Medi-Cal DHCS Carve Out Medication List

The drugs shown below are non-capitated or carved-out of IEHP. This means they are not reimbursed by IEHP except where indicated and they should be billed to Fee-For-Service (FFS) Medi-Cal for payment. Please note that this list is frequently updated by Medi-Cal with additions and deletions of drugs. For questions about a benefit or service listed here, please call Medi-Cal Support at 1-800-541-5555.

Psychiatric Drugs

Drug Name (Brand Name) Amantadine HCl Amantadine HCl ER Aripiprazole Aripiprazole lauroxil (Aristada Initio) Asenapine (Saphris) Benztropine Mesylate Brexpiprazole Cariprazine Chlorpromazine HCl Clozapine Fluphenazine Decanoate Fluphenazine HCl Haloperidol Haloperidol Decanoate Haloperidol Lactate Iloperidone (Fanapt) Isocarboxazid Lithium Carbonate Lithium Citrate Loxapine Succinate Loxapine Aerosol Powder Breath Activated (Adasuve) Lurasidone Hydrochloride Molindone HCl Olanzapine Olanzapine Fluoxetine HCl Olanzapine Pamoate Monohydrate (Zyprexa Relprevv) Paliperidone (Invega) Paliperidone Palmitate (Invega Sustenna) Paliperidone Palmitate (Invega Trinza) Perphenazine Phenelzine Sulfate Pimavanserin (Nuplazid) Pimozide Quetiapine Risperidone

10801 6th St., Suite 120, Rancho Cucamonga, CA 91730 Tel (909) 890-2049 Fax (909) 890-2058 Visit our web site at: www.iehp.org Updated 01/07/2020 (v14) A Public Entity 1

Drug Name (Brand Name) Risperidone ER injectable suspension (Perseris) Risperidone Microspheres Selegiline (transdermal only) Thioridazine HCl Thiothixene Thiothixene HCl Tranylcypromine Sulfate Trifluoperazine HCl Trihexyphenidyl Ziprasidone HCl Ziprasidone Mesylate

AIDS Drugs

Drug Name (Brand Name) Abacavir/Lamivudine Abacavir Sulfate Abacavir Sulfate/Dolutegravir/Lamivudine (Triumeq) Atazanavir Sulfate Atazanavir/Cobicistat (Evotaz) Bictegravir/Emtricitabine/Tenofovir Alafenamide (Biktarvy) Cobicistat (Tybost) Darunavir Ethanolate Darunavir/Cobicistat (Prezcobix) Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (Symtuza) Delavirdine Mesylate Dolutegravir (Tivicay) Dolutegravir/Lamivudine (Dovato) Dolutegravir/ Rilpivirine (Juluca) Doravine (Pifeltro) Doravirine/ Lamivudine/ Tenofovir disoproxil fumarate (Delstrigo) Efavirenz Efavirenz/Emtricitabine/Tenofovir Disoproxil Fumarate (Atripla) Efavirenz/Lamivudine/Tenofovir Disoproxil Fumarate (Symfi LO) Efavirenz/Lamivudine/Tenofovir Disoproxil Fumarate (Symfi) Elvitegravir (Vitekta) Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Disoproxil Fumarate (Stribild) Elvitegravir/Cobicistat/Emtricitabine/Tenofovir alafenamide (Genvoya) Emtricitabine/Rilpivirine/Tenofovir Alafenamide (Odefsey) Emtricitabine/Rilpivirine/ Tenofovir Disoproxil Fumarate (Complera) Emtricitabine/Tenofovir Alafenamide (Descovy) Emtricitabine Enfuvirtide Etravirine 10801 6th St., Suite 120, Rancho Cucamonga, CA 91730 Tel (909) 890-2049 Fax (909) 890-2058 Visit our web site at: www.iehp.org Updated 01/07/2020 (v14) A Public Entity 2

Drug Name (Brand Name) Fosamprenavir Calcium Ibalizumab-uiyk (Trogarzo) Indinavir Sulfate Lamivudine Lamivudine/Tenofovir Disoproxil Fumarate (Cimduo) Lamivudine/ Tenofovir Disoproxil Fumarate (Temixys) Lopinavir/Ritonavir Maraviroc Nelfinavir Mesylate Nevirapine Raltegravir Potassium Rilpivirine Hydrochloride Ritonavir Saquinavir Saquinavir Mesylate Stavudine Tenofovir Alafenamide (Vemlidy) Tenofovir Disoproxil-Emtricitabine Tenofovir Disoproxil Fumarate Tipranavir Zidovudine/Lamivudine Zidovudine/Lamivudine/ Abacavir Sulfate

Alcohol, Heroin Detoxification, and Dependency Treatment Drugs

Drug Name (Brand Name) Acamprosate Calcium Buprenorphine HCl Buprenorphine Extended-Release Inj (Sublocade) Buprenorphine HCl (Belbuca) Buprenorphine Implant (Probuphine) Buprenorphine/Naloxone HCl Disulfiram (Antabuse) Lofexidine Hydrochloride (Lucemyra) Naloxone HCl Naltrexone (oral) Naltrexone Microsphere Injectable Suspension (Vivitrol)

Blood Factor Products

Drug Name (Brand Name) Antihemophilic factor VIII/von Willebrand factor complex (human) Anti-inhibitor

10801 6th St., Suite 120, Rancho Cucamonga, CA 91730 Tel (909) 890-2049 Fax (909) 890-2058 Visit our web site at: www.iehp.org Updated 01/07/2020 (v14) A Public Entity 3

Drug Name (Brand Name) Coagulation factor X (human) Factor VIIa (antihemophilic factor, recombinant) Factor VIII (antihemophilic factor, human) Factor VIII (antihemophilic factor, recombinant) Factor VIII (antihemophilic factor, recombinant) (Novoeight) Factor IX (antihemophilic factor, purified, nonrecombinant) Factor IX (antihemophilic factor, recombinant) Factor IX (antihemophilic factor, recombinant) (Rixubis) Factor IX (antihemophilic factor, recombinant), glycopegylated, (Rebinyn), Per IU Factor IX complex Factor XIII (antihemophilic factor, human) Factor XIII A-Subunit (recombinant) Hemlibra Hemophilia clotting factor, not otherwise classified Injection, factor VIII (antihemophilic factor, recombinant) (Obizur) Injection, factor VIII, fc fusion (recombinant) Injection, factor VIII, fc fusion protein (recombinant) Injection, factor IX fusion protein (recombinant) Von Willebrand factor complex (human), Wilate Von Willebrand factor complex (Humate-P)

10801 6th St., Suite 120, Rancho Cucamonga, CA 91730 Tel (909) 890-2049 Fax (909) 890-2058 Visit our web site at: www.iehp.org Updated 01/07/2020 (v14) A Public Entity 4