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(Medicare-Medicaid Plan) Formulary Maintenance Drug List

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IEHP DualChoice Cal MediConnect (Medicare-Medicaid Plan) Formulary Maintenance Drug List The following formulary medications may be approvable up to a three-month supply. Certain medications on this list may require prior approval from the plan based on existing criteria before being covered. For coverage information please see our formulary located on our website. BRAND GENERIC STRENGTH DOSAGE FORM ABACAVIR ABACAVIR SULFATE 20 MG/ML SOLUTION ABACAVIR ABACAVIR SULFATE 300 MG TABLET TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR 600-50-300 TABLET SODIUM/LAMIVUDINE ABACAVIR-LAMIVUDINE ABACAVIR SULFATE/LAMIVUDINE 600-300MG TABLET ABACAVIR-LAMIVUDINE- ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 150-300 MG TABLET ZIDOVUDINE TYMLOS ABALOPARATIDE 80MCG/DOSE PEN INJCTR ORENCIA ABATACEPT 125 MG/ML SYRINGE ORENCIA CLICKJECT ABATACEPT 125 MG/ML AUTO INJCT ORENCIA ABATACEPT 50MG/0.4ML SYRINGE ORENCIA ABATACEPT 87.5MG/0.7 SYRINGE VERZENIO ABEMACICLIB 50 MG TABLET VERZENIO ABEMACICLIB 100 MG TABLET VERZENIO ABEMACICLIB 150 MG TABLET VERZENIO ABEMACICLIB 200 MG TABLET ZYTIGA ABIRATERONE ACETATE 500 MG TABLET ABIRATERONE ACETATE ABIRATERONE ACETATE 250 MG TABLET YONSA ABIRATERONE ACETATE, SUBMICRONIZED 125 MG TABLET CALQUENCE ACALABRUTINIB 100 MG CAPSULE ACAMPROSATE CALCIUM ACAMPROSATE CALCIUM 333 MG TABLET DR ACARBOSE ACARBOSE 25 MG TABLET ACARBOSE ACARBOSE 50 MG TABLET ACARBOSE ACARBOSE 100 MG TABLET ACEBUTOLOL HCL ACEBUTOLOL HCL 200 MG CAPSULE ACEBUTOLOL HCL ACEBUTOLOL HCL 400 MG CAPSULE ACETAZOLAMIDE ER ACETAZOLAMIDE 500 MG CAPSULE ER ACETAZOLAMIDE ACETAZOLAMIDE 125 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 250 MG TABLET 411_CMC_FormularyMaintenance_October2020 Page 1 of 57 BRAND GENERIC STRENGTH DOSAGE FORM TUDORZA PRESSAIR ACLIDINIUM BROMIDE 400 MCG AER POW BA TUDORZA PRESSAIR ACLIDINIUM BROMIDE 400 MCG AER POW BA ACYCLOVIR ACYCLOVIR 200 MG/5ML ORAL SUSP ACYCLOVIR ACYCLOVIR 400 MG TABLET ACYCLOVIR ACYCLOVIR 800 MG TABLET ACYCLOVIR ACYCLOVIR 200 MG CAPSULE HUMIRA(CF) ADALIMUMAB 40MG/0.4ML SYRINGEKIT HUMIRA(CF) PEN ADALIMUMAB 40MG/0.4ML PEN IJ KIT HUMIRA(CF) ADALIMUMAB 20MG/0.2ML SYRINGEKIT HUMIRA(CF) ADALIMUMAB 10MG/0.1ML SYRINGEKIT HUMIRA(CF) PEDIATRIC ADALIMUMAB 80MG/0.8ML SYRINGEKIT CROHN'S HUMIRA ADALIMUMAB 40MG/0.8ML SYRINGEKIT HUMIRA PEN ADALIMUMAB 40MG/0.8ML PEN IJ KIT HUMIRA PEN CROHN'S- ADALIMUMAB 40MG/0.8ML PEN IJ KIT UC-HS HUMIRA PEN PSOR- ADALIMUMAB 40MG/0.8ML PEN IJ KIT UVEITS-ADOL HS HUMIRA ADALIMUMAB 10MG/0.2ML SYRINGEKIT HUMIRA ADALIMUMAB 20MG/0.4ML SYRINGEKIT GILOTRIF AFATINIB DIMALEATE 30 MG TABLET GILOTRIF AFATINIB DIMALEATE 40 MG TABLET GILOTRIF AFATINIB DIMALEATE 20 MG TABLET ALBUTEROL SULFATE HFA ALBUTEROL SULFATE 90 MCG HFA AER AD VENTOLIN HFA ALBUTEROL SULFATE 90 MCG HFA AER AD ALBUTEROL SULFATE HFA ALBUTEROL SULFATE 90 MCG HFA AER AD ALBUTEROL SULFATE ALBUTEROL SULFATE 2 MG TABLET ALBUTEROL SULFATE ALBUTEROL SULFATE 4 MG TABLET ALBUTEROL SULFATE ALBUTEROL SULFATE 4 MG TAB ER 12H ALBUTEROL SULFATE ALBUTEROL SULFATE 8 MG TAB ER 12H ALBUTEROL SULFATE ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 1.25MG/3ML VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/0.5 VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 2 MG/5 ML SYRUP ALBUTEROL SULFATE HFA ALBUTEROL SULFATE 90 MCG HFA AER AD ALECENSA ALECTINIB HCL 150 MG CAPSULE ALENDRONATE SODIUM ALENDRONATE SODIUM 10 MG TABLET 411_CMC_FormularyMaintenance_October2020 Page 2 of 57 BRAND GENERIC STRENGTH DOSAGE FORM ALENDRONATE SODIUM ALENDRONATE SODIUM 35 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 70 MG TABLET ALFUZOSIN HCL ER ALFUZOSIN HCL 10 MG TAB ER 24H ALISKIREN ALISKIREN HEMIFUMARATE 150 MG TABLET ALISKIREN ALISKIREN HEMIFUMARATE 300 MG TABLET ALLOPURINOL ALLOPURINOL 100 MG TABLET ALLOPURINOL ALLOPURINOL 300 MG TABLET ALOGLIPTIN ALOGLIPTIN BENZOATE 6.25 MG TABLET ALOGLIPTIN ALOGLIPTIN BENZOATE 12.5 MG TABLET ALOGLIPTIN ALOGLIPTIN BENZOATE 25 MG TABLET ALOGLIPTIN-METFORMIN ALOGLIPTIN BENZOATE/METFORMIN HCL 12.5-500MG TABLET ALOGLIPTIN-METFORMIN ALOGLIPTIN BENZOATE/METFORMIN HCL 12.5-1000 TABLET PIQRAY ALPELISIB 200 MG/DAY TABLET PIQRAY ALPELISIB 300 MG/DAY TABLET PIQRAY ALPELISIB 250 MG/DAY TABLET ZEMAIRA ALPHA-1-PROTEINASE INHIBITOR 1000 MG VIAL AMANTADINE AMANTADINE HCL 50 MG/5 ML SOLUTION AMANTADINE AMANTADINE HCL 100 MG TABLET AMANTADINE AMANTADINE HCL 100 MG CAPSULE AMBRISENTAN AMBRISENTAN 5 MG TABLET AMBRISENTAN AMBRISENTAN 10 MG TABLET AMILORIDE HCL AMILORIDE HCL 5 MG TABLET AMIODARONE HCL AMIODARONE HCL 400 MG TABLET AMIODARONE HCL AMIODARONE HCL 200 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 10 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 25 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 50 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 75 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 100 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 150 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 2.5 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 10 MG TABLET AMLODIPINE BESYLATE- AMLODIPINE BESYLATE/BENAZEPRIL HCL 2.5MG-10MG CAPSULE BENAZEPRIL AMLODIPINE BESYLATE- AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-10 MG CAPSULE BENAZEPRIL 411_CMC_FormularyMaintenance_October2020 Page 3 of 57 BRAND GENERIC STRENGTH DOSAGE FORM AMLODIPINE BESYLATE- AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-20 MG CAPSULE BENAZEPRIL AMLODIPINE BESYLATE- AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-40 MG CAPSULE BENAZEPRIL AMLODIPINE BESYLATE- AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 MG-20MG CAPSULE BENAZEPRIL AMLODIPINE BESYLATE- AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 MG-40MG CAPSULE BENAZEPRIL AMOXAPINE AMOXAPINE 25 MG TABLET AMOXAPINE AMOXAPINE 50 MG TABLET AMOXAPINE AMOXAPINE 100 MG TABLET AMOXAPINE AMOXAPINE 150 MG TABLET ANAGRELIDE HCL ANAGRELIDE HCL 1 MG CAPSULE ANAGRELIDE HCL ANAGRELIDE HCL 0.5 MG CAPSULE KINERET ANAKINRA 100MG/0.67 SYRINGE ANASTROZOLE ANASTROZOLE 1 MG TABLET ERLEADA APALUTAMIDE 60 MG TABLET ELIQUIS APIXABAN 2.5 MG TABLET ELIQUIS APIXABAN 5 MG TABLET APOKYN APOMORPHINE HCL 10 MG/ML CARTRIDGE ARIPIPRAZOLE ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE ARIPIPRAZOLE 20 MG TABLET ABILIFY MAINTENA ARIPIPRAZOLE 300 MG SUSER VIAL ABILIFY MAINTENA ARIPIPRAZOLE 400 MG SUSER VIAL ABILIFY MAINTENA ARIPIPRAZOLE 300 MG SUSER SYR ABILIFY MAINTENA ARIPIPRAZOLE 400 MG SUSER SYR ARIPIPRAZOLE ODT ARIPIPRAZOLE 10 MG TAB RAPDIS ARIPIPRAZOLE ODT ARIPIPRAZOLE 15 MG TAB RAPDIS ARIPIPRAZOLE ARIPIPRAZOLE 1 MG/ML SOLUTION ARIPIPRAZOLE ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE ARIPIPRAZOLE 30 MG TABLET SECUADO ASENAPINE 3.8MG/24HR PATCH TD24 SECUADO ASENAPINE 5.7MG/24HR PATCH TD24 SECUADO ASENAPINE 7.6MG/24HR PATCH TD24 SAPHRIS ASENAPINE MALEATE 2.5 MG TAB SUBL SAPHRIS ASENAPINE MALEATE 5 MG TAB SUBL 411_CMC_FormularyMaintenance_October2020 Page 4 of 57 BRAND GENERIC STRENGTH DOSAGE FORM SAPHRIS ASENAPINE MALEATE 10 MG TAB SUBL ASPIRIN-DIPYRIDAMOLE ASPIRIN/DIPYRIDAMOLE 25MG- CPMP 12HR ER 200MG REYATAZ ATAZANAVIR SULFATE 50 MG POWD PACK ATAZANAVIR SULFATE ATAZANAVIR SULFATE 150 MG CAPSULE ATAZANAVIR SULFATE ATAZANAVIR SULFATE 200 MG CAPSULE ATAZANAVIR SULFATE ATAZANAVIR SULFATE 300 MG CAPSULE EVOTAZ ATAZANAVIR SULFATE/COBICISTAT 300-150 MG TABLET ATENOLOL ATENOLOL 100 MG TABLET ATENOLOL ATENOLOL 25 MG TABLET ATENOLOL ATENOLOL 50 MG TABLET ATENOLOL- ATENOLOL/CHLORTHALIDONE 50 MG-25MG TABLET CHLORTHALIDONE ATENOLOL- ATENOLOL/CHLORTHALIDONE 100MG- TABLET CHLORTHALIDONE 25MG ATOMOXETINE HCL ATOMOXETINE HCL 10 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 18 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 25 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 40 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 60 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 80 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 100 MG CAPSULE ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG TABLET RIDAURA AURANOFIN 3 MG CAPSULE AYVAKIT AVAPRITINIB 100 MG TABLET AYVAKIT AVAPRITINIB 200 MG TABLET AYVAKIT AVAPRITINIB 300 MG TABLET INLYTA AXITINIB 1 MG TABLET INLYTA AXITINIB 5 MG TABLET AZATHIOPRINE AZATHIOPRINE 50 MG TABLET AZELASTINE HCL AZELASTINE HCL 137 MCG SPRAY/PUMP BACLOFEN BACLOFEN 10 MG TABLET BACLOFEN BACLOFEN 20 MG TABLET QVAR REDIHALER BECLOMETHASONE DIPROPIONATE 40 MCG HFA AEROBA QVAR REDIHALER BECLOMETHASONE DIPROPIONATE 80 MCG HFA AEROBA 411_CMC_FormularyMaintenance_October2020 Page 5 of 57 BRAND GENERIC STRENGTH DOSAGE FORM BENAZEPRIL HCL BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 10 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 20 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 40 MG TABLET BENAZEPRIL- BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET HYDROCHLOROTHIAZIDE BENAZEPRIL- BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 20 MG-25MG TABLET HYDROCHLOROTHIAZIDE BENAZEPRIL- BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 5-6.25MG TABLET HYDROCHLOROTHIAZIDE BENAZEPRIL- BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET HYDROCHLOROTHIAZIDE BENZTROPINE MESYLATE BENZTROPINE MESYLATE 0.5 MG TABLET BENZTROPINE MESYLATE BENZTROPINE MESYLATE 1 MG TABLET BENZTROPINE MESYLATE BENZTROPINE MESYLATE 2 MG TABLET CYSTADANE BETAINE 1 G/1.7 ML POWDER BETAXOLOL HCL BETAXOLOL HCL 10 MG TABLET BETAXOLOL HCL BETAXOLOL HCL 20 MG TABLET BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 5 MG TABLET BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 10 MG TABLET BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 25 MG TABLET BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE 50
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