Medi-Cal Carve-Out Medication List

The drugs shown below are contractually carved-out to the Department of Health Care Services (DHCS). This means that these medications are covered by the Medi-Cal Fee-for-Service (FFS) program and are billed to State Medi-Cal by the pharmacy and are not reimbursable by Partnership Healthplan (PHC).

There are four (4) classes of medication that are carved out: 1. Certain alcohol and heroin detoxification and dependency treatment drugs to help treat substance abuse (e.g., Suboxone, Narcan, Naltrexone, Antabuse) 2. Certain psychotherapeutic drugs (e.g., Abilify®, Risperdal®). 3. Human Immunodeficiency Virus (HIV) and AIDS treatment and prevention 4. Blood factor products used for treatment of Hemophilia.

Note that carve-out status is assigned to specific drugs by DHCS, regardless of reasons or diagnosis for use.

Please note that this list is frequently updated by Medi-Cal with additions and deletions of drugs.

If you have questions regarding the content of this notice, please contact Member Services at (800) 863-4155 Monday through Friday, 8:00am – 5:00pm.

DETOX/DEPENDENCY Carve-Out Drugs Acamprosate (Campral) Buprenorphine HCl Buprenorphine extended release injection (Sublocade) Buprenorphine HCL (Belbuca) Buprenorphine/Naloxone HCL Buprenorphine implant (Probuphine) Disulfiram (Antabuse) Lofexidine HCl (Lucemyra) Naloxone HCl Naltrexone oral Naltrexone Microsphere injectable suspension (Vivitrol) Lofexidine Hydrochloride (Lucemyra)

Managed Care Medi-Cal Carve-Out Drugs July 2020 *Pending carve out

Medi-Cal Carve-Out Medication List

PSYCHIATRIC Carve-Out Drugs Amantadine HCL (Symmetrel) Molindone HCl (Moban) Amantadine HCl ER (Zyprexa, Zyprexa (Abilify) Olanzapine/Fluoxetine HCl (Symbyax) (Aristada) Olanzapine Pamoate Monohyd. (Zyprexa Relprew) Asenapine (Saphris) Paliperidone (Invega) Asenapine (Secuado)* Paliperidone (Invega Sustenna) Benztropine Mesylate (Cogentin) Paliperidone Palmitate (Invega Trinza) Brexpiprazole (Rexulti) (Trilafon) Cariprazine (Vraylar) Phenelzine Sulfate (Nardil) Chlorpromazine HCl (Thorazine) Pimavanserin (Nuplazid) (Clozaril, FazaClo) Pimozide (Orap) Decanoate Quetiapine (Seroquel, Seroquel XR) Fluphenazine HCL Risperidone (Risperdal, Risperdal Consta) Haloperidol (Haldol) Risperidone ER injectable suspension (Perseris) Haloperidol Decanoate Risperidone Microspheres Haloperidol Lactate Selegiline (transdermal only) (Emsam) Iloperidone (Fanapt) Thioridazine HCl (Mellaril) Isocarboxazid (Marplan) Thiothixene (Navane) Lithium (Eskalith, Eskalith CR) Thiothixene HCl Lithium Citrate Tranylcypromine Sulfate (Parnate) Succinate (Loxitane) HCl (Stelazine) Loxapine Aerosol Powder Breath Activated (Adasuve) Trihexyphenidyl (Artane) Lumateperone (Caplyta) * (Geodon) Hydrochloride (Latuda) Ziprasidone Mesylate (Geodon IM)

Managed Care Medi-Cal Carve-Out Drugs July 2020 *Pending carve out

Medi-Cal Carve-Out Medication List

ANTIRETROVIRAL Carve-Out Drugs / (Epzicom) / Abacavir Sulfate (Ziagen) Emtricitabine(Descovy) (Emtriva) Abacavir //Lamivudine (Triumeq) (Fuzeon) Sulfate (Reytaz) (Intelence) Atazanavir/ (Evotaz) Calcium (Lexiva) /Emtricitabine/Tenofovir Alf (Biktarvy) -uiyk (Trogarzo) Cobicistat (Tybost) Sulfate (Crixivan) Ethanoate (Prezista) Lamivudine (Epivir) Darunavir/Cobicistat (Prezcobix) Lamivudine/Tenofovir Dis. (Cimduo) Darunavir/Cobi/Emtri/Tenofovir Alf (Symtuza) Lamivudine/ fumarate Delavirdine Mesylate (Rescriptor) /RitonavirTemixys)* (Kaletra) Dolutegravir (Tivicay) (Selzentry) Dolutegravir/ Lamivudine (Dovato) Mesylate (Viracept) Dolutegravir/ (Juluca) (Viramune) Doravine (Pifeltro) Potassium (Isentress) / Lamivudine/ Tenofovir disoproxil fumarate (Delstrigo) Rilpivirine Hydrochloride (Edurant) (Sustiva) (Norvir) Efavirenz/Emtricitabine/Tenofovir Dis. (Atripla) Mesylate (Invirase) Efavirenz/Lamivudine/Tenofovir Dis. (Symfi) (Zerit) Efavirenz/Lamivudine/Tenofovir Dis. (Symfi Lo) Tenofovir Alafenamide Fumarate (Vemlidy) (Vitekta) Tenofovir Disoproxil/Emtricitabine (Truvada) Elvitegravir/Cobicistat/Emtricitabine/Tenofovir alafenamide Tenofovir Disoproxil Fumarate (Viread) Elvitegravir/Cobicistat/Emtricitabine/(Genvoya) Tenofovir Disoproxil Fumarate (Aptivus) (Stribild) Emtricitabine/Rilpivirine/Tenofovir alafenamide (Odefsey) /Lamivudine (Combivir)

Emtricitabine/Rilpivirine/ Tenofovir Disoproxil Fumarate (Complera) Zidovudine/Lamivudine/ Abacavir (Trizivir)

Managed Care Medi-Cal Carve-Out Drugs July 2020 *Pending carve out

Medi-Cal Carve-Out Medication List

Saquinavir (Fortovase)

BLOOD AND COAGULATION FACTOR Carve-Out Drugs Von willebrand factor (recombinant) (Vonvendi), Factor VIII (Antihemophilic Factor, Recombinant), per IU (NOVOEIGHT), per IU

Factor X (Human), per IU Von Willebrand Factor Complex, human

Factor XIII, anti-hemophilic factor Factor VIII (antihemophilic factor, human), per IU Factor xiii a-subunit, (recombinant), per iu Recombinant factor VIIa Factor IX, complex, per IU Factor VIII (antihemophilic factor, recombinant), per IU Anti -inhibitor Factor IX (antihemophilic factor, recombinant) IU Von Willebrand Factor/Coagulation Factor VIII Factor VIII (antihemophilic factor, (recombinant), per IU Complex (Human) (formerly Q2023) Antihemophilic factor VIII/von willebrand factor Injection, factor viii (antihemophilic factor, recombinant), complex (human), per factor VIII IU (obizur), per IU Factor IX (antihemophilic factor purified, non- Factor IX (antihemophilic factor, recombinant), Rixubis, per recombinant) per IU i.u. Injection, factor IX, Fc fusion protein Factor IX, albumin fusion protein, (recombinant), (Idelvion) (recombinant), per IU (Alprolix™) per IU Factor IX (antihemophilic factor, recombinant), Injection, Factor VIII, Fc fusion protein (recombinant), per IU glycopegylated, (Rebinyn), per IU (formerly Q9975) Factor VIII (antihemophilic factor, recombinant) Factor VIII (antihemophilic factor, recombinant), PEGylated- PEGylated, per IU (formerly C9137) aucl, (Jivi), per IU (formerly C9141) Factor VIII (antihemophilic factor, recombinant) Factor VIII (antihemophilic factor, recombinant) (Afstyla), per (Nuwiq), per IU (formerly C9138) IU (formerly C9140)

Factor VIII, (antihemophilic factor, recombinant) Emicizumab -kxwh (Hemlibra) (Kovaltry), per IU (formerly J7192)

Managed Care Medi-Cal Carve-Out Drugs July 2020 *Pending carve out

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