND THEN Pataday or Patanol. QL: Quantity limit of 1 bottle/30 days. PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindications to Alaway OTC or Zaditor OTC AND THEN Pataday or Patanol. For members without OTC coverage, tried and failed OR contraindications to Crolom AND THEN Pataday or Patanol. QL: Quantity limit of 1 bottle/30 days. B PA: Approvable for diagnosis vernal conjunctivitis, vernal keratitis or vernal kerato-conjunctivitis. QL: Quantity limit of 1 bottle / 30days B QL: Quantity limit of 1 bottle / 30days BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 22 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Naphazoline HCl/Pheniramine Maleate NAPHCON A Nedrocromil ALOCRIL Olopatadine PATADAY Olopatadine HCl PATANOL Pemirolast ALAMAST NOTES B QL: Quantity limit of 1 bottle / 30days PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindications to Alaway OTC or Zaditor OTC AND THEN Pataday or Patanol. For members without OTC coverage, tried and failed OR contraindications to Crolom AND THEN Pataday or Patanol. QL: Quantity limit of 1 bottle/30 days. PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindication to ketotifen (Zaditor OTC or Alaway OTC) AND Crolom. QL: Quantity limit of 1 bottle/30 days. PA: Approvable for diagnosis vernal conjunctivitis, vernal keratitis or vernal kerato-conjunctivitis. Approvable for diagnosis of allergic conjunctivitis if tried and failed or contraindication to ketotifen (Zaditor OTC or Alaway (OTC) AND Crolom. QL: Quantity limit of 1 bottle / 30days PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindications to Alaway OTC or Zaditor OTC AND THEN Pataday or Patanol. For members without OTC coverage, tried and failed OR contraindications to Crolom AND THEN Pataday or Patanol. QL: Quantity limit of 1 bottle per 30 days. Other Ophthalmic Medications Proparacaine ALCAINE Atropine ISOPTOATROPINE Bevacizumab AVASTIN Cyclopentolate CYCLOGYL Cyclosporine 0.05% emulsion Restasis Homatropine ISOPTOHOMATROPINE Scopolamine ISOPTOHYOSCINE Sodium Chloride Ophthalmic MURO-128 Tropicamide MYDRIACYL Tyloxapol with Benzalkonium Chloride ENUCLENE QL: Quantity limit of 5mg per 30 days, for the treatment of diabetic macular edema. PA M M Medications For The Ear Acetic Acid/Aluminum Acetate DOMEBORO Acetic Acid/HC VOSOL HC Benzocaine/Antipyrine Otic AURALGAN Ciprofloxacin/dexamethasone CIPRODEX OTIC Ciprofloxacin/hydrocortisone Neomycin Sulfate/Polymyxin B Sulfate/Buffers/ Hydrocortisone (Otic Suspension) Neomycin Sulfate/Polymyxin B Sulfate/ Hydrocortisone (Otic Solution) Neomycin Sulfate/Polymyxin B Sulfate/ Hydrocortisone (Otic Suspension) Ofloxacin (OTIC) CIPRO HC PEDIOTIC OTIC SUSPENSION CORTISPORIN OTIC SOLN CORTISPORIN OTIC SUSPENSION FLOXIN BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 23 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Medications For The Nose Beclomethasone QNASL, BECONASE AQ Ciclesonide OMNARIS, ZETONNA Flunisolide Nasal Soln 0.025% NASAREL PA: Tried and failed OR contraindications to Flonase AND Nasacort for 2 weeks therapy of each, followed by Nasarel for 4 weeks of therapy PA: Tried and failed OR contraindications to Flonase AND Nasacort for 2 weeks therapy of each, followed by Nasarel for 4 weeks of therapy ST Fluticasone Propionate FLONASE Azelastine Nasal Spray ASTELIN Mometasone NASONEX Triamcinolone Acetonide NASACORT AQ (OTC) Ipratropium ATROVENT NASAL SPRAY PA: Tried and failed OR contraindications to Flonase AND Nasacort for 2 weeks therapy of each, followed by Nasarel for 4 weeks of therapy Medications For The Throat And Mouth Chlorhexidine Gluconate (for the mouth) PERIDEX Lidocaine, viscous VISCOUS XYLOCAINE Cevimeline HCL EVOXAC Glycopyrrolate Solution CUVPOSA Triamcinolone 0.1% in Orabarol KENALOG in ORABASE PA MEDICATIONS THAT AFFECT THE NERVOUS SYSTEM Antianxiety Medications Alprazolam XANAX Buspirone BUSPAR, VANSPAR Chlordiazepoxide LIBRIUM Clorazepate TRANXENE SD, TRANXENE T Diazepam VALIUM Lorazepam ATIVAN Oxazepam SERAX PA: Tried and failed OR contraindications to at least one preferred alternative. Anticonvulsants Clonazepam CARBATROL, EQUETRO, TEGRETOL, TEGRETOL XR KLONOPIN, KLONOPIN WAFERS Clorazepate TRANXENE SD, TRANXENE T Diazepam VALIUM Divalproex sodium DEPAKOTE, DEPAKOTE ER, DEPAKOTE SPRINKLE Ethosuximide ZARONTIN Felbamate FELBATOL Pregabalin LYRICA Gabapentin NEURONTIN Lamotrigine LAMICTAL Levetiracetam KEPPRA Mephenytoin MESANTOIN Methosuximide CELONTIN KAPSEALS Oxcarbazepine TRILEPTAL Phenobarbital PHENOBARBITAL Carbamazepine PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Pre-requisite therapy required. PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Tried and failed OR contraindications to at least one preferred alternative. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 24 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Phenytoin DILANTIN, PHENYTEK Primidone MYSOLINE Rufinamide BANZEL Tiagabine GABITRIL Topiramate TOPAMAX Trimethadione TRIDIONE Valproic acid DEPAKENE Zonisamide ZONEGRAN NOTES PA: Tried and failed OR contraindications to at least one preferred alternative and a Dx of LennoxGastaut syndrome. PA: Tried and failed OR contraindications to at least one preferred alternative. Used as an anticonvulsant. Fibromyalgia Milnacipran Hydrochloride PA: Fibromyalgia Agent. Requires a trial and failure or contraindication to gabapentin for a minimum of 30 days of therapy in the last 120 days at a minimum dose of 1800mg daily. SAVELLA Antidepressants Amitriptyline ELAVIL Bupropion WELLBUTRIN Bupropion SR WELLBUTRIN SR Bupropion XL WELLBUTRIN XL Citalopram Hydrobromide CELEXA Clomipramine ANAFRANIL Desipramine NORPRAMIN Doxepin SINEQUAN Duloxetine CYMBALTA Escitalopram LEXAPRO Fluoxetine PROZAC Fluvoxamine LUVOX Imipramine TOFRANIL Imipramine TOFRANIL PM Maprotiline LUDIOMIL Mirtazapine REMERON Mirtazapine ODT REMERON SolTab Nefazodone SERZONE Nortriptyline PAMELOR Paroxetine PAXIL Paroxetine PAXIL CR Protriptyline Sertraline VIVACTIL ZOLOFT Trazodone DESYREL Venlafaxine tablets EFFEXOR Venlafaxine XR capsules EFFEXOR XR CAPSULES Venlafaxine XR tablets EFFEXOR XR TABLETS ST: For insomnia must have tried and failed or contraindications to zolpidem or zaleplon QL: 60 capsules per month Only 20mg/30mg/60mg capsules. 40mg dose must use 2x20mg capsules. 20mg tablets are non-preferred, use 20mg capsule PA: For Prozac 90mg weekly tablet. PA: Tried and failed OR Contraindications to Tofranil. dfdPA: Tried and failed OR contraindications to at least one preferred alternative PA: Tried and failed OR contraindications to at least one preferred alternative, including Paxil. PA: Tried and failed OR contraindications to at least one preferred alternative. PA BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 25 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Anti-Mania *Medications are carved-out for Medi-Cal members Lithium Carbonate ESKALITH, LITHONATE Lithium Carbonate Sustained Release ESKALITH CR Lithium Citrate LITHIUM Anti-Psychotic Medications *Anti-Psychotic Medications are carved-out for Medi-Cal members PA : Tried and failed OR contraindications to at least three atypical antipsychotics PA: : Tried and failed OR contraindications to at least two atypical antipsychotics Aripiprazole ABILIFY Asenapine SAPHRIS Chlorpromazine THORAZINE Clozapine Fluphenazine Hydrochloride, Fluphenazine Decanoate, Enanthate Haloperidol Decanoate, Lactate CLOZARIL Loxapine LOXITANE Molindone MOBAN Olanzapine ZYPREXA Olanzapine ODT ZYPREXA ZYDIS Perphenazine TRILAFON Pimozide ORAP Quetiapine SEROQUEL, SEROQUEL XR Risperidone RISPERDAL, RISPERDAL M-TAB Risperidone IM injection CONSTA Thioridazine MELLARIL Thiothixene NAVANE Trifluoperazine STELAZINE Ziprasidone GEODON Amyotrophic Lateral Sclerosis Agent(ALS) Riluzole RILUTEK PROLIXIN HALDOL PA: Tried and failed OR contraindications to at least one preferred alternative. Indicated for treatment of Psychosis. PA PA ALCOHOL CESSATION MEDICATIONS Disulfiram ANTABUSE SMOKING CESSATION MEDICATIONS Bupropion Sustained Release WELLBUTRIN SR Nicotine (Transdermal) NICODERM CQ (TRANSDERMAL) Varenicline CHANTIX Nicotine Gum NICORETTE Nicotine Inhaler NICOTROL INHALER Nicotine Lozenges NICORETTE Nicotine Nasal Spray NICOTROL NASAL SPRAY 150mg BID QL: 28 patches/28 days each fill Maximum six months treatment per year Maximum six months treatment per year QL: 340 pieces every 30 days Maximum six months treatment per year PA: Tried and failed or contraindicated to patch, gum, and lozenge QL: 324 pieces every 30 days Maximum six months treatment per year PA: Tried and failed or contraindicated to patch, gum, and lozenge MISCELLANEOUS MEDICATIONS AFFECTING THE BRAIN Alzheimer’s Medications Donepezil ARICEPT Donepezil ODT ARICEPT ODT PA: 23mg tablet, consider 2x10mg tab BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 26 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Galantamine RAZADYNE ER Memantine NAMENDA NOTES PA: Tried and failed OR contraindications to preferred alternatives Immediate Release (IR) on formulary PA: Namenda XR (extended release) Myasthenia Gravis Medications Guanidine GUANIDINE Neostigmine PROSTIGMIN Pyridostigmine MESTINON Multiple Sclerosis Medications Dalfampridine AMPYRA PA Dimethyl fumarate Tecfidera PA Fingolimod Gilenya PA Glatiramer acetate Copaxone Interferon Beta-1 Avonex Parkinson’s Medications Amantadine SYMMETREL Bill fee-for-service Medi-Cal for MCAL members Benztropine Mesylate COGENTIN Bill fee-for-service Medi-Cal for MCAL members Bromocriptine PARLODEL Carbidopa/levodopa SINEMET Carbidopa/levodopa CR SINEMET CR Entacapone COMTAN Levodopa DOPAR Ropinirole REQUIP Selegiline ELDEPRYL Trihexiphenidyl ARTANE QL: max 4 tablets per day On Formulary PA: Emsam formulation only Bill fee-for-service Medi-Cal for MCAL members Sedative/Hypnotics Flurazepam DALMANE Hydroxyzine HCL ATARAX Hydroxyzine Pamoate VISTARIL Eszopiclone LUNESTA Ramelteon ROZEREM Temazepam RESTORIL Triazolam HALCION Zaleplon SONATA ST: Trial and failure of zolpidem Zolpidem AMBIEN Zolpidem CR AMBIEN CR PA: Female new starts limited to 5mg QHS PA: Tried and failed at least 14-days of (1) zolpidem AND (2) zaleplon PA: Tried and failed at least 14-days of (1) zolpidem IR and (2) zaleplon PA: Tried and failed at least 14-days of (1) zolpidem IR and zolpidem ER (2) zaleplon AND (3) eszopiclone PA: 7.5 mg and 22.5mg capsules Stimulants Amphetamine & dextroamphetamine mixture ADDERALL, ADDERALL XR Formulary for patients <18 years old. PA: Required for patients >18 years old or >1 capsule per day for Adderall XR. Dexmethylphenidate FOCALIN PA: Tried and failed OR contraindications to at least two preferred alternatives Dextroamphetamine DEXEDRINE Formulary for patients <18 years old. PA: Required for patients > 18 years old. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 27 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Lisdexamfetamine VYVANSE Methylphenidate RITALIN Methylphenidate Extended Release RITALIN SR, METHADATE ER, CONCERTA, RITALIN LA Methylphenidate, Transdermal DAYTRANA Modafinil PROVIGIL PA: Tried and failed OR contraindications to at least two preferred alternatives Formulary for patients <18 years old. PA: Required for patients > 18 years old. Formulary for patients <18 years old. PA: Required for patients >18 years old or >1 tablet per day for Concerta, Ritalin LA. Concerta 36mg limit: 2 tablets per day. PA: Tried and failed OR contraindications to at least three preferred alternatives PA: Tried and failed OR contraindications to at least two preferred alternatives. Indicated for treatment of narcolepsy. MEDICATIONS TO TREAT INFECTIONS Antibiotics Amoxicillin Amoxicillin/Clarithromycin/Lansoprazole AMOXIL, TRIMOX AUGMENTIN, AUGMENTIN ES, AUGMENTIN XR PREVPAC Ampicillin PRINCIPEN Azithromycin ZITHROMAX Cefaclor CECLOR Cefdinir OMNICEF Cefixime SUPRAX C1: Otitis Media (O.M.) in children < 8 y.o. Cefpodoxime VANTIN QL: Limit 2 tabs per fill & 2 fills per 180 days. Cefuroxime CEFTIN Cephalexin KEFLEX Ciprofloxacin CIPRO Clarithromycin BIAXIN Clindamycin CLEOCIN Daptomycin CUBICIN Demeclocycline DECLOMYCIN Dicloxacillin DYNAPEN Doxycycline hyclate tab VIBRAMYCIN, DORYX Doxycycline monohydrate tab ADOXA Eryth Es,Sulf Oral Susp PEDIAZOLE Erythromycin Base ERY-TAB (Enteric Coated) Erythromycin Ethylsuccinate EES Erythromycin Stearate ERYTHROCIN Levofloxacin LEVAQUIN QL: 30 tablets per month Linezolid ZYVOX PA: Pre-requisite therapy required. Minocycline capsules MINOCIN Tablets non-formulary. Moxifloxacin AVELOX QL: 21 tabs twice per 12 months Neomycin MYCIFRADIN Ofloxacin FLOXIN Amoxicillin/potassium clavulanate QL: Limit duration of therapy to 14 days, & 2 fills/90 days PA: Tried and failed separate agents QL: 2 fills/90 days. Formulary: Capsules & Suspension PA: Chewable tablets & SR12H. Formulary: 250mg & 500mg Capsules & Suspension. PA: Tablets & 750mg Capsules. Immediate-release tablets are formulary PA: Suspension & XR Tablets. Formulary: 250mg & 500mg tablets PA: Oral Suspension 125mg/5 mL and 250mg/5mL Formulary: 75mg, 150mg, 300mg capsules PA: Oral solutions PA PA: Tried and failed OR contraindications to at least one preferred alternative. Used for treatment of SIADH. PA: Tried and failed OR contraindications to at least one preferred alternative. One dose for GYN indications is covered without PA. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 28 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Penicillin VK VEETIDS Rifaximin XIFAXAN Sulfadiazine SULFADIAZINE Sulfisoxazole GANTRISIN Tetracycline SUMYCIN Trimethoprim/ Sulfamethoxazole BACTRIM, BACTRIM DS, SEPTRA DS Vancomycin - oral VANCOCIN PA PA: Tried and failed OR contraindications to at least one preferred alternative. Indicated for: Pseudomembranous colitis. Restricted to pts who have failed Metronidazole therapy. Immunizations (Vaccines) **Use of all vaccines must be based on the guidelines published by the Centers for Disease Control and Prevention (CDC)** AL: >18 years old Haemophilus B Vaccine ACTHIB QL: 3 fills per lifetime AL: >18 years old Hepatitis A Vaccine HAVRIX QL: 2 fills per lifetime AL: >18 years old Hepatitis B Vaccine ENGERIX B QL: 3 fills per lifetime AL: >18 years old Hepatitis A+B Vaccine TWINRIX QL: 3 fills per lifetime AL: 19-26 years old Human Papilloma Virus Vaccine CERVARIX, GARDASIL, GARDASIL 9 QL: 3 fills per lifetime AL: >18 years old (>65 years old for high dose flu) FLUZONE, FLUZONE QUAD, FLUVIRIN, Influenza Vaccine QL: 1 fill per 270 days FLUCELVAX, AFLURIA, FLULAVAL AL: >18 years old Measles/Mumps/Rubella Vaccine MMR QL: 2 fills per lifetime AL: >18 years old Meningococcal Vaccine BEXSERO, MENVEO, MENACTRA, TRUMENBA QL: Bexsero, Menactra, and Menveo (2 fills per lifetime), Trumenba (3 fills per lifetime) AL: >50 years old QL: Prevnar 13 (1 fill per lifetime), Pneumovax 23 Pneumococcal Vaccine PREVNAR 13, PNEUMOVAX 23 (2 fills per lifetime) AL: >18 years old Rabies Vaccine IMOVAX, RABAVERT Tetanus/Diphtheria Vaccine TENIVAC AL: >18 years old Tetanus/Diphtheria/Pertussis Vaccine ADACEL, BOOSTRIX AL: >18 years old Typhoid Vaccine VIVOTIF BERNA Varicella Vaccine VARIVAX Zoster-vaccine, live attenuated ZOSTAVAX QL: 4 capsules per dispensing, PA required AL: >18 years old QL: 2 fills per lifetime AL: must be at least 60 years old QL: 1 fill per lifetime Antimalarials Atovaquone/Proguanil MALARONE Chloroquine ARALEN Mefloquine LARIAM Primaquine Phosphate PRIMAQUINE Pyrimethamine DARAPRIM Primethamine/ Sufadoxine FANSIDAR Quinine sultfate QUALAQUIN PA: Use for prophylaxis of malaria in regions where chloroquine resistance exists. PA: For treatment of Malaria only Anti-Parasitic Medications Iodoquinol YODOXIN Metronidazole FLAGYL Antituberculosis Medications Ethambutol MYAMBUTOL Ethionamide TRECATOR-SC BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 29 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Pyrazinamide PYRAZINAMIDE Isoniazid INH Rif/INH RIFAMATE Rif/INH/PZA RIFATER Rifabutin MYCOBUTIN NOTES Rifampin RIFADIN ANTIRETROVIRALS All oral FDA-approved HIV agents are eligible for coverage. *The following HIV Medications are carved-out for Medi-Cal members (billed to State Medi-Cal): Abacavir/Lamivudine(Ziagen), Abacavir(Epzicom), Abacavir/Lamivudine/Zidovudine(Trizivir), Amprenavir(Agenerase), Atazanavir(Reyataz), Darunavir(Prezista), Delavirdine(Rescriptor), Dolutegravir (Tivicay), Efavirenz(Sustiva), Efavirenz/Emtricitabine/Tenofovir(Atripla), Saquinavir, Tenofovir/Emtricitabine, Darunavir/Cobicistat (Prezcobix), Abacavir/Lamivudine/Dolutegravir (Triumeq), Zidovudine/Lamivudine/Abacavir(Trizivir), Elvitegravir/Cobicistat/Emtricitabine/Tenofovir(Stribild), Emtricitabine (Emtriva), Cobicistat (Tybost), Elvitegravir (Vitekta), Etravirine, Rilpivirine, Emtricitabine/Tenofovir(Truvada), Enfuvirtide(Fuzeon), Fosamprenavir(Lexiva), Indinavir(Crixivan), Lamivudine(Epivir or 3TC), Tenofovir(Viread), Lamivudine/Zidovudine(Combivir), Lopinavir/Ritonavir(Kaletra), Maraviroc(Selzentry), Nelfinavir(Viracept), Nevirapine(Viramune), Raltegravir(Isentress), Ritonavir(Norvir), Saquinavir(Invirase), Stavudine(Zerit), Emtricitabine/Rilpivirine/Tenofovir, Atazanavir/Cobicistat (Evotaz), Tipranavir(Aptivus), Zidovudine/Lamivudine(Combivir). *Antiretroviral Medications are limited to a 30-day supply per fill. *Please note lamivudine is also available as brand name Epivir HBV, which is used for the treatment of hepatitis and not HIV. Anti-HIV Medications, CCR5 Co-Receptor Antagonists Maraviroc PA: Pre-requisite therapy required FUZEON PA: Pre-requisite therapy required. Anti-HIV Medications, Fusion Inhibitors Enfuvirtide SELZENTRY Anti-HIV Medications, Integrase Strand Transfer Inhibitors Dolutegravir TIVICAY Raltegravir ISENTRESS Anti-HIV Medications, Non-Nucleoside Reverse Transcriptase Inhibitors Delavirdine RESCRIPTOR Efavirenz SUSTIVA Etravirine INTELENCE Nevirapine VIRAMUNE Rilpivirine EDURANT PA: Pre-requisite therapy required Anti-HIV Medications, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors and Single-Tablet Regimens Abacavir ZIAGEN Abacavir/Lamivudine EPZICOM Abacavir/Zidovudine TRIZIVIR Abacavir/Lamivudine/Dolutegravir TRIUMEQ Atazanavir/Cobicistat EVOTAZ Darunavir/Cobicistat PREZCOBIX Didanosine VIDEX EC, VIDEX PEDIATRIC Efavirenz/Emtricitabine/Tenofovir ATRIPLA Elvitegravir/Cobicistat/Emtricitabine/Tenofovir STRIBILD Emtricitabine/Rilpivirine/Tenofovir COMPLERA Emtricitabine EMTRIVA Emtricitabine/Tenofovir TRUVADA Lamivudine EPIVIR Lamivudine/Zidovudine COMBIVIR BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 30 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Stavudine ZERIT Tenofovir VIREAD Zidovudine RETROVIR NOTES Anti-HIV Medications, Protease Inhibitors Atazanavir REYATAZ Darunavir PREZISTA Fosamprenavir LEXIVA Indinavir CRIXIVAN Lopinavir/Ritonavir KALETRA Nelfinavir VIRACEPT Ritonavir NORVIR Saquinavir INVIRASE Tipranavir APTIVUS Hepatitis C Medications Elbasvir/grazoprevir ZEPATIER PA: Refer to DHCS Treatment Policy Ledipasvir/Sofosbuvir HARVONI PA: Refer to DHCS Treatment Policy Ombitasvir/paritaprevir/ritonavir and Dasabuvir VIEKIRA PA: Refer to DHCS Treatment Policy Ombitasvir/ paritaprevir/ritonavir TECHNIVIE PA: Refer to DHCS Treatment Policy Sofosbuvir SOVALDI PA: Refer to DHCS Treatment Policy Sofosbuvir/velpatasvir EPCLUSA PA: Refer to DHCS Treatment Policy Misc. Antiviral Medications Acyclovir ZOVIRAX Valacyclovir VALTREX Docosanol ABREVA Oseltamvir TAMIFLU Zanamivir RELENZA PA: capsules covered; topical forms such as ointment or cream require a PA QL: 2 grams per fill QL: Suspension - 120mL per 6 months. Capsules - 10 per 6 months. QL: 20 units (1 package) per 6 months. Oral Antifungals Clotrimazole MYCELEX TROCHE Fluconazole DIFLUCAN Flucytosine ANCOBON Griseofulvin Microsize GRIFULVIN Griseofulvin GRISPEG PA: Restricted to use in immunocompromised pts, treatment of documented Aspergillosis, tried and failure of amphotericin B, or tried and failure to a preferred antifungal. Itraconazole SPORANOX Nystatin MYCOSTATIN Terbinafine LAMISIL Voriconazole VFEND PA Atovaquone MEPRON PA: Diagnosis of PCP, failure of TMP/SMX. Dapsone DAPSONE Neomycin MYCIFARDIN, NEO-FRADIN Other Oral Anti-Infective Medications BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 31 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Vaginal Anti-Infectives Acetic Acid, vag ACID JELLY, VAG GEL Clindamycin Vaginal Cream CLEOCIN VAGINAL CREAM Clotrimazole GYNE-LOTRIMIN, GYNE-LOTRIMIN 3 Metronidazole METROGEL VAGINAL Miconazole Nitrate MONISTAT-7 Nystatin NYSTATIN Terconazole TERAZOL-3, TERAZOL-7 VAGINAL CREAM B B IMMUNOLOGICAL AGENTS Entecavir BARACLUDE Famciclovir FAMVIR Interferon Alfa-2B INTRON-A Pegylated Interferon Alfa-2A PEGASYS Lamivudine EPIVIR HBV Pegylated Interferon Alfa-2B PEG-INTRON Ribavirin COPEGUS , REBETOL Valganciclovir VALCYTE PA: Required except when prescribed by exempt physicians. Subject to tablet splitting regardless of prescribing physician. PA: Tried and failed OR contraindications to preferred alternatives PA: Pre-requisite therapy required. PA: Tried and failed OR contraindications to at least one preferred alternative. GI consult (including CCRMC GI specialists), is mandatory. PA PA: Tried and failed OR contraindications to at least one preferred alternative. GI consult (including CCRMC GI specialists), is mandatory. PA: Tried and failed OR contraindications to at least one preferred alternative. CMV retinitis/AID-Ophthamology consult required. ANALGESICS/PAIN/RHEUMATIC MEDICATIONS Acetaminophen TYLENOL B Aspirin BAYER HYALGAN, SUPARTZ, ORTHOVISC, MONOVISC, GEL-ONE PA: Tried and failed OR contraindications to preferred alternatives Hyaluronic Acid Anti-Inflammatory Medications (NSAIDS) Celecoxib CELEBREX Diclofenac CATAFLAM, VOLTAREN Etodolac LODINE, LODINE XL Fenoprofen NALFON Flurbiprofen ANSAID Ibuprofen MOTRIN Indomethacin INDOCIN Ketorolac TORADOL Ketoprofen ORUDIS Meclofenamate MECLOMEN PA: Restricted to one of the following criteria: geriatrics (age>65) OR patients with history of GI bleed OR tried and failed 3 formulary NSAIDs from 3 different NSAID categories OR concurrent anticoagulant, antiplatelet or corticosteroid therapy QL: Lodine limit #360/90 days, Lodine XL limit #90/90 days PA: Tried and failed OR contraindications to preferred alternatives PA: Tried and failed OR contraindications to preferred alternatives Motrin Rx covered for all CCHP membership B 400mg, 600mg, 800mg, 100mg/5ml suspension only. PA: Tried and failed OR contraindications to at least one preferred alternative. Not to exceed 5 days. PA: Tried and failed OR contraindications to at least one preferred alternative. Tried and failed OR contraindications to at least one preferred alternative BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 32 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Meloxicam MOBIC Nabumetone RELAFEN Naproxen NAPROSYN Oxaprozin DAYPRO Piroxicam FELDENE Salsalate DISALCID Sulindac CLINORIL Tolmetin TOLECTIN PA: Tried and failed OR contraindications to at least one preferred alternative. Adalimumab HUMIRA PA Auranofin RIDAURA Etanercept ENBREL Golimumab SIMPONI Hydroxychlorquine PLAQUENIL Infliximab REMICADE Leflunomide ARAVA Methotrexate METHOTREXATE, MTX QL: Max #270/90 days Anti-Rheumatic Medications PA PA:Tried and failed OR contraindications to preferred alternatives PA Migraine Medications Ergotamine/caffeine CAFERGOT Almotriptan AXERT Eletriptan RELPAX Frovatriptan FROVA Naratriptan AMERGE Rizatriptan MAXALT, MAXALT-MLT Sumatriptan IMITREX Zolmitriptan ZOMIG, ZOMIG-ZMT PA: Tried and failed OR contraindications to two preferred agents sumatriptan, rizatriptan, naratriptan QL: 12 tablets/month with each PA. PA: Tried and failed OR contraindications to two preferred agents sumatriptan, rizatriptan, naratriptan QL: 12 tablets/month with each PA. ST: 2.5mg is formulary after failure of sumatriptan and rizatriptan. Naraptriptan 1mg is nonformulary QL: 12 tablets/month with each PA. ST: 2.5mg is formulary after failure of sumatriptan and rizatriptan. Naraptriptan 1mg is nonformulary QL: 12 tablets/month with each PA. 5mg and 10mg tablets QL: 12 tablets/month. Oral tablets covered. QL: 12 tablets/month. PA: nasal spray and injection PA: Tried and failed OR contraindications to two preferred agents sumatriptan, rizatriptan, naratriptan QL: 12 tablets/month with each PA. Analgesics Diclofenac/Misoprostol ARTHROTEC Lidocaine LIDODERM Lidocaine 4% cream LIDOCAINE EXTERNAL Lidocaine 5% ointment LIDOCAINE EXTERNAL Tramadol ULTRAM PA: Tried and failed OR contraindications to preferred alternatives. Separate agents are formulary. PA: Tried and failed OR contraindications to preferred alternatives PA: Tried and failed OR contraindications to preferred alternatives. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 33 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME Tramadol/APAP BRAND NAME NOTES ULTRACET Narcotic Analgesics Maximum Acetaminophen daily dose = 4gm/day. Acetaminophen/codeine tabs TYLENOL #2, #3, #4 Acetaminophen/codeine Elixir TYLENOL w/CODEINE Acetaminophen/hydrocodone NORCO 325/5 Acetaminophen/hydrocodone NORCO 325/7.5 Acetaminophen/hydrocodone NORCO 325/10 Acetaminophen/hydrocodone LORTAB ELIXIR 167/2.5 Butalbital/acetaminophen/caffeine ESGIC, ESGIC PLUS Butalbital/acetaminophen/caffeine FIORICET Butalbital/acetaminophen/caffeine/codeine FIORICET/ CODEINE Butalbital/aspirin/caffeine FIORINAL TABS Butalbital/aspirin/caffeine/codeine FIORINAL/CODEINE Codeine Tabs CODEINE SULFATE Codeine Tabs CODEINE PHOSPHATE Codeine/Aspirin EMPIRIN w/Codeine Dihydrocodeine/Aspirin/Caffeine Panlor DC, Panlor SS Fentanyl transdermal patch DURAGESIC (TRANSDERMAL PATCH) Hydromorphone DILAUDID Ibuprofen/hydrocodone VICOPROFEN Levorphanol LEVO-DROMORAN Meperidine DEMEROL Methadone DOLOPHINE Morphine (Concentrate). ROXANOL(CONCENTRATE) Morphine (Solution & Tablet) MSIR (Solution & Tablet) Morphine (Suppositories) RMS (SUPPOSITORIES) Morphine SR MS CONTIN Oxycodone IR tablet OXY-IR, ROXICODONE Oxycodone SR OXYCONTIN Oxycodone/acetaminophen 5/325 tablet PERCOCET 5/325 Oxycodone/acetaminophen 10/325 tablet PERCOCET 10/325 Oxycodone/acetaminophen 5/500 capsule TYLOX 5/500 PA: Tried and failed OR contraindications to at least one preferred alternative. Treatment of Tension headache/headache symptom complex. PA: Tried and failed OR contraindications to at least one preferred alternative. Treatment of migraine or tension headache. PA: Tried and failed or contraindications to Codeine Sulfate PA: : Tried and failed OR contraindications to at least one preferred alternative PA: Diagnosis of Terminal disease, and tried and failed or contraindications to Morphine SR and justification why oral agents cannot be used Limit: 1 patch every 3 days. PA: Tried and failed OR contraindications to at least one preferred alternative. Restricted to patients refractory to other pain management therapies. PA: Tried and failed OR contraindications to at least one preferred alternative. Restricted to patients refractory to other pain management therapies. PA: Tried and failed or contraindications to morphine IR and hydromorphone PA: Tried and failed or contraindications to Morphine Sulfate. QL: 30 tablets per fill. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 34 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Oxycodone/aspirin PERCODAN Pentazocine TALWIN Tapentadol NUCYNTA NOTES PA: Tried and failed or contraindications to preferred alternatives. PA: Tried and failed OR contraindications to at least one preferred alternative. Restricted to pts refractory to other pain management therapies. PA: Tried and failed or contraindications to preferred alternatives. Opiate Antagonists *Medications are carved-out for Medi-Cal members Buprenorphine SUBUTEX Carved-out for Medi-Cal members Buprenorphine/naloxone SUBOXONE Carved-out for Medi-Cal members Naltrexone REVIA Carved-out for Medi-Cal members Naloxone 1mg/ml Injector NALOXONE Carved-out for Medi-Cal members Anti-psoriatic Agent Apremilast OTEZLA Infliximab REMICADE PA: Tried and failed or contraindications to preferred alternatives PA Ustekinumab STELARA PA Skeletal Muscle Relaxants Baclofen LIORESAL Carisoprodol SOMA Chlorzoxazone PARAFON, PARAFON FORTE Cyclobenzaprine FLEXERIL Dantrolene Sodium DANTRIUM Diazepam VALIUM Metaxalone SKELAXIN Methocarbamol ROBAXIN Tizanidine ZANAFLEX QL: 30 tablets per month of 350mg PA: 250mg tablets PA: Tried and failed OR contraindications to at least one preferred alternative 2mg and 4mg tablets are formulary. Capsules are non-formulary. NUTRITION Electrolytes KCL (potassium chloride) GENERIC FORMULATIONS Potassium Iodide SSKI Potassium Acid Phosphate K-PHOS Vitamins and Minerals Calcitriol ROCALTROL Calcium Carbonate TITRALAC B Calcium Gluconate CALCIUM GLUCONATE M Calcium Lactate CALCIUM LACTATE M Electrolytes, Oral Maintenance PEDIALYTE Ergocalciferol (Vitamin D) VITAMIN D Ferrous Sulfate FEOSOL B B: OTC formulation A: Rx formulation B Ferrous Gluconate FERROUS GLUCONATE Folic Acid FOLIC ACID Covered: Prescription strength 1mg tablet only. Leucovorin LEUCOVORIN Covered: 5mg tablets only Levocarnitine CARNITOR Magnesium Oxide 400mg tablet MAG-OX 400 Iron Sucrose, Intravenous VENOFER B PA: Labs indicating iron deficiency anemia; trial and failure of oral iron supplementation BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 35 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES B Pyridoxine VITAMIN B-6 Sodium Flouride (drops & tabs) LURIDE(DROPS&TABLETS) Vitamins A, D, C TRI-VI-SOL B Vitamins A, D, C with Iron TRI-VI-SOL w/IRON B Vitamin A, D, C, & Fluoride TRI-VI-FLOR Vitamin A, C, D, Fluoride, & Iron TRI-VI-FLOR w/IRON Vitamin B-12 CYANOCOBALAMIN Vitamin B Complex RENA-VITE, NEPHROVITE Vitamin K MEPHYTON B Obesity Medications Phentermine ADIPEX-P PA Orlistat ALLI; XENICAL PA Lorcaserin BELVIQ PA Naltrexone/bupropion extended release CONTRAVE PA Phentermine/topiramate QSYMIA PA Phosphate Binding Medications Calcium acetate PHOSLO Lanthanum FOSRENOL Sevelamer RENVELA TABLET, RENVELA PACKET ST: Tried and failed calcium acetate PA: Maximum dose: 12,000mg/day. Max approvable quantity: Renagel 400mg tablets 30/day. Renagel 800mg tablet 15/day. Approvable if patient on dialysis AND tried and failed Phoslo (calcium acetate) or serum calcium >10mg/dL.or Ca*P > 55 AND Lanthanum (Fosrenol) Calcimimetic Cinacalcet SENSIPAR PA: Tried and failed at least one phosphate binder Chelating Agents Succimer CHEMET RESPIRATORY DRUGS Antihistamine/Decongestants Carbinoxamine/ Pseudoephdrine RONDEC, RONDEC DM Antihistamines Brompheniramine J-TAN PD, LODRANE, VAZOL B: available Rx only Brompheniramine/Phenylephrine DIMETAPP B Cetirizine ZYRTEC B Cetirizine/Pseudoephedrine ZYRTEC-D B Levocetirizine XYZAL B Chlorpheniramine CHLOR-TRIMETON, CHLORITON, CPM B: OTC formulations. Chlorpheniramine/Dextromethorphan SCOT-TUSSIN DM B Cyproheptadine PERIACTIN Desloratadine CLARINEX Doxylamine DOXYSOM Fexofenadine ALLEGRA Hydroxyzine HCl ATARAX PA: Tried and failed OR contraindications to at least two preferred alternatives (i.e., OTC Claritin and OTC Zyrtec). B B PA: Tried and failed OR contraindications to at least two preferred alternatives (i.e., OTC Claritin and OTC Zyrtec). BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 36 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Hydroxyzine Pamoate VISTARIL Loratadine CLARITIN B Loratadine and pseudoephedrine CLARITIN-D B Promethazine PHENERGAN Pseudoephedrine PEDIACARE, SUDAFED B Pseudoephedrine/Guaifenesin ROBITUSSIN PE B Triprolidine TRIPOHIST, ZYMINE, ZYMINE XR Cough Medications Carbinoxamine/Pseudoephdrine RONDEC Carbinoxamine/Pseudoephdrine/Dextromethorp RONDEC-DM han Dextromethorphan ROBITUSSIN MAXIMUM STRENGTH B Guaifenesin (Syrup) ROBITUSSIN (SYRUP) B Guaifenesin (Tablet) MUCINEX (TABLET) B Guaifenesin/Codeine ROBITUSSIN AC Guaifenesin/Dextromethorphan (Syrup) ROBITUSSIN DM (SYRUP) B B Guaifenesin/Dextromethorphan (Tablet) MUCINEX DM (TABLET) Guaifenesin/Dextromethorphan/Pseudoephedri ROBITUSSIN CF ne Guaifenesin/Pseudoephedrine (Tablet) MUCINEX D (TABLET) B B Hydrocodone/Chlorpheniramine TUSSIONEX Hydrocodone/Homatropine HYCODAN Promethazine/Dextromethorphan PHENERGAN w/DM Promethazine PHENERGAN Promethazine/Codeine PHENERGAN w/CODEINE Promethazine/Phenylephrine PHENERGAN VC Promethazine/Phenylephrine/Codeine PHENERGAN VC w/CODEINE QL: 240ml per 30days QL: 240ml per 30days Medications For Asthma & COPD Albuterol HFA MDI, Nebulization VENTOLIN HFA, VENTOLIN Albuterol Sulfate (Syrup) VENTOLIN (SYRUP) Albuterol Sulfate Tab VOSPIRE ER Albuterol-ipratropium (Inhaler) COMBIVENT, COMBIVENT RESPIMAT Umeclidinium-vilanterol ANORO ELLIPTA Ipratropium Bromide ATROVENT HFA Tiotropium Bromide SPIRIVA Albuterol-ipratropium, (Nebulization) DUONEB (NEBULIZATION) Aminophylline AMINOPHYLLINE Beclomethasone Dipropionate QVAR FLOVENT DISKUS, FLOVENT HFA, ARNUITY ELLIPTA Fluticasone Propionate Budesonide Budesonide Respules Note: Respimat preferred PULMICORT TURBUHALER PA: Tried and failed or contraindications to other formulary inhaled corticosteroids including. PULMICORT RESPULES Formulary for patients <8 years of age and younger if dosed within appropriate dosing guidelines as follows: 0.25mg/2mL once daily (BID requires PA) 0.5mg/2mL once or twice daily 1mg/2mL once daily PA: Required for patients 9 and older for Diagnosis BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 37 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES of Asthma. Requires tried and failure of a formulary corticosteroid. Budesonide/Formoterl SYMBICORT Mometasone/formoterol DULERA Fluticasone Propionate/Salmeterol Xinafoate ADVAIR DISKUS, ADVAIR HFA Flunisolide AEROBID, AEROBID-M Formoterol FORADIL Levalbuterol Nebulizer XOPENEX, XOPENEX HFA Mometasone furoate ASMANEX Cromolyn INTAL Metaproterenol ALUPENT Montelukast Sodium SINGULAIR, SINGULAIR CHEW Nedocromil Sodium TILADE Omalizumab XOLAIR Pirbuterol MAXAIR AUTOHALER Salmetrol SEREVENT DISKUS Sodium Chloride for Inhalation SODIUM CHLORIDE FOR INHALATION Terbutaline BRETHINE Theophylline Elixir ELIXOPHYLLIN Theophyline SR THEO-DUR, UNIPHYL Theophylline SLO-PHYLLIN Triamcinolone AZMACORT Zafirlukast ACCOLATE Zileuton ZYFLOW CR PA: Trial/failure or contraindications to Symbicort or Dulera. Formulary for 4 thru 11 years old. PA: Tried and failed or contraindications to other Formulary inhaled corticosteroids including Qvar. PA: Tried and failed or contraindication to at least one preferred alternative including Albuterol solution for nebulization. PA B PA: Tried and failed or contraindication to other formulary inhaled corticosteroids including Qvar. PA: Diagnosis: Asthma – Tried and failed preferred inhaled corticosteroids or insufficient control with inhaled corticosteroids. QL: #180/90days PA: Tried and failed OR contraindications to at least one preferred alternative in patients > 12 years old. Indication: Asthma. Mucolytic Agent Acetylcysteine MUCOMYST SKIN MEDICATIONS (TOPICAL) Acne Medications Adapalene /Benzoyl peroxide EPIDUO Benzoyl peroxide DESQUAM-E, DESQUAM-X Benzoyl peroxide/Clindamycin BENZACLIN Benzoyl peroxide/Erythromycin BENZAMYCIN Clindamycin CLEOCIN-T Erythromycin ERYCETTE, ERY-GEL, PA: Tried and failed or contraindicated to topical benzoyl peroxide alone and topical tretinoin alone Formulary: Only 2.5%, 5%, and 10% strengths for all dosage forms. PA: Tried and failed or contraindicated to the products separately PA: Tried and failed or contraindicated to the products separately BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 38 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Erythromycin/Benzoyl peroxide BENZAMYCIN Metronidazole METROGEL Tretinoin RETIN-A Tretinoin RETIN-A MICRO PA required regardless of age CLARAVIS, AMNESTEEM PA: Tried and failed OR contraindications to at least one preferred alternative. Severe recalcitrant nodular acne. Formulary for CCRMC Dermatology. Crotamiton EURAX QL: 120g (2 tubes) per rolling 365 days Ivermectin STROMECTOL Permethrin ELIMITE Permethrin NIX B: OTC formulation (1% topical liquid) Piperonyl Butoxide/Pyrethrins R & C, PYRINYL II, B Pyrantel Pamoate REESE'S PINWORM, PIN-X B Isotretinoin C1: Treatment of acne rosacea Formulary for Individuals < 30 years old; PA required for patients > 30 years old. Formulary for CCRMC Dermatology regardless of age. Topical Antiparasitics/Anti-helmintic Other Topical Medications Aluminum Chloride DRYSOL Aluminum Acetate ACID MANTLE B Bacitracin Ointment BACIGUENT(OINMENT) B Bacitracin/polymyxin B Sulfate POLYSPORIN Becaplermin REGRANEX B PA: Approvable for diabetic neuropathic ulcers in the lower extremities. It is not indicated in children under the age of 16 years. Refer these to professional services. Ulcer size must be submitted on PA form. QL: 15-gram tube per month x 12 weeks Capsaicin topical cream 0.025,0.075,0.1% ZOSTRIX, ZOSTRIX-HP Collagenase SANTYL Calamine Lotion CALAMINE LOTION Calcipotriene DOVONEX Coal Tar IONIL T Diclofenac 1% topical gel VOLTAREN 1% GEL Fluorouracil EFUDEX Gentamicin GARAMYCIN Imiquimod ALDARA QL: 1 package per 30 days. Mupirocin BACTROBAN Ointment only. Cream is not covered. Normal Saline Irrigation Papain/Urea/Chlorophyllin Copper Complex Sodium Papain/Urea NS 0.9% Irrigation Podofilox Gel CONDYLOX Salicylic acid 6% lotion, cream & shampoo SALACYLIC ACID Selenium sulfide 2.5% EXSEL,SELSUN RX Silver Sulfadiazine SILVADENE, SSD Trioxsalen TRISORALEN B PA: : Tried and failed OR contraindications to at least two preferred alternative. Formulary for CCRMC Dermatology. M PA: Requires 2 oral NSAIDs and capsaicin or contraindications to use PANAFIL ACCUZYME QL: Gel-7gm x 4 weeks, Soln-8mL x 4 weeks. 2 units each solution, or gel. Treatment >4 weeks requires PA. PA: Tried and failed OR contraindications to at least one preferred alternative. Indicated for BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 39 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Vitiligo OR enhanced pigmentation. Per dermatologists only. Topical Immunomodulator Pimecrolimus ELIDEL Tacrolimus PROTOPIC QL: 1 large tube every 30 days. PA: Exception if written by a CCRMC dermatologist AND patient has tried and failed at least one (1) formulary medium or high potency topical corticosteroid (7 day trial within past 90 days). QL: 1 large tube every 30 days. PA: Exception if Rx written by a CCRMC dermatologist AND patient has tried and failed at least one (1) formulary medium or high potency topical corticosteroid (7 day trial within past 90 days). Topical Antifungal B Clotrimazole LOTRIMIN AF Clotrimazole/Betamethasone LOTRISONE Econazole SPECTAZOLE Gentian Violet 1% GENTIAN VIOLET Ketoconazole 2% (cream & shampoo) NIZORAL (CREAM & SHAMPOO) Miconazole 2% cream MICATIN, MONISTAT-DERM Nystatin MYCOSTATIN Triamcinolone/Nystatin MYCOLOG II Sodium Thiosulfate/Salicylic Acid EXODERM, VERSICLEAR Sulconazole EXELDERM Tolnaftate TINACTIN B B Topical Coricosteroids Grade 1 (Very High Potency) Betamethasone dipropionate 0.05%, aug DIPROLENE AF CREAM Clobetasol propionate 0.05% cream, oint, soln TEMOVATE, TEMOVATE E Clobetasol propionate 0.05% scalp foam OLUX Diflorasone diacetate ointment 0.5% PSORCON E Halobetasol propionate 0.05% ULTRAVATE PA: no PA for RMC dermatology PA: Tried and failed OR contraindications to preferred alternatives. PA: Tried and failed OR contraindications to clobetasol. Claim pays on-line if criteria met. Grade 2 (High Potency) PA: Tried and failed OR contraindications to at least two preferred alternatives. Amcinonide 0.1% CYCLOCORT Betamethasone dipropionate 0.05-0.1% DIPROSONE Desoximetasone 0.05-0.25% TOPICORT Fluocinonide 0.05% LIDEX Halcinonide 0.1% HALOG Triamcinolone acetonide 0.5% ARISTOCORT, KENALOG PA: Tried and failed OR contraindications to at least two preferred alternatives. PA: Tried and failed OR contraindications to at least two preferred alternatives. Grade 3 (Medium Potency) Formulary: Cream PA: Foam formulation PA: Tried and failed OR contraindications to at least three preferred alternatives. PA: Tried and failed OR contraindications to at least two preferred alternatives. Betamethasone valerate VALISONE Clocortolone pivalate 0.1% CLODERM Desoximetasone 0.05% TOPICORT LP Fluocinolone acetonide 0.025-0.01% SYNALAR, DERMA-SMOOTHE/FS Fluticasone propionate 0.05% CUTIVATE Formulary: Cream and ointment PA: Lotion BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 40 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Hydrocortisone Probutate 0.1% PANDEL Hydrocortisone Butyrate 0.1% LOCOID, LOCOID LIPOCREAM Hydrocortisone Valerate 0.2% WESTCORT Mometasone furoate 0.1% ELOCON Prednicarbate 0.1% DERMATOP Triamcinolone acetonide 0.025-0.1% ARISTOCORT, KENALOG PA: Tried and failed OR contraindications to at least three preferred alternatives. PA: Tried and failed OR contraindications to at least three preferred alternatives. PA: Tried and failed OR contraindications to at least three preferred alternatives. PA: Tried and failed OR contraindications to at least three preferred alternatives. Grade 4 (Low Potency) PA: Tried and failed OR contraindications to at least two formulary low potency alternatives. Alclometasone dipropionate 0.05% ACLOVATE Desonide 0.05% DESOWEN Fluocinolone Acetonide 0.01% DERMA-SMOOTHE/FS, SYNALAR Hydrocortisone 0.5-2.5% CORTAID, HYTONE B: OTC products covered for Medi-Cal & BHC only. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 41 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST INDEX Abacavir, 29 Abacavir/Lamivudine, 29 Abacavir/Lamivudine/Dolutegravir, 29 Abacavir/Zidovudine, 29 ABREVA, 30 Acarbose, 10 ACCOLATE, 37 ACCUZYME, 38 Acebutolol, 17 Acetaminophen, 31 Acetaminophen/codeine Elixir, 32 Acetaminophen/codeine tabs, 32 Acetaminophen/hydrocodone, 32, 33 Acetazolamide Caps, 20 Acetic Acid 2%, 23 Acetic Acid, vag, 30 Acetic Acid/HC, 23 Acetylcysteine, 37 ACID MANTLE, 38 ACID-JELLY, 30 ACIPHEX, 14 ACLOVATE, 40 ACTONEL, 11 ACTOS, 11 ACTOSPLUS MET, 11 ACULAR, 20 Acyclovir, 30 ADALAT, 18 ADALAT CC, 18 ADDERALL, 27 ADDERALL XR, 27 ADOXA, 28 ADVAIR DISKUS, 37 ADVAIR HFA, 37 AEROBID, AEROBID-M, 37 AFEDITAB, 18 AGGRENOX, 19 AGRYLIN, 19 AKBETA, 20 AK-PRED, 20 AKPRO, 21 AK-TRACIN, 21 ALAMAST, 23 ALAWAY OTC,, 22 Albiglutide, 10 Albuterol HFA MDI, Nebulization, 36 Albuterol Sulfate (Syrup), 36 Albuterol Sulfate Tab, 36 Albuterol-ipratropium (Inhaler), 36 Albuterol-ipratropium, nebulizer, 36 Alclometasone dipropionate 0.05%, 40 ALDACTAZIDE, 19 ALDACTONE, 19 ALDARA, 38 ALDOMET, 18 Alendronate, 11 ALESSE, 12 Alfuzosin ER, 16 ALKERAN, 9 ALLEGRA, 35 Allopurinol, 13 Almotriptan, 32 ALOCRIL, 22 ALOMIDE, 22 ALPHAGAN P, 20 Alprazolam, 24 Alprostadil, 16 Altretamine, 9 Aluminum Acetate, 38 Aluminum Chloride Hexahydrate, 38 Aluminum Hydroxide Gel, 15 Aluminum Hydroxide, Magnesium Hydroxide, and Simethicone, 15 ALUPENT, 37 Amantadine, 26 AMARYL, 10 AMBIEN, 27 AMBIEN CR, 27 Amcinonide 0.1%, 39 AMERGE, 32 AMETHIA, 12 Amiloride, 19 Amiloride/HCTZ, 19 Aminophylline, 36 AMINOPHYLLINE, 36 Amiodarone, 17 Amitriptyline, 25 Amlodipine, 17 Amnesteem, 37 Amoxicillin, 27 Amoxicillin/potassium clavulanate, 27 AMOXIL, 27 Amphetamine & dextroamphetamine mixture, 27 AMPHOGEL, 15 Ampicillin, 27 Amylase/ Lipase/ Protease, 14 ANAFRANIL, 25 Anagrelide, 19 Anastrozole, 9 ANCOBON, 30 ANDROGEL, 10 ANDRODERM, 10 ANORO ELLIPTA, 37 ANTABUSE, 26 Antihistamine with Antitussive, 35 Antihistamine with Nasal Decongestant, 35 ANTIVERT, 15 ANUSOL-HC CREAM, SUPP, 15 APIDRA, 11 Aprepitant, 14 Apremilast, 34 APRESOLINE, 19, 20 APTIVUS, 30 ARALEN, 28 ARAVA, 32 ARICEPT, 26 ARICEPT ODT, 26 ARIMIDEX, 9 ARISTOCORT, 39, 40 ARMOUR THYROID, 13 42 ARNUITY ELLIPTA, 37 AROMASIN, 9 ARTANE, 26 ARTHROTEC, 32 ASACOL HD, 15 ASMANEX, 37 Aspirin, 19, 31 ASTELIN, 23 ATARAX, 27, 35 Atazanavir, 30 Atazanavir/Cobicistat, 29 Atenolol, 17 Atenolol/Chlorthalidone, 17 ATIVAN, 24 Atorvastatin, 18 Atovaquone, 30 Atovaquone/Proguanil, 28 ATRIPLA, 29 Atropine, 23 ATROVENT HFA, 36 ATROVENT NASAL SPRAY, 23 AUGMENTIN, 27 AUGMENTIN ES, 27 AUGMENTIN XR, 27 AURALGAN, 23 Auranofin, 32 AVELOX, 28 AXERT, 32 AYGESTIN, 13 Azathioprine, 15 Azelastine HCl, 22 Azelastine Nasal Spray, 23 Azithromycin, 27 AZMACORT, 37 AZOPT, 20 AZULFIDINE, 15 BACIGUENT, 38 Bacitracin ophthalmic, 21 Bacitracin or Bacitracin Zinc Topical Ointment, 38 Bacitracin/ Polymyxin B Sultate, 21 Bacitracin/polymyxin, 38 Baclofen, 34 BACTRIM, 28 BACTRIM DS, 28 BACTROBAN, 38 Balsalazide, 15 BANZEL, 24 BARACLUDE, 31 BAYER, 19, 31 Becaplermin, 38 Beclomethasone Dipropionate, 36 Belladonna Alkaloids/Phenobarbital, 13 BELLERGAL-S, 14 BELVIQ, 35 Benazepril, 16 Benazepril/HCTZ, 16 BENEMID, 13 BENICAR, 16 BENICAR HCT, 17 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST BENTYL, 14 BENZAMYCIN, 37 Benzocaine/Antipyrine Otic, 23 Benzoyl peroxide gel, 37 Benztropine Mesylate, 26 BETAGAN, 20 Betamethasone dipropionate 0.05%, 39 Betamethasone dipropionate 0.050.1%, 39 Betamethasone valerate, 39 BETAPACE, 17 BETAPACE AF, 17 Betaxolol, 20 Bethanechol, 16 BETIMOL, 20 BETOPTIC, 20 BEYAZ, 12 BIAXIN, 27 Bicalutamide, 10 Bimatoprost, 21 Bisacodyl, 15 Bismuth Subsalicylate, 15 Bisoprolol/HCTZ, 17 BLEPH 10, 21 BLEPHAMIDE, 22 BLEPHAMIDE S.O.P, 22 BRETHINE, 37 Brimonidine, 20 Brinzolamide, 20 Bromocriptine, 26 Budesonide Respules, 36 Budesonide Turbuhaler, 36 Budesonide/Formoterl, 36 Bumetanide, 19 BUMEX, 19 Buprenoprhine naloxone, 34 Bupropion, 25 Bupropion SR, 25 Bupropion Sustained Release, 26 Bupropion XL, 25 BUSPAR, 24 Buspirone, 24 Busulfan, 9 Butalbital/acetaminophen/caffeine, 33 Butalbital/acetaminophen/caffeine/cod eine, 33 Butalbital/aspirin/caffeine, 33 Butalbital/aspirin/caffeine/codeine, 33 BYETTA, 10 CABERGOLINE, 13 CAFERGOT, 32 Calamine Lotion, 38 CALAMINE LOTION, 38 CALAN, 18 CALAN SR, 18 Calcitonin-Salmon, 11 Calcitriol, 34 Calcium acetate, 35 Calcium Carbonate, 34 Calcium Carbonate/Magnesium Carbonate, 15 Calcium Gluconate, 34 Calcium Lactate, 34 CAMRESE, 12 CANASA, 15 Capecitabine, 9 CAPOTEN, 16 Capsaicin topical cream 0.025%, 0.075%,0.1% 38 Captopril, 16 CARAFATE, 14 Carbachol, 21 Carbamazepine, 24 CARBATROL, 24 Carbidopa/levodopa, 26 Carbidopa/levodopa CR, 26 Carbinoxamine/ Pseudoephdrine, 35 CARDENE, 18 CARDENE SR, 18 CARDIZEM, 17 CARDIZEM CD, 18 CARDIZEM LA, 18 CARDIZEM SR, 18 CARDURA, 16, 20 Carisoprodol, 34 CARTIA XT, 17 Carvedilol, 17 CASODEX, 10 CATAFLAM, 31 CATAPRES, 18 CAVERJECT, 16 CAZIANT, 12 CECLOR, 27 CEENU, 9 Cefaclor, 27 Cefdinir, 27 Cefixime, 27 Cefpodoxime, 27 CEFTIN, 27 Cefuroxime, 27 CELEBREX, 31 Celecoxib, 31 CELEXA, 25 CELLCEPT, 10 CELONTIN KAPSEALS, 24 Cephalexin, 27 CERVICAL CAP, 12 Cetirizine, 35 Cevimeline HCL, 24 CHANTIX, 26 Chlorambucil, 9 Chlordiazepoxide, 24 Chlorhexidine Gluconate, 23 CHLORITON, 35 Chloroquine, 28 Chlorpromazine, 25 Chlorthalidone, 19 CHLOR-TRIMETON, 35 Chlorzoxazone, 34 Cholestyramine, 18 Cilostazol, 19 CILOXAN, 21 Cimetidine, 14 CIPRO, 27 Cipro HC, 23 Ciprodex OTIC, 23 Ciprofloxacin, 21 43 Ciprofloxacin, 27 ciprofloxacin/dexamethasone, 23 ciprofloxacin/hydrocortisone, 23 Citalopram Hydrobromide, 25 CITRATE OF MAGNESIUM, 15 Claravis, 37 Clarithromycin, 27 CLARITIN, 35 CLARITIN-D, 35 CLEOCIN, 27, 30 CLEOCIN VAGINAL CREAM, 30 CLEOCIN-T, 37 CLIMARA, 12 Clindamycin, 27, 30, 37 Clindamycin Vaginal Cream, 30 Clinidium/Chlordiazepoxide, 13 CLINORIL, 31 Clobetasol propionate 0.05%, 39 Clocortolone pivalate 0.1%, 39 CLODERM, 39 Clomipramine, 25 Clonazepam, 24 Clonidine, 18 Clopidogrel, 19 Clorazepate, 24 Clotrimazole, 30, 31, 39 Clotrimazole/Betamethasone, 39 Clozapine, 25 CLOZARIL, 25 Coal Tar, 38 CODEINE PHOSPHATE, 33 CODEINE SULFATE, 33 Codeine Tabs, 33 Codeine/Aspirin, 33 Codeine/Guaifenesin, 36 CODEINE®, 33 COGENTIN, 26 COLAZAL, 15 Colchicine, 13 Colchicine/Probenecid, 13 COLCRYS, 13 COLESTID, 18 Colestipol, 18 Collagenase, 38 COL-PROBENECID, 13 COLYTE, 14, 15 COMBIPATCH, 12 COMBIVENT, 36 COMBIVENT RESPIMAT, 36 COMBIVIR, 30 COMPAZINE, 15 COMPLERA, 29 CONCERTA, 27 CONDOMS, 12 CONDYLOX, 38 Conjugated Estrogen vag, 11 Conjugated Estrogens/Medroxy Progesterone, 12 CONTRAVE, 35 COPEGUS, 31 CORDARONE, 17 COREG, 17 CORGARD, 17 CORTAID, HYTONE, 40 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST CORTEF, 10 CORTENEMA, 15 CORTIFOAM, 15 CORTISPORIN OPHTH OINT, 21 CORTISPORIN OPHTH SUSP, 22 CORTISPORIN OTIC SOLN, 23 CORTISPORIN OTIC SUSP, 23 COSOPT XE, 20 COUMADIN, 19 COZAAR, 16 CPM, 35 CREON, 14 CRIXIVAN, 30 CROLOM, 22 Cromolyn, 22, 37 Crotamiton, 38 CUTIVATE, 40 CYANOCOBALAMIN, 34 CYCLESSA, 12 Cyclobenzaprine, 34 CYCLOCORT, 39 CYCLOGYL, 23 Cyclopentolate, 23 Cyclophosphamide, 9 Cyclosporine Modified, 10 Cyclosporine non-modified, 10 Cyproheptadine, 35 CYTOMEL, 13 CYTOTEC, 14 CYTOXAN, 9 DALMANE, 26 DANTRIUM, 34 Dantrolene Sodium, 34 Dapsone, 30 DAPSONE, 30 DARAPRIM, 28 Darunavir, 30 Darunavir/Cobicistat, 29 Dasatinib, 9 DAYPRO, 31 DDAVP, 13 DECADRON, 10, 20 DECLOMYCIN, 27 Delavirdine, 29 DELZICOL, 15 DEMADEX, 19 Demeclocycline, 27 DEMEROL TABS, 33 DEMSER, 9 DEMULEN, 12 DEPAKENE, 24 DEPAKOTE, 24 DEPAKOTE ER, 24 DEPAKOTE SPRINKLE, 24 DEPEN, 32 DEPO-PROVERA, 13 DEPO-TESTOSTERONE (inj), 10 DERMA-SMOOTHE/FS, 40 DERMA-SMOOTHE/FS, SYNALAR, 40 DERMATOP, 40 Desipramine, 25 Desmopressin Acetate, 13 DESOGEN, 12 Desonide 0.05%, 40 DESOWEN, 40 Desoximetasone 0.05%, 40 Desoximetasone 0.25%, 39 DESQUAM-E, 37 DESQUAM-X, 37 DESYREL, 25 DETROL, 16 DETROL LA, 16 Dexamethasone, 10, 20 DEXEDRINE, 27 DEXILANT, 14 Dexlansoprazole, 14 Dextroamphetamine, 27 Dextromethorphan, 35 DIABETA/MICRONASE, 10 DIAMOX, 18, 20 DIAMOX SEQUELS, 18, 20 DIAPHRAGM, 12 Diazepam, 24, 34 DIBENZYLINE, 9 Diclofenac, 31 Diclofenac 1% topical gel, 38 Diclofenac/Misoprostol, 32 Dicloxacillin, 27 Dicyclomine, 14 Didanosine, 29 DIDRONEL, 11 Diflorasone diacetate ointment 0.5%, 39 DIFLUCAN, 30 DIGEL, 15 Digoxin, 17 DILACOR XR, 18 DILANTIN, 24 DILATRATE, 19 DILATRATE SR, 19 DILAUDID, 33 DILT XR, 18 Diltiazem, 17 Diltiazem CR, 18 Diltiazem SR, Diltiazem ER, 18 DIMETAPP, 35 DIPENTUM, 15 Diphenoxylate/Atropine, 14 Dipivefrin, 21 DIPROLENE AF CREAM, 39 DIPROSONE, 39 Dipyridamole, 19 Dipyridamole/Aspirin, 19 DISALCID, 31 Disopyramide, 17 Disulfiram, 26 DITROPAN, 16 DITROPAN XL, 16 Divalproex sodium, 24 Docosanol, 30 Docusate Sodium, 15 Dofetilide, 17 Dolasetron, 14 DOLOPHINE, 33 Dolutegravir, 29 DOMEBORO, 23 Donepezil, 26 44 Donepezil ODT, 26 DONNATAL, 13 DOPAR, 26 DORYX, 27 Dorzolamide, 20 DOSTINEX, 13 Doxazosin, 20 Doxazosin Mesylate, 16 Doxepin, 25 Doxycycline hyclate tab, 27 Doxycycline monohydrate tab, 28 Doxylamine, 35 DOXYSOM, 35 Dronabinol, 14 DROXIA, 9 DRYSOL, 38 DSS, 15 DUETACT, 10 DULCOLAX, 15 DULERA, 36 DUONEB, 36 DURAGESIC, 33 DYAZIDE, 19 DYNACIRC, 18 DYNACIRC CR, 18 DYNAPEN, 27 Echothiophate Iodide, 21 Econazole, 39 ECONOPRED PLUS, 20 EDURANT, 29 EES, 28 Efavirenz, 29 Efavirenz/Emtricitabine/Tenofovir, 29 EFFEXOR, EFFEXOR XR, 25 EFUDEX, 38 ELAVIL, 25 ELDEPRYL, 26 Electrolytes, Oral Maintenance, 34 Elestat, 22 Eletriptan, 32 ELIDEL, 38 ELIMITE, 38 ELIQUIS, 19 ELLA, 13 ELMIRON, 16 ELOCON, 40 Elvitegravir/Cobicistat/Emtricitabine/Te nofovir, 29 EMADINE, 22 EMCYT, 9 Emedastine Difumarate, 22 EMEND, 14 EMPIRIN w/Codeine, 33 Emtricitabine, 29 Emtricitabine/Rilpivirine/Tenofovir, 29 Emtricitabine/Tenofovir, 30 EMTRIVA, 29 Enalapril, 16 Enfuvirtide, 29 Enoxaparin, 19 Entacapone, 26 Entecavir, 31 ENTRESTO, 17 ENUCLENE, 23 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST EPCLUSA, 30 Epinastine HCl, 22 EPIPEN, 20 EPIPEN JR, 20 EPIVIR, 30 EPIVIR HBV, 31 EPOGEN, 19 EPZICOM, 29 ESTROSTEP, 12 EQUETRO, 24 Ergocalciferol (Vitamin D), 34 Ergotamine/Belladonna/Phenobarb, 14 Ergotamine/caffeine, 32 Erlotinib, 9 ERYCETTE, 37 ERY-GEL, 37 ERY-TAB (Enteric Coated), 28 Eryth Es,Sulf Oral Susp, 28 ERYTHROCIN, 28 Erythromycin, 21, 37 Erythromycin Base, 28 Erythromycin Ethylsuccinate, 28 Erythromycin Stearate, 28 Erythromycin/Benzoyl peroxide, 37 Erythropoietin (Epoetin Alfa), 19 ESGIC, 33 ESGIC PLUS, 33 ESKALITH, 25 ESKALITH CR, 25 Esomeprazole, 14 Esterified Estrogens, 11 Esterified Estrogens/ Methyltestosterone, 13 ESTINYL, ESTRACE, 11, 12 Estradiol, 11, 12 Estradiol, transdermal, 12 Estradiol/Norethindrone, transdermal, 12 Estradiol/Norgestrel, 12 Estramustine, 9 ESTRATEST, 13 Estropipate, 12 Ethambutol, 28 Ethinyl Estradiol/Desogestrel, 12 Ethinyl Estradiol/Drospirenone, 12 Ethinyl Estradiol/Ethynodiol, 12 Ethinyl Estradiol/Etonogestrel, 13 Ethinyl Estradiol/Levonorgestrel, 12 Ethinyl Estradiol/Norelgestromin, 13 Ethinyl Estradiol/Norethindrone, 12 Ethinyl Estradiol/Norgestimate, 12 Ethinyl Estradiol/Norgestrel, 12 Ethionamide, 28 Ethosuximide, 24 Etidronate Disodium, 11 Etodolac, 31 ETOPOPHOS, 9 Etoposide, 9 Etravirine, 29 EURAX, 38 EVISTA, 11 EVOTAZ, 29 EVOXAC, 24 EXELDERM, 39 Exemestane, 9 Exenatide, 10 EXODERM, 39 EXSEL, 38 Famotidine, 14 FANSIDAR, 28 FARESTON, 9 Felbamate, 24 FELBATOL, 24 FELDENE, 31 Felodipine, 18 FEMARA, 9 Fenofibrate, 18 Fentanyl transdermal patch, 33 FEOSOL, 34 Ferrous Gluconate, 34 FERROUS GLUCONATE, 34 Ferrous Sulfate, 34 Fexofenadine, 35 Finasteride, 16 FIORICET, 33 FIORICET TABS, 33 FIORINAL TABS, 33 FIORINAL/CODEINE TABS, 33 FLAGYL, 28 FLAREX, 20 Flecainide, 17 FLEXERIL, 34 FLOMAX, 16 FLONASE, 23 FLORINEF, 10 FLOVENT DISKUS, 36 FLOVENT HFA, 36 FLOXIN, 23, 28 Fluconazole, 30 Flucytosine, 30 Fludrocortisone, 10 Flunisolide, 37 Flunisolide Nasal Soln 0.025%, 23 Fluocinolone Acetonide 0.01%, 40 Fluocinolone acetonide 0.025-0.01%, 40 Fluocinonide 0.01-0.05%, 39 Fluorometholone, 20 Fluorouracil, 38 Fluoxetine, 25 Fluphenazine Decanoate, Enanthate, 25 Fluphenazine Hydrochloride, 25 Flurazepam, 26 FLUR-OP, 20 Flutamide, 10 FLUTAMIDE, 10 Fluticasone Propionate, 36 Fluticasone propionate 0.05%, 40 Fluticasone Propionate Nasal Inhaler 50 Mcg/dose, 23 Fluticasone Propionate/Salmeterol Xinafoate, 37 Fluvastatin, 18 Fluvoxamine, 25 FML FORTE, 20 FML LIQUIFILM, 20 Folic Acid, 34 45 FOLIC ACID, 34 FORADIL, 37 Formoterol, 37 FOSAMAX, 11 Fosamprenavir, 30 FURADANTIN, 16 Furosemide, 19 FUZEON, 29 Gabapentin, 24 GABITRIL, 24 GANTRISIN, 28 GARAMYCIN, 38 Gefitinib, 9 Gemfibrozil, 18 GENERIC FORMULATIONS, 34 GENGRAF, 10 GENOPTIC, 21 GENOPTIC S.O.P., 21 Gentamicin, 21, 38 Gentamicin/Prednisolone, 21 GENTIAN VIOLET, 39 Gentian Violet 1%, 39 GEODON, 26 GIANVI, 12 GLEEVEC, 9 Glatiramer Acetate, 26 Glimepiride, 10 Glimepiride/Pioglitazone, 10 Glipizide, 10 GLUCOPHAGE, 11 GLUCOPHAGE XR, 11 GLUCOTROL, 10 Glyburide, 10 GLYCOLAX, 14 GLYSET, 11 Granisetron, 15 GRIFULVIN, 30 Griseofulvin, 30 GRISPEG, 30 Guaifenesin, 35 Guaifenesin/Dextromethorphan (Syrup), 36 Guaifenesin/Dextromethorphan (Tablet), 36 Guanfacine, 18 Guanidine, 26 GUANIDINE, 26 GYNE-LOTRIMIN, 31 GYNE-LOTRIMIN 3, 31 Haemophilus B Vaccine, 28 Halcinonide 0.025-0.1%, 39 HALCION, 27 HALDOL, 25 Halobetasol propionate 0.05%, 39 HALOG, 39 Haloperidol Decanoate, Lactate, 25 HCTZ/Triamterene, 19 Hepatitis A & B vaccine, 28 HEXALEN, 9 HIV agents, 29 Homatropine, 23 HPV vaccine, 28 HUMALOG, 11 HUMULIN 50/50, 11 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST HUMULIN 70/30, 11 HUMULIN N, 11 HUMULIN R, 11 HYCODAN, 36 Hydralazine, 19, 20 HYDREA, 9 Hydrochlorothiazide, 19 Hydrocodone/Chlorpheniramine, 36 Hydrocodone/Homatropine, 36 Hydrocortisone, 10, 15, 40 Hydrocortisone 0.5-2.5%, 40 Hydrocortisone Acetate Rectal, 15 Hydrocortisone Butyrate 0.1%, 40 Hydrocortisone Probutate 0.1%, 40 Hydrocortisone Retention Enema, 15 Hydrocortisone Valerate 0.2%, 40 HYDRODIURIL, 19 Hydromorphone, 33 Hydroxychlorquine, 32 Hydroxyurea, 9 Hydroxyzine, 35 Hydroxyzine HCL, 27 Hydroxyzine Pamoate, 27, 35 HYGROTON, 19 Hyoscyamine, 14 Hyoscyamine Sulfate CR, 14 HYTRIN, 16, 20 HYZAAR, 17 Ibuprofen, 31 Ibuprofen/hydrocodone, 33 ILOTYCIN OPHTH OINT, 21 Imatinib, 9 IMDUR, 19 IMDUR/ ISMO/ MONOKET, 19 Imipramine, 25 Imiquimod, 38 IMITREX, 32 IMODIUM, 14 IMURAN, 15 Indapamide, 19 INDERAL, 17 INDERAL LA, 17 INDERIDE, 17 Indinavir, 30 INDOCIN, 31 Indomethacin, 31 INFLAMASE FORTE, 20 Influenza vaccine, 28 INH, 28 Insulin, 11 INTAL, 37 INTELENCE, 29 Interferon Alfa-2B, 31 Interferon Beta-1A, 26 INTRON-A, 31 INVIRASE, 30 Iodoquinol, 28 IONIL T, 38 Ipratropium, 23 Ipratropium Bromide, 36 IRESSA, 9 ISENTRESS, 29 ISMO, 19 Isoniazid, 28 ISOPTIN SR, 18 ISOPTO CARPINE,, 21 ISOPTOATROPINE, 23 ISOPTO-CARBACHOL, 21 ISOPTOHOMATROPINE, 23 ISOPTOHYOSCINE, 23 ISORDIL, 19 Isosorbide Dinitrate, 19 Isosorbide Dinitrate SR, 19 Isosorbide Mononitrate, 19 Isotretinoin, 37 Isradipine, 18 Itraconazole, 30 Ivermectin, 38 JANUMET, 11 JANUVIA, 11 J-TAN PD, 35 JOLESSA, 12 KALETRA, 30 KCL, 34 KEFLEX, 27 KENALOG, 39, 40 KENALOG in ORABASE, 24 KEPPRA, 24 Ketoconazole (cream & shampoo), 39 Ketorolac, 31 Ketorolac OPHTH, 20 Ketotifen furmarate, 22 KLONOPIN, 24 KLONOPIN WAFERS, 24 K-PHOS, 34 KYTRIL, 15 Labetalol, 17 LAMICTAL, 24 LAMISIL, 30 Lamivudine, 30, 31 Lamivudine/Zidovudine, 30 Lamotrigine, 24 LANOXIN, 17 Lansoprazole, 14 LANTUS, 11 Lapatinib, 9 LARIAM, 28 LASIX, 19 Latanoprost, 21 Leflunomide, 32 Lenalidomide, 9 LESCOL, 18 Letrozole, 9 Leucovorin, 35 LEUKERAN, 9 Leuprolide, 13 Levalbuterol Nebulizer, 37 LEVAQUIN, 28 LEVEMIR, 11 Levetiracetam, 24 Levobunolol, 20 Levocetirizine, 35 Levocarnitine, 35 Levodopa, 26 LEVO-DROMORAN, 33 Levofloxacin, 28 Levonorgestrel, 13 46 Levorphanol, 33 Levothyroxine, 13 LEVSIN, 14 LEVSINEX, 14 LEXIVA, 30 LIBRAX, 13 LIBRIUM, 24 LIDEX, 39 Lidocaine (viscous), 23 Lidocaine cream, 33 Lidocaine ointment, 33 LIORESAL, 34 Liothyronine, 13 Liotrix, 13 LIPITOR, 18 Liraglutide, 11 Lisinopril, 16 Lisinopril/HCTZ, 16 LITHIUM, 25 Lithium Carbonate, 25 Lithium Carbonate Sustained Release, 25 Lithium Citrate, 25 LITHONATE, 25 LO OVRAL, 12 LOCOID, LOCOID LIPOCREAM, 40 LODINE, 31 LODINE XL, 31 Lodoxamide, 22 LODRANE, 35 LOESTRIN FE 1.5/30, 12 LOESTRIN FE 1/20, 12 LOFIBRA, 18 LOMOTIL, 14 Lomustine, 9 LONITEN, 18, 20 Loperamide (2 mg capsules), 14 LOPID, 18 Lopinavir/Ritonavir, 30 LOPRESSOR, 17 Loratadine, 35 Loratadine and pseudoephedrine, 35 Lorazepam, 24 Lorcaserin, 35 LORCET 650/10, 32 LORTAB 500/10, 33 LORTAB 500/5, 32 LORTAB 500/7.5, 32 LORTAB ELIXIR 167/2.5, 33 Losartan, 16 Losartan/HCTZ, 17 LOTENSIN, 16 LOTENSIN HCT, 16 LOTRIMIN AF, 39 LOTRISONE, 39 Lovastatin, 18 LOVAZA, 19 LOVENOX, 19 Loxapine, 25 LOXITANE, 25 LOZOL, 19 LUMIGAN, 21 LURIDE, 34 LUVOX, 25 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST LYBREL, 12 LYRICA, 24 LYSODREN, 10 Macitentan, 20 MACROBID, 16 MACRODANTIN, 16 Magnesium Citrate, 15 Magnesium Oxide 400mg tablet, 34 MAG-OX 400, 34 MALARONE, 28 Maraviroc, 29 MARINOL, 14 MATULANE, 9 MAXAIR AUTOHALER, 37 MAXALT, 32 MAXALT-MLT, 32 MAXITROL OINTMENT & SUSP, 21 MAXZIDE, 19 Meclizine, 15 MEDROL, 10 Medroxyprogesterone Acetate, 13 Mefloquine, 28 MELLARIL, 26 Meloxicam, 31 Melphalan, 9 MENEST, 11 Meningococcal vaccine, 28 Meperidine, 33 Mephenytoin, 24 MEPHYTON, 35 MEPRON, 30 Mercaptopurine (6M-P), 15 Mesalamine, 15 Mesalamine Supp, 15 Mesalamine, Enema, 15 MESANTOIN, 24 Mesna, 9 MESNEX, 9 MESTINON, 26 Mestranol/Norethindrone, 12 Metaproterenol, 37 Metformin, 11 Metformin ER, 11 METHADATE ER, 27 Methadone, 33 Methazolamide, 21 Methenamine/Methylene Blue Atropine, 16 METHERGINE, 13 Methimazole, 13 Methocarbamol, 34 Methotrexate, 32 METHOTREXATE, 32 Methsuximide, 24 Methyldopa, 18 Methylergonorine, 13 Methylphenidate, 27 Methylphenidate Extended Release, 27 Methylprednisolone, 10 Metipranolol, 20 Metoclopramide, 14 Metolazone, 19 Metoprolol, 17 Metoprolol ER, 17 METROGEL, 37 Metronidazole, 28, 31, 37 METRONIDAZOLE VAG CRM, VAG TABS, 31 Metyrosine, 9 MEVACOR, 18 MEXITIL, 17 Mexitiline, 17 MIACALCIN NASAL SPRAY, 11 MICARDIS, 16 MICARDIS HCT, 17 MICATIN, 39 Miconazole Cr, 2%, 39 Miconazole Nitrate, 31 MICRONOR, 12 MIDAMOR, 19 Miglitol, 11 Milnacipran Hydrochloride, 25 MINASTRIN, 12 MINIPRESS, 16, 20 MINOCIN, 28 Minocycline, 28 Minoxidil, 20 Minoxidil tablets, 18 MIRCETTE, 12 Mirtazapine, 25 Mirtazapine ODT, 25 Misoprostol, 14 Mitotane, 10 MMR vaccine, 28 MOBAN, 25 MOBIC, 31 Modafinil, 27 MODURETIC, 19 Molindone, 25 Mometasone furoate, 37, 40 Mometasone/formoterol, 36 MONISTAT-7, 31 MONISTAT-DERM, 39 MONOKET, 19 Montelukast Sodium, 37 Morphine soln., 33 Morphine SR, 33 Morphine suppositories, 33 MOTRIN, 31 Moxifloxacin, 28 MS CONCENTRATE, 33 MS CONTIN, 33 MSIR, 33 MTX, 32 MUCINEX (TABLET), 35 MUCOMYST, 37 Mupirocin, 38 MURO-128, 23 MUSE, 16 MYAMBUTOL, 28 MYCELEX TROCHE, 30 MYCIFARDIN, 30 MYCOBUTIN, 29 MYCOLOG II, 39 Mycophenolate mofetil, 10 Mycophenolic acid, 10 MYCOSTATIN, 30, 39 47 MYDRIACYL, 23 MYFORTIC, 10 MYLANTA, 15 MYLERAN, 9 MYSOLINE, 24 NA Thiosulfate 25%, 39 Nabumetone, 31 Nadolol, 17 NALOXONE, 34 Naloxone 1mg/ml Injector, 34 Naltrexone, 34 Naltrexone/bupropion ER, 35 Naphazoline HCl, 22 Naphazoline HCl and Pheniramine Maleate, 22 NAPHCON, 22 NAPHCON A, 22 NAPROSYN, 31 Naproxen, 31 Naratriptan, 32 NASACORT AQ, 23 NASACORT AQ (OTC), 23 NASAREL, 23 NATAZIA, 12 Nateglinide, 11 NATURE-THROID, 13 NAVANE, 26 Nedocromil Sodium, 37 Nedrocromil, 22 Needles & Syringes (Not including diabetic), 11 Nefazodone, 25 Nelfinavir, 30 Neo/Poly/Prednisolone, 22 NEO-FRADIN, 30 Neomy, Polym, Bac, 21 Neomy,Polym,HC Otic Susp, 23 Neomy,Polym,HC-Otic Soln, 23 Neomycin, 28, 30 NEOMYCIN, 28 Neomycin Sulfate, Polymyxin B Sulfate, Dexamethasone, 21 Neomycin Sulfate,Polymyxin B Sulfate,Hydrocortizone, 22 Neomycin Sulfate/Polymyxin B Sulfate/Bacitracin/ Hydrocortisone, 21 Neomycin Sulfate/Polymyxin B Sulfate/Gramicidin, 21 Neomycin Sulfate/Polymyxin B Sulfate/Prednisolone, 21 Neomycin Sultate, Polymyxin B Sulfate, Bacitracin, 21 NEORAL, 10 NEOSPORIN OPHTH OINT, 21 NEOSPORIN OPHTH SOLUTION, 21 Neostigmine, 26 NEPTAZANE, 21 NEURONTIN, 24 Nevirapine, 29 NEXAVAR, 9 NEXIUM, 14 NIACIN, 18 NIASPAN, 18 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST Nicardipine, 18 Nicardipine SR, 18 NICODERM, 26 Nicotine Transdermal, 26 Nicotinic Acid, 18 Nicotinic Acid SR, 18 NiFEDIAC CC, 18 NIFEDICAL XL, 18 Nifedipine, 18 Nifedipine SR, 18 NILANDRON, 10 Nilotinib, 9 Nilutamide, 10 NITRO-BID, 20 NITRO-DUR, 20 Nitrofurantoin, 16 Nitrofurantoin ER, 16 Nitrofurantoin Macrocrystals, 16 Nitroglycerin, 20 Nitroglycerin (ointment), 20 Nitroglycerin (patch), 20 Nitroglycerin SR, 20 NITROL, 20 NITROSTAT, 20 NIX, 38 NIZORAL, 39 NOLVADEX, 12 NORCO 325/10, 32 NORCO 325/5, 32 NORCO 325/7.5, 32 NOREDETTE, 12 Norethindro 1 mg, eth estradio 20 mg, 12 Norethindro 1.5 mg, eth estradio 30 mg, 12 Norethindrone, 12 Norethindrone Acetate, 13 Normal Saline Irrigation, 39 NORMODYNE, 17 NORPACE, NORPACE CR, 17 NORPRAMIN, 25 Nortriptyline, 25 NORVASC, 17 NORVIR, 30 NOVOLOG, 11 NUVARING, 12 Nystatin, 30, 31, 39 NYSTATIN, 31 OCUFLOX, 21 Ofloxacin, 28 Ofloxacin (OTIC), 23 Ofloxacin 0.3% drop, 21 OGEN, 12 Olanzapine, 26 Olmesartan, 16 Olmesartan/HCTZ, 17 Olopatadine, 22 Olopatadine HCl, 22 Olsalazine, 15 OLUX, 39 Omeprazole Magnesium, 14 Omeprazole OTC, 14 Omeprazole/Sodium Bicarbonate, 14 OMNICEF, 27 Ondansetron, 15 OPSUMIT, 20 OPTIPRANOLOL, 20 OPTIVAR, 22 ORAP, 26 ORAPRED, 10 ORASONE, 10 ORINASE, 11 Orlistat, 35 ORTHO CYCLEN, 12 ORTHO EVRA, 13 ORTHO NOVUM 10/11, 12 ORTHO NOVUM 7/7/7, 12 ORTHO TRI-CYCLEN, 12 ORTHONOVUM 1/35, 12 ORTHONOVUM 1/50, 12 Oseltamvir, 30 OTEZLA, 34 OVCON 35, 12 OVCON 50, 12 OVRAL, 12 Oxaprozin, 31 Oxazepam, 24 Oxcarbazepine, 24 Oxybutynin, 16 Oxycodone, 33 Oxycodone/acetaminophen, 33 Oxycodone/aspirin, 33 OXYCONTIN, 33 PAMELOR, 25 PANAFIL, 38 PANDEL, 40 Pantoprazole, 14 Papain/Urea, 38 Papain/Urea/Chlorophyllin Copper Complex, 38 PARAFON, 34 PARAFON FORTE, 34 PARLODEL, 26 Paroxetine, 25 PATADAY, 22 PATANOL, 22 PAXIL, 25 PAXIL CR, 25 PEDIALYTE, 34 PEDIAZOLE, 28 PEDIOTIC OTIC SUSP, 23 PEG Solution, 14, 15 PEGASYS, 31 PEG-INTRON, 31 Pegylated Interferon Alfa-2A, 31 Pegylated Interferon Alfa-2B, 31 Pemirolast, 23 Penicillamine, 32 Penicillin VK, 28 PENTASA, 15 Pentazocine, 33 Pentosan, 16 Pentoxifylline, 19 PEPCID, 14 PEPTO-BISMOL, 15 PERCOCET 5/325, 33 PERCODAN, 33 48 PERIACTIN, 35 PERIDEX, 23 Permethrin, 38 Perphenazine, 26 PERSANTINE, 19 Phenazopyridine, 16 PHENERGAN, 15, 35, 36 PHENERGAN DM, 36 PHENERGAN VC, 36 PHENERGAN VC w/ CODEINE, 36 PHENERGAN w/ CODEINE, 36 Phenobarbital, 24 PHENOBARBITAL, 24 Phenoxybenzamine, 9 Phentermine, 35 Phentermine/topiramate, 35 PHENYTEK, 24 Phenytoin, 24 PHOSLO, 35 PHOSPHOLINE IODIDE, 21 PILOCAR, 21 PILOCAR HS, 21 Pilocarpine 5mg tablet, 15 Pilocarpine HCl, 21 Pimecrolimus, 38 Pimozide, 26 PIN-X, 38 Pioglitazone, 11 Pioglitazone/Metformin, 11 Pirbuterol, 37 Piroxicam, 31 PLAN B, 13 PLAQUENIL, 32 PLAVIX, 19 PLENDIL, 18 PLETAL, 19 Pneumococcal vaccine, 28 Podofilox Gel, 38 Polyethylene Glycol 3350 oral powder, 14 Polymyxin B Sulfate/TMP, 22 POLY-PRED, 21, 22 POLYSPORIN, 38 POLYSPORIN OINTMENT, 21 POLYTRIM, 22 Potassium Acid Phosphate, 34 potassium chloride, 34 Potassium Iodide, 34 PRANDIN, 11 PRAVACHOL, 18 Pravastatin, 18 Prazosin, 16, 20 PRECOSE, 10 PRED FORTE, 20 PRED-G, 21 PRED-G SOP, 21 PRED-MILD, 20 Prednicarbate 0.1%, 40 Prednisolone, 10 PREDNISOLONE, 10 Prednisolone acetate, 20 Prednisolone sodium, 20 Prednisolone syrup, 10 Prednisone, 10 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST Pregabalin, 24 PRELONE, 10 PREMARIN VAG, 11 PREMPRO/PREMPHASE, 12 PRENATAL, 13 PRENATAL FORTE, 13 PRENATAL RX, 13 Prenatal Vitamins, 13 PRENAVITE, 13 PREVACID, 14 PREVACID 24HR OTC, 14 PREZCOBIX, 29 PREZISTA, 30 PRILOSEC, 14 PRIMAQUINE, 28 Primaquine Phosphate, 28 Primethamine/ Sufadoxine, 28 Primidone, 24 PRINCIPEN, 27 PRINIZIDE, 16 PRO-BANTHINE, 14 Probenecid, 13 Procainamide, 17 Procarbazine, 9 PROCARDIA, 18 PROCARDIA XL, 18 Prochlorperazine, 15 Progesterone, oral micronized, 13 PROGRAF, 10 PROLIXIN, 25 Promethazine, 15, 35, 36 Promethazine/ Dextromethorphan, 36 Promethazine/Codeine, 36 Promethazine/Phenylephrine, 36 Promethazine/Phenylephrine/ Codeine, 36 PROMETRIUM, 13 PRONESTYL, 17 PRONESTYL-SR, 17 Propafenone, 17 Propantheline, 14 PROPINE, 21 Proparacaine, 23 Propranolol, 17 Propranolol LA, 17 Propranolol/HCTZ, 17 Propylthiouracil, 13 PROSCAR, 16 PROSTIGMIN, 26 PROTONIX, 14 PROTOPIC, 39 Protriptyline, 25 PROVENTIL, VENTOLIN (SYRUP), 36 PROVERA, 13 PROVIGIL, 27 PROZAC, 25 Pseudoephedrine, 35 Pseudoephedrine with Guaifenesin, 35 PSORCON E, 39 PTU, 13 PULMICORT RESPULES, 36 PULMICORT TURBUHALER, 36 PURINETHOL, 15 Pyrantel Pamoate,Susp, 38 Pyrazinamide, 28 PYRAZINAMIDE, 28 Pyrethrins, Piperonyl Butoxide, Petroleum Distillate, 38 PYRIDIUM, 16 Pyridostigmine, 26 Pyridoxine, 34 Pyrimethamine, 28 PYRINYL II, 38 QSYMIA, 35 QUALAQUIN, 28 QUARTETTE, 12 QUESTRAN, 18 Quetiapine Fumarate, 26 QUINAGLUTE, 17 Quinidine Gluconate, 17 Quinidine Sulfate, 17 QUINIDINE SULFATE, 17 Quinine, 28 QVAR, 36 R & C, 38 Rabeprazole, 14 Rabies vaccine, 28 Raloxifene, 11 Raltegravir, 29 Rameltoeon, 27 Ranitidine, 14 RAPAMUNE, 10 REBETOL, 31 REESE'S PINWORM MEDICATION, 38 REGLAN, 14 REGRANEX, 38 RELAFEN, 31 RELENZA, 30 RELPAX, 32 REMERON, 25 REMERON SolTab, 25 RENVELA, 35 Repaglinide, 11 REQUIP, 26 RESCRIPTOR, 29 Reserpine, 18 RESTASIS, 23 RESTORIL, 27 RETIN-A, 37 RETIN-A MICRO, 37 RETROVIR, 30 REVIA, 34 REVLIMID, 9 REYATAZ, 30 Ribavirin, 31 RIDAURA, 32 Rif/INH, 28 Rif/INH/PZA, 28 Rifabutin, 29 RIFADIN, 29 RIFAMATE, 28 Rifampin, 29 RIFATER, 28 Rilpivirine, 29 Riluzole, 26 Risedronate, 11 RISPERDAL, 26 49 RISPERDAL M-TAB, 26 Risperidone, 26 RITALIN, 27 RITALIN LA, 27 RITALIN SR, 27 Ritonavir, 30 Rivaroxaban, 19 Rizatriptan, 32 RMS SUPPOSITORIES, 33 ROBAXIN, 34 ROBITUSSIN, 35 ROBITUSSIN AC, 36 ROBITUSSIN DM (SYRUP), 36 ROBITUSSIN DM (TABLET), 36 ROBITUSSIN MAXIMUM STRENGTH, 35 ROBITUSSIN PE, 35 ROBITUSSIN-CF, 36 ROCALTROL, 34 RONDEC, 35 RONDEC DM, 35 RONDEC, RONDEC DM, 35 Ropinirole, 26 ROWASA, 15 ROXICODONE, 33 ROZEREM, 27 Rufinamide, 24 RYTHMOL, 17 RYTHMOL SR, 17 Sacubitril/valsartan, 17 SAFYRAL, 12 SALACYLIC ACID, 38 SALAGEN, 15 Salicylic acid 6% lotion and cream, 38 Salmetrol, 37 Salsalate, 31 SANDIMMUNE, 10 SANTYL, 38 Saquinavir, 30 SAVELLA, 25 Scopolamine, 23 Scopolamine (Transderm-Scop), 15 SCOT-TUSSIN DM, 35 SEASONALE, 12 SECTRAL, 17 Selegiline, 26 Selenium sulfide 2.5%, 38 Selexipag, 20 SELSUN RX, 38 SELZENTRY, 29 SEPTRA DS, 28 SERAX, 24 SEREVENT DISKUS, 37 SEROQUEL, 26 SERPASIL, 18 Sertraline, 25 SERZONE, 25 Sevelamer, 35 Sildenafil, 16 SILVADENE, 38 Silver Sulfadiazine, 38 SIMCOR, 18 Simvastatin, 18 SINEMET, 26 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST SINEMET CR, 26 SINEQUAN, 25 SINGULAIR, 37 SINGULAIR CHEW, 37 Sirolimus, 10 Sitagliptin, 11 Sitagliptin/Metformin, 11 SLO-NIACIN, 18 SLO-PHYLLIN, 37 Sodium Chloride for Inhalation, 37 Sodium Chloride Ophthalmic, 23 Sodium Flouride (drops & tabs), 34 SODIUM SULAMYD, 21 Sofosbuvir, 30 SOMA, 34 SONATA, 27 Sorafenib, 9 SORBITOL, 14 Sorbitol 70% solution, 14 Sotalol, 17 Sotalol AF, 17 SPECTAZOLE, 39 Spermicidal Sponge/Film/Jelly/Gel, 12 SPIRIVA, 36 Spironolactone, 19 Spironolactone/HCTZ, 19 SPORANOX, 30 SPRYCEL, 9 SSKI, 34 ST. JOSEPH, 19 STARLIX, 11 Stavudine, 30 STELAZINE, 26 STRIBILD, 29 Succimer, 35 Sucralfate, 14 Sulconazole, 39 Sulfacetamide, 21 Sulfacetamide/Prednisolone (ointment), 22 Sulfadiazine, 28 SULFADIAZINE, 28 Sulfasalazine, 15 Sulfisoxazole, 28 Sulindac, 31 Sumatriptan, 32 SUMYCIN, 28 Sunitinib, 9 SUPRAX, 27 SUSTIVA, 29 SUTENT, 9 SYMBICORT, 36 SYMMETREL, 26 SYNALAR, 40 SYNTHROID, 13 TABLOID, 9 Tacrolimus, 10, 39 TAGAMET, 14 TALWIN, 33 TAMBOCOR, 17 TAMIFLU, 30 Tamoxifen, 12 Tamsulosin, 16 TANZEUM, 10 TAPAZOLE, 13 TARCEVA, 9 TASIGNA, 9 Tdap vaccine, 28 TEGRETOL, 24 TEGRETOL XR, 24 Telmisartan, 16 Telmisartan/HCTZ, 17 Temazepam, 27 TEMODAR, 9 TEMOVATE, 39 TEMOVATE E, 39 Temozolomide, 9 TENEX, 18 Tenofovir, 30 TENORMIN, 17 TERAZOL 3, 7, 31 Terazosin, 16, 20 Terbinafine, 30 Terbutaline, 37 Terconazole, 31 TESLAC, 9 Testolactone, 9 TESTOSTERONE (inj), 10 Testosterone Cypionate, 10 Testosterone Enanthate, 10 Tetanus diphtheria vaccine, 28 Tetracycline, 28 Thalidomide, 9 THALOMID, 9 THEO-DUR, 37 Theophyline SR Sprinkles, 37 Theophylline, 37 Theophylline Liquid, 37 Thioguanine, 9 Thioridazine, 26 Thiothixene, 26 THORAZINE, 25 Thyroid dessicated, 13 THYROLAR, 13 Tiagabine, 24 TIGAN, 15 TIKOSYN, 17 TILADE, 37 Timolol Hemihydrate, 20 Timolol Maleate, 20 TIMOPTIC, 20 TIMOPTIC XE, 20 TINACTIN, 39 Tiotropium Bromide, 36 Tipranavir, 30 TITRALAC, 34 TIVICAY, 29 Tizanidine, 34 TOBRADEX, 22 Tobramycin, 21 Tobramycin Sulfate/Dexamethasone, 22 TOBREX, 21 TOFRANIL, 25 TOFRANIL PM, 25 Tolazamide, 11 Tolbutamide, 11 TOLECTIN, 31 50 TOLINASE, 11 Tolmetin, 31 Tolnaftate, 39 Tolterodine, 16 TOPAMAX, 24 TOPICORT, 39 TOPICORT LP, 40 Topiramate, 24 TOPROL XL, 17 TORADOL, 31 Toremifene, 9 Torsemide, 19 Tramadol, 32 Tramadol/APAP, 32 TRANDATE, 17 TRANXENE SD, 24 TRANXENE T, 24 Travaprost, 21 TRAVATAN, 21 TRAVATAN Z, 21 Trazodone, 25 TRECATOR-SC, 28 TRENTAL, 19 Tretinoin, 37 Triamcinolone, 37 Triamcinolone 0.1% in Orabarol, 24 Triamcinolone Acetonide, 23 Triamcinolone acetonide 0.025-0.1%, 40 Triamcinolone acetonide 0.5%, 39 Triamcinolone Acetonide Nasal Inhal 55 Mcg/Act, 23 Triamcinolone/Nystatin, 39 Triazolam, 27 TRIDIONE, 24 Trifluoperazine, 26 Trifluridine, 21 Trihexiphenidyl, 26 TRILAFON, 26 TRILEPTAL, 24 TRI-LEVLEN, 12 TRI-NORINYL, 12 Trimethadione, 24 Trimethobenzamide, 15 Trimethoprim, 16 Trimethoprim/ Sulfamethoxazole, 28 TRIMOX, 27 TRIMPEX, 16 TRI-NORINYL, 12 Trioxsalen, 38 TRIPOHIST, 35 Triprolidine, 35 TRISORALEN, 38 TRIUMEQ, 29 TRI-VI-FLOR, 34 TRI-VI-SOL, 34 TRI-VI-SOL & Fe, 34 TRIZIVIR, 29 Tropicamide, 23 TRUETEST, 10 TRUETEST STRIPS, 10 TRUETRACK, 10 TRUETRACK STRIPS, 10 TRUSOPT, 20 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST TRUVADA, 30 TUSSIONEX, 36 TYKERB, 9 TYLENOL, 31 TYLENOL #2, #3, #4, …, 32 TYLENOL ELIXIR, 32 TYLOX 5/500, 33 Tyloxapol with Benzalkonium Chloride, 23 Typhoid Vaccine, 28 Ulipristal, 13 ULTRACET, 32 ULTRAM, 32 ULTRAVATE, 39 UNIPHYL, 37 UPTRAVI, 20 URECHOLINE, 16 URISED, 16 UROXATRAL, 16 VAG GEL, 30 Valacyclovir, 30 VALCYTE, 31 Valganciclovir, 31 VALISONE, 39 VALIUM, 24, 34 Valproic acid, 24 VALTREX, 30 VANCOCIN, 28 Vancomycin - oral, 28 VANSPAR, 24 VANTIN, 27 Varicella vaccine, 28 VASOTEC, 16 VAZOL, 35 VEETIDS, 28 Velivet, 12 Venlafaxine, 25 VENTOLIN HFA, 36 Verapamil, 18 Verapamil SR, 18 VERSICLEAR, 39 VIAGRA, 16 VIBRAMYCIN, 27 VICODIN 500/5, 32 VICODIN E.S. 750/7.5, 32 VICOPROFEN, 33 VICTOZA, 11 VIDEX EC, 29 VIDEX PEDIATRIC, 29 VIRACEPT, 30 VIRAMUNE, 29 VIREAD, 30 VIROPTIC, 21 VISCOUS XYLOCAINE, 23 VISTARIL, 27, 35 Vitamin A, D, C, & Fluoride, 34 Vitamin B-12, 34 VITAMIN B-6, 34 VITAMIN D, 34 Vitamin K, 35 Vitamins A, D, C, 34 Vitamins A, D, C with Iron, 34 VIVACTIL, 25 VIVELLE-DOT, 12 VIVOTIF BERNA, 28 VOLTAREN, 31 VOLTAREN 1% GEL, 38 Vorinostat, 9 VOSOL HC, 23 VOSPIRE ER, 36 WELLBUTRIN, 25 WELLBUTRIN SR, 25, 26 WELLBUTRIN XL, 25 WESTCORT, 40 XALATAN, 21 XANAX, 24 XARELTO, 19 XELODA, 9 XOPENEX, 37 XOPENEX HFA, 37 XYZAL, 35 YASMIN, 12 YODOXIN, 28 ZADITOR OTC, 22 Zafirlukast, 37 Zaleplon, 27 51 ZANAFLEX, 34 Zanamivir, 30 ZANTAC, 14 ZARONTIN, 24 ZAROXOLYN, 19 ZEGERID OTC, 14 ZENPEP, 14 ZERIT, 30 ZESTORETIC, 16 ZESTRIL, 16 ZIAC, 17 ZIAGEN, 29 Zidovudine, 30 Zileuton, 37 Ziprasidone, 26 ZITHROMAX, 27 ZOCOR, 18 ZOFRAN, 15 ZOLINZA, 9 Zolmitriptan, 32 ZOLOFT, 25 Zolpidem, 27 Zolpidem CR, 27 ZOMIG, 32 ZOMIG-ZMT, 32 ZONEGRAN, 24 Zonisamide, 24 ZOSTAVAX, 30 Zoster-vaccine, live attenuated, 30 ZOSTRIX, 38 ZOSTRIX-HP, 38 ZOVIRAX, 30 ZYFLOW CR, 37 ZYLOPRIM, 13 ZYMINE, 35 ZYMINE XR, 35 ZYPREXA, 26 ZYPREXA ZYDIS, 26 ZYRTEC, 35 ZYRTEC-D, 35 ZYVOX, 28
