SAN FRANCISCO HEALTH PLAN Medi-Cal Formulary
San Francisco Health Plan Medi-Cal FormularyAS OF November 2021SAN FRANCISCO HEALTH PLANMedi-CalFormularyAs of November 2021
San Francisco Health Plan Medi-Cal FormularyAS OF November 2021San Francisco Health Plan Medi-Cal FormularyThe San Francisco Health Plan (SFHP), with the direction from the Pharmacy and TherapeuticsCommittee (P&T), has developed a formulary to be used by members, clinicians, and pharmacists. TheP&T Committee is composed of the SFHP Chief Medical Officer, the SFHP Pharmacy Director, physiciansfrom various medical specialties and clinics, and community clinical pharmacists. The P&T meetsquarterly to review formulary changes based on quality of care considerations and soundpharmacoeconomic principles.The formulary is a list of drug products designed to reflect the most appropriate, high quality and costeffective drug therapies. The formulary is updated regularly and is subject to change without notice.The formulary requires the continuous support of all our providers and pharmacists. Please contact us at(415) 547-7818 x 7085 option 3 or medpharm@sfhp.org if you have any questions regarding theformulary. The SFHP formulary can be easily accessed online mulary/.Request for Addition or Deletion of a Drug to the FormularySFHP providers may request evaluation of drugs for addition to or deletion from the formulary bysubmitting the Formulary Modification Request Form available on our website /prior-authorization-requests/.Request for Non-Preferred MedicationsNon-preferred or non-formulary medications may be authorized when there is clinical justification fordoing so. Providers can submit a prior authorization (PA) request by:1. Fax: Download a Prior Authorization Request Form and fax to (855) 461-2778 for both standardand urgent requests. Urgent requests should be clearly labeled “URGENT” at the top of the priorauthorization request form.2. Phone: Pharmacy Benefits Manager (PBM) Magellan at (800) 424-4331 to submit a verbalrequest.The Prior Authorization Request Form can be accessed from our website /prior-authorization-requests/.Brand Medication PolicySFHP has a mandatory generic policy and requires generic substitution when an equivalent AB-ratedgeneric product is available. Dispensing of brand name medications when generic equivalent is availableis allowed only in certain cases:
San Francisco Health Plan Medi-Cal FormularyAS OF November 2021 Pharmacy bills brand medication as DAW 5 (i.e. billed as a generic product).Pharmacy bills brand medication as DAW 8 (i.e. generic formulation is not currently available).Pharmacy is dispensing one (1) of the following narrow therapeutic index drugs/classes: Dilantin(phenytoin), thyroid hormones, coumarin type anticoagulants.For all other brand name medication requests, prior authorization with documentation that two(2) generic medications from different manufacturers were tried and did not meet the medicalneeds of the member.All brand name medication prior authorization requests are reviewed by an SFHP pharmacist or MedicalDirector. In all other cases, a prior authorization (PA) request should be submitted using the instructionsabove.Medi-Cal Formulary ExclusionsThe following drugs classes are excluded from the SFHP Medi-Cal formulary and are covered by fee-forservice (FFS) Medi-Cal. TAR may need to be submitted to FFS Medi-Cal for certain medications. For moreinformation, refer to the “Capitiated/Noncapitated Drugs” section in the “MCP: Two-Plan Model”document available at Medi-Cal’s website (www.medi-cal.ca.gov). Anti-psychoticsAIDs/HIV drugs (except didanosine, zidovudine covered on SFHP Medi-Cal formulary)o Note: If a medication is carved out, it is carved out regardless of indications. Forexample, Viread (tenofovir) and Epivir (lamivudine) are carved out whether they areused for treatment of HIV or Hepatitis B.Alcohol, heroin detoxification and dependency treatment drugsMedications in the following categories are excluded from the SFHP Medi-Cal formulary: Erectile dysfunction drugs Fertility medications Medications for cosmetic uses (e.g. hydroquinone for hyperpigmentation of the skin)Day Supply PolicySFHP standard day supply policy is 30-day supply for most brand medications and 90 day supply forgeneric medications with some exceptions. Refills are allowed when 75% of the medication has beenused, except for opiate pain medications where refills are allowed when 90% of the medication hasbeen used.Exceptions to the 30-day supply policy for brand medications are as follows: Up to 100-day supply is allowed for test strips, lancets, insulin syringes and urine ketone testingstrips Up to 90-day supply is allowed for select medications used for treatment of chronic conditions.Examples include but are not limited to antidiabetic medications including insulin,
San Francisco Health Plan Medi-Cal FormularyAS OF November 2021anticonvulsants, anticoagulants, antidepressants, antihyperlipidemics, antihypertensives,inhaled steroids and contraceptives.Exceptions to the 90-day supply policy for generic medications are as follows: 30-day supply only is allowed for all opiate medications except tramadolFormulary RestrictionsStandard formulary restrictions applicable to SFHP formulary are medication quantity and agelimitations. All formulary restrictions are based on FDA approved indications, standards of practice andsafety and abuse potential considerations.Step Therapy (ST)Step Therapy (ST) medications will process at point of sale at the pharmacy if there are paid prescriptionclaims for preferred medications. If there are no paid prescription claims, a prior authorization (PA)request must be submitted for consideration of coverage. Visit our website mulary/ for detailed information on all active steptherapy rules.Therapeutic Interchange PolicyPer American College of Clinical Pharmacy (AACP), therapeutic interchange is defined as the dispensingof a drug that is therapeutically equivalent to but chemically different from the drug originallyprescribed by a physician or other authorized prescriber. SFHP follows ACCP’s definition of therapeuticinterchange and will only employ therapeutic interchange with prescriber’s approval. Criteria forconsideration in therapeutic interchange include availability of agents within a therapeutic class,therapeutic equivalence, safety data, and costs.Diabetic SuppliesThe following diabetic supplies are covered on SFHP formulary as a pharmacy benefit: Glucometers: ACCU-CHEK Guide, 1 glucometer per 365 days Test strips: ACCU-CHEK Guide, ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus teststrips with the following quantity limits:o 400 per 100 days for all memberso 800 per 100 days for members with gestational diabetes Lancets: ACCU-CHEK FastClix, Multiclix, SoftClix lancets, 100-day supplyRespiratory SuppliesThe following respiratory supplies are covered as a pharmacy benefit for a quantity of 2 per 365 days: Inhalers and inhaler assist devices Nebulizers Peak flow meters
San Francisco Health Plan Medi-Cal FormularyAS OF November 2021Home Blood Pressure MonitorsOmron Series 3, 5, 7, and 10 home blood pressure monitors are covered as a pharmacy benefit for aquantity of 1 monitor per member every 5 years.VaccinesCertain vaccines are covered as a pharmacy benefit for Medi-Cal members over the age of 18. Pleasevisit SFHP website at lary/ for a detailed list ofcovered vaccines.Children 18 years of age or younger are eligible for vaccinations through the California Vaccines forChildren (VFC) Program. Please contact VFC at 1-877-243-8832 for more information.Formulary Document DetailsThe SFHP formulary document is listed by drug class and includes the following information: drug name,dosage form, drug tier, quantity and age limit and prior authorization or step therapyrequirements. Brand products are listed in all uppercase letters and generic products are listed in alllowercase letters. Tier 1 drugs are formulary preferred and will pay at point of sale if quantity and agelimits are met (see “Formulary Restrictions” above). Tier 2 drugs require a Prior Authorization (see“Request for Non-Preferred Medications” above) or Step Therapy (see “Step Therapy (ST)” above).**Some medications may be listed as both Tier 1 and Tier 2 due to a particular strength being formularyand another strength of the same medication requiring a prior authorization.If you are hearing impaired, please call the TDD/TYY line at 1(415) 547-7830,toll-free at 1(888) 883-7347 or through the California Relay Service at 711. Youmay request this document in alternative formats like Braille, large size print, andaudio. To request other formats, or for help with reading this document and otherSFHP materials, please call Customer Service at 1(415) 547-7800 or toll-free at1(800) 288-5555.
LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTIONTIERLIMITS & RESTRICTIONSALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTSERGOMARphenoxybenzamine hcl23CCPASELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENTalfuzosin hcl er1tamsulosin hcl1ANALGESICS AND ANTIPYRETICSANALGESICS AND ANTIPYRETICS, MISC.butalb-acetamin-caff 50-325-403CCPAOPIATE AGONISTSacetaminop-codeine 120-12 mg/5acetaminophen-codeine (#2 tablet, #3 tablet, #4 tablet)codeine sulfatePAGE 1111QLCC12 / dayALAt least 12 yrsoldQLCC4 / dayALAt least 12 yrsoldQLCC4 / dayALAt least 12 yrsoldLAST UPDATED 11/2021
PRODUCT taminophen (2.5-325, 5-325 mg, 7.5325, 10-325 mg)hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mgtablet)morphine sulfate (10 mg/5 ml soln, 20 mg/5 ml soln, 100mg/5 ml conc)morphine sulfate (ir 15 mg tab, ir 30 mg tab)morphine sulfate er (er 10 mg cap, er 20 mg cap, er 30 mgcap, er 40 mg cap, er 50 mg cap, er 60 mg cap, er 80 mgcap, er 100 mg cap)morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er60 mg tablet, er 100 mg tablet, er 200 mg tablet)PAGE 2TIERLIMITS & RESTRICTIONS3CCPA1QLCC3CCPA4 / day1QLCC4 / day1QLCC12 / day1QLCC4 / day1QLCC3CCPA1QLCC4 / day3 / dayLAST UPDATED 11/2021
PRODUCT DESCRIPTIONoxycodone hcl (5 mg/5 ml soln, 100 mg/5 ml conc)oxycodone hcl (5 mg tablet, 10 mg tab, 15 mg tab, 20 mgtab, 30 mg tab)oxycodone hcl eroxycodone-acetaminophen (oxycodone-acetaminophen 5325, oxycodone-acetaminophen 10-325, oxycodoneacetaminophn 2.5-325, oxycodone-acetaminophn 7.5325)OXYCONTINtramadol hcl 50 mg tablettramadol hcl-acetaminophenPAGE 3TIERLIMITS & RESTRICTIONS12 / day1QLCC4 / day1QLCC3CCPA1QLCC3CCPA114 / dayQLCC8 / dayALAt least 18 yrsoldQLCC4 / dayALAt least 18 yrsoldLAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERLIMITS & RESTRICTIONSANOREXIGENIC AGENTSAMPHETAMINE DERIVATIVESADIPEX-P (37.5 MG CAPSULE, 37.5 MG TABLET)phentermine hcl (15 mg capsule, 30 mg capsule, 37.5 mgcapsule, 37.5 mg tablet)3CCPA3CCPA3CCPAANOREXIGENIC AGENTS, MISCELLANEOUSCONTRAVESELECTIVE SEROTONIN RECEPTOR AGONISTSBELVIQ XR3PAANOREXIGENICS;RESPIRATORY,CNS STIMULANTSAMPHETAMINESdextroamphetamine 10 mg tab1QLCC120 / 30 DAYSALAt least 5 yrsoldPAdextroamphetamine 5 mg tab1QLCC60 / 30 DAYSALAt least 5 yrsoldPAPAGE 4LAST UPDATED 11/2021
PRODUCT DESCRIPTIONdextroamphetamine sulfate erTIER1LIMITS & RESTRICTIONSQLCC60 / 30 DAYSALAt least 5 yrsoldPAdextroamphetamine-amphet er1QLCC60 / 30 DAYSALAt least 5 yrsoldPAdextroamphetamine-amphetamine1QLCC60 / 30 DAYSALAt least 5 yrsoldPAZENZEDI 10 MG TABLET1QLCC120 / 30 DAYSALAt least 5 yrsoldPAZENZEDI 5 MG TABLET1QLCC60 / 30 DAYSALAt least 5 yrsoldPAPAGE 5LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERLIMITS & RESTRICTIONSRESPIRATORY AND CNS STIMULANTSdexmethylphenidate hcl1QLCC60 / 30 DAYSALAt least 5 yrsoldPAdexmethylphenidate hcl erMETADATE ER11QLCC60 / 30 DAYSALAt least 5 yrsoldQLCC90 / 30 DAYSALAt least 5 yrsoldPAmethylphenidate er (er 10 mg tab, er 18 mg tab, er 27 mgtab, er 36 mg tab, er 54 mg tab)1QLCC60 / 30 DAYSALAt least 5 yrsoldPAmethylphenidate er 20 mg tab1QLCC90 / 30 DAYSALAt least 5 yrsoldPAPAGE 6LAST UPDATED 11/2021
PRODUCT DESCRIPTIONmethylphenidate 10 mg/5 ml solmethylphenidate 5 mg/5 ml solnmethylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mgtablet)TIER111LIMITS & RESTRICTIONSQLCCAL900 / 30 DAYSQLCCAL300 / 30 DAYSQLCC90 / 30 DAYSALAt least 5 yrsoldUp to 12 yrs oldUp to 12 yrs oldPAmethylphenidate hcl cd1QLCC60 / 30 DAYSALAt least 5 yrsoldPAmethylphenidate hcl er (cd)1QLCC60 / 30 DAYSALAt least 5 yrsoldPAmethylphenidate la1QLCC60 / 30 DAYSALAt least 5 yrsoldPAPAGE 7LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERLIMITS & RESTRICTIONSWAKEFULNESS-PROMOTING A3CCPA3CCPAANTI-INFECTIVE AGENTSANTHELMINTICSalbendazole1ivermectin 3 mg tablet1praziquantel1QL6 / 365 DAYSQL30 / 365 DAYSQL15 / 365 DAYSALUp to 12 yrs oldURINARY ANTI-INFECTIVESmethenamine hippurate1nitrofurantoin (25 mg cap, 50 mg cap, 100 mg cap)1nitrofurantoin 25 mg/5 ml susp1PAGE 8LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERnitrofurantoin mono-macro1trimethoprim1LIMITS & RESTRICTIONSANTI-INFECTIVES (EENT)ANTIBACTERIALS (EENT)AK-POLY-BAC1bacitracin 500 unit/gm ophth1bacitracin-polymyxin1BLEPHAMIDE3BLEPHAMIDE S.O.P.3ciprofloxacin 0.3% eye drop1ciprofloxacin-dexamethasone1doxycycline hyclate 20 mg tab1erythromycin 0.5% eye ointment1GENTAK1gentamicin 0.3% eye drop1NEO-POLYCIN1NEO-POLYCIN -polymyxin1neomycin-polymyxin-dexameth (neomyc-polym-dexametointm, neomyc-polym-dexameth drop)1PAGE 9STSTQL7.5 / 30 DAYSQL60 / 30 DAYSLAST UPDATED 11/2021
PRODUCT xacin (ear drops, eye drops)1POLYCIN1polymyxin b sul-trimethoprim1sulfacetamide sodium (drops, ointment)1sulfacetamide-prednisolone1TOBRADEX EYE OINTMENT3tobramycin 0.3% eye drop1tobramycin-dexamethasone1LIMITS & RESTRICTIONSSTANTIFUNGALS (EENT)NATACYN2ANTIVIRALS (EENT)trifluridine1ZIRGAN2EENT ANTI-INFECTIVES, MISCELLANEOUSacetic acid 2% ear solution1chlorhexidine gluconate1hydrocortisone-acetic acid1PAROEX1PERIOGARD1PAGE 10LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERLIMITS & RESTRICTIONSANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)CENTANY2CLINDACIN P1clindamycin phosphate (ph 1% gel, ph 1% solution, phos1% pledget, phosp 1% lotion, 2% vaginal cream)1erythromycin (gel, solution)1metronidazole (cream, topical gl)1metronidazole (top gel pump, topical gel)3metronidazole vaginal 0.75% gl1metronidazole 0.75% lotion1mupirocin 2% ointment1ROSADAN (CREAM, GEL)1VANDAZOLE1QL45 / 30 DAYSQLST60 / 30 DAYSQL59 / 30 DAYSQL45 / 30 DAYSANTIVIRALS (SKIN AND MUCOUS MEMBRANE)acyclovir (cream, ointment)DENAVIRPAGE 113CCPA3CCPALAST UPDATED 11/2021
PRODUCT DESCRIPTIONZOVIRAX (CREAM, OINTMENT)TIER3LIMITS & RESTRICTIONSCCPALOCAL ANTI-INFECTIVES, MISCELLANEOUSselenium sulfide 2.5% lotion1silver sulfadiazine1SSD1SCABICIDES AND spinosad3CCCCPAANTI-INFLAMMATORY AGENTS (EENT)CORTICOSTEROIDS (EENT)dexamethasone 0.1% eye dropdifluprednatePAGE 1213QLST5 / 30 daysLAST UPDATED 11/2021
PRODUCT DESCRIPTIONFLAC OTIC OILTIER1fluocinolone acetonide oil1fluorometholone1fluticasone prop 50 mcg spray1PRED MILD3prednisolone ac 1% eye drop1prednisolone sod 1% eye drop1triamcinolone 55 mcg nasal spr1LIMITS & RESTRICTIONSQLCLimit 3 fills peryearQLCLimit 3 fills peryearQL16 / 30 daysSTQL16.9 / 30 daysEENT ANTI-INFLAMMATORY AGENTS, MISC.RESTASISRESTASIS MULTIDOSEXIIDRA3CCPA3CCPA3CCPAEENT NONSTEROIDAL ANTI-INFLAM. AGENTSdiclofenac 0.1% eye dropsPAGE 131CCLAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERflurbiprofen sodium1ketorolac tromethamine (0.4% solution, 0.5% solution)1LIMITS & RESTRICTIONSANTI-INFLAMMATORY AGENTS (RESPIRATORY)INTERLEUKIN ANTAGONISTSDUPIXENT 200 MG/1.14 ML PENDUPIXENT 100 MG/0.67 ML SYRINGDUPIXENT 200 MG/1.14 ML SYRING444CCSPACCPACCSPALEUKOTRIENE MODIFIERSmontelukast sod 4 mg granules1montelukast sodium (4 mg tab chew, 5 mg tab chew, 10mg tablet)1ALUp to 2 yrs oldMAST-CELL STABILIZERScromolyn sodium (4% eye drops, 20 mg/2 ml neb soln, 100mg/5 ml oral conc)PAGE 141LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERLIMITS & RESTRICTIONSANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)ALA-CORT1ANUCORT-HC1ANUSOL-HC 25 MG SUPPOSITORY1betamethasone diprop augmented (crm, gel, lot, oin)1betamethasone dipropionate (crm, lot)1betamethasone dp 0.05% oint1betamethasone valerate (va cream, va lotion, valer ointm)1clobetasol propionate (cream, gel, ointment)1clobetasol 0.05% shampoo1clobetasol 0.05% solution1CLODAN 0.05% SHAMPOO1desoximetasone 0.25% cream1fluocinolone 0.025% cream1PAGE 15QL240 / 30 DAYSQL120 / 30 DAYSQL240 / 30 DAYSQL120 / 30 DAYSQL240 / 30 DAYSQL120 / 30 DAYSQL118 / 30 DAYSQL100 / 30 DAYSQL118 / 30 DAYSQL120 / 30 DAYSQL240 / 30 DAYSLAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERfluocinolone acetonide (body oil, scalp oil)1fluocinolone 0.01% solution1fluocinonide (cream, gel, ointment, solution)1fluticasone prop 0.05% cream1halobetasol propionate (cream, ointmnt)1HEMMOREX-HC 25 MG SUPPOSITORY1hydrocortisone 2.5% cream1hydrocortisone 100 mg/60 ml1hydrocortisone (1% cream, 1% ointment, 2.5% lotion,2.5% ointment)1hydrocortisone ac 25 mg supp1mometasone furoate 0.1% cream1mometasone furoate (oint, soln)1ORALONE1PROCTO-MED HC1PROCTOCORT 1% CREAM1PAGE 16LIMITS & RESTRICTIONSQL119 / 30 DAYSQL180 / 30 DAYSQL240 / 30 DAYSQL240 / 30 DAYSQL120 / 30 DAYSQL60 / 30 DAYSQL240 / 30 DAYSQL60 / 30 DAYSQL240 / 30 DAYSQL60 / 30 DAYSLAST UPDATED 11/2021
PRODUCT NE-HC1triamcinolone 0.05% ointment1triamcinolone acetonide (0.025% cream, 0.025% lotion,0.025% oint, 0.1% lotion, 0.5% cream, 0.5% ointment)1triamcinolone acetonide (cream, ointment)1triamcinolone 0.1% paste1TRIDERM 0.1% CREAM1TRIDERM 0.5% CREAM1LIMITS & RESTRICTIONSQL60 / 30 DAYSQL60 / 30 DAYSCCQL240 / 30 DAYSQL454 / 30 DAYSQL454 / 30 DAYSQL240 / 30 DAYSANTIARRHYTHMIC AGENTSCLASS IA ANTIARRHYTHMICSdisopyramide phosphate1NORPACE CR2quinidine gluconate1CLASS IB ANTIARRHYTHMICSmexiletine hclPAGE 171LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERLIMITS & RESTRICTIONSCLASS IC ANTIARRHYTHMICSflecainide acetate1propafenone hcl1CLASS III ANTIARRHYTHMICSamiodarone hcl (100 mg tablet, 200 mg tablet, 400 mgtablet)1dofetilide1MULTAQ2PACERONE (200 MG TABLET, 400 MG TABLET)1ANTIBACTERIALSAMINOGLYCOSIDE ANTIBIOTICSneomycin sulfateTOBItobramycin 300 mg/5 ml ampule144CCSPACCSPAQUINOLONE ANTIBIOTICSciprofloxacin1ciprofloxacin hcl (100 mg tab, 250 mg tab, 500 mg tab,750 mg tab)1PAGE 18ALUp to 12 yrs oldLAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERlevofloxacin 25 mg/ml solution1levofloxacin (250 mg tablet, 500 mg tablet, 750 mgtablet)1moxifloxacin hcl3LIMITS & RESTRICTIONSALUp to 12 yrs oldCCPASULFONAMIDE ANTIBIOTICS (SYSTEMIC)sulfadiazine1sulfamethoxazole-tmp susp1sulfamethoxazole-trimethoprim (ds tablet, ss tablet)1sulfasalazine1sulfasalazine dr1SULFATRIM1ALUp to 12 yrs oldQL60 / 30 DAYSQL60 / 30 DAYSQL60 / 30 DAYSQL60 / 30 daysQL60 / 30 DAYSTETRACYCLINE ANTIBIOTICSAVIDOXY1doxycycline hyclate (50 mg cap, 100 mg cap, 100 mg tab)1doxycycline monohydrate (50 mg cap, 100 mg cap, 100mg tablet)1LYMEPAK1minocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule)1PAGE 19LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERMONDOXYNE NL 100 MG CAPSULE1MORGIDOX 100 MG CAPSULE1tetracycline hcl1LIMITS & RESTRICTIONSQL60 / 30 DAYSQL60 / 30 DAYSQL120 / 30 DAYSALUp to 12 yrs oldALUp to 12 yrs oldALUp to 12 yrs oldALUp to 12 yrs oldQLCCST90 / 30 DAYSANTIBACTERIALS, MISCELLANEOUSGLYCOPEPTIDE ANTIBIOTICSFIRVANQ2vancomycin hcl (125 mg capsule, 250 mg capsule)1vancomycin 250 mg/5 ml soln1LINCOMYCIN ANTIBIOTICSclindamycin (pediatric)1clindamycin hcl1OXAZOLIDINONE ANTIBIOTICSlinezolid 100 mg/5 ml susp1linezolid 600 mg tablet1RIFAMYCIN ANTIBIOTICSXIFAXAN 200 MG TABLETPAGE 203LAST UPDATED 11/2021
PRODUCT DESCRIPTIONXIFAXAN 550 MG TABLETTIER3LIMITS & RESTRICTIONSQLCCST60 / 30 DAYSQL25.8 / 30 DAYSQL10.7 / 30 daysQL4 / 20 DAYSQL30 / 30 DAYSQL312.5 / 30DAYSQL570 / 30 DAYSANTICHOLINERGIC AGENTSANTIMUSCARINICS/ANTISPASMODICSATROVENT HFA2BEVESPI AEROSPHERE2chlordiazepoxide-clidinium1COMBIVENT RESPIMAT2dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mgtablet)1glycopyrrolate (1 mg tablet, 2 mg tablet)1hyoscyamine sulfate (0.125 mg tab sl, sulf 0.125 mg tab)1hyoscyamine sulfate er1hyoscyamine sulfate sr1INCRUSE ELLIPTA2ipratropium br 0.02% soln1ipratropium-albuterol1PAGE 21LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIEROSCIMIN1OSCIMIN SL1OSCIMIN SR1SPIRIVA RESPIMAT2STIOLTO RESPIMAT2SYMAX-SL1SYMAX-SR1LIMITS & RESTRICTIONSQL4 / 30 DAYSQL4 / 30 DAYSQL74 / 30 DAYSQL60 / 30 DAYSQL30 / 30 DAYSQL51 / 30 DAYSQL30 / 30 DAYSANTICOAGULANTSCOUMARIN DERIVATIVESJANTOVEN1warfarin sodium1DIRECT FACTOR XA INHIBITORSELIQUIS DVT-PE TREAT START 5MG2ELIQUIS (2.5 MG TABLET, 5 MG TABLET)2SAVAYSA2XARELTO DVT-PE TREAT START 30D2XARELTO (10 MG TABLET, 20 MG TABLET)2PAGE 22LAST UPDATED 11/2021
PRODUCT DESCRIPTIONXARELTO (2.5 MG TABLET, 15 MG TABLET)TIER2LIMITS & RESTRICTIONSQL60 / 30 DAYSDIRECT THROMBIN INHIBITORSPRADAXA3CCPAHEPARINSenoxaparin 40 mg/0.4 ml syr1enoxaparin 60 mg/0.6 ml syr1enoxaparin sodium (100 mg/ml syringe, 150 mg/mlsyringe)1enoxaparin sodium (80 mg/0.8 ml syr, 120 mg/0.8 ml syr)1enoxaparin sodium (30 mg/0.3 ml syr, 300 mg/3 ml vial)1heparin sodium (sod 10,000 unit/ml vl, sod 20,000 unit/mlvl, 40,000 unit/4 ml vial, 50,000 unit/5 ml vial)1heparin sodium in 0.45% nacl1heparin-12,500 unit/250-1/2 ns1QL24 / 30 DAYSQL36 / 30 DAYSQL60 / 30 DAYSQL48 / 30 DAYSQL18 / 30 DAYSANTICONVULSANTSANTICONVULSANTS, MISCELLANEOUSAPTIOM2BRIVIACT (10 MG TABLET, 25 MG TABLET, 50 MG TABLET,75 MG TABLET, 100 MG TABLET)2PAGE 23LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERcarbamazepine (100 mg tab chew, 100 mg/5 ml susp)1carbamazepine 200 mg tablet1carbamazepine er (er 100 mg cap, er 100 mg tablet, er200 mg cap, er 200 mg tablet, er 300 mg cap, er 400 mgtablet)1divalproex sodium (dr 125 mg cap sprnk, dr 125 mgcp(sprnk), sod dr 125 mg tab, sod dr 250 mg tab, sod dr500 mg tab)1divalproex sodium er1EPITOL1felbamate (400 mg tablet, 600 mg tablet)1FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8MG TABLET, 10 MG TABLET, 12 MG TABLET)2gabapentin 250 mg/5 ml soln1gabapentin (100 mg capsule, 300 mg capsule, 400 mgcapsule, 600 mg tablet, 800 mg tablet)1lamotrigine (25 mg tablet, 100 mg tablet, 150 mg tablet,200 mg tablet)1lamotrigine (5 mg disper tablet, 25 mg disper tab)1levetiracetam (100 mg/ml soln, 1000 mg/10 ml)1levetiracetam (250 mg tablet, 500 mg tablet, 750 mgtablet, 1,000 mg tablet)1levetiracetam er1oxcarbazepine 300 mg/5 ml susp1PAGE 24LIMITS & RESTRICTIONSALUp to 16 yrs oldALUp to 16 yrs oldALUp to 16 yrs oldALUp to 16 yrs oldALUp to 16 yrs oldLAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERoxcarbazepine (150 mg tablet, 300 mg tablet, 600 mgtablet)1pregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule,100 mg capsule, 150 mg capsule, 200 mg capsule, 225 mgcapsule, 300 mg capsule)1ROWEEPRA1ROWEEPRA XR1rufinamide (200 mg tablet, 400 mg tablet)1SUBVENITE1topiramate (15 mg sprinkle cap, 25 mg sprinkle cap, 25mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)1valproic acid 250 mg capsule1valproic acid 250 mg/5 ml soln1vigabatrin 500 mg tablet4VIMPAT 10 MG/ML SOLUTION2VIMPAT (50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET, 200 MG/20 ML VIAL)2zonisamide1LIMITS & RESTRICTIONSQL2 / DAYALUp to 16 yrs oldSPAALUp to 16 yrs oldALUp to 16 yrs oldBARBITURATES (ANTICONVULSANTS)primidone1BENZODIAZEPINES (ANTICONVULSANTS)clobazam 2.5 mg/ml suspensionPAGE 251LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERclobazam (10 mg tablet, 20 mg tablet)1clonazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet)1clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mgodt, 0.5 mg dis tablet, 0.5 mg odt, 1 mg dis tablet, 1 mgodt, 2 mg odt)1NAYZILAM2LIMITS & RESTRICTIONSQL60 / 30 DAYSQLAL90 / 30 DAYSUp to 12 yrs oldQL3 / 365 DAYSALUp to 16 yrs oldALUp to 16 yrs oldHYDANTOINSDILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MGCAPSULE)2DILANTIN-1252PHENYTEK2phenytoin (50 mg infatab, 50 mg tablet chew, 125 mg/5ml susp)1phenytoin sodium extended1SUCCINIMIDESCELONTIN2ethosuximide 250 mg capsule1ethosuximide 250 mg/5 ml soln1ANTIDEPRESSANTSANTIDEPRESSANTS, MISCELLANEOUSbupropion hcl1bupropion hcl sr1PAGE 26LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERbupropion xl (150 mg tablet, 300 mg tablet)1mirtazapine (7.5 mg tablet, 15 mg odt, 15 mg tablet, 30mg odt, 30 mg tablet, 45 mg odt, 45 mg tablet)1LIMITS & RESTRICTIONSSEL.SEROTONIN,NOREPI REUPTAKE INHIBITORdesvenlafaxine succinate er1duloxetine hcl1venlafaxine hcl1venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er 150mg cap)1CCSELECTIVE-SEROTONIN REUPTAKE INHIBITORScitalopram hbr (10 mg tablet, 20 mg tablet, 20 mg/10 mlsol, 40 mg tablet)1citalopram hbr 10 mg/5 ml soln1escitalopram oxalate 5 mg/5 ml1escitalopram oxalate (5 mg tablet, 10 mg tablet, 20 mgtablet)1fluoxetine hcl (10 mg capsule, 20 mg capsule, 40 mgcapsule)1fluoxetine 20 mg/5 ml solution1fluoxetine hcl (10 mg tablet, 20 mg tablet, 60 mg tablet)1fluvoxamine maleate1paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet,40 mg tablet)1PAGE 27ALUp to 12 yrs oldALUp to 12 yrs oldALUp to 12 yrs oldLAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERsertraline 20 mg/ml oral conc1sertraline hcl (25 mg tablet, 50 mg tablet, 100 mg tablet)1LIMITS & RESTRICTIONSALUp to 12 yrs oldSEROTONIN MODULATORStrazodone hcl1TRICYCLICS, OTHER NOREPI-RU INHIBITORSamitriptyline hcl1desipramine hcl1doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mgcapsule, 50 mg capsule, 75 mg capsule, 100 mg capsule,150 mg capsule)1imipramine hcl1nortriptyline hcl (10 mg cap, 25 mg cap, 50 mg cap, 75 mgcap)1ANTIDIABETIC AGENTSALPHA-GLUCOSIDASE INHIBITORSacarbose1BIGUANIDESmetformin hcl (500 mg tablet, 850 mg tablet, 1,000 mgtablet)1metformin hcl er1DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSalogliptinPAGE 283CCSTLAST UPDATED 11/2021
PRODUCT zoneTIERLIMITS & RESTRICTIONS3CCST3CCSTINCRETIN MIMETICSOZEMPIC (0.25-0.5 MG/DOSE PEN, 1 MG/DOSE (2MG/1.5ML))OZEMPIC 1 MG/DOSE (4 MG/3 ML)RYBELSUSSAXENDAVICTOZA 2-PAKVICTOZA 3-PAKPAGE 29333333QLCCST9 / 84 DAYSQLCCST9 / 84 daysQLCCST90 / 90 daysCCPAQLCCST27 / 90 DAYSQLCCST27 / 90 DAYSLAST UPDATED 11/2021
PRODUCT DESCRIPTIONWEGOVYTIER3LIMITS & e1SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBINVOKAMETINVOKAMET XRINVOKANAJARDIANCESYNJARDYSYNJARDY XRPAGE 303CCST3CCST3CCST3CCST3CCST3CCSTLAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERLIMITS & pizide er1glipizide in hcl1THIAZOLIDINEDIONESpioglitazone hcl1ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS3CCPAondansetron 4 mg/5 ml solution3CCPAondansetron hcl 4 mg tablet1ondansetron hcl 8 mg tablet1ondansetron odt 4 mg tablet1granisetron hcl 1 mg tabletPAGE 31QL180 / 30 DAYSQL90 / 30 DAYSQL180 / 30 DAYSLAST UPDATED 11/2021
PRODUCT DESCRIPTIONondansetron odt 8 mg tabletTIER1LIMITS & RESTRICTIONSQL90 / 30 DAYSANTIEMETICS, -SCOP3CCPA3CCPA3CCPA3CCPAANTIHISTAMINES (GI DRUGS)COMPAZINE 25 MG SUPPOSITORY1COMPRO1meclizine hcl1prochlorperazine1prochlorperazine maleate1NEUROKININ-1 RECEPTOR ANTAGONISTSAKYNZEO 300-0.5 MG CAPSULEPAGE 323CCPALAST UPDATED 11/2021
PRODUCT DESCRIPTIONaprepitant (40 mg capsule, 80 mg capsule, 125 mgcapsule, 125-80-80 mg pack)EMEND (80 MG CAPSULE, 125 MG POWDER PACKET,TRIPACK)TIERLIMITS & RESTRICTIONS3CCPA3CCPAANTIFUNGAL (SYSTEMIC)ALLYLAMINE ANTIFUNGALSterbinafine hcl1QL180 / 365 DAYSANTIFUNGALS, MISCELLANEOUSgriseofulvin (125 mg/5 ml susp, micro 500 mg tab)1griseofulvin ultramicrosize1AZOLE ANTIFUNGALSfluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet,100 mg tablet, 150 mg tablet, 200 mg tablet)1itraconazole 100 mg capsule3ketoconazole 200 mg tablet1ONMELSPORANOX 100 MG CAPSULEPAGE 33CCPA3CCPA3CCPALAST UPDATED 11/2021
PRODUCT DESCRIPTIONVFEND (40 MG/ML SUSPENSION, 50 MG TABLET, 200 MGTABLET)voriconazole (40 mg/ml susp, 50 mg tablet, 200 mgtablet)TIERLIMITS & RESTRICTIONS3CCPA3CCPAPOLYENE ANTIFUNGALSnystatin (100,000 unit/ml susp, 500,000 unit oral tab,500,000 unit/5 ml sus)1ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)AZOLES (SKIN AND MUCOUS MEMBRANE)clotrimazole 1% topical cream1clotrimazole (1% solution, 10 mg troche)1clotrimazole-betamethasone crm1econazole nitrate1ketoconazole (cream, shampoo)1miconazole 31terconazole (0.4% cream, 0.8% cream)1QL180 / 30 DAYSQL180 / 30 DAYSQL340 / 30 DAYSQL90 / 30 DAYSQL6.6 / 30 DAYSLimit 12 fillsper lifetimeHYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)CICLODAN 0.77% CREAMCICLODAN 8% SOLUTIONPAGE 3411QLCLAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERciclopirox 0.77% cream1ciclopirox 8% solution1LIMITS & RESTRICTIONSQL90 / 30 DAYSQL0.22 / dayQL1280 / 30 DAYSQL120 / 30 DAYSQL1280 / 30 DAYSQL480 / 30 DAYSQL1280 / 30 DAYSPOLYENES (SKIN AND MUCOUS MEMBRANE)NYAMYC1nystatin (unit/gm cream, unit/gm oint)1nystatin 100,000 unit/gm powd1nystatin-triamcinolone (cream, ointm)1NYSTOP1ANTIGLAUCOMA AGENTSALPHA-ADRENERGIC AGONISTS (EENT)ALPHAGAN P 0.1% DROPS2brimonidine tartrate1COMBIGAN2BETA-ADRENERGIC BLOCKING AGENTS (EENT)betaxolol hcl 0.5% eye drop1levobunolol hcl1timolol maleate (0.25% drop, 0.5% drops)1PAGE 35LAST UPDATED 11/2021
PRODUCT DESCRIPTIONTIERLIMITS & RESTRICTIONSCARBONIC ANHYDRASE INHIBITORS (EENT)acetazolamide1acetazolamide er1dorzolamide hcl1dorzolamide-timolol eye drops1methazolamide 25 mg tablet1MIOTICSpilocarpine hcl (1% drops, 2% drops, 4% drops)1PROSTAGLANDIN ANALOGSbimatoprost 0.03% eye drops1latanoprost 0.005% eye drops1ALAt least 21 yrsoldQL30 / 30 day
Glucometers: ACCU-CHEK Nano SmartView, ACCU-CHEK Aviva Plus, Accu-Chek Designer Care Kit, 1 glucometer per 365 days Test strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with the following quantity limits: o 400 per 100 days for all members
info@medi.hu www.medi.hu medi Medical Support Sdn Bhd medi representative office Asia Unit No. B-2-19, Block B, No.2, Jalan PJU 1A/7A Oasis Ara Damansara, PJU 1A, 47301 PETALING JAYA Darul Ehsan Malaysia T: 6 03 7832 3591 F: 6 03 78323921 info@medi-asia.com www.medi-asia.com medi Middle East P. O. Box: 109307 Abu Dhabi United Arab Emirates
San Francisco Public Works Making San Francisco a beautiful, livable, vibrant, and sustainable city. City and County of San Francisco San Francisco Public Works INFRASTRUCTURE DIVISION Project Management & Construction 30 Van Ness, 5th Avenue San Francisco, Ca 94102 (415) 554-4045 www.SFPublicWorks.org Mark Farrell, Mayor
Technical Data (updated May2019) V26. Medi-Shower Tel: 44 2033 569 769 info@medi-shower.co.uk www.medi-shower.co.uk. Technical Data Sheet. Description. Medi-Shower's unique design is coupled with an antimicrobial additive. The Medi-Shower system is designed and manufactured in the UK. 100% dry air test is carried out prior to shipping.
info@medi.hu www.medi.hu medi Nederland BV Heusing 5 4817 ZB Breda The Netherlands T 31-76 57 22 555 F 31-76 57 22 565 info@medi.nl www.medi.nl medi Orient M.E.A. ZZC TAURUS GROUP Suite No. M01 Wasel Al Mamzar Bldg. Al Wuhida Road, Al Mamzar P.O.BOX NO. 91464 DUBAI, UAE United Arab Emirates T: 971-4 2557344 F: 971- 4 2557399 md@taurusgroup.net
Directorio de Proveedores y Servicios Medi-Cal Network 661.716.7270 Toll Free: 800.918.7302 Contracted with Health Net Medi-Cal Plan Contratado con el Plan de Health Net Medi-Cal . Aceptando pacientes mayores de 5 Ned Devasia, MD (m) 661.327.3747 5801 Truxtun Ave Bakersfield, CA 93309 BC: Internal Medicine LS: Spanish. 4 Medi-Cal Jae Kim, MD .
ford Chang (San Francisco), Dr. Daniel Beltran (San Fran-cisco), Dr. Keith Gualderama (Urban Eyes, San Francisco), . San Francisco), Carolyn Chu (Dr. Michael Chew, Daly City and San Rafael), Irina Volkova (Dr. Joanne Yee, San Francisco) PVI Top 5 dinners held on March 8th at Gary Danko’s on June 28th, at Asia de Cuba, and on September 16th .
55 11-13 Crisis Referral Not Medi-Cal Eligible 55 14-16 MHS Contract Admin. Not Medi-Cal Eligible 55 17-19 Discounted MH Outreach Not Medi-Cal Eligible 55 21-23 SPMP Case Management Not Medi-Cal Eligible 55 24-26 SPMP Program Planning Not Medi-Cal Eligible 55
Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) Medi-Cal Point of Service (POS) Network/Internet Agreement Note: These forms can be downloaded from the Forms page on the Medi-Cal Provider website (www.medi-cal.ca.gov). When the provider or submitter has approval for electronic submission, then a .
