Drugs: Contract Drugs List Part 1 – Prescription Drugs (A .

drugs cdl p1a11Page updated: November 2020AllopurinolDosage FormStrength and/or SizeBilling UnitTablets 100 mgeachTablets 300 mgeachAlogliptin ** ‹‹Alogliptin is›› restricted to NDC labeler code 64764 (Takeda Pharmaceuticals America,Inc.) only.Dosage FormStrength and/or SizeBilling UnitTablets6.25 mgeachTablets12.5 mgeachTablets25 mgeachAlogliptin/Metformin HCl ** ‹‹Alogliptin/Metformin HCl is›› restricted to NDC labeler code 64764 (TakedaPharmaceuticals America, Inc.) only.Dosage FormStrength and/or SizeBilling UnitTablets12.5 mg/500 mgeachTablets12.5 mg/1000 mgeachPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a12Page updated: November 2020Alogliptin/Pioglitazone ** ‹‹Alogliptin/Pioglitazone is›› restricted to NDC labeler code 64764 (TakedaPharmaceuticals America, Inc.) only.Dosage FormStrength and/or SizeBilling UnitTablets12.5 mg/15 mgeachTablets12.5 mg/30 mgeachTablets12.5 mg/45 mgeachTablets25 mg/15 mgeachTablets25 mg/30 mgeachTablets25 mg/45 mgeachAlpelisib ‡ ** ‹‹The following text is effective July 1, 2019: Alpelisib is›› restricted to use in the treatmentof cancer only. Also restricted to NDC labeler code 00078 (Novartis PharmaceuticalsCorporation) only.‹‹The text in the following table is›› effective July 1, 2019:Dosage FormStrength and/or SizeBilling UnitTablets50 mgeachTablets150 mgeachTablets200 mgeachAltretamine ‡ ** ‹‹Altretamine is›› restricted to use in the treatment of cancer only.Dosage FormCapsulesStrength and/or SizeBilling Unit50 mgeachPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a13Page updated: November 2020Amantadine ** ‹‹Amantadine›› use in beneficiaries less than 2 years of age requires treatmentauthorization approval.Dosage FormStrength and/or SizeBilling Unit100 mgeach50 mg/5 mlmilliliterStrength and/or SizeBilling UnitInjection, vial50 mg/mlmilliliterInjection, vial250 mg/mlmilliliterStrength and/or SizeBilling UnitInjection250 mg, 10 mlmilliliterInjection500 mg, 20 mlmilliliterSuppository0.25 gmeachSuppository0.5 gmeachTablets 100 mgeachTablets 200 mgeach105 mg/5 mlmilliliterCapsules LiquidAmikacin SulfateDosage FormAminophyllineDosage FormLiquidPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a14Page updated: July 2021AmiodaroneDosage FormTabletsStrength and/or SizeBilling Unit200 mgeachAmitriptyline ** Use of Amitriptyline in beneficiaries less than 12 years of age requires treatmentauthorization approval.Dosage FormStrength and/or SizeBilling Unit10 mg/mlmilliliterTablets10 mgeachTablets25 mg, 1000seachTablets50 mgeachTablets75 mgeachTablets100 mgeachTablets150 mgeachStrength and/or SizeBilling UnitTablets10 mg/2 mgeachTablets10 mg/4 mgeachTablets25 mg/2 mg, 500seachTablets25 mg/4 mgeachInjectionAmitriptyline HCl/PerphenazineDosage Form‹‹Amivantamab-vmjw ‡ ** Amivantamab-vmjw is added effective August 1, 2021, and restricted to use in thetreatment of cancer only. Also restricted to NDC labeler code 57894 only.Dosage FormInjectionStrength and/or SizeBilling Unit350 mg/ 7 mlmilliliter››Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a15Page updated: July 2021Amlodipine BesylateDosage FormStrength and/or SizeBilling UnitTablets 2.5 mgeachTablets 5 mgeachTablets 10 mgeachAmlodipine Besylate/Atorvastatin Calcium ** Amlodipine Besylate/Atorvastatin Calcium is restricted to claims with dates of service fromDecember 1, 2007, through October 31, 2016. Continuing care with a date of service on orafter November 1, 2016, is available when the following conditions are met: 1) Thebeneficiary had a paid fee-for-service claim for this drug on or before October 31, 2016;2) A claim has been submitted and paid within the past 100 days; and 3) The claim beingsubmitted is within 100 days of the date of service of the last paid claim.Dosage FormStrength and/or SizeBilling UnitTablets 2.5 mg – 10 mgeachTablets 2.5 mg – 20 mgeachTablets 2.5 mg – 40 mgeachTablets 5 mg – 10 mgeachTablets 5 mg – 20 mgeachTablets 5 mg – 40 mgeachTablets 5 mg – 80 mgeachTablets 10 mg – 10 mgeachTablets 10 mg – 20 mgeachTablets 10 mg – 40 mgeachTablets 10 mg – 80 mgeachPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a16Page updated: August 2021Amlodipine Besylate/Benazepril HydrochlorideDosage FormStrength and/or SizeBilling UnitCapsules 2.5 mg – 10 mgeachCapsules 5 mg – 10 mgeachCapsules 5 mg – 20 mgeachCapsules 10 mg – 20 mgeachCapsules 5 mg – 40 mgeachCapsules 10 mg – 40 mgeachAmlodipine/Telmisartan ** Amlodipine/Telmisartan is restricted to NDC labeler code 00597 (Boehringer IngelheimPharmaceuticals, Inc.) and to claims with dates of service from June 1, 2010, throughMay 31, 2013, only.Dosage FormStrength and/or SizeBilling UnitTablets5 mg/40 mgeachTablets5 mg/80 mgeachTablets10 mg/40 mgeachTablets10 mg/80 mgeachStrength and/or SizeBilling UnitTablets5 mg/160 mgeachTablets10 mg/160 mgeachTablets5 mg/320 mgeachTablets10 mg/320 mgeachAmlodipine/ValsartanDosage Form‹‹The following text is removed effective October 1, 2021: Amlodipine/Valsartan isrestricted to NDC labeler code 00078 (Novartis Pharmaceuticals Corporation) only.End of removed text.››Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a17Page updated: August 2021Amlodipine/Valsartan/HydrochlorothiazideDosage FormStrength and/or SizeBilling UnitTablets5 mg/160 mg/12.5 mgeachTablets10 mg/160 mg/12.5 mgeachTablets5 mg/160 mg/25 mgeachTablets10 mg/160 mg/25 mgeachTablets10 mg/320 mg/25 mgeach‹‹The following text is removed effective October 1, 2021,Amlodipine/Valsartan/Hydrochlorothiazide is restricted to NDC labeler code 00078(Novartis Pharmaceuticals Corporation) only. End of removed text.››Amoxicillin/Clavulanate Potassium *Dosage FormStrength and/or SizeBilling UnitTablets, chewable *125 mgeachTablets, chewable *200 mgeachTablets, chewable *250 mgeachTablets, chewable *400 mgeach* The chewable tablets are restricted to a maximum dispensing quantity of thirty (30) tabletsand a maximum of two (2) dispensings in any 30-day period.Dosage FormStrength and/or SizeBilling UnitTablets, oral *250 mgeachTablets, oral *500 mgeach* Restricted to a maximum dispensing quantity of thirty (30) tablets and a maximum oftwo (2) dispensings in any 30-day period for the 250 mg and 500 mg oral tablets only.Dosage FormStrength and/or SizeBilling UnitTablets, oral *875 mgeach* Restricted to a maximum dispensing quantity of twenty (20) tablets and a maximum oftwo (2) dispensings in any 30-day period for the 875 mg oral tablets only.Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a18Page updated: August 2021Amoxicillin/Clavulanate Potassium (continued) *Dosage FormStrength and/or SizeBilling UnitTablets, oral *1 gmeach* Restricted to a maximum dispensing quantity of forty (40) tablets and a maximum of two(2) dispensings in any 30-day period for the 1 gm oral tablets only.Dosage FormStrength and/or SizeBilling UnitSolution or suspension *125 mg/5 mlmilliliterSolution or suspension *200 mg/5 mlmilliliterSolution or suspension *250 mg/5 mlmilliliterSolution or suspension *400 mg/5 mlmilliliterThe solution or suspension is restricted to a maximum of two (2) dispensings in any 30-dayperiod.Amoxicillin TrihydrateThe 200 mg/5 ml solution or suspension, 400 mg/5 ml solution or suspension, and 125 mgchewable tablets are added to the following table effective April 1, 2020.Dosage FormStrength and/or SizeBilling UnitSolution or suspension125 mg/5 mlmilliliterSolution or suspension200 mg/5 mlmilliliterSolution or suspension250 mg/5 mlmilliliterSolution or suspension400 mg/5 mlmilliliter50 mg/mlmilliliterCapsules250 mgeachCapsules500 mgeachChewable tablets125 mgeachChewable tablets250 mgeachPediatric dropsPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a19Page updated: November 2020Amphetamine, Mixed Salts (Amphetamine Sulfate, AmphetamineAspartate Monohydrate, Dextroamphetamine Sulfate andDextroamphetamine Saccharate) ** ‹‹Amphetamine, Mixed Salts are›› restricted to use in Attention Deficit Disorder inindividuals from 6 through 17 years of age only.‹‹Dosage FormStrength and/or SizeBilling UnitTablets5 mgeachTablets7.5 mgeachTablets10 mgeachTablets12.5 mgeachTablets15 mgeachTablets20 mgeachTablets30 mgeachCapsules, extended release5 mgeachCapsules, extended release10 mgeachCapsules, extended release15 mgeachCapsules, extended release20 mgeachCapsules, extended release25 mgeachCapsules, extended release30 mgeach‹‹The following text is removed›› effective April 1, 2020: Restricted to NDC labeler code54092 (Shire US, Inc.) for extended release capsules only. ‹‹Removed text ends here.››Amphotericin BDosage FormStrength and/or SizeBilling n ‡‹‹blank››eachNote: Cream, Ointment, and Lotion products are no longer manufactured or available.Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a20Page updated: November 2020AmpicillinDosage FormStrength and/or SizeBilling UnitPowder for injection125 mg/vialeachPowder for injection250 mg/vialeachPowder for injection500 mg/vialeachPowder for injection1 gm/vialeachPowder for injection2 gm/vialeachPowder for injection2.5 gm/vialeachPowder for injection10 gm/vialeachPowder for injection500 mg, piggybackeachPowder for injection1 gm, piggybackeachPowder for injection2 gm, piggybackeachTablets or capsules250 mg, 500s ˠeachTablets or capsules500 mgeachSolution or suspension125 mg/5 ml, 100 mlmilliliterSolution or suspension125 mg/5 ml, 150 mlmilliliterSolution or suspension125 mg/5 ml, 200 mlmilliliterSolution or suspension250 mg/5 ml, 100 mlmilliliterSolution or suspension250 mg /5 ml, 150 mlmilliliterSolution or suspension250 mg /5 ml, 200 mlmilliliter100 mg/ml, 20 mlmilliliterDropsPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a21Page updated: November 2020Amprenavir ‡ ** ‹‹Amprenavir is›› restricted to use as combination therapy in the treatment of HumanImmunodeficiency Virus (HIV) infection.Dosage FormStrength and/or SizeBilling UnitCapsules50 mgeachCapsules150 mgeach15 mg/mlmilliliterOral solutionNote: These products are no longer manufactured or available.Anastrozole ‡* ‹‹Anastrozole is›› restricted to use in the treatment of cancer only.Dosage FormStrength and/or SizeBilling Unit‹‹Blank››eachStrength and/or SizeBilling UnitCapsules0.5 mgeachCapsules1.0 mgeachTabletsAnagrelide HClDosage FormAntipyrine and Benzocaine ** ‹‹Antipyrine and Benzocaine are›› restricted to claims submitted with dates of servicethrough November 30, 2015, only.Dosage FormOtic dropsStrength and/or SizeBilling Unit‹‹Blank››milliliterPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a22Page updated: June 2021Apalutamide ‡ ** Apalutamide is restricted to use in the treatment of cancer only. Also restricted to NDClabeler code 59676 (Janssen Products, L.P.) only.Dosage FormStrength and/or SizeBilling Unit60 mgeachTabletsApixaban ** Effective April 1, 2020: Apixaban is restricted to NDC labeler code 00003 (E.R. Squibb &Sons, LLC.) only.The text in the table below is effective April 1, 2020.Dosage FormStrength and/or SizeBilling UnitTablets2.5 mgeachTablets5 mgeachStarter Pack Tablets5 mgeachStrength and/or SizeBilling UnitOphthalmic solution0.5 %, 5 mlmilliliterOphthalmic solution0.5 %, 10 mlmilliliterApraclonidineDosage Form‹‹Apremilast ** The following text is effective July 1, 2021. Apremilast is restricted to the treatmentof adult patients with psoriatic arthritis, plaque psoriasis or oral ulcers associatedwith Behçet's Disease. Also restricted to NDC labeler code 55513 only.Dosage FormTabletStrength and/or SizeBilling Unit30 mgeach››Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a23Page updated: September 2021AprepitantDosage FormStrength and/or SizeBilling UnitCapsules * 80 mgeachCapsules * 125 mgeach‹‹1 x 125 mg and2 x 80 mg››eachCapsules ‹‹(tri-fold pack)›› * * The 80 mg and 125 mg capsules are restricted to use in cancer patients and to a maximumof either 1) one tri-fold pack per dispensing, or 2) one 125 milligrams capsule and/or two80 milligrams capsules per dispensing. Effective July 1, 2019.Dosage FormCapsules * Strength and/or SizeBilling Unit40 mgeach* The 40 mg capsules are restricted to use for the prevention of postoperative nausea andvomiting and limited to a maximum of one capsule per dispensing, not to exceed onedispensing in any 30-day period.‹‹The following text is removed effective November 1, 2021: * Aprepitant is restrictedto NDC labeler code 00006 (Merck & Co., Inc.) only. End of removed text.››Aripiprazole ** Aripiprazole is restricted to: 1) The use of antipsychotics for Medi-Cal beneficiaries lessthan 18 years of age requires treatment authorization approval; 2) The use of antipsychoticsfor Medi-Cal beneficiaries residing in nursing facilities is restricted to FDA approvedindications.Dosage FormStrength and/or SizeBilling UnitTablets2 mgeachTablets5 mgeachTablets10 mgeachTablets15 mgeachTablets20 mgeachTablets30 mgeachTablets, orally disintegrating10 mgeachTablets, orally disintegrating15 mgeach1 mg/mlmilliliterOral solutionPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a24Page updated: August 2021Arsenic Trioxide ‡ ** The following text is effective July 1, 2019: Arsenic Trioxide is restricted to use in thetreatment of cancer only and to claims submitted with a date of service on or afterJuly 1, 2016, and to NDC labeler code 63459 (Cephalon, Inc.) only.The 12 mg/6 ml injection in the table below is effective July 1, 2019.Dosage FormStrength and/or SizeBilling UnitInjection1 mg/mlmilliliterInjection12 mg/6 mlmilliliterAsenapine ** Effective April 1, 2021: 1) The use of antipsychotics for Medi-Cal beneficiaries less than18 years of age requires a prior authorization; 2) Restricted to labeler code 00456 (ForestLaboratories, Inc.).Dosage FormStrength and/or SizeBilling UnitSublingual Tablets2.5 mgeachSublingual Tablets5 mgeachSublingual Tablets10 mgeachAsparaginase ‡ ** Asparaginase is restricted to claims submitted with dates of service through June 12, 2014,only.Dosage FormPowder for injectionStrength and/or SizeBilling Unit10,000 IU/vialeach‹‹Asparaginase Erwinia Chrysanthemi (Recombinant)-rywn ‡ ** Effective September 1, 2021, Asparaginase Erwinia Chrysanthemi(Recombinant)-rywn is restricted to use in the treatment of cancer only. Priorauthorization required.Dosage FormInjectionStrength and/or SizeBilling Unit10 mg/ 0.5mleach››Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a25Page updated: November 2020Aspirin ** ‹‹Aspirin is›› restricted to use for arthritis.Dosage FormStrength and/or SizeBilling UnitTablets or capsules, long acting 800 mgeachTablets or capsules, enteric-coated 975 mgeachAspirin/Extended-Release Dipyridamole ** ‹‹Aspirin/Extended-Release Dipyridamole is›› restricted to use in individuals who have hadtransient ischemia of the brain and have failed on aspirin therapy, or completed ischemicstroke due to thrombosis.‹‹The following text is removed›› effective October 1, 2020: Restricted to NDC labeler code00597 (Boehringer Ingelheim Pharmaceuticals, Inc.) ‹‹Removed text ends here.››Dosage FormCapsulesStrength and/or SizeBilling Unit25 mg/200 mgeachAtazanavir/Cobicistat ‡ ** ‹‹Atazanavir/Cobicistat is›› restricted to use as combination therapy in the treatment ofHuman Immunodeficiency Virus (HIV) infection only. Also restricted to NDC labeler code00003 (E. R. Squibb & Sons, Inc.) only.Dosage FormTabletsStrength and/or SizeBilling Unit300 mg/150 mgeachPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a26Page updated: November 2020Atazanavir Sulfate ‡ ** ‹‹Atazanavir Sulfate is›› is restricted to use as combination therapy in the treatment ofHuman Immunodeficiency Virus (HIV) infection. Also restricted to NDC labeler code 00003(E. R. Squibb & Sons, Inc.) only.Dosage FormStrength and/or SizeBilling UnitCapsules100 mgeachCapsules150 mgeachCapsules200 mgeachCapsules300 mgeach50 mg/packeteachStrength and/or SizeBilling UnitTablets 25 mgeachTablets 50 mgeachTablets 100 mgeachOral powderAtenololDosage FormAtezolizumab ‡ ** ‹‹Atezolizumab is›› restricted to use in the treatment of cancer only. Also restricted to NDCLabeler code 50242 (Genentech USA, Inc.) only.Dosage FormStrength and/or SizeBilling UnitInjection1200 mg/20 mlmilliliterInjection840 mg/14 mlmilliliterPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a27Page updated: November 2020Atomoxetine HCl ** ‹‹The following text is effective August 1, 2020: Use of Atomoxetine HCl›› in beneficiariesless than 6 years of age or greater than 16 years of age requires a treatment authorizationapproval.‹‹The text in the following table is›› effective August 1, 2020.Dosage FormStrength and/or SizeBilling UnitCapsules10 mgeachCapsules18 mgeachCapsules25 mgeachCapsules40 mgeachCapsules60 mgeachCapsules80 mgeachCapsules100 mgeachStrength and/or SizeBilling UnitTablets 10 mgeachTablets 20 mgeachTablets 40 mgeachTablets 80 mgeachAtorvastatin CalciumDosage FormAtovaquone ‡ ** ‹‹Atovaquone is›› restricted to use for the treatment or prevention of Pneumocystis cariniipneumonia in patients who are intolerant to trimethoprim-sulfamethoxazole.Dosage FormTabletsOral suspensionStrength and/or SizeBilling Unit250 mgeach750 mg/5 mlmilliliterPart 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a28Page updated: November 2020AtropineDosage FormStrength and/or SizeBilling Unit‹‹blank››milliliterOphthalmic ointment1/2%, 4 gmgramOphthalmic ointment1%, 4 gmgramOphthalmic solution1/2%, 5 mlmilliliterOphthalmic solution1%, 5 mlmilliliterOphthalmic solution1%, 15 mlmilliliterOphthalmic solution2%milliliterOphthalmic solution3%milliliterOphthalmic solution4%milliliterStrength and/or SizeBilling Unit3 mgeachStrength and/or SizeBilling osage FormCapsules AurothioglucoseDosage FormInjectionNote: This product is no longer manufactured or available.Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D)

drugs cdl p1a29Page updated: July 2021Avapritinib ‡ ** Avapritinib is restricted to use in the treatment of cancer only. Also restricted to NDClabeler code 72064 (Blueprint Medicines Corporation) only. ‹‹Effective August 1, 2021,

NDC labeler code 47335 (Sun Pharmaceutical Industries, Inc.) only. drugs cdl p1a 3 Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D) Page u