SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

May, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/14/2021 sodium fluoride fluoride (sodium) ADD TO FORMULARY Tier 1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 1 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

July, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 BOOSTRIX diphtheria,pertussis(acellular CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per TDAP,BOOSTRI ),tetanus vaccine lifetime X 07/01/2021 BOOSTRIX diphtheria,pertussis(acellular CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per TDAP,BOOSTRI ),tetanus vaccine lifetime X 07/01/2021 MENACTRA meningococcalvaccine CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per a,c,y,w-135,diphtheria toxoid lifetime conj/pf 07/01/2021 ADACEL TDAP diphtheria,pertussis(acellular CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per ),tetanus vaccine/pf lifetime 07/01/2021 BEXSERO meningococcal group b CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per vaccine, 4-component lifetime 07/01/2021 DECAVAC,TENI tetanus and diphtheria CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per VAC toxoids, adsorbed, adult/pf lifetime 07/01/2021 PREVNAR 13 pneumococcal 13-valent CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per conjugate vaccine lifetime (diphtheria crm)/pf 07/01/2021 TRUMENBA neisseria meningitidis group CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per b, lipidated fhbp lifetime recombinant 07/01/2021 TENIVAC,TETAN tetanus and diphtheria CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per US-DIPHTERIA- toxoids, adsorbed, adult/pf lifetime DECAVAC 07/01/2021 ADACEL TDAP diphtheria,pertussis(acellular CHANGE UM: QUANTITY 0.5 / DAY 1 fill (0.5 ml) per ),tetanus vaccine/pf lifetime 07/01/2021 TRUMENBA neisseria meningitidis group REMOVE UM: QUANTITY 1 fill (0.5 ml) per b, lipidated fhbp lifetime recombinant

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 2 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ESTRING estradiol CHANGE UM: QUANTITY 1 / 30 DAYS 1 / 90 days 07/01/2021 M-M-R II measles, mumps, and REMOVE UM: QUANTITY 1 / DAY VACCINE rubella vaccine live/pf,measles,mumps&rub ella vaccine live/pf 07/01/2021 ACTHIB,HIBERI haemophilus b conjugate REMOVE UM: QUANTITY X vaccine(tetanus toxoid conjugate)/pf 07/01/2021 M-M-R II measles, mumps, and ADD UM: QUANTITY max 2 fills per VACCINE rubella vaccine lifetime live/pf,measles,mumps&rub ella vaccine live/pf 07/01/2021 ACTHIB,HIBERI haemophilus b conjugate ADD UM: QUANTITY max 2 fills per X vaccine(tetanus toxoid lifetime conjugate)/pf 07/01/2021 ACTHIB,HIBERI haemophilus b conjugate REMOVE UM: Limit 3 fills per X vaccine(tetanus toxoid QUANTITYCUSTOM lifetime conjugate)/pf 07/01/2021 M-M-R II measles, mumps, and REMOVE UM: Limit 2 fills per VACCINE rubella vaccine QUANTITYCUSTOM lifetime live/pf,measles,mumps&rub ella vaccine live/pf 07/01/2021 PNEUMOVAX 23 pneumococcal 23-valent REMOVE UM: Limit 2 fills per polysaccharide QUANTITYCUSTOM lifetime vaccine,pneumococcal 23- val p-sac vac 07/01/2021 PNEUMOVAX 23 pneumococcal 23-valent CHANGE UM: QUANTITY 1 / DAY max 2 fills per polysaccharide lifetime vaccine,pneumococcal 23- val p-sac vac 07/01/2021 ACTHIB,HIBERI haemophilus b conjugate CHANGE UM: QUANTITY max 2 fills per max 3 fills per X vaccine(tetanus toxoid lifetime lifetime conjugate)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 3 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 moban,molindon molindone hcl REMOVE FROM Non-Formulary e hcl FORMULARY 07/01/2021 moban,molindon molindone hcl ADD UM: NTWK CARVE OUT: e hcl FFS MEDI-CAL 07/01/2021 NUPLAZID pimavanserin tartrate REMOVE FROM Non-Formulary FORMULARY 07/01/2021 NUPLAZID pimavanserin tartrate ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 NUPLAZID pimavanserin tartrate ADD UM: COV Excluded 07/01/2021 moban,molindon molindone hcl ADD UM: COV Excluded e hcl 07/01/2021 VONVENDI von willebrand factor REMOVE FROM Non-Formulary (recombinant) FORMULARY 07/01/2021 VONVENDI von willebrand factor ADD UM: NTWK CARVE OUT: (recombinant) FFS MEDI-CAL 07/01/2021 VONVENDI von willebrand factor ADD UM: COV Excluded (recombinant) 07/01/2021 KCENTRA,BEBU human prothrombin complex REMOVE FROM Non-Formulary LIN VH concentrate (pcc), 4- FORMULARY IMMUNO,BEBUL factor,factor ix complex, IN,PROFILNINE prothrombin complex conc. SD,PROFILNINE (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3- factor,factor ix complex, prothrombin complex conc. (pcc) comb. 4,factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 4 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 KCENTRA,BEBU human prothrombin complex CHANGE UM: NTWK CARVE OUT: LIN VH concentrate (pcc), 4- FFS MEDI-CAL IMMUNO,BEBUL factor,factor ix complex, IN,PROFILNINE prothrombin complex conc. SD,PROFILNINE (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3- factor,factor ix complex, prothrombin complex conc. (pcc) comb. 4,factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor 07/01/2021 KCENTRA,BEBU human prothrombin complex CHANGE UM: COV Excluded LIN VH concentrate (pcc), 4- IMMUNO,BEBUL factor,factor ix complex, IN,PROFILNINE prothrombin complex conc. SD,PROFILNINE (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3- factor,factor ix complex, prothrombin complex conc. (pcc) comb. 4,factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor 07/01/2021 suprax,cefixime cefixime CHANGE UM: AGE Up to 12 yrs old 07/01/2021 cefdinir,omnicef cefdinir CHANGE UM: AGE At least 13 yrs Up to 12 yrs old old 07/01/2021 cefpodoxime cefpodoxime proxetil CHANGE UM: AGE At least 13 yrs Up to 12 yrs old proxetil old 07/01/2021 cefprozil,cefzil cefprozil CHANGE UM: AGE At least 13 yrs Up to 12 yrs old old 07/01/2021 tamiflu,oseltamivi oseltamivir phosphate CHANGE UM: AGE Up to 12 yrs old r phosphate 07/01/2021 cefprozil,cefzil cefprozil CHANGE UM: AGE At least 13 yrs Up to 12 yrs old old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 5 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 carbamazepine carbamazepine ADD UM: AGE Up to 12 yrs old 07/01/2021 cefdinir,omnicef cefdinir CHANGE UM: AGE At least 13 yrs Up to 12 yrs old old 07/01/2021 multivitamins with pediatric multivitamins no.17 CHANGE UM: AGE Up to 12 yrs old fluoride,multivita with sodium fluoride min with fluoride,multi- vitamin with fluoride 07/01/2021 isoniazid isoniazid CHANGE UM: AGE At least 13 yrs Up to 12 yrs old old 07/01/2021 cefpodoxime cefpodoxime proxetil CHANGE UM: AGE At least 13 yrs Up to 12 yrs old proxetil old 07/01/2021 sucralfate,carafat sucralfate CHANGE UM: AGE Up to 12 yrs old e 07/01/2021 cefaclor,ceclor cefaclor CHANGE UM: AGE At least 13 yrs Up to 12 yrs old old 07/01/2021 cefaclor,ceclor cefaclor CHANGE UM: AGE At least 13 yrs Up to 12 yrs old old 07/01/2021 methylphenidate methylphenidate hcl CHANGE UM: AGE Up to 12 yrs old hcl,methylin 07/01/2021 methylphenidate methylphenidate hcl CHANGE UM: AGE Up to 12 yrs old hcl,methylin 07/01/2021 cefaclor cefaclor CHANGE UM: AGE At least 13 yrs Up to 12 yrs old old 07/01/2021 cleocin clindamycin palmitate hcl CHANGE UM: AGE Up to 12 yrs old pediatric,clindam ycin (pediatric),clinda mycin pediatric 07/01/2021 lexapro,escitalopr escitalopram oxalate CHANGE UM: AGE At least 13 yrs Up to 12 yrs old am oxalate old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 6 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 tamiflu,oseltamivi oseltamivir phosphate CHANGE UM: AGE Up to 12 yrs old r phosphate 07/01/2021 suprax,cefixime cefixime CHANGE UM: AGE Up to 12 yrs old 07/01/2021 certainty incontinence pad,liner,disp ADD TO FORMULARY Tier 2 07/01/2021 syringe luer-lok syringe, disposable, 50 ml ADD TO FORMULARY Tier 2 07/01/2021 syringe catheter syringe, disposable, 50 ml ADD TO FORMULARY Tier 2 tip 07/01/2021 poise pads incontinence pad,liner,disp ADD TO FORMULARY Tier 2 07/01/2021 personal best peak flow meter ADD TO FORMULARY Tier 2 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 2 needle,insulin,0.3 ml 07/01/2021 NICORETTE nicotine polacrilex ADD TO FORMULARY Tier 2 07/01/2021 veo insulin syringe with ADD TO FORMULARY Tier 2 syringe needle,insulin,0.5 ml 07/01/2021 NIX permethrin ADD TO FORMULARY Tier 2 07/01/2021 veo insulin syringe with ADD TO FORMULARY Tier 2 syringe needle,insulin,0.3 ml 07/01/2021 veo insulin syringe with ADD TO FORMULARY Tier 2 syringe needle,disposable,insulin 1 ml 07/01/2021 VAGISIL benzocaine/resorcinol/aloe ADD TO FORMULARY Tier 2 vera/vitamin e acetate/vit a,d 07/01/2021 ALEVE naproxen sodium ADD TO FORMULARY Tier 2 07/01/2021 AYR SALINE sodium chloride ADD TO FORMULARY Tier 2 07/01/2021 veo insulin syringe with needle,insulin ADD TO FORMULARY Tier 2 syringe 0.3 ml (half unit mark) 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 7 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 TUMS calcium carbonate ADD TO FORMULARY Tier 2 07/01/2021 trueplus ketone urine acetone test,strips ADD TO FORMULARY Tier 2 test strip 07/01/2021 COMPOUND W salicylic acid ADD TO FORMULARY Tier 2 07/01/2021 NOVOLIN 70-30 insulin nph human ADD TO FORMULARY Tier 2 isophane/insulin regular, human,nph, human insulin isophane/insulin regular, human 07/01/2021 DULCOLAX bisacodyl ADD TO FORMULARY Tier 2 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 PEDIASURE nutritional supplement ADD TO FORMULARY Tier 2 PEPTIDE 1.0 CAL 07/01/2021 CHILDREN'S loratadine ADD TO FORMULARY Tier 2 CLARITIN 07/01/2021 monoject insulin syringe with ADD TO FORMULARY Tier 2 syringe needle,disposable,insulin 1 ml 07/01/2021 trueplus insulin syringe with ADD TO FORMULARY Tier 2 syringe needle,disposable,insulin 1 ml 07/01/2021 monoject insulin syringe with ADD TO FORMULARY Tier 2 syringe needle,insulin,0.5 ml 07/01/2021 monoject insulin syringe with ADD TO FORMULARY Tier 2 syringe needle,insulin,0.3 ml 07/01/2021 CHILDREN'S pseudoephedrine hcl ADD TO FORMULARY Tier 2 SUDAFED

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 8 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 alcohol alcohol antiseptic pads ADD TO FORMULARY Tier 2 swabs,alcohol swab,alcohol prep pads,alcohol wipes 07/01/2021 depend diaper,brief,adult, ADD TO FORMULARY Tier 2 protection disposable 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 trueplus insulin syringe with ADD TO FORMULARY Tier 2 syringe needle,insulin,0.3 ml 07/01/2021 trueplus insulin syringe with ADD TO FORMULARY Tier 2 syringe needle,insulin,0.5 ml 07/01/2021 CLARITIN-D 24 loratadine/pseudoephedrine ADD TO FORMULARY Tier 2 HOUR sulfate 07/01/2021 PLAN B ONE- levonorgestrel ADD TO FORMULARY Tier 2 STEP 07/01/2021 NOVOLIN N insulin nph human isophane ADD TO FORMULARY Tier 2 FLEXPEN 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 SELSUN BLUE selenium sulfide ADD TO FORMULARY Tier 2 2-IN-1 07/01/2021 PHOSPHOROUS sodium ADD TO FORMULARY Tier 2 phosphate/potassium phosphates, monobasic and bibasic 07/01/2021 CAPZASIN-HP capsaicin ADD TO FORMULARY Tier 2 07/01/2021 easy touch syringe,safety with needle,3 ADD TO FORMULARY Tier 2 fliplock syringes ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 9 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 CHILDREN'S acetaminophen ADD TO FORMULARY Tier 2 TYLENOL 07/01/2021 MIRALAX polyethylene glycol 3350 ADD TO FORMULARY Tier 2 07/01/2021 SPECTRAVITE multivitamin with ADD TO FORMULARY Tier 2 ADULT minerals/folic 50+,SPECTRAVI acid/lycopene/lutein TE ADULT 50 PLUS 07/01/2021 REFRESH carboxymethylcellulose ADD TO FORMULARY Tier 2 TEARS sodium 07/01/2021 certainty underpads ADD TO FORMULARY Tier 2 07/01/2021 MONISTAT 7 miconazole nitrate ADD TO FORMULARY Tier 2 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 2 needle,disposable,insulin 1 ml 07/01/2021 ELFOLATE levomefolate calcium ADD TO FORMULARY Tier 2 07/01/2021 BENGAY ULTRA methyl ADD TO FORMULARY Tier 2 STRENGTH salicylate/menthol/camphor 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 2 needle,insulin,0.5 ml 07/01/2021 CERTAVITE multivitamin with ADD TO FORMULARY Tier 2 SENIOR minerals/folic acid/lycopene/lutein 07/01/2021 NOVOLIN 70-30 insulin nph human ADD TO FORMULARY Tier 2 FLEXPEN isophane/insulin regular, human 07/01/2021 cetaphil skin cleanser,paraben/cetyl ADD TO FORMULARY Tier 2 alcohol/stearyl alc/prop gly/sod lauryl sulf 07/01/2021 DEBROX carbamide peroxide ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 10 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 OPCON-A naphazoline hcl/pheniramine ADD TO FORMULARY Tier 2 maleate 07/01/2021 depend diaper,brief,adult, ADD TO FORMULARY Tier 2 disposable 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 SELSUN BLUE selenium sulfide ADD TO FORMULARY Tier 2 07/01/2021 webcol alcohol antiseptic pads ADD TO FORMULARY Tier 2 07/01/2021 TYLENOL 8 acetaminophen ADD TO FORMULARY Tier 2 HOUR 07/01/2021 PEDIALYTE electrolytes/dextrose ADD TO FORMULARY Tier 2 ADVANCED CARE 07/01/2021 CORN-CALLUS salicylic acid ADD TO FORMULARY Tier 2 REMOVER 07/01/2021 CHILDREN'S pediatric multivitamin ADD TO FORMULARY Tier 2 MULTIVITAMIN no.42,pediatric multivitamin no.73,pediatric multivitamin no.101,pediatric multivitamin no.119,pediatric multivitamin no.120,pediatric multivitamin no.17 07/01/2021 FUNGOID miconazole nitrate ADD TO FORMULARY Tier 2 TINCTURE 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 2 needle,insulin,0.5 ml,syringe with needle,insulin disposable,0.5 ml 07/01/2021 condoms condoms, latex, lubricated ADD TO FORMULARY Tier 2 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 5 ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 11 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 certainty diaper,brief,adult, ADD TO FORMULARY Tier 2 disposable 07/01/2021 PEDIALYTE electrolytes/dextrose,electrol ADD TO FORMULARY Tier 2 yte,oral 07/01/2021 certainty diaper,brief,adult, ADD TO FORMULARY Tier 2 disposable,diaper,brief,adult ,disposable 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 2 needle,disposable,insulin 1 ml 07/01/2021 fc2 female condoms, female ADD TO FORMULARY Tier 2 condom 07/01/2021 safetyglide syringe with ADD TO FORMULARY Tier 2 syringe needle,disposable, 3 ml 07/01/2021 CLARITIN loratadine ADD TO FORMULARY Tier 2 07/01/2021 CHILDREN'S dextromethorphan polistirex ADD TO FORMULARY Tier 2 DELSYM COUGH 07/01/2021 CHILDREN'S diphenhydramine hcl ADD TO FORMULARY Tier 2 BENADRYL ALLERGY,BENA DRYL ALLERGY 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 2 needle,insulin,0.3 ml,syringe with needle,insulin disposable,0.3 ml 07/01/2021 DOUBLE bacitracin zinc/polymyxin b ADD TO FORMULARY Tier 2 ANTIBIOTIC sulfate 07/01/2021 easy touch alcohol antiseptic pads ADD TO FORMULARY Tier 2 alcohol prep pads 07/01/2021 MUCINEX guaifenesin ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 12 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 COLACE docusate sodium ADD TO FORMULARY Tier 2 07/01/2021 NAPHCON-A naphazoline hcl/pheniramine ADD TO FORMULARY Tier 2 maleate 07/01/2021 NICODERM CQ nicotine ADD TO FORMULARY Tier 2 07/01/2021 certainty diaper,brief,adult, ADD TO FORMULARY Tier 2 disposable,diaper,brief,adult ,disposable 07/01/2021 D-VI-SOL cholecalciferol (vitamin d3) ADD TO FORMULARY Tier 2 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 ZADITOR ketotifen fumarate ADD TO FORMULARY Tier 2 07/01/2021 METAMUCIL psyllium husk ADD TO FORMULARY Tier 2 07/01/2021 EXCEDRIN acetaminophen/caffeine ADD TO FORMULARY Tier 2 TENSION HEADACHE 07/01/2021 MIRALAX polyethylene glycol 3350 ADD TO FORMULARY Tier 2 07/01/2021 syringe- syringe with ADD TO FORMULARY Tier 2 precisionglide needle,disposable, 1 ml needle 07/01/2021 CHILDREN'S fexofenadine hcl ADD TO FORMULARY Tier 2 ALLEGRA ALLERGY 07/01/2021 INFANTS' acetaminophen ADD TO FORMULARY Tier 2 TYLENOL 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 5 ml 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 CLARITIN loratadine ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 13 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 TYLENOL acetaminophen ADD TO FORMULARY Tier 2 ARTHRITIS 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 2 needle,disposable,insulin 1 ml 07/01/2021 MUCINEX D guaifenesin/pseudoephedrin ADD TO FORMULARY Tier 2 e hcl 07/01/2021 sure comfort syringe with ADD TO FORMULARY Tier 2 needle,insulin,0.5 ml 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 FLORASTOR saccharomyces boulardii ADD TO FORMULARY Tier 2 07/01/2021 MAG-G magnesium gluconate ADD TO FORMULARY Tier 2 07/01/2021 peak-air peak flow meter ADD TO FORMULARY Tier 2 07/01/2021 NEPHRO-VITE folic acid/vitamin b complex ADD TO FORMULARY Tier 2 and vitamin c,folic acid/vitamin b comp w-c 07/01/2021 MURO-128 sodium chloride ADD TO FORMULARY Tier 2 07/01/2021 NEXIUM 24HR esomeprazole magnesium ADD TO FORMULARY Tier 2 07/01/2021 HIGH POTENCY multivits with calcium and ADD TO FORMULARY Tier 2 MULTIVITAMIN minerals/iron fumarate/folic acid 07/01/2021 nu-fit brief diaper,brief,adult, ADD TO FORMULARY Tier 2 disposable 07/01/2021 durex avanti bare condoms, non-latex, ADD TO FORMULARY Tier 2 real feel lubricated 07/01/2021 SLO-NIACIN niacin ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 14 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 single use swab alcohol antiseptic pads ADD TO FORMULARY Tier 2 07/01/2021 sure comfort syringe with ADD TO FORMULARY Tier 2 needle,insulin,0.3 ml 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 2 needle,disposable,insulin 1 ml 07/01/2021 GENTEAL dextran 70/hypromellose/pf ADD TO FORMULARY Tier 2 TEARS 07/01/2021 CENTRUM multivitamin/ferrous ADD TO FORMULARY Tier 2 WOMEN fumarate/folic acid 07/01/2021 CLARITIN-D 12 loratadine/pseudoephedrine ADD TO FORMULARY Tier 2 HOUR sulfate 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 2 needle,insulin,0.3 ml 07/01/2021 FULL folic acid/vitamin b complex ADD TO FORMULARY Tier 2 SPECTRUM B and vitamin c 07/01/2021 THEREMS-M multivits with calcium and ADD TO FORMULARY Tier 2 minerals/iron fumarate/folic acid 07/01/2021 PEPTO-BISMOL bismuth subsalicylate ADD TO FORMULARY Tier 2 07/01/2021 kimono condoms, latex, non- ADD TO FORMULARY Tier 2 lubricated 07/01/2021 safetyglide syringe with ADD TO FORMULARY Tier 2 syringe needle,disposable, 3 ml 07/01/2021 PEPTO-BISMOL bismuth subsalicylate ADD TO FORMULARY Tier 2 07/01/2021 CENTRUM multivitamin w-minerals/folic ADD TO FORMULARY Non-Formulary Tier 2 SILVER acid/lycopene/lutein,multivita min with minerals/folic acid/lycopene/lutein 07/01/2021 NASACORT triamcinolone acetonide ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 15 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ENEMA,FLEET sodium ADD TO FORMULARY Tier 2 ENEMA phosphate,monobasic/sodiu m phosphate,dibasic 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 PEPTO-BISMOL bismuth subsalicylate ADD TO FORMULARY Tier 2 07/01/2021 METAMUCIL psyllium husk (with sugar) ADD TO FORMULARY Tier 2 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 3 ml 07/01/2021 luer-lok syringe- syringe with ADD TO FORMULARY Tier 2 needle needle,disposable, 1 ml 07/01/2021 ZYRTEC cetirizine hcl ADD TO FORMULARY Tier 2 07/01/2021 ECOTRIN aspirin ADD TO FORMULARY Tier 1 07/01/2021 ONCE DAILY multivitamin ADD TO FORMULARY Tier 1 07/01/2021 BISMATROL bismuth subsalicylate ADD TO FORMULARY Tier 1 07/01/2021 mineral oil mineral oil ADD TO FORMULARY Tier 1 07/01/2021 GENTLE bisacodyl ADD TO FORMULARY Tier 1 LAXATIVE 07/01/2021 vitamin c ascorbic acid ADD TO FORMULARY Tier 1 07/01/2021 SENNA LAX sennosides ADD TO FORMULARY Tier 1 07/01/2021 sure comfort syringe with ADD TO FORMULARY Tier 1 needle,insulin,0.3 ml 07/01/2021 capsaicin capsaicin ADD TO FORMULARY Tier 1 07/01/2021 pseudoephedrine pseudoephedrine hcl ADD TO FORMULARY Tier 1 er 07/01/2021 BAYER aspirin ADD TO FORMULARY Tier 1 CHEWABLE ASPIRIN

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 16 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 DERMACERIN mineral oil/petrolatum,white ADD TO FORMULARY Tier 1 07/01/2021 children's cetirizine hcl ADD TO FORMULARY Tier 1 cetirizine hcl 07/01/2021 ZOSTRIX HP capsaicin ADD TO FORMULARY Tier 1 07/01/2021 AYR SALINE sodium chloride ADD TO FORMULARY Tier 1 07/01/2021 NASAL pseudoephedrine hcl ADD TO FORMULARY Tier 1 DECONGESTAN T 07/01/2021 FLINTSTONES multivitamin with iron and ADD TO FORMULARY Tier 1 COMPLETE other minerals 07/01/2021 SOOTHE bismuth subsalicylate ADD TO FORMULARY Tier 1 07/01/2021 trueplus insulin syringe with ADD TO FORMULARY Tier 1 syringe needle,insulin,0.5 ml 07/01/2021 benzoyl peroxide benzoyl peroxide ADD TO FORMULARY Tier 1 07/01/2021 8 HOUR PAIN acetaminophen ADD TO FORMULARY Tier 1 RELIEF,8 HOUR PAIN RELIEVER,8 HOUR ACETAMINOPH EN,8HR ARTHRITIS PAIN,8HR ARTHRITIS PAIN RELIEF 07/01/2021 GERI-LANTA magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 WAL-FEX fexofenadine hcl ADD TO FORMULARY Tier 1 ALLERGY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 17 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 trueplus insulin syringe with ADD TO FORMULARY Tier 1 syringe needle,disposable,insulin 1 ml 07/01/2021 ATHLETE'S clotrimazole ADD TO FORMULARY Tier 1 FOOT 07/01/2021 ALLER-CHLOR chlorpheniramine maleate ADD TO FORMULARY Tier 1 07/01/2021 LICE permethrin ADD TO FORMULARY Tier 1 TREATMENT 07/01/2021 ADULT WAL- guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 TUSSIN DM MAX an hbr 07/01/2021 ROBAFEN DM guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 COUGH-CHEST an hbr CONGEST 07/01/2021 lidocaine pain lidocaine ADD TO FORMULARY Tier 1 relief,lidocaine 07/01/2021 ANTIFUNGAL clotrimazole ADD TO FORMULARY Tier 1 07/01/2021 POLY-VITAMIN multivitamin ADD TO FORMULARY Tier 1 07/01/2021 integra syringe syringe,safety with needle,3 ADD TO FORMULARY Tier 1 ml 07/01/2021 clotrimazole-3 clotrimazole ADD TO FORMULARY Tier 1 07/01/2021 BISMATROL bismuth subsalicylate ADD TO FORMULARY Tier 1 07/01/2021 exel syringe, disposable, 3 ml ADD TO FORMULARY Tier 1 syringe,syringe 07/01/2021 PREPARATION witch hazel ADD TO FORMULARY Tier 1 H,PREPARATIO N H TOTABLES 07/01/2021 ANTIFUNGAL tolnaftate ADD TO FORMULARY Tier 1 CREAM

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 18 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 CHILDREN'S acetaminophen ADD TO FORMULARY Tier 1 FEVER REDUCER,CHIL DREN'S FEVER REDUCING 07/01/2021 GERI-LANTA magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 gas relief simethicone ADD TO FORMULARY Tier 1 07/01/2021 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Tier 1 07/01/2021 LUBRICANT carboxymethylcellulose ADD TO FORMULARY Tier 1 EYE DROP sodium 07/01/2021 tuberculin syringe syringe, disposable, 1 ml ADD TO FORMULARY Tier 1 07/01/2021 GAS RELIEF simethicone ADD TO FORMULARY Tier 1 07/01/2021 ANTACID calcium carbonate ADD TO FORMULARY Tier 1 EXTRA STRENGTH,ANT ACID 07/01/2021 ALL DAY cetirizine hcl ADD TO FORMULARY Tier 1 ALLERGY,CHILD REN'S ALL DAY ALLERGY 07/01/2021 calcium 500-vit calcium ADD TO FORMULARY Tier 1 d3,calcium 500 + carbonate/cholecalciferol vit d,calcium 500 (vitamin d3) + d 07/01/2021 levonorgestrel levonorgestrel ADD TO FORMULARY Tier 1 07/01/2021 ALAWAY ketotifen fumarate ADD TO FORMULARY Tier 1 07/01/2021 ALLERGY diphenhydramine hcl ADD TO FORMULARY Tier 1 RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 19 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 safety-lok safety syringe,safety with needle,3 ADD TO FORMULARY Tier 1 syringes ml 07/01/2021 SILADRYL diphenhydramine hcl ADD TO FORMULARY Tier 1 07/01/2021 EXTRA ACTION guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 COUGH,COUGH an hbr SYRUP DM,COUGH DM 07/01/2021 SALONPAS lidocaine ADD TO FORMULARY Tier 1 07/01/2021 ACID famotidine ADD TO FORMULARY Tier 1 CONTROLLER 07/01/2021 children's ibuprofen ADD TO FORMULARY Tier 1 ibuprofen 07/01/2021 ALLERGY chlorpheniramine maleate ADD TO FORMULARY Tier 1 07/01/2021 triamcinolone triamcinolone acetonide ADD TO FORMULARY Tier 1 acetonide 07/01/2021 TUSSIN DM guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 an hbr 07/01/2021 safety-lok syringe,safety with needle,3 ADD TO FORMULARY Tier 1 syringes ml 07/01/2021 ALLERGY loratadine/pseudoephedrine ADD TO FORMULARY Tier 1 RELIEF D- sulfate 24HR,ALLERGY RELIEF D- 24,ALLERGY RELIEF D 07/01/2021 acetaminophen acetaminophen ADD TO FORMULARY Tier 1 07/01/2021 PURELAX polyethylene glycol 3350 ADD TO FORMULARY Tier 1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 20 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ACNE FOAMING benzoyl peroxide ADD TO FORMULARY Tier 1 FACE WASH,FOAMING ACNE FACE WASH 07/01/2021 BANOPHEN diphenhydramine hcl ADD TO FORMULARY Tier 1 07/01/2021 M-DRYL diphenhydramine hcl ADD TO FORMULARY Tier 1 07/01/2021 children's cetirizine hcl ADD TO FORMULARY Tier 1 cetirizine hcl 07/01/2021 M-PAP acetaminophen ADD TO FORMULARY Tier 1 07/01/2021 vitamin b-2 riboflavin,riboflavin (vitamin ADD TO FORMULARY Tier 1 b2) 07/01/2021 vitamin d,vitamin cholecalciferol (vitamin d3) ADD TO FORMULARY Tier 1 d3 07/01/2021 PAIN RELIEVER acetaminophen ADD TO FORMULARY Tier 1 07/01/2021 tioconazole- tioconazole ADD TO FORMULARY Tier 1 1,tioconazole 1 07/01/2021 SILTUSSIN DM guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 an hbr 07/01/2021 ACID REDUCER famotidine ADD TO FORMULARY Tier 1 07/01/2021 SOOTHE bismuth subsalicylate ADD TO FORMULARY Tier 1 07/01/2021 DAILY VITE multivitamin with iron ADD TO FORMULARY Tier 1 WITH IRON 07/01/2021 stool softener- sennosides/docusate ADD TO FORMULARY Tier 1 laxative,stool sodium softener 07/01/2021 DIABETIC guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 TUSSIN DM an hbr 07/01/2021 CHILDREN'S acetaminophen ADD TO FORMULARY Tier 1 PAIN RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 21 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 vitamins a,c,d pediatric multivit with a,c,d3 ADD TO FORMULARY Tier 1 and no.21/sodium fluoride fluoride,vitamins a,d,c and fluoride 07/01/2021 SOOTHE bismuth subsalicylate ADD TO FORMULARY Tier 1 07/01/2021 TUSSIN DM guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 an hbr 07/01/2021 INFANTS' GAS simethicone ADD TO FORMULARY Tier 1 RELIEF,INFANT GAS RELIEF 07/01/2021 children's cetirizine hcl ADD TO FORMULARY Tier 1 cetirizine hcl 07/01/2021 BION TEARS dextran 70/hypromellose/pf ADD TO FORMULARY Tier 1 07/01/2021 luer-lok syringe syringe, disposable, 1 ml ADD TO FORMULARY Tier 1 07/01/2021 24 HOUR NASAL triamcinolone acetonide ADD TO FORMULARY Tier 1 ALLERGY 07/01/2021 DAILY- multivitamin with folic ADD TO FORMULARY Tier 1 VITE,DAILY VITE acid,multivitamin 07/01/2021 STOMACH bismuth subsalicylate ADD TO FORMULARY Tier 1 RELIEF 07/01/2021 DOCU LIQUID docusate sodium ADD TO FORMULARY Tier 1 07/01/2021 GUAIATUSSIN codeine ADD TO FORMULARY Tier 1 AC phosphate/guaifenesin 07/01/2021 saline mist sodium chloride ADD TO FORMULARY Tier 1 07/01/2021 DAILY saccharomyces boulardii ADD TO FORMULARY Tier 1 PROBIOTIC 07/01/2021 ultra comfort syringe with ADD TO FORMULARY Tier 1 needle,disposable,insulin 1 ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 22 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 RECTASMOOTH lidocaine ADD TO FORMULARY Tier 1 E 07/01/2021 ATHLETE'S terbinafine hcl ADD TO FORMULARY Tier 1 FOOT 07/01/2021 ALMACONE-2 magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 PETROLATUM mineral ADD TO FORMULARY Tier 1 oil/petrolatum,hydrophilic 07/01/2021 GENTEAL dextran 70/hypromellose ADD TO FORMULARY Tier 1 TEARS 07/01/2021 COMFORT GEL magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 MUCUS D guaifenesin/pseudoephedrin ADD TO FORMULARY Tier 1 e hcl 07/01/2021 simethicone simethicone ADD TO FORMULARY Tier 1 07/01/2021 syringe syringe, disposable, 3 ml ADD TO FORMULARY Tier 1 07/01/2021 oyster shell calcium ADD TO FORMULARY Tier 1 calcium w-vit carbonate/cholecalciferol d,oyster shell (vitamin d3) calcium-vit d3 07/01/2021 ADULT TUSSIN guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 DM an hbr 07/01/2021 vitamin c ascorbic acid ADD TO FORMULARY Tier 1 07/01/2021 monoject syringe,safety with needle,1 ADD TO FORMULARY Tier 1 tuberculin safety ml syr

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 23 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 calcium 600 + vit calcium ADD TO FORMULARY Tier 1 d,calcium 600-vit carbonate/cholecalciferol d3,super calcium (vitamin d3) 600-vit d3,calcium with vitamin d 07/01/2021 oyster shell calcium carbonate ADD TO FORMULARY Tier 1 calcium 07/01/2021 ALL DAY PAIN naproxen sodium ADD TO FORMULARY Tier 1 RELIEF 07/01/2021 NATURAL FIBER psyllium seed (with ADD TO FORMULARY Tier 1 dextrose),psyllium seed (with sugar),psyllium seed 07/01/2021 COUGH DM ER dextromethorphan polistirex ADD TO FORMULARY Tier 1 07/01/2021 TRAVEL meclizine hcl ADD TO FORMULARY Tier 1 SICKNESS 07/01/2021 SENNA sennosides ADD TO FORMULARY Tier 1 LAXATIVE 07/01/2021 safety-lok safety syringe,safety with needle,3 ADD TO FORMULARY Tier 1 syringes ml 07/01/2021 ibuprofen ib ibuprofen ADD TO FORMULARY Tier 1 07/01/2021 ANTIBIOTIC neomycin sulfate/bacitracin ADD TO FORMULARY Tier 1 zinc/polymyxin b 07/01/2021 pain relief acetaminophen ADD TO FORMULARY Tier 1 07/01/2021 sure comfort syringe with ADD TO FORMULARY Tier 1 needle,insulin,0.5 ml 07/01/2021 antacid- magnesium ADD TO FORMULARY Tier 1 antigas,antacid- hydroxide/aluminum gas relief hydroxide/simethicone

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 24 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ANTACID magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 integra syringe syringe,safety with needle,3 ADD TO FORMULARY Tier 1 ml 07/01/2021 MINTOX magnesium ADD TO FORMULARY Tier 1 MAXIMUM hydroxide/aluminum STRENGTH hydroxide/simethicone 07/01/2021 ADULT WAL- guaifenesin ADD TO FORMULARY Tier 1 TUSSIN 07/01/2021 WAL-SOM doxylamine succinate ADD TO FORMULARY Tier 1 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 1 needle,insulin,0.3 ml,syringe with needle,insulin disposable,0.3 ml 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 1 needle,insulin,0.3 ml,syringe with needle,insulin disposable,0.3 ml 07/01/2021 BANOPHEN diphenhydramine hcl ADD TO FORMULARY Tier 1 07/01/2021 ALLERGY loratadine/pseudoephedrine ADD TO FORMULARY Tier 1 RELIEF-NASAL sulfate DECONGEST 07/01/2021 WAL-DRYL diphenhydramine hcl ADD TO FORMULARY Tier 1 ALLERGY 07/01/2021 PINWORM pyrantel pamoate ADD TO FORMULARY Tier 1 MEDICINE,PINW ORM TREATMENT 07/01/2021 PANOXYL benzoyl peroxide ADD TO FORMULARY Tier 1 07/01/2021 ROBAFEN guaifenesin ADD TO FORMULARY Tier 1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 25 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 MUSCLE RUB methyl ADD TO FORMULARY Tier 1 ULTRA salicylate/menthol/camphor STRENGTH 07/01/2021 children's acetaminophen ADD TO FORMULARY Tier 1 acetaminophen 07/01/2021 METAMUCIL psyllium husk (with sugar) ADD TO FORMULARY Tier 1 07/01/2021 allergy loratadine ADD TO FORMULARY Tier 1 relief,allergy 07/01/2021 LITTLE simethicone ADD TO FORMULARY Tier 1 REMEDIES GAS RELIEF 07/01/2021 saccharomyces saccharomyces boulardii ADD TO FORMULARY Tier 1 boulardii,sacchar omycin df 07/01/2021 WAL-FEX fexofenadine hcl ADD TO FORMULARY Tier 1 ALLERGY 07/01/2021 WAL-FINATE chlorpheniramine maleate ADD TO FORMULARY Tier 1 07/01/2021 MINTOX magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 MUCUS RELIEF guaifenesin ADD TO FORMULARY Tier 1 ER,MUCUS ER,MUCUS-ER 07/01/2021 CHILDREN'S diphenhydramine hcl ADD TO FORMULARY Tier 1 ALLERGY,CHILD REN'S ALLERGY RELIEF 07/01/2021 BENADRYL diphenhydramine hcl ADD TO FORMULARY Tier 1 ITCH STOPPING 07/01/2021 FLINTSTONES multivitamin ADD TO FORMULARY Tier 1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 26 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 senna s,senna- sennosides/docusate ADD TO FORMULARY Tier 1 s,senna-s sodium laxative 07/01/2021 CHILDREN'S cetirizine hcl ADD TO FORMULARY Tier 1 WAL-ZYR 07/01/2021 CHEWABLE- multivitamin with iron ADD TO FORMULARY Tier 1 VITE WITH IRON 07/01/2021 vitamin b-12,b-12 cyanocobalamin (vitamin b- ADD TO FORMULARY Tier 1 12) 07/01/2021 GAS RELIEF simethicone ADD TO FORMULARY Tier 1 07/01/2021 multivitamins with multivitamin with ADD TO FORMULARY Tier 1 iron iron,multivitamins with iron 07/01/2021 COL-RITE docusate sodium ADD TO FORMULARY Tier 1 07/01/2021 RENA-VITE folic acid/vitamin b complex ADD TO FORMULARY Tier 1 and vitamin c,folic acid/vitamin b comp w-c 07/01/2021 DOK docusate sodium ADD TO FORMULARY Tier 1 07/01/2021 LICE permethrin ADD TO FORMULARY Tier 1 TREATMENT 07/01/2021 STOOL docusate sodium ADD TO FORMULARY Tier 1 SOFTENER 07/01/2021 MOTION dimenhydrinate ADD TO FORMULARY Tier 1 SICKNESS 07/01/2021 children's acetaminophen ADD TO FORMULARY Tier 1 acetaminophen,c hildrens suspension 07/01/2021 GAS RELIEF simethicone ADD TO FORMULARY Tier 1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 27 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ALLERGY loratadine ADD TO FORMULARY Tier 1 RELIEF,CHILDR EN'S ALLERGY RELIEF 07/01/2021 STOMACH bismuth subsalicylate ADD TO FORMULARY Tier 1 RELIEF 07/01/2021 CHILDREN'S diphenhydramine hcl ADD TO FORMULARY Tier 1 AURODRYL ALLERGY 07/01/2021 pain reliever,pain acetaminophen ADD TO FORMULARY Tier 1 relief extra strength 07/01/2021 ultra comfort syringe with ADD TO FORMULARY Tier 1 needle,disposable,insulin 1 ml 07/01/2021 DAIRY RELIEF lactase ADD TO FORMULARY Tier 1 07/01/2021 CHILDREN'S acetaminophen ADD TO FORMULARY Tier 1 AUROPHEN PAIN-FEVER 07/01/2021 ALLERGY diphenhydramine hcl ADD TO FORMULARY Tier 1 RELIEF,CHILDR EN'S ALLERGY RELIEF 07/01/2021 safetyglide tb syringe with ADD TO FORMULARY Tier 1 syringe needle,disposable, 1 ml 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 1 needle,disposable,insulin 1 ml 07/01/2021 HEARTBURN famotidine ADD TO FORMULARY Tier 1 RELIEF 07/01/2021 ZEASORB- miconazole nitrate ADD TO FORMULARY Tier 1 AF,ZEASORB AF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 28 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 monoject syringe syringe, disposable, 3 ml ADD TO FORMULARY Tier 1 07/01/2021 CLEARLAX polyethylene glycol 3350 ADD TO FORMULARY Tier 1 07/01/2021 slow release iron ferrous sulfate ADD TO FORMULARY Tier 1 07/01/2021 CLEARLAX polyethylene glycol 3350 ADD TO FORMULARY Tier 1 07/01/2021 underpad underpads ADD TO FORMULARY Tier 1 07/01/2021 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Tier 1 07/01/2021 GAVILAX polyethylene glycol 3350 ADD TO FORMULARY Tier 1 07/01/2021 SILAPAP acetaminophen ADD TO FORMULARY Tier 1 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 1 needle,disposable,insulin 1 ml 07/01/2021 WAL-DRYL diphenhydramine hcl ADD TO FORMULARY Tier 1 07/01/2021 pain relief acetaminophen ADD TO FORMULARY Tier 1 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 1 needle,insulin,0.5 ml 07/01/2021 nasal pseudoephedrine hcl ADD TO FORMULARY Tier 1 decongestant 07/01/2021 calcium calcium carbonate ADD TO FORMULARY Tier 1 carbonate 07/01/2021 ASPERCREME lidocaine ADD TO FORMULARY Tier 1 LIDOCAINE 07/01/2021 MUCUS RELIEF guaifenesin/pseudoephedrin ADD TO FORMULARY Tier 1 D e hcl 07/01/2021 CHILDREN'S sodium chloride ADD TO FORMULARY Tier 1 SALINE NASAL SPRAY 07/01/2021 ANTACID PLUS magnesium ADD TO FORMULARY Tier 1 ANTI-GAS hydroxide/aluminum hydroxide/simethicone

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 29 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 DIPHEDRYL diphenhydramine hcl ADD TO FORMULARY Tier 1 07/01/2021 VIRTUSSIN AC codeine ADD TO FORMULARY Tier 1 phosphate/guaifenesin 07/01/2021 vitamin cholecalciferol (vitamin d3) ADD TO FORMULARY Tier 1 d3,vitamin d 07/01/2021 ONE DAILY multivitamin ADD TO FORMULARY Tier 1 MULTIVITAMIN, ONE-DAILY MULTI-VITAMIN 07/01/2021 calcium 500-vit calcium ADD TO FORMULARY Tier 1 d3 carbonate/cholecalciferol (vitamin d3) 07/01/2021 vitamin b-1 thiamine ADD TO FORMULARY Tier 1 mononitrate,thiamine mononitrate (vit b1) 07/01/2021 8HR MUSCLE acetaminophen ADD TO FORMULARY Tier 1 ACHES-PAIN 07/01/2021 WAL-ITIN D loratadine/pseudoephedrine ADD TO FORMULARY Tier 1 sulfate 07/01/2021 AQUANIL HC hydrocortisone ADD TO FORMULARY Tier 1 07/01/2021 GUMMI BEAR multivitamin ADD TO FORMULARY Tier 1 MULTIVITAMIN, KID'S GUMMY BEAR VITAMINS 07/01/2021 COMFORT GEL magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 12 hour pseudoephedrine hcl ADD TO FORMULARY Tier 1 decongestant 07/01/2021 fish oil omega-3 fatty ADD TO FORMULARY Tier 1 acids/docosahexanoic acid/epa/fish oil

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 30 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 WAL-MUCIL psyllium husk (with sugar) ADD TO FORMULARY Tier 1 NATURAL FIBER LAX 07/01/2021 ANIMAL pediatric multivitamin no.17 ADD TO FORMULARY Tier 1 SHAPES 07/01/2021 NEW DAY levonorgestrel ADD TO FORMULARY Tier 1 07/01/2021 vitamin b-6 pyridoxine hcl (vitamin ADD TO FORMULARY Tier 1 b6),pyridoxine hcl 07/01/2021 STIMULANT sennosides/docusate ADD TO FORMULARY Tier 1 LAXATIVE PLUS sodium 07/01/2021 vitamin b- cyanocobalamin (vitamin b- ADD TO FORMULARY Tier 1 12,cyanocobalam 12) in,b-12 07/01/2021 wal-itin loratadine ADD TO FORMULARY Tier 1 07/01/2021 ARTHRITIS diclofenac sodium ADD TO FORMULARY Tier 1 PAIN,ARTHRITIS PAIN RELIEVER 07/01/2021 REESE'S pyrantel pamoate ADD TO FORMULARY Tier 1 PINWORM 07/01/2021 acid reducer famotidine ADD TO FORMULARY Tier 1 07/01/2021 HEALTHYLAX polyethylene glycol 3350 ADD TO FORMULARY Tier 1 07/01/2021 vitamin b- cyanocobalamin (vitamin b- ADD TO FORMULARY Tier 1 12,cyanocobalam 12) in 07/01/2021 ANTIBIOTIC bacitracin zinc ADD TO FORMULARY Tier 1 07/01/2021 ACID famotidine ADD TO FORMULARY Tier 1 CONTROLLER,A CID CONTROL 07/01/2021 eye itch relief ketotifen fumarate ADD TO FORMULARY Tier 1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 31 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 CHILDREN'S cetirizine hcl ADD TO FORMULARY Tier 1 ALLERGY RELIEF 07/01/2021 WAL-MUCIL psyllium husk ADD TO FORMULARY Tier 1 07/01/2021 PURELAX polyethylene glycol 3350 ADD TO FORMULARY Tier 1 07/01/2021 luer-lok syringe syringe, disposable, 3 ml ADD TO FORMULARY Tier 1 07/01/2021 CEROVITE multivitamin with ADD TO FORMULARY Tier 1 SENIOR minerals/lutein 07/01/2021 MY CHOICE levonorgestrel ADD TO FORMULARY Tier 1 07/01/2021 LORATA-DINE D loratadine/pseudoephedrine ADD TO FORMULARY Tier 1 sulfate 07/01/2021 ALL DAY cetirizine hcl ADD TO FORMULARY Tier 1 ALLERGY 07/01/2021 bismuth bismuth subsalicylate ADD TO FORMULARY Tier 1 07/01/2021 STOOL docusate calcium ADD TO FORMULARY Tier 1 SOFTENER 07/01/2021 BP benzoyl peroxide ADD TO FORMULARY Tier 1 07/01/2021 DERMAREST hydrocortisone ADD TO FORMULARY Tier 1 ECZEMA 07/01/2021 calcium 250-vit calcium ADD TO FORMULARY Tier 1 d3,oyster shell carbonate/cholecalciferol calcium-vit d3 (vitamin d3) 07/01/2021 ulticare syringe with ADD TO FORMULARY Tier 1 needle,insulin,0.5 ml 07/01/2021 ANTI-GAS simethicone ADD TO FORMULARY Tier 1 07/01/2021 BP benzoyl peroxide ADD TO FORMULARY Tier 1 07/01/2021 saline nasal sodium chloride ADD TO FORMULARY Tier 1 spray

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 32 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 arthritis acetaminophen ADD TO FORMULARY Tier 1 pain,arthritis pain relief,arthritis pain reliever 07/01/2021 NASAL sodium chloride ADD TO FORMULARY Tier 1 MOISTURIZING 07/01/2021 REFRESH carboxymethylcellulose ADD TO FORMULARY Tier 1 CELLUVISC sodium 07/01/2021 MI ACID,MI-ACID magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 ANTI-ITCH hydrocortisone ADD TO FORMULARY Tier 1 07/01/2021 D3-2000 cholecalciferol (vitamin d3) ADD TO FORMULARY Tier 1 07/01/2021 ADVANCED magnesium ADD TO FORMULARY Tier 1 ANTACID- hydroxide/aluminum ANTIGAS,ADVA hydroxide/simethicone NCED ANTACID 07/01/2021 ulticare syringe with ADD TO FORMULARY Tier 1 needle,disposable,insulin 1 ml 07/01/2021 easy touch syringe with ADD TO FORMULARY Tier 1 needle,insulin,0.5 ml 07/01/2021 guaifenesin guaifenesin ADD TO FORMULARY Tier 1 07/01/2021 CHILDREN'S diphenhydramine hcl ADD TO FORMULARY Tier 1 ALLERGY RELIEF 07/01/2021 TUSSIN MUCUS- guaifenesin ADD TO FORMULARY Tier 1 CHEST CONGESTION,A DULT TUSSIN CHEST CONGESTION

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 33 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 WAL-PROFEN ibuprofen ADD TO FORMULARY Tier 1 07/01/2021 tuberculin syringe syringe with ADD TO FORMULARY Tier 1 needle,disposable, 1 ml 07/01/2021 ANTACID calcium carbonate ADD TO FORMULARY Tier 1 EXTRA STRENGTH,ANT ACID 07/01/2021 GERI-MOX magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 HEADACHE aspirin/acetaminophen/caffei ADD TO FORMULARY Tier 1 FORMULA,HEAD ne ACHE RELIEF 07/01/2021 carboxymethylcel carboxymethylcellulose ADD TO FORMULARY Tier 1 lulose sodium sodium 07/01/2021 MI-ACID simethicone ADD TO FORMULARY Tier 1 07/01/2021 MAPAP acetaminophen ADD TO FORMULARY Tier 1 07/01/2021 ANTI-FUNGAL tolnaftate ADD TO FORMULARY Tier 1 07/01/2021 multivitamins,mult multivitamin ADD TO FORMULARY Tier 1 ivitamin 07/01/2021 purified water ADD TO FORMULARY Tier 1 water,water,distill ed water 07/01/2021 MOTION meclizine hcl ADD TO FORMULARY Tier 1 SICKNESS RELIEF 07/01/2021 SELSUN BLUE salicylic acid ADD TO FORMULARY Tier 1 NATURALS 07/01/2021 TOTAL B WITH b-complex with vitamin c ADD TO FORMULARY Tier 1 C 07/01/2021 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Tier 1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 34 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ADULT WAL- guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 TUSSIN an hbr DM,WAL- TUSSIN DM 07/01/2021 ANTACID- magnesium ADD TO FORMULARY Tier 1 ANTIGAS hydroxide/aluminum hydroxide/simethicone 07/01/2021 ANTACID- magnesium ADD TO FORMULARY Tier 1 ANTIGAS hydroxide/aluminum hydroxide/simethicone 07/01/2021 vitamin cholecalciferol (vitamin d3) ADD TO FORMULARY Tier 1 d3,vitamin d 07/01/2021 WAL-MUCIL psyllium husk (with sugar) ADD TO FORMULARY Tier 1 07/01/2021 WAL-DRYL diphenhydramine hcl ADD TO FORMULARY Tier 1 ALLERGY 07/01/2021 NATURAL DAILY psyllium husk (with sugar) ADD TO FORMULARY Tier 1 FIBER 07/01/2021 INFANTS' PAIN- acetaminophen ADD TO FORMULARY Tier 1 FEVER,INFANT PAIN-FEVER 07/01/2021 TAKE ACTION levonorgestrel ADD TO FORMULARY Tier 1 07/01/2021 FEROSUL ferrous sulfate ADD TO FORMULARY Tier 1 07/01/2021 GERI-DRYL diphenhydramine hcl ADD TO FORMULARY Tier 1 07/01/2021 PHILLIPS' docusate sodium ADD TO FORMULARY Tier 1 LAXATIVE 07/01/2021 CHILDREN'S acetaminophen ADD TO FORMULARY Tier 1 PAIN-FEVER 07/01/2021 integra syringe syringe,safety with needle,3 ADD TO FORMULARY Tier 1 ml 07/01/2021 iron ferrous sulfate ADD TO FORMULARY Tier 1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 35 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ALLERGY diphenhydramine hcl ADD TO FORMULARY Tier 1 07/01/2021 BANOPHEN diphenhydramine hcl ADD TO FORMULARY Tier 1 07/01/2021 SILACE docusate sodium ADD TO FORMULARY Tier 1 07/01/2021 ADVANCED magnesium ADD TO FORMULARY Tier 1 ANTACID- hydroxide/aluminum ANTIGAS hydroxide/simethicone 07/01/2021 stool softener docusate sodium ADD TO FORMULARY Tier 1 07/01/2021 balanced b- folic acid/vitamin b complex ADD TO FORMULARY Tier 1 complex,b- and vitamin c,folic complex with acid/vitamin b comp w-c vitamin c,super b- complex,super b complex,b- complex,super vitamin b,b- complex plus vitamin c,super vitamin b complex,super b complex-vitamin c,vitamin b complex-vitamin c 07/01/2021 OYSCO 500-VIT calcium ADD TO FORMULARY Tier 1 D3 carbonate/cholecalciferol (vitamin d3) 07/01/2021 PAIN acetaminophen ADD TO FORMULARY Tier 1 RELIEF,PAIN RELIEVER 07/01/2021 NIGHTTIME doxylamine succinate ADD TO FORMULARY Tier 1 SLEEP-AID 07/01/2021 TRUEPLUS dextrose ADD TO FORMULARY Tier 1 GLUCOSE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 36 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 CERTAVITE- multivitamin/ferrous ADD TO FORMULARY Tier 1 ANTIOXIDANT fumarate/folic acid 07/01/2021 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Tier 1 07/01/2021 LITTLE sodium chloride ADD TO FORMULARY Tier 1 REMEDIES,LITT LE REMEDIES STUFFY NOSE 07/01/2021 CALCIUM calcium carbonate ADD TO FORMULARY Tier 1 ANTACID 07/01/2021 KONSYL psyllium husk (with sugar) ADD TO FORMULARY Tier 1 07/01/2021 ALLERGY fexofenadine hcl ADD TO FORMULARY Tier 1 RELIEF 07/01/2021 EAR WAX carbamide peroxide ADD TO FORMULARY Tier 1 REMOVAL 07/01/2021 CHILDREN'S guaifenesin ADD TO FORMULARY Tier 1 CHEST CONGESTION 07/01/2021 miconazole miconazole nitrate ADD TO FORMULARY Tier 1 nitrate,miconazol e-7,miconazole 7 07/01/2021 ANTIFUNGAL miconazole nitrate ADD TO FORMULARY Tier 1 CREAM,ANTI- FUNGAL CREAM 07/01/2021 WAL-PHED pseudoephedrine hcl ADD TO FORMULARY Tier 1 07/01/2021 multiple vitamins multivitamin ADD TO FORMULARY Tier 1 07/01/2021 FIBER psyllium husk (with sugar) ADD TO FORMULARY Tier 1 THERAPY,FIBE R

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 37 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 1 needle,insulin,0.5 ml,syringe with needle,insulin disposable,0.5 ml 07/01/2021 natural fiber psyllium seed (with ADD TO FORMULARY Tier 1 powder dextrose),psyllium seed (with sugar) 07/01/2021 WAL-PHED 12 pseudoephedrine hcl ADD TO FORMULARY Tier 1 HOUR 07/01/2021 ADULT glycerin ADD TO FORMULARY Tier 1 GLYCERIN 07/01/2021 FLINTSTONES multivitamin ADD TO FORMULARY Tier 1 WITH EXTRA C 07/01/2021 WAL-ACT D triprolidine ADD TO FORMULARY Tier 1 COLD & hcl/pseudoephedrine hcl ALLERGY 07/01/2021 vitamin c with ascorbic acid ADD TO FORMULARY Tier 1 rose hips 07/01/2021 clotrimazole- clotrimazole ADD TO FORMULARY Tier 1 3,clotrimazole 3 07/01/2021 vitamin b-6 pyridoxine hcl (vitamin ADD TO FORMULARY Tier 1 b6),pyridoxine hcl 07/01/2021 vitamin c ascorbic acid,ascorbate ADD TO FORMULARY Tier 1 calcium 07/01/2021 CITROMA magnesium citrate ADD TO FORMULARY Tier 1 07/01/2021 diphenhydramine diphenhydramine hcl ADD TO FORMULARY Tier 1 hcl 07/01/2021 SILTUSSIN SA guaifenesin ADD TO FORMULARY Tier 1 07/01/2021 MEDICATED glycerin/aloe vera/witch ADD TO FORMULARY Tier 1 WIPES,MEDICA hazel,witch hazel TED PADS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 38 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 tuberculin syringe syringe with ADD TO FORMULARY Tier 1 needle,disposable, 1 ml 07/01/2021 ROBAFEN DM guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 COUGH an hbr 07/01/2021 EAR WAX carbamide peroxide ADD TO FORMULARY Tier 1 REMOVAL 07/01/2021 CAL-GEST calcium carbonate ADD TO FORMULARY Tier 1 07/01/2021 oyster shell calcium ADD TO FORMULARY Tier 1 calcium-vitamin carbonate/cholecalciferol d,oyster shell (vitamin d3) calcium 07/01/2021 pain relief extra acetaminophen ADD TO FORMULARY Tier 1 strength,pain relief 07/01/2021 ONE DAILY multivitamin ADD TO FORMULARY Tier 1 ESSENTIAL 07/01/2021 WART salicylic acid ADD TO FORMULARY Tier 1 REMOVER 07/01/2021 CALCIDOL ergocalciferol (vitamin d2) ADD TO FORMULARY Tier 1 07/01/2021 REGULOID psyllium husk (with sugar) ADD TO FORMULARY Tier 1 07/01/2021 WAL-PHED D ER pseudoephedrine hcl ADD TO FORMULARY Tier 1 07/01/2021 ANECREAM5 lidocaine ADD TO FORMULARY Tier 1 07/01/2021 vitamin b-6 pyridoxine hcl (vitamin ADD TO FORMULARY Tier 1 b6),pyridoxine hcl 07/01/2021 thiamine thiamine hcl ADD TO FORMULARY Tier 1 hcl,vitamin b-1 07/01/2021 ONE DAILY multivitamin/ferrous ADD TO FORMULARY Tier 1 PLUS IRON,ONE fumarate/folic acid DAILY WITH IRON

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 39 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ACNE benzoyl peroxide ADD TO FORMULARY Tier 1 MEDICATION 07/01/2021 TUSSIN MUCUS- guaifenesin ADD TO FORMULARY Tier 1 CHEST CONGESTION 07/01/2021 CHILDREN'S ketotifen fumarate ADD TO FORMULARY Tier 1 ALAWAY 07/01/2021 ARTHRITIS PAIN acetaminophen ADD TO FORMULARY Tier 1 RELIEVER 07/01/2021 ENEMA sodium ADD TO FORMULARY Tier 1 phosphate,monobasic/sodiu m phosphate,dibasic 07/01/2021 LUBRIFRESH mineral oil/petrolatum,white ADD TO FORMULARY Tier 1 PM 07/01/2021 SILTUSSIN DM guaifenesin/dextromethorph ADD TO FORMULARY Tier 1 DAS an hbr 07/01/2021 sure comfort syringe with ADD TO FORMULARY Tier 1 needle,insulin,0.5 ml 07/01/2021 insulin syringe syringe with ADD TO FORMULARY Tier 1 needle,disposable,insulin 1 ml 07/01/2021 MYLANTA,MYLA magnesium ADD TO FORMULARY Tier 1 NTA MAXIMUM hydroxide/aluminum STRENGTH,MYL hydroxide/simethicone ANTA DOUBLE- STRENGTH 07/01/2021 MIGRAINE aspirin/acetaminophen/caffei ADD TO FORMULARY Tier 1 RELIEF ne 07/01/2021 ARTHRITIS PAIN capsaicin ADD TO FORMULARY Tier 1 RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 40 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 calcium 600-vit calcium ADD TO FORMULARY Tier 1 d3 carbonate/cholecalciferol (vitamin d3) 07/01/2021 PREPARATION hydrocortisone ADD TO FORMULARY Tier 1 H 07/01/2021 MAPAP acetaminophen ADD TO FORMULARY Tier 1 07/01/2021 PAIN RELIEVER aspirin/acetaminophen/caffei ADD TO FORMULARY Tier 1 PLUS ne 07/01/2021 ANTACID magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 NATURAL dextran 70/hypromellose/pf ADD TO FORMULARY Tier 1 TEARS 07/01/2021 ANTACID magnesium ADD TO FORMULARY Tier 1 hydroxide/aluminum hydroxide/simethicone 07/01/2021 SARNA pramoxine hcl ADD TO FORMULARY Tier 1 SENSITIVE,SAR NA 07/01/2021 CHILDREN'S diphenhydramine hcl ADD TO FORMULARY Tier 1 WAL-DRYL ALLERGY 07/01/2021 SUDOGEST pseudoephedrine hcl ADD TO FORMULARY Tier 1 07/01/2021 clotrimazole-7 clotrimazole ADD TO FORMULARY Tier 1 07/01/2021 CHILDREN'S cetirizine hcl ADD TO FORMULARY Tier 1 ALL DAY ALLERGY 07/01/2021 GERI-KOT sennosides ADD TO FORMULARY Tier 1 07/01/2021 ACNE benzoyl peroxide ADD TO FORMULARY Tier 1 MEDICATION

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 41 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ALLERGY EYE naphazoline hcl/pheniramine ADD TO FORMULARY Tier 1 maleate 07/01/2021 ASPIR 81 aspirin ADD TO FORMULARY Tier 1 07/01/2021 saline nasal sodium chloride ADD TO FORMULARY Tier 1 spray,ultra saline 07/01/2021 GENTLE bisacodyl ADD TO FORMULARY Tier 1 LAXATIVE 07/01/2021 ALLERGY cetirizine hcl ADD TO FORMULARY Tier 1 RELIEF,ALLERG Y 07/01/2021 MAPAP acetaminophen ADD TO FORMULARY Tier 1 ARTHRITIS PAIN 07/01/2021 ENSURE LIQUID lactose-reduced food ADD TO FORMULARY Tier 3 07/01/2021 ENSURE HIGH lactose-reduced food ADD TO FORMULARY Tier 3 PROTEIN 07/01/2021 ENSURE lactose-reduced food ADD TO FORMULARY Tier 3 ACTIVE PROTEIN- MUSCLE 07/01/2021 trueplus ketone urine acetone test,strips ADD UM: QUANTITY 100 / 100 days test strip 07/01/2021 ATHLETE'S terbinafine hcl ADD UM: QUANTITY 120 / 30 days FOOT 07/01/2021 ANTIFUNGAL tolnaftate ADD UM: QUANTITY 120 / 30 days CREAM 07/01/2021 WART salicylic acid ADD UM: QUANTITY 15 / 30 days REMOVER 07/01/2021 triamcinolone triamcinolone acetonide ADD UM: QUANTITY 16.9 / 30 days acetonide 07/01/2021 24 HOUR NASAL triamcinolone acetonide ADD UM: QUANTITY 16.9 / 30 days ALLERGY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 42 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ANTIFUNGAL clotrimazole ADD UM: QUANTITY 180 / 30 days 07/01/2021 ATHLETE'S clotrimazole ADD UM: QUANTITY 180 / 30 days FOOT 07/01/2021 ARTHRITIS diclofenac sodium ADD UM: QUANTITY 300 / 30 days PAIN,ARTHRITIS PAIN RELIEVER 07/01/2021 ARTHRITIS PAIN capsaicin ADD UM: QUANTITY 42.5 / 30 days RELIEF 07/01/2021 ZOSTRIX HP capsaicin ADD UM: QUANTITY 42.5 / 30 days 07/01/2021 capsaicin capsaicin ADD UM: QUANTITY 42.5 / 30 days 07/01/2021 CHILDREN'S guaifenesin ADD UM: AGE At least 2 yrs old CHEST CONGESTION 07/01/2021 ROBAFEN guaifenesin ADD UM: AGE At least 2 yrs old 07/01/2021 ADULT WAL- guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old TUSSIN DM MAX an hbr 07/01/2021 guaifenesin guaifenesin ADD UM: AGE At least 2 yrs old 07/01/2021 TUSSIN MUCUS- guaifenesin ADD UM: AGE At least 2 yrs old CHEST CONGESTION,A DULT TUSSIN CHEST CONGESTION 07/01/2021 SILTUSSIN DM guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old an hbr 07/01/2021 ROBAFEN DM guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old COUGH-CHEST an hbr CONGEST 07/01/2021 ADULT WAL- guaifenesin ADD UM: AGE At least 2 yrs old TUSSIN

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 43 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ADULT TUSSIN guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old DM an hbr 07/01/2021 TUSSIN MUCUS- guaifenesin ADD UM: AGE At least 2 yrs old CHEST CONGESTION 07/01/2021 DIABETIC guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old TUSSIN DM an hbr 07/01/2021 EXTRA ACTION guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old COUGH,COUGH an hbr SYRUP DM,COUGH DM 07/01/2021 SILTUSSIN DM guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old DAS an hbr 07/01/2021 ADULT WAL- guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old TUSSIN an hbr DM,WAL- TUSSIN DM 07/01/2021 SILTUSSIN SA guaifenesin ADD UM: AGE At least 2 yrs old 07/01/2021 TUSSIN DM guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old an hbr 07/01/2021 TUSSIN DM guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old an hbr 07/01/2021 ROBAFEN DM guaifenesin/dextromethorph ADD UM: AGE At least 2 yrs old COUGH an hbr 07/01/2021 WAL-PHED pseudoephedrine hcl ADD UM: AGE At least 4 yrs old 07/01/2021 COUGH DM ER dextromethorphan polistirex ADD UM: AGE At least 4 yrs old 07/01/2021 nasal pseudoephedrine hcl ADD UM: AGE At least 4 yrs old decongestant 07/01/2021 SUDOGEST pseudoephedrine hcl ADD UM: AGE At least 4 yrs old 07/01/2021 FLINTSTONES multivitamin ADD UM: AGE At least 13 yrs WITH EXTRA C old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 44 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 POLY-VITAMIN multivitamin ADD UM: AGE At least 13 yrs old 07/01/2021 vitamins a,c,d pediatric multivit with a,c,d3 ADD UM: AGE At least 13 yrs and no.21/sodium fluoride old fluoride,vitamins a,d,c and fluoride 07/01/2021 FLINTSTONES multivitamin ADD UM: AGE At least 13 yrs old 07/01/2021 ANIMAL pediatric multivitamin no.17 ADD UM: AGE At least 13 yrs SHAPES old 07/01/2021 CHEWABLE- multivitamin with iron ADD UM: AGE At least 13 yrs VITE WITH IRON old 07/01/2021 GUMMI BEAR multivitamin ADD UM: AGE At least 13 yrs MULTIVITAMIN, old KID'S GUMMY BEAR VITAMINS 07/01/2021 WAL-PHED D ER pseudoephedrine hcl ADD UM: AGE At least 12 yrs old 07/01/2021 pseudoephedrine pseudoephedrine hcl ADD UM: AGE At least 12 yrs er old 07/01/2021 NASAL pseudoephedrine hcl ADD UM: AGE At least 12 yrs DECONGESTAN old T 07/01/2021 12 hour pseudoephedrine hcl ADD UM: AGE At least 12 yrs decongestant old 07/01/2021 WAL-PHED 12 pseudoephedrine hcl ADD UM: AGE At least 12 yrs HOUR old 07/01/2021 WAL-ACT D triprolidine ADD UM: AGE At least 6 yrs old COLD & hcl/pseudoephedrine hcl ALLERGY 07/01/2021 MUCUS RELIEF guaifenesin/pseudoephedrin ADD UM: AGE At least 6 yrs old D e hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 45 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 MUCUS D guaifenesin/pseudoephedrin ADD UM: AGE At least 6 yrs old e hcl 07/01/2021 GUAIATUSSIN codeine ADD UM: AGE At least 18 yrs AC phosphate/guaifenesin old 07/01/2021 VIRTUSSIN AC codeine ADD UM: AGE At least 18 yrs phosphate/guaifenesin old 07/01/2021 CALCIDOL ergocalciferol (vitamin d2) ADD UM: AGE Up to 12 yrs old 07/01/2021 ENSURE LIQUID lactose-reduced food ADD UM: PANAME PA Applies 07/01/2021 ENSURE HIGH lactose-reduced food ADD UM: PANAME PA Applies PROTEIN 07/01/2021 ENSURE lactose-reduced food ADD UM: PANAME PA Applies ACTIVE PROTEIN- MUSCLE 07/01/2021 PRED FORTE prednisolone acetate REMOVE FROM Tier 2 Non-Formulary FORMULARY 07/01/2021 pediatric dinosaur nebulizer and compressor ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 aerochamber z- inhaler, assist devices ADD TO FORMULARY Tier 2 stat plus 07/01/2021 aerochamber z- inhaler,assist device with ADD TO FORMULARY Tier 2 stat small mask plus,aerochambe r plus z stat 07/01/2021 mini-wright peak peak flow meter ADD TO FORMULARY Tier 2 flow meter 07/01/2021 aerochamber z- inhaler,assist device with ADD TO FORMULARY Tier 2 stat medium mask plus,aerochambe r plus z stat 07/01/2021 vixone nebulizer nebulizer ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 46 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 sidestream nebulizer ADD TO FORMULARY Tier 2 nebulizer,sidestre am 07/01/2021 aerochamber mv inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 clever choice inhaler,assist device with ADD TO FORMULARY Tier 2 holding chamber small mask 07/01/2021 clever choice inhaler,assist device with ADD TO FORMULARY Tier 2 holding chamber medium mask 07/01/2021 primeaire inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 clever choice nebulizer and compressor ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 pflex trainer spirometers and accessories ADD TO FORMULARY Tier 2 07/01/2021 threshold imt spirometers and accessories ADD TO FORMULARY Tier 2 07/01/2021 threshold pep spirometers and accessories ADD TO FORMULARY Tier 2 07/01/2021 aerochamber z- inhaler,assist device with ADD TO FORMULARY Tier 2 stat large mask plus,aerochambe r plus z stat 07/01/2021 pediatric dog nebulizer and compressor ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 aerogear asthma peak flow meter/inhaler, ADD TO FORMULARY Tier 2 action kit assist devices 07/01/2021 my mdi portable nebulizer and compressor ADD TO FORMULARY Tier 2 nebuliser 07/01/2021 vios aerosol nebulizer and compressor ADD TO FORMULARY Tier 2 delivery system 07/01/2021 provent nasal exhalation resistance ADD TO FORMULARY Tier 2 sr,provent device 07/01/2021 easivent inhaler, assist devices ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 47 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 compact space inhaler, assist devices ADD TO FORMULARY Tier 2 chamber 07/01/2021 compact space inhaler,assist device with ADD TO FORMULARY Tier 2 chamber large mask 07/01/2021 easivent inhaler, assist devices, ADD TO FORMULARY Tier 2 accessories 07/01/2021 compact space inhaler,assist device with ADD TO FORMULARY Tier 2 chamber small mask 07/01/2021 compact space inhaler,assist device with ADD TO FORMULARY Tier 2 chamber medium mask 07/01/2021 innospire nebulizer and compressor ADD TO FORMULARY Tier 2 elegance 07/01/2021 innospire nebulizer and compressor ADD TO FORMULARY Tier 2 essence 07/01/2021 mini plus nebulizer ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 devilbiss traveler nebulizer and compressor ADD TO FORMULARY Tier 2 07/01/2021 litetouch inhaler, assist devices, ADD TO FORMULARY Tier 2 accessories 07/01/2021 litetouch inhaler, assist devices, ADD TO FORMULARY Tier 2 accessories 07/01/2021 pocket chamber inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 sinustar nebulizer and compressor ADD TO FORMULARY Tier 2 07/01/2021 pediatric comp- nebulizer and compressor ADD TO FORMULARY Tier 2 air compres neb 07/01/2021 prochamber inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 innospire mini nebulizer and compressor ADD TO FORMULARY Tier 2 07/01/2021 compressor nebulizer and compressor ADD TO FORMULARY Tier 2 nebulizer

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 48 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 portable nebulizer and compressor ADD TO FORMULARY Tier 2 nebulizer system 07/01/2021 willis the whale nebulizer and compressor ADD TO FORMULARY Tier 2 compressr neb 07/01/2021 aerochamber inhaler, assist devices ADD TO FORMULARY Tier 2 with flowsignal 07/01/2021 pediatric frog nebulizer and compressor ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 sinustar nebulizer ADD TO FORMULARY Tier 2 07/01/2021 quake mucus clearing device ADD TO FORMULARY Tier 2 07/01/2021 home nebulizer nebulizer and compressor ADD TO FORMULARY Tier 2 plus sidestream 07/01/2021 clever choice nebulizer and compressor ADD TO FORMULARY Tier 2 whisper aire ped 07/01/2021 innospire go nebulizer ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 mistassist spirometers and accessories ADD TO FORMULARY Tier 2 07/01/2021 pari lc sprint nebulizer ADD TO FORMULARY Tier 2 sinus 07/01/2021 vortex vhc frog inhaler,assist device with ADD TO FORMULARY Tier 2 mask medium mask 07/01/2021 vortex vhc inhaler,assist device with ADD TO FORMULARY Tier 2 ladybug mask small mask 07/01/2021 pro comfort inhaler,assist device with ADD TO FORMULARY Tier 2 spacer with mask small mask 07/01/2021 pro comfort inhaler,assist device with ADD TO FORMULARY Tier 2 spacer with mask large mask 07/01/2021 aerotrach plus inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 vixone nebulizer nebulizer ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 49 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 procare spacer inhaler,assist device with ADD TO FORMULARY Tier 2 with adult mask large mask 07/01/2021 procare spacer inhaler,assist device with ADD TO FORMULARY Tier 2 with child mask medium mask 07/01/2021 devilbiss nebulizer and compressor ADD TO FORMULARY Tier 2 pulmoneb lt comp-neb 07/01/2021 optichamber inhaler, assist devices, ADD TO FORMULARY Tier 2 accessories 07/01/2021 vortex holding inhaler,assist device with ADD TO FORMULARY Tier 2 chamber-toddler small mask 07/01/2021 sidestream nebulizer ADD TO FORMULARY Tier 2 07/01/2021 space chamber- inhaler,assist device with ADD TO FORMULARY Tier 2 large mask large mask 07/01/2021 microchamber inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 space chamber- inhaler,assist device with ADD TO FORMULARY Tier 2 medium mask medium mask 07/01/2021 erapid nebulizer nebulizer ADD TO FORMULARY Tier 2 07/01/2021 pulmo-aide compressor, for nebulizer ADD TO FORMULARY Tier 2 07/01/2021 aerochamber inhaler, assist devices ADD TO FORMULARY Tier 2 mini 07/01/2021 altera nebulizer nebulizer ADD TO FORMULARY Tier 2 07/01/2021 space chamber inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 aeroneb go nebulizer ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 space chamber- inhaler,assist device with ADD TO FORMULARY Tier 2 small mask small mask 07/01/2021 flyp nebulizer nebulizer ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 50 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 comp-air nebulizer and compressor ADD TO FORMULARY Tier 2 nebulizer compressor 07/01/2021 ace aerosol cloud inhaler, assist devices ADD TO FORMULARY Tier 2 enhancer 07/01/2021 aerochamber inhaler, assist devices ADD TO FORMULARY Tier 2 plus flow-vu 07/01/2021 altera nebulizer nebulizer ADD TO FORMULARY Tier 2 07/01/2021 microair mesh nebulizer ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 provent nasal exhalation resistance ADD TO FORMULARY Tier 2 device 07/01/2021 pediatric bear nebulizer and compressor ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 pari sinus aerosol nebulizer and compressor ADD TO FORMULARY Tier 2 system 07/01/2021 devilbiss pulmo- compressor, for nebulizer ADD TO FORMULARY Tier 2 aide 07/01/2021 flexichamber inhaler, assist devices, ADD TO FORMULARY Tier 2 mask accessories 07/01/2021 flexichamber inhaler, assist devices, ADD TO FORMULARY Tier 2 mask accessories 07/01/2021 asthmapack peak flow meter/inhaler, ADD TO FORMULARY Tier 2 children's assist devices 07/01/2021 lc star nebulizer ADD TO FORMULARY Tier 2 07/01/2021 lc plus nebulizer ADD TO FORMULARY Tier 2 07/01/2021 procare pediatric nebulizer and compressor ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 aura portaneb nebulizer ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 51 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 sidestream plus nebulizer ADD TO FORMULARY Tier 2 07/01/2021 proneb ultra ii nebulizer/compressor, for ADD TO FORMULARY Tier 2 nebulizer,nebulizer and compressor 07/01/2021 trek s compact nebulizer and ADD TO FORMULARY Tier 2 compressor compressor,nebulizer/compr essor, for nebulizer 07/01/2021 trek s combo nebulizer and compressor ADD TO FORMULARY Tier 2 pack 07/01/2021 flexichamber inhaler, assist devices, ADD TO FORMULARY Tier 2 mask accessories 07/01/2021 lc sprint nebulizer nebulizer ADD TO FORMULARY Tier 2 07/01/2021 sootheneb nebulizer and compressor ADD TO FORMULARY Tier 2 compressor nebulizer 07/01/2021 aerobika mucus clearing device ADD TO FORMULARY Tier 2 07/01/2021 optichamber inhaler,assist device with ADD TO FORMULARY Tier 2 diamond small mask 07/01/2021 optichamber inhaler,assist device with ADD TO FORMULARY Tier 2 diamond medium mask 07/01/2021 flexichamber inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 liteaire inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 riteflo inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 aerovent plus inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 microspacer inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 sootheneb mesh nebulizer ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 devilbiss compressor, for nebulizer ADD TO FORMULARY Tier 2 pulmomate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 52 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 inspirachamber inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 lc d nebulizer set nebulizer ADD TO FORMULARY Tier 2 07/01/2021 inspirachamber inhaler,assist device with ADD TO FORMULARY Tier 2 small mask 07/01/2021 inspirachamber inhaler,assist device with ADD TO FORMULARY Tier 2 medium mask 07/01/2021 easivent inhaler, assist devices, ADD TO FORMULARY Tier 2 accessories 07/01/2021 baby nebulizer nebulizer ADD TO FORMULARY Tier 2 07/01/2021 breatherite inhaler,assist device with ADD TO FORMULARY Tier 2 spacer-adult large mask mask 07/01/2021 breatherite inhaler,assist device with ADD TO FORMULARY Tier 2 spacer-lg chld medium mask msk 07/01/2021 silicone mask inhaler, assist devices, CHANGE TIER Tier 1 Tier 2 accessories 07/01/2021 mistassist kit spirometer with drug ADD TO FORMULARY Tier 2 delivery adapters 07/01/2021 breatherite inhaler,assist device with ADD TO FORMULARY Tier 2 spacer-sm chld small mask msk 07/01/2021 easivent inhaler, assist devices, ADD TO FORMULARY Tier 2 accessories 07/01/2021 sunrise compressor, for nebulizer ADD TO FORMULARY Tier 2 compressor- nebulizer 07/01/2021 breathrite inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 vortex inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 breathrite inhaler, assist devices ADD TO FORMULARY Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 53 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 breatherite inhaler,assist device with ADD TO FORMULARY Tier 2 spacer-infant small mask mask 07/01/2021 breatherite inhaler,assist device with ADD TO FORMULARY Tier 2 spacer-neonate small mask msk 07/01/2021 vortex holding inhaler,assist device with ADD TO FORMULARY Tier 2 chamber-child medium mask 07/01/2021 aerochamber inhaler,assist device with ADD TO FORMULARY Tier 2 plus flow-vu medium mask 07/01/2021 breatherite inhaler, assist devices ADD TO FORMULARY Tier 2 07/01/2021 litetouch inhaler, assist devices, ADD TO FORMULARY Tier 2 accessories 07/01/2021 airs disposable nebulizer ADD TO FORMULARY Tier 2 nebulizer 07/01/2021 pulmoneb lt nebulizer and compressor ADD TO FORMULARY Tier 2 compressor nebul 07/01/2021 space chamber inhaler, assist devices ADD TO FORMULARY Tier 2 plus 07/01/2021 compact space inhaler, assist devices ADD TO FORMULARY Tier 2 chamber plus 07/01/2021 optichamber inhaler,assist device with ADD TO FORMULARY Tier 2 diamond large mask 07/01/2021 aerochamber inhaler,assist device with ADD TO FORMULARY Tier 2 plus flow-vu large mask 07/01/2021 ebase controller compressor, for nebulizer ADD TO FORMULARY Tier 2 07/01/2021 lc plus nebulizer- nebulizer ADD TO FORMULARY Tier 2 ped mask 07/01/2021 optichamber inhaler, assist devices ADD TO FORMULARY Tier 2 diamond

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 54 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 prodigy mini-mist nebulizer ADD TO FORMULARY Tier 2 07/01/2021 ombra nebulizer and compressor ADD TO FORMULARY Tier 2 compressor system 07/01/2021 sami the seal nebulizer and compressor ADD TO FORMULARY Tier 2 07/01/2021 innospire deluxe nebulizer and compressor ADD TO FORMULARY Tier 2 07/01/2021 procare nebulizer and compressor ADD TO FORMULARY Tier 2 compressor nebulizer 07/01/2021 devilbiss nebulizer ADD TO FORMULARY Tier 2 disposable nebulizer 07/01/2021 inspirachamber inhaler,assist device with ADD TO FORMULARY Tier 2 large mask 07/01/2021 clever choice inhaler,assist device with ADD TO FORMULARY Tier 2 holding chamber large mask 07/01/2021 truneb nebulizer nebulizer ADD TO FORMULARY Tier 2 07/01/2021 vixone nebulizer nebulizer ADD TO FORMULARY Tier 2 07/01/2021 pediatric dinosaur nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 aerochamber z- inhaler, assist devices ADD UM: QUANTITY 2 / 365 days stat plus 07/01/2021 aerochamber z- inhaler,assist device with ADD UM: QUANTITY 2 / 365 days stat small mask plus,aerochambe r plus z stat 07/01/2021 mini-wright peak peak flow meter ADD UM: QUANTITY 2 / 365 days flow meter

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 55 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 aerochamber z- inhaler,assist device with ADD UM: QUANTITY 2 / 365 days stat medium mask plus,aerochambe r plus z stat 07/01/2021 vixone nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 sidestream nebulizer ADD UM: QUANTITY 2 / 365 days nebulizer,sidestre am 07/01/2021 aerochamber mv inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 clever choice inhaler,assist device with ADD UM: QUANTITY 2 / 365 days holding chamber small mask 07/01/2021 clever choice inhaler,assist device with ADD UM: QUANTITY 2 / 365 days holding chamber medium mask 07/01/2021 primeaire inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 clever choice nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 pflex trainer spirometers and accessories ADD UM: QUANTITY 2 / 365 days 07/01/2021 threshold imt spirometers and accessories ADD UM: QUANTITY 2 / 365 days 07/01/2021 threshold pep spirometers and accessories ADD UM: QUANTITY 2 / 365 days 07/01/2021 aerochamber z- inhaler,assist device with ADD UM: QUANTITY 2 / 365 days stat large mask plus,aerochambe r plus z stat 07/01/2021 pediatric dog nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 aerogear asthma peak flow meter/inhaler, ADD UM: QUANTITY 2 / 365 days action kit assist devices 07/01/2021 my mdi portable nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebuliser

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 56 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 vios aerosol nebulizer and compressor ADD UM: QUANTITY 2 / 365 days delivery system 07/01/2021 provent nasal exhalation resistance ADD UM: QUANTITY 2 / 365 days sr,provent device 07/01/2021 easivent inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 compact space inhaler, assist devices ADD UM: QUANTITY 2 / 365 days chamber 07/01/2021 compact space inhaler,assist device with ADD UM: QUANTITY 2 / 365 days chamber large mask 07/01/2021 easivent inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days accessories 07/01/2021 compact space inhaler,assist device with ADD UM: QUANTITY 2 / 365 days chamber small mask 07/01/2021 compact space inhaler,assist device with ADD UM: QUANTITY 2 / 365 days chamber medium mask 07/01/2021 innospire nebulizer and compressor ADD UM: QUANTITY 2 / 365 days elegance 07/01/2021 innospire nebulizer and compressor ADD UM: QUANTITY 2 / 365 days essence 07/01/2021 mini plus nebulizer ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 devilbiss traveler nebulizer and compressor ADD UM: QUANTITY 2 / 365 days 07/01/2021 litetouch inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days accessories 07/01/2021 litetouch inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days accessories 07/01/2021 pocket chamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 sinustar nebulizer and compressor ADD UM: QUANTITY 2 / 365 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 57 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 pediatric comp- nebulizer and compressor ADD UM: QUANTITY 2 / 365 days air compres neb 07/01/2021 prochamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 innospire mini nebulizer and compressor ADD UM: QUANTITY 2 / 365 days 07/01/2021 compressor nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 portable nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebulizer system 07/01/2021 willis the whale nebulizer and compressor ADD UM: QUANTITY 2 / 365 days compressr neb 07/01/2021 aerochamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days with flowsignal 07/01/2021 pediatric frog nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 sinustar nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 quake mucus clearing device ADD UM: QUANTITY 2 / 365 days 07/01/2021 home nebulizer nebulizer and compressor ADD UM: QUANTITY 2 / 365 days plus sidestream 07/01/2021 clever choice nebulizer and compressor ADD UM: QUANTITY 2 / 365 days whisper aire ped 07/01/2021 innospire go nebulizer ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 mistassist spirometers and accessories ADD UM: QUANTITY 2 / 365 days 07/01/2021 pari lc sprint nebulizer ADD UM: QUANTITY 2 / 365 days sinus 07/01/2021 vortex vhc frog inhaler,assist device with ADD UM: QUANTITY 2 / 365 days mask medium mask 07/01/2021 vortex vhc inhaler,assist device with ADD UM: QUANTITY 2 / 365 days ladybug mask small mask

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 58 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 pro comfort inhaler,assist device with ADD UM: QUANTITY 2 / 365 days spacer with mask small mask 07/01/2021 pro comfort inhaler,assist device with ADD UM: QUANTITY 2 / 365 days spacer with mask large mask 07/01/2021 aerotrach plus inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 vixone nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 procare spacer inhaler,assist device with ADD UM: QUANTITY 2 / 365 days with adult mask large mask 07/01/2021 procare spacer inhaler,assist device with ADD UM: QUANTITY 2 / 365 days with child mask medium mask 07/01/2021 devilbiss nebulizer and compressor ADD UM: QUANTITY 2 / 365 days pulmoneb lt comp-neb 07/01/2021 optichamber inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days accessories 07/01/2021 vortex holding inhaler,assist device with ADD UM: QUANTITY 2 / 365 days chamber-toddler small mask 07/01/2021 sidestream nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 space chamber- inhaler,assist device with ADD UM: QUANTITY 2 / 365 days large mask large mask 07/01/2021 microchamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 space chamber- inhaler,assist device with ADD UM: QUANTITY 2 / 365 days medium mask medium mask 07/01/2021 erapid nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 pulmo-aide compressor, for nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 aerochamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days mini 07/01/2021 altera nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 space chamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 59 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 aeroneb go nebulizer ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 space chamber- inhaler,assist device with ADD UM: QUANTITY 2 / 365 days small mask small mask 07/01/2021 flyp nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 comp-air nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebulizer compressor 07/01/2021 ace aerosol cloud inhaler, assist devices ADD UM: QUANTITY 2 / 365 days enhancer 07/01/2021 aerochamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days plus flow-vu 07/01/2021 altera nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 microair mesh nebulizer ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 provent nasal exhalation resistance ADD UM: QUANTITY 2 / 365 days device 07/01/2021 pediatric bear nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 pari sinus aerosol nebulizer and compressor ADD UM: QUANTITY 2 / 365 days system 07/01/2021 devilbiss pulmo- compressor, for nebulizer ADD UM: QUANTITY 2 / 365 days aide 07/01/2021 flexichamber inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days mask accessories 07/01/2021 flexichamber inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days mask accessories 07/01/2021 asthmapack peak flow meter/inhaler, ADD UM: QUANTITY 2 / 365 days children's assist devices 07/01/2021 lc star nebulizer ADD UM: QUANTITY 2 / 365 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 60 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 lc plus nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 procare pediatric nebulizer and compressor ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 aura portaneb nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 sidestream plus nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 proneb ultra ii nebulizer/compressor, for ADD UM: QUANTITY 2 / 365 days nebulizer,nebulizer and compressor 07/01/2021 trek s compact nebulizer and ADD UM: QUANTITY 2 / 365 days compressor compressor,nebulizer/compr essor, for nebulizer 07/01/2021 trek s combo nebulizer and compressor ADD UM: QUANTITY 2 / 365 days pack 07/01/2021 flexichamber inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days mask accessories 07/01/2021 lc sprint nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 sootheneb nebulizer and compressor ADD UM: QUANTITY 2 / 365 days compressor nebulizer 07/01/2021 aerobika mucus clearing device ADD UM: QUANTITY 2 / 365 days 07/01/2021 optichamber inhaler,assist device with ADD UM: QUANTITY 2 / 365 days diamond small mask 07/01/2021 optichamber inhaler,assist device with ADD UM: QUANTITY 2 / 365 days diamond medium mask 07/01/2021 flexichamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 liteaire inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 riteflo inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 aerovent plus inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 microspacer inhaler, assist devices ADD UM: QUANTITY 2 / 365 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 61 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 sootheneb mesh nebulizer ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 devilbiss compressor, for nebulizer ADD UM: QUANTITY 2 / 365 days pulmomate 07/01/2021 inspirachamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 lc d nebulizer set nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 inspirachamber inhaler,assist device with ADD UM: QUANTITY 2 / 365 days small mask 07/01/2021 inspirachamber inhaler,assist device with ADD UM: QUANTITY 2 / 365 days medium mask 07/01/2021 easivent inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days accessories 07/01/2021 baby nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 breatherite inhaler,assist device with ADD UM: QUANTITY 2 / 365 days spacer-adult large mask mask 07/01/2021 breatherite inhaler,assist device with ADD UM: QUANTITY 2 / 365 days spacer-lg chld medium mask msk 07/01/2021 mistassist kit spirometer with drug ADD UM: QUANTITY 2 / 365 days delivery adapters 07/01/2021 breatherite inhaler,assist device with ADD UM: QUANTITY 2 / 365 days spacer-sm chld small mask msk 07/01/2021 easivent inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days accessories 07/01/2021 sunrise compressor, for nebulizer ADD UM: QUANTITY 2 / 365 days compressor- nebulizer 07/01/2021 breathrite inhaler, assist devices ADD UM: QUANTITY 2 / 365 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 62 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 vortex inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 breathrite inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 breatherite inhaler,assist device with ADD UM: QUANTITY 2 / 365 days spacer-infant small mask mask 07/01/2021 breatherite inhaler,assist device with ADD UM: QUANTITY 2 / 365 days spacer-neonate small mask msk 07/01/2021 vortex holding inhaler,assist device with ADD UM: QUANTITY 2 / 365 days chamber-child medium mask 07/01/2021 aerochamber inhaler,assist device with ADD UM: QUANTITY 2 / 365 days plus flow-vu medium mask 07/01/2021 breatherite inhaler, assist devices ADD UM: QUANTITY 2 / 365 days 07/01/2021 litetouch inhaler, assist devices, ADD UM: QUANTITY 2 / 365 days accessories 07/01/2021 airs disposable nebulizer ADD UM: QUANTITY 2 / 365 days nebulizer 07/01/2021 pulmoneb lt nebulizer and compressor ADD UM: QUANTITY 2 / 365 days compressor nebul 07/01/2021 space chamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days plus 07/01/2021 compact space inhaler, assist devices ADD UM: QUANTITY 2 / 365 days chamber plus 07/01/2021 optichamber inhaler,assist device with ADD UM: QUANTITY 2 / 365 days diamond large mask 07/01/2021 aerochamber inhaler,assist device with ADD UM: QUANTITY 2 / 365 days plus flow-vu large mask 07/01/2021 ebase controller compressor, for nebulizer ADD UM: QUANTITY 2 / 365 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 63 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 lc plus nebulizer- nebulizer ADD UM: QUANTITY 2 / 365 days ped mask 07/01/2021 optichamber inhaler, assist devices ADD UM: QUANTITY 2 / 365 days diamond 07/01/2021 prodigy mini-mist nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 ombra nebulizer and compressor ADD UM: QUANTITY 2 / 365 days compressor system 07/01/2021 sami the seal nebulizer and compressor ADD UM: QUANTITY 2 / 365 days 07/01/2021 innospire deluxe nebulizer and compressor ADD UM: QUANTITY 2 / 365 days 07/01/2021 procare nebulizer and compressor ADD UM: QUANTITY 2 / 365 days compressor nebulizer 07/01/2021 devilbiss nebulizer ADD UM: QUANTITY 2 / 365 days disposable nebulizer 07/01/2021 inspirachamber inhaler,assist device with ADD UM: QUANTITY 2 / 365 days large mask 07/01/2021 clever choice inhaler,assist device with ADD UM: QUANTITY 2 / 365 days holding chamber large mask 07/01/2021 truneb nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 vixone nebulizer nebulizer ADD UM: QUANTITY 2 / 365 days 07/01/2021 blood pressure blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 07/01/2021 blood pressure blood pressure test kit-large ADD UM: 1 Fill per 5 years monitor QUANTITYCUSTOM 07/01/2021 blood pressure blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 07/01/2021 blood pressure blood pressure test kit-large ADD UM: 1 Fill per 5 years monitor QUANTITYCUSTOM

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 64 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 series 100 bp blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 07/01/2021 series 100 bp blood pressure test kit-large ADD UM: 1 Fill per 5 years monitor QUANTITYCUSTOM 07/01/2021 blood pressure blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 07/01/2021 blood pressure blood pressure test kit-large ADD UM: 1 Fill per 5 years monitor QUANTITYCUSTOM 07/01/2021 blood pressure blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 07/01/2021 blood pressure blood pressure test kit-large ADD UM: 1 Fill per 5 years monitor QUANTITYCUSTOM 07/01/2021 blood pressure blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 07/01/2021 blood pressure blood pressure test kit-large ADD UM: 1 Fill per 5 years monitor QUANTITYCUSTOM 07/01/2021 blood pressure blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 07/01/2021 blood pressure blood pressure test kit-large ADD UM: 1 Fill per 5 years monitor QUANTITYCUSTOM 07/01/2021 blood pressure blood pressure test kit CHANGE UM: 1 fill per 5 years 1 Fill per 5 years monitor medium and large cuffs QUANTITYCUSTOM 07/01/2021 deluxe arm bp blood pressure test kit ADD TO FORMULARY Tier 1 monitor medium and large cuffs 07/01/2021 deluxe arm bp blood pressure test kit ADD UM: 1 Fill per 5 years monitor medium and large cuffs QUANTITYCUSTOM 07/01/2021 blood pressure blood pressure test kit- ADD TO FORMULARY Tier 1 monitor medium 07/01/2021 blood pressure blood pressure test kit- ADD UM: 1 Fill per 5 years monitor medium QUANTITYCUSTOM

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 65 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 blood pressure blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 07/01/2021 blood pressure blood pressure test kit-large ADD UM: 1 Fill per 5 years monitor QUANTITYCUSTOM 07/01/2021 blood pressure blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 07/01/2021 blood pressure blood pressure test kit-large ADD UM: 1 Fill per 5 years monitor QUANTITYCUSTOM 07/01/2021 BIKTARVY bictegravir ADD UM: NTWK CARVE OUT: sodium/emtricitabine/tenofov FFS MEDI-CAL ir alafenamide fumar 07/01/2021 BIKTARVY bictegravir ADD UM: COV Excluded sodium/emtricitabine/tenofov ir alafenamide fumar 07/01/2021 BELBUCA buprenorphine hcl REMOVE FROM Non-Formulary FORMULARY 07/01/2021 BELBUCA buprenorphine hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 BELBUCA buprenorphine hcl ADD UM: COV Excluded 07/01/2021 INVIRASE saquinavir mesylate REMOVE FROM Non-Formulary FORMULARY 07/01/2021 INVIRASE saquinavir mesylate ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 INVIRASE saquinavir mesylate ADD UM: COV Excluded 07/01/2021 BELBUCA buprenorphine hcl REMOVE FROM Non-Formulary FORMULARY 07/01/2021 BELBUCA buprenorphine hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 BELBUCA buprenorphine hcl ADD UM: COV Excluded

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 66 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 BELBUCA buprenorphine hcl REMOVE FROM Non-Formulary FORMULARY 07/01/2021 BELBUCA buprenorphine hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 BELBUCA buprenorphine hcl ADD UM: COV Excluded 07/01/2021 PIFELTRO doravirine REMOVE FROM Non-Formulary FORMULARY 07/01/2021 PIFELTRO doravirine ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 PIFELTRO doravirine ADD UM: COV Excluded 07/01/2021 BELBUCA buprenorphine hcl REMOVE FROM Non-Formulary FORMULARY 07/01/2021 BELBUCA buprenorphine hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 BELBUCA buprenorphine hcl ADD UM: COV Excluded 07/01/2021 BELBUCA buprenorphine hcl REMOVE FROM Non-Formulary FORMULARY 07/01/2021 BELBUCA buprenorphine hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 BELBUCA buprenorphine hcl ADD UM: COV Excluded 07/01/2021 BELBUCA buprenorphine hcl REMOVE FROM Non-Formulary FORMULARY 07/01/2021 BELBUCA buprenorphine hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 BELBUCA buprenorphine hcl ADD UM: COV Excluded 07/01/2021 CIMDUO,TEMIX lamivudine/tenofovir REMOVE FROM Non-Formulary YS disoproxil fumarate FORMULARY 07/01/2021 CIMDUO,TEMIX lamivudine/tenofovir ADD UM: NTWK CARVE OUT: YS disoproxil fumarate FFS MEDI-CAL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 67 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 CIMDUO,TEMIX lamivudine/tenofovir ADD UM: COV Excluded YS disoproxil fumarate 07/01/2021 fluphenazine fluphenazine decanoate REMOVE FROM Non-Formulary decanoate FORMULARY 07/01/2021 fluphenazine fluphenazine decanoate ADD UM: NTWK CARVE OUT: decanoate FFS MEDI-CAL 07/01/2021 fluphenazine fluphenazine decanoate ADD UM: COV Excluded decanoate 07/01/2021 butrans,buprenor buprenorphine REMOVE FROM Non-Formulary phine FORMULARY 07/01/2021 butrans,buprenor buprenorphine ADD UM: NTWK CARVE OUT: phine FFS MEDI-CAL 07/01/2021 butrans,buprenor buprenorphine ADD UM: COV Excluded phine 07/01/2021 ISENTRESS HD raltegravir potassium REMOVE FROM Non-Formulary FORMULARY 07/01/2021 ISENTRESS HD raltegravir potassium ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 ISENTRESS HD raltegravir potassium ADD UM: COV Excluded 07/01/2021 LUCEMYRA lofexidine hcl REMOVE FROM Non-Formulary FORMULARY 07/01/2021 LUCEMYRA lofexidine hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 LUCEMYRA lofexidine hcl ADD UM: COV Excluded 07/01/2021 SELZENTRY maraviroc REMOVE FROM Non-Formulary FORMULARY 07/01/2021 SELZENTRY maraviroc ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 SELZENTRY maraviroc ADD UM: COV Excluded

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 68 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 BIKTARVY bictegravir REMOVE FROM Non-Formulary sodium/emtricitabine/tenofov FORMULARY ir alafenamide fumar 07/01/2021 naloxone naloxone hcl REMOVE FROM Non-Formulary hcl,naloxone FORMULARY 07/01/2021 naloxone naloxone hcl ADD UM: NTWK CARVE OUT: hcl,naloxone FFS MEDI-CAL 07/01/2021 naloxone naloxone hcl ADD UM: COV Excluded hcl,naloxone 07/01/2021 kaletra,lopinavir- lopinavir/ritonavir REMOVE FROM Non-Formulary ritonavir FORMULARY 07/01/2021 kaletra,lopinavir- lopinavir/ritonavir CHANGE UM: NTWK CARVE OUT: ritonavir FFS MEDI-CAL 07/01/2021 kaletra,lopinavir- lopinavir/ritonavir CHANGE UM: COV Excluded ritonavir 07/01/2021 zerit,stavudine stavudine REMOVE FROM Non-Formulary FORMULARY 07/01/2021 zerit,stavudine stavudine ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 zerit,stavudine stavudine ADD UM: COV Excluded 07/01/2021 JULUCA dolutegravir REMOVE FROM Non-Formulary sodium/rilpivirine hcl FORMULARY 07/01/2021 JULUCA dolutegravir ADD UM: NTWK CARVE OUT: sodium/rilpivirine hcl FFS MEDI-CAL 07/01/2021 JULUCA dolutegravir ADD UM: COV Excluded sodium/rilpivirine hcl 07/01/2021 BEBULIN VH factor ix complex, REMOVE FROM Non-Formulary IMMUNO,BEBUL prothrombin complex conc. FORMULARY IN (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3-factor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 69 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 BEBULIN VH factor ix complex, ADD UM: NTWK CARVE OUT: IMMUNO,BEBUL prothrombin complex conc. FFS MEDI-CAL IN (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3-factor 07/01/2021 BEBULIN VH factor ix complex, ADD UM: COV Excluded IMMUNO,BEBUL prothrombin complex conc. IN (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3-factor 07/01/2021 butrans,buprenor buprenorphine REMOVE FROM Non-Formulary phine FORMULARY 07/01/2021 butrans,buprenor buprenorphine ADD UM: NTWK CARVE OUT: phine FFS MEDI-CAL 07/01/2021 butrans,buprenor buprenorphine ADD UM: COV Excluded phine 07/01/2021 kaletra,lopinavir- lopinavir/ritonavir REMOVE FROM Non-Formulary ritonavir FORMULARY 07/01/2021 kaletra,lopinavir- lopinavir/ritonavir CHANGE UM: NTWK CARVE OUT: ritonavir FFS MEDI-CAL 07/01/2021 kaletra,lopinavir- lopinavir/ritonavir CHANGE UM: COV Excluded ritonavir 07/01/2021 benztropine benztropine mesylate REMOVE FROM Non-Formulary mesylate FORMULARY 07/01/2021 benztropine benztropine mesylate ADD UM: NTWK CARVE OUT: mesylate FFS MEDI-CAL 07/01/2021 RESCRIPTOR delavirdine mesylate REMOVE FROM Non-Formulary FORMULARY 07/01/2021 RESCRIPTOR delavirdine mesylate ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 RESCRIPTOR delavirdine mesylate ADD UM: COV Excluded

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 70 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 EVZIO naloxone hcl REMOVE FROM Non-Formulary FORMULARY 07/01/2021 EVZIO naloxone hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 EVZIO naloxone hcl ADD UM: COV Excluded 07/01/2021 intelence,etravirin etravirine REMOVE FROM Non-Formulary e FORMULARY 07/01/2021 intelence,etravirin etravirine CHANGE UM: NTWK CARVE OUT: e FFS MEDI-CAL 07/01/2021 intelence,etravirin etravirine CHANGE UM: COV Excluded e 07/01/2021 BELBUCA buprenorphine hcl REMOVE FROM Non-Formulary FORMULARY 07/01/2021 BELBUCA buprenorphine hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 BELBUCA buprenorphine hcl ADD UM: COV Excluded 07/01/2021 DOVATO dolutegravir REMOVE FROM Non-Formulary sodium/lamivudine FORMULARY 07/01/2021 DOVATO dolutegravir ADD UM: NTWK CARVE OUT: sodium/lamivudine FFS MEDI-CAL 07/01/2021 intelence,etravirin etravirine REMOVE FROM Non-Formulary e FORMULARY 07/01/2021 intelence,etravirin etravirine CHANGE UM: NTWK CARVE OUT: e FFS MEDI-CAL 07/01/2021 intelence,etravirin etravirine CHANGE UM: COV Excluded e 07/01/2021 NORVIR ritonavir REMOVE FROM Non-Formulary FORMULARY 07/01/2021 NORVIR ritonavir ADD UM: NTWK CARVE OUT: FFS MEDI-CAL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 71 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 NORVIR ritonavir ADD UM: COV Excluded 07/01/2021 fluphenazine fluphenazine decanoate REMOVE FROM Non-Formulary decanoate FORMULARY 07/01/2021 fluphenazine fluphenazine decanoate ADD UM: NTWK CARVE OUT: decanoate FFS MEDI-CAL 07/01/2021 fluphenazine fluphenazine decanoate ADD UM: COV Excluded decanoate 07/01/2021 MARPLAN isocarboxazid REMOVE FROM Non-Formulary FORMULARY 07/01/2021 MARPLAN isocarboxazid ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 MARPLAN isocarboxazid ADD UM: COV Excluded 07/01/2021 buprenorphine buprenorphine REMOVE FROM Non-Formulary hcl,buprenorphin hcl,buprenorphine FORMULARY e- hcl/naloxone naloxone,suboxo hcl,buprenorphine ne,subutex,zubso lv,bunavail,probu phine,sublocade 07/01/2021 buprenorphine buprenorphine CHANGE UM: NTWK CARVE OUT: hcl,buprenorphin hcl,buprenorphine FFS MEDI-CAL e- hcl/naloxone naloxone,suboxo hcl,buprenorphine ne,subutex,zubso lv,bunavail,probu phine,sublocade 07/01/2021 buprenorphine buprenorphine CHANGE UM: COV Excluded hcl,buprenorphin hcl,buprenorphine e- hcl/naloxone naloxone,suboxo hcl,buprenorphine ne,subutex,zubso lv,bunavail,probu phine,sublocade

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 72 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 haloperidol haloperidol REMOVE FROM Non-Formulary lactate,haloperido lactate,haloperidol,droperido FORMULARY l,droperidol,halop l,haloperidol decanoate eridol decanoate,halop eridol decanoate 100,haldol decanoate 50,haldol decanoate 100,haldol,inapsi ne 07/01/2021 haloperidol haloperidol CHANGE UM: NTWK CARVE OUT: lactate,haloperido lactate,haloperidol,droperido FFS MEDI-CAL l,droperidol,halop l,haloperidol decanoate eridol decanoate,halop eridol decanoate 100,haldol decanoate 50,haldol decanoate 100,haldol,inapsi ne 07/01/2021 haloperidol haloperidol CHANGE UM: COV Excluded lactate,haloperido lactate,haloperidol,droperido l,droperidol,halop l,haloperidol decanoate eridol decanoate,halop eridol decanoate 100,haldol decanoate 50,haldol decanoate 100,haldol,inapsi ne

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 73 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 saphris,olanzapin asenapine REMOVE FROM Non-Formulary e maleate,olanzapine,olanzapi FORMULARY odt,zyprexa,zypre ne pamoate,ziprasidone xa zydis,zyprexa mesylate,ziprasidone relprevv,geodon,r hcl,risperidone,quetiapine isperidone,quetia fumarate,clozapine,iloperido pine ne,paliperidone,risperidone fumarate,clozaril,f microspheres,paliperidone anapt,clozapine palmitate,lurasidone odt,clozapine,ola hcl,asenapine,lumateperone nzapine,seroquel, tosylate seroquel xr,risperidone odt,ziprasidone hcl,risperdal,faza clo,invega,risperd al consta,risperdal m-tab,invega sustenna,latuda,v ersacloz,invega trinza,paliperidon e er,quetiapine fumarate er,perseris,secua do,caplyta,ziprasi done mesylate,asenapi ne maleate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 74 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 saphris,olanzapin asenapine CHANGE UM: NTWK CARVE OUT: e maleate,olanzapine,olanzapi FFS MEDI-CAL odt,zyprexa,zypre ne pamoate,ziprasidone xa zydis,zyprexa mesylate,ziprasidone relprevv,geodon,r hcl,risperidone,quetiapine isperidone,quetia fumarate,clozapine,iloperido pine ne,paliperidone,risperidone fumarate,clozaril,f microspheres,paliperidone anapt,clozapine palmitate,lurasidone odt,clozapine,ola hcl,asenapine,lumateperone nzapine,seroquel, tosylate seroquel xr,risperidone odt,ziprasidone hcl,risperdal,faza clo,invega,risperd al consta,risperdal m-tab,invega sustenna,latuda,v ersacloz,invega trinza,paliperidon e er,quetiapine fumarate er,perseris,secua do,caplyta,ziprasi done mesylate,asenapi ne maleate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 75 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 saphris,olanzapin asenapine CHANGE UM: COV Excluded e maleate,olanzapine,olanzapi odt,zyprexa,zypre ne pamoate,ziprasidone xa zydis,zyprexa mesylate,ziprasidone relprevv,geodon,r hcl,risperidone,quetiapine isperidone,quetia fumarate,clozapine,iloperido pine ne,paliperidone,risperidone fumarate,clozaril,f microspheres,paliperidone anapt,clozapine palmitate,lurasidone odt,clozapine,ola hcl,asenapine,lumateperone nzapine,seroquel, tosylate seroquel xr,risperidone odt,ziprasidone hcl,risperdal,faza clo,invega,risperd al consta,risperdal m-tab,invega sustenna,latuda,v ersacloz,invega trinza,paliperidon e er,quetiapine fumarate er,perseris,secua do,caplyta,ziprasi done mesylate,asenapi ne maleate 07/01/2021 abilify,abilify aripiprazole,brexpiprazole,ar REMOVE FROM Non-Formulary maintena,abilify ipiprazole FORMULARY discmelt,aripipraz lauroxil,aripiprazole lauroxil, ole,rexulti,aripipra submicronized zole odt,aristada,arist ada initio,abilify mycite

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 76 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 abilify,abilify aripiprazole,brexpiprazole,ar CHANGE UM: NTWK CARVE OUT: maintena,abilify ipiprazole FFS MEDI-CAL discmelt,aripipraz lauroxil,aripiprazole lauroxil, ole,rexulti,aripipra submicronized zole odt,aristada,arist ada initio,abilify mycite 07/01/2021 abilify,abilify aripiprazole,brexpiprazole,ar CHANGE UM: COV Excluded maintena,abilify ipiprazole discmelt,aripipraz lauroxil,aripiprazole lauroxil, ole,rexulti,aripipra submicronized zole odt,aristada,arist ada initio,abilify mycite

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 77 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 KOGENATE antihemophilic factor, hum REMOVE FROM Non-Formulary FS,HUMATE- rec,antihemophilic factor FORMULARY P,MONOCLATE- (fviii) recomb,full length (alb- P,HELIXATE free),antihemophilic factor FS,NOVOSEVEN (fviii) recombinant,full RT,NOVOSEVE length,antihemophilic factor, N,RECOMBINAT human/von willebrand E,ADVATE,HEM factor,human,antihemophilic OFIL M,ADVATE factor, L,ADVATE human,antihemophilic factor M,ADVATE viii, human H,ADVATE recombinant,coagulation SH,ADVATE factor viia UH,KOATE- (recombinant),antihemophili DVI,XYNTHA,XY c factor (factor viii) NTHA recomb,b-domain SOLOFUSE,FEI deleted,anti-inhibitor BA VH coagulant IMMUNO,FEIBA complex,antihemophilic NF,WILATE,ALP factor (fviii) recombinant, fc HANATE,REFAC fusion protein,antihemophilic TO,MONARC- factor viii, recombinant M,ELOCTATE,O porcine BIZUR,NOVOEI sequence,antihemophilic GHT,KOATE,NU factor viii recombinant, b- WIQ,ADYNOVAT domain E,KOVALTRY,AF truncated,antihemophilic STYLA,JIVI,ESP factor viii rec hek cell, b- EROCT,SEVENF domain ACT deleted,antihemophilic factor (fviii) recombinant, full length, peg,antihemophilic factor viii recomb,single- chn,b-dom truncated,antihemophilic factor (fviii) rec, b-domain deleted peg- aucl,antihemophilic factor (fviii) rec, b-dom truncated

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 78 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value peg-exei,coagulation factor viia recombinant-jncw

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 79 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 KOGENATE antihemophilic factor, hum CHANGE UM: NTWK CARVE OUT: FS,HUMATE- rec,antihemophilic factor FFS MEDI-CAL P,MONOCLATE- (fviii) recomb,full length (alb- P,HELIXATE free),antihemophilic factor FS,NOVOSEVEN (fviii) recombinant,full RT,NOVOSEVE length,antihemophilic factor, N,RECOMBINAT human/von willebrand E,ADVATE,HEM factor,human,antihemophilic OFIL M,ADVATE factor, L,ADVATE human,antihemophilic factor M,ADVATE viii, human H,ADVATE recombinant,coagulation SH,ADVATE factor viia UH,KOATE- (recombinant),antihemophili DVI,XYNTHA,XY c factor (factor viii) NTHA recomb,b-domain SOLOFUSE,FEI deleted,anti-inhibitor BA VH coagulant IMMUNO,FEIBA complex,antihemophilic NF,WILATE,ALP factor (fviii) recombinant, fc HANATE,REFAC fusion protein,antihemophilic TO,MONARC- factor viii, recombinant M,ELOCTATE,O porcine BIZUR,NOVOEI sequence,antihemophilic GHT,KOATE,NU factor viii recombinant, b- WIQ,ADYNOVAT domain E,KOVALTRY,AF truncated,antihemophilic STYLA,JIVI,ESP factor viii rec hek cell, b- EROCT,SEVENF domain ACT deleted,antihemophilic factor (fviii) recombinant, full length, peg,antihemophilic factor viii recomb,single- chn,b-dom truncated,antihemophilic factor (fviii) rec, b-domain deleted peg- aucl,antihemophilic factor (fviii) rec, b-dom truncated

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 80 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value peg-exei,coagulation factor viia recombinant-jncw

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 81 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 KOGENATE antihemophilic factor, hum CHANGE UM: COV Excluded FS,HUMATE- rec,antihemophilic factor P,MONOCLATE- (fviii) recomb,full length (alb- P,HELIXATE free),antihemophilic factor FS,NOVOSEVEN (fviii) recombinant,full RT,NOVOSEVE length,antihemophilic factor, N,RECOMBINAT human/von willebrand E,ADVATE,HEM factor,human,antihemophilic OFIL M,ADVATE factor, L,ADVATE human,antihemophilic factor M,ADVATE viii, human H,ADVATE recombinant,coagulation SH,ADVATE factor viia UH,KOATE- (recombinant),antihemophili DVI,XYNTHA,XY c factor (factor viii) NTHA recomb,b-domain SOLOFUSE,FEI deleted,anti-inhibitor BA VH coagulant IMMUNO,FEIBA complex,antihemophilic NF,WILATE,ALP factor (fviii) recombinant, fc HANATE,REFAC fusion protein,antihemophilic TO,MONARC- factor viii, recombinant M,ELOCTATE,O porcine BIZUR,NOVOEI sequence,antihemophilic GHT,KOATE,NU factor viii recombinant, b- WIQ,ADYNOVAT domain E,KOVALTRY,AF truncated,antihemophilic STYLA,JIVI,ESP factor viii rec hek cell, b- EROCT,SEVENF domain ACT deleted,antihemophilic factor (fviii) recombinant, full length, peg,antihemophilic factor viii recomb,single- chn,b-dom truncated,antihemophilic factor (fviii) rec, b-domain deleted peg- aucl,antihemophilic factor (fviii) rec, b-dom truncated

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 82 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value peg-exei,coagulation factor viia recombinant-jncw 07/01/2021 MONONINE,RIX factor ix,factor ix human REMOVE FROM Non-Formulary UBIS,BENEFIX,P recombinant,factor ix FORMULARY ROFILNINE complex human,factor ix SD,ALPHANINE recombinant, fc fusion SD,ALPROLIX,IX protein,factor ix human INITY,IDELVION, recombinant, threonine REBINYN 148,factor ix recombinant,albumin fusion protein,factor ix (human) recombinant, pegylated 07/01/2021 MONONINE,RIX factor ix,factor ix human CHANGE UM: NTWK CARVE OUT: UBIS,BENEFIX,P recombinant,factor ix FFS MEDI-CAL ROFILNINE complex human,factor ix SD,ALPHANINE recombinant, fc fusion SD,ALPROLIX,IX protein,factor ix human INITY,IDELVION, recombinant, threonine REBINYN 148,factor ix recombinant,albumin fusion protein,factor ix (human) recombinant, pegylated 07/01/2021 MONONINE,RIX factor ix,factor ix human CHANGE UM: COV Excluded UBIS,BENEFIX,P recombinant,factor ix ROFILNINE complex human,factor ix SD,ALPHANINE recombinant, fc fusion SD,ALPROLIX,IX protein,factor ix human INITY,IDELVION, recombinant, threonine REBINYN 148,factor ix recombinant,albumin fusion protein,factor ix (human) recombinant, pegylated

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 83 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ISENTRESS,TIVI raltegravir REMOVE FROM Non-Formulary CAY,VITEKTA,IS potassium,dolutegravir FORMULARY ENTRESS sodium,elvitegravir,cabotegr HD,TIVICAY avir sodium PD,VOCABRIA 07/01/2021 ISENTRESS,TIVI raltegravir CHANGE UM: NTWK CARVE OUT: CAY,VITEKTA,IS potassium,dolutegravir FFS MEDI-CAL ENTRESS sodium,elvitegravir,cabotegr HD,TIVICAY avir sodium PD,VOCABRIA 07/01/2021 ISENTRESS,TIVI raltegravir CHANGE UM: COV Excluded CAY,VITEKTA,IS potassium,dolutegravir ENTRESS sodium,elvitegravir,cabotegr HD,TIVICAY avir sodium PD,VOCABRIA 07/01/2021 JULUCA,CABEN dolutegravir REMOVE FROM Non-Formulary UVA sodium/rilpivirine FORMULARY hcl,cabotegravir/rilpivirine 07/01/2021 JULUCA,CABEN dolutegravir CHANGE UM: NTWK CARVE OUT: UVA sodium/rilpivirine FFS MEDI-CAL hcl,cabotegravir/rilpivirine 07/01/2021 JULUCA,CABEN dolutegravir CHANGE UM: COV Excluded UVA sodium/rilpivirine hcl,cabotegravir/rilpivirine 07/01/2021 VIDEX EC didanosine REMOVE FROM Non-Formulary FORMULARY 07/01/2021 VIDEX EC didanosine ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 VIDEX EC didanosine ADD UM: COV Excluded 07/01/2021 VIDEX EC didanosine REMOVE FROM Non-Formulary FORMULARY 07/01/2021 VIDEX EC didanosine ADD UM: NTWK CARVE OUT: FFS MEDI-CAL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 84 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 VIDEX EC didanosine ADD UM: COV Excluded 07/01/2021 VIDEX EC didanosine REMOVE FROM Non-Formulary FORMULARY 07/01/2021 VIDEX EC didanosine ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 VIDEX EC didanosine ADD UM: COV Excluded 07/01/2021 RETROVIR zidovudine REMOVE FROM Non-Formulary FORMULARY 07/01/2021 RETROVIR zidovudine ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 RETROVIR zidovudine ADD UM: COV Excluded 07/01/2021 RETROVIR zidovudine REMOVE FROM Non-Formulary FORMULARY 07/01/2021 RETROVIR zidovudine ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 07/01/2021 RETROVIR zidovudine ADD UM: COV Excluded 07/01/2021 VSL#3,VISBIOM lactobacillus CHANGE TIER Tier 3 E,HIGH no.2/s.thermophilus/bifidoba POTENCY cterium no.1,lactobacillus PROBIOTIC combination no.2/s.thermophl/bif cmb no.1 07/01/2021 VSL#3,VISBIOM lactobacillus CHANGE UM: PANAME PA Applies E,HIGH no.2/s.thermophilus/bifidoba POTENCY cterium no.1,lactobacillus PROBIOTIC combination no.2/s.thermophl/bif cmb no.1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 85 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 kaopectate,childr bismuth subsalicylate CHANGE TIER Tier 1 en's kaopectate,stoma ch relief,peptic relief,soothe,diarr hea relief,bismatrol,ka o-tin,pepto- bismol,pink bismuth,bismuth, bismuth subsalicylate,k- pec,stomach relief original,kapectoli n,bismate,anti- diarrheal,geri- pectate,digestive relief 07/01/2021 child pain rel- acetaminophen CHANGE TIER Tier 1 fever reducer,children's fever reducer,feverall,a cetaminophen,ac ephen,children's non-aspirin,fever reducer,children's fever reducing,child fever reducer 07/01/2021 nicotine nicotine polacrilex CHANGE TIER Tier 1 lozenge,commit,n icorette,nicorelief, stop smoking aid,quit 4

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 86 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 nicotine nicotine polacrilex CHANGE TIER Tier 1 lozenge,commit,n icorette,nicorelief, stop smoking aid,quit 2 07/01/2021 vitamin d,vitamin cholecalciferol (vitamin d3) CHANGE TIER Tier 1 d3,kids vitamin d3,children's vitamin d 07/01/2021 valu-dryl,benadryl diphenhydramine hcl CHANGE TIER Tier 1 allergy,diphedryl allergy,children's allergy rapid melts,children's benadryl allergy,children's allergy relief,diphenhydr amine hcl 07/01/2021 desenex,lamisil terbinafine hcl,clotrimazole CHANGE TIER Tier 1 at,terbinafine,lami sil,athlete's foot,antifungal,at hlete's foot af,jock itch,foot antifungal 07/01/2021 ferrous ferrous sulfate CHANGE TIER Tier 1 sulfate,ferosul

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 87 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 sudafed 12 pseudoephedrine hcl CHANGE TIER Tier 1 hour,sudafed 12- hour,suphedrine 12 hour,wal-phed 12 hour,pseudoephe drine er,sudogest,sinus 12- hour,suphedrine 12-hour,long acting nasal decongestant,12 hour decongestant,12 hour nasal decongestant,sin us & allergy,nasal decongestant,me di-phedrine,12 hour cold relief,12 hour cold,12-hour sinus decongestant,wal -phed d er,sinus 12 hour 07/01/2021 miconazole miconazole nitrate CHANGE TIER Tier 1 7,miconazole nitrate,monistat 7 07/01/2021 vitamin c,acerola ascorbic acid CHANGE TIER Tier 1 c,c-500,fruit c- 500,vitamin c with acerola,orange chewable c,vitamin c with rose hips

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 88 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 florastor,digestive saccharomyces boulardii CHANGE TIER Tier 1 probiotic,florastor kids,probiotic,dail y probiotic,sacchar omyces boulardii,sacchar omycin df 07/01/2021 ureacin- urea CHANGE TIER Tier 1 20,carmol 20,gormel,urea,c arb-o-philic 07/01/2021 cetirizine hcl,all cetirizine hcl,loratadine CHANGE TIER Tier 1 day allergy,wal- zyr,zyrtec,all day allergy relief,allergy relief,allergy,aller- tec,24hour allergy

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 89 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 cetirizine cetirizine hcl CHANGE TIER Tier 1 hcl,children's all day allergy,children's wal-zyr,wal- zyr,children's zyrtec,all day allergy,children's allergy relief,children's cetirizine hcl,children's allergy,children's allergy complete,children 's aller- tec,children's zyrtec hives relief,zyrtec,allerg y relief

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 90 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 maalox maximum magnesium CHANGE TIER Tier 1 strength,maalox hydroxide/aluminum plus extra hydroxide/simethicone strength,antacid with simethicone,anta cid plus anti- gas,mag-al plus xs,antacid double strength,comfort gel,antacid maximum strength,almacon e-2,antacid- antigas,antacid m,mi-acid,mintox maximum strength,alum- mag hydroxide- simethicone,adva nced antacid- antigas,antacid,a ntacid-gas relief,antacid anti- gas double str,mylanta,mylan ta double- strength,mylanta maximum strength,masanti, antacid extra strength,antacid ii plus simethicone,ri-gel ii,geri- lanta,mylantex double- strength,liquid antacid,gelusil,mi

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 91 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value -acid ii 07/01/2021 cromolyn cromolyn sodium CHANGE TIER Tier 1 sodium,nasal allergy spray,nasalcrom 07/01/2021 MITRAZOL,DES miconazole nitrate CHANGE TIER Tier 1 ENEX,ZEASORB ,LOTRIMIN AF,MICRO- GUARD,MICONA ZORB AF,ANTI- FUNGAL,REMED Y ANTIFUNGAL,ZE ASORB- AF,REMEDY PHYTOPLEX ANTIFUNGAL,AT HLETE'S FOOT,ANTI- FUNGAL POWDER,ZEAS ORB AF,ANTIFUNGAL POWDER,MYCO ZYL AP,THERA ANTIFUNGAL 07/01/2021 imodium a- loperamide hcl CHANGE TIER Tier 1 d,loperamide,anti -diarrheal

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 92 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 sleep ii,nighttime diphenhydramine hcl CHANGE TIER Tier 1 sleep aid,sleep aid,sominex,simp ly sleep,sleep- eze 3,sleep tabs,diphenhydra mine hcl,nytol,sleep tablet,alka-seltzer plus allergy,rest simply,restfully sleep,nytol quickcaps,compo z,nyt-time sleep 07/01/2021 children's wal- cetirizine hcl CHANGE TIER Tier 1 zyr,cetirizine hcl,all day allergy,children's cetirizine hcl,zyrtec,childre n's allergy relief,allergy relief,children's zyrtec 07/01/2021 refresh carboxymethylcellulose CHANGE TIER Tier 1 tears,lubricant sodium eye drop,moisturizing lubricant,ultra fresh,carboxymet hylcellulose sodium,restore tears

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 93 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 pain acetaminophen,aspirin CHANGE TIER Tier 1 reliever,tylenol extra strength,pain relief,acetaminop hen,pain & fever,q-pap extra strength,mapap,n on-aspirin extra strength,pain relief extra strength,acetami nophen extra strength,masoph en,extra strength non- aspirin,pharbetol, non-aspirin pain relief,aspirin free,medi- tabs,medi-tabs extra strength,tylenol extra strength arthrit,tactinal,ace taminophen es,genebs,pain relief cool ice,maxapap,gen apap,pain reliver super strength,acetami nophen pain relief,shake that ache

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 94 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 pain acetaminophen CHANGE TIER Tier 1 relief,genebs,acet aminophen,pain reliever,tylenol,pa in & fever,q- pap,mapap,non- aspirin,athenol,m asophen,pharbet ol,pain reliever w- o aspirin,aspirin free,medi- tabs,maxapap,tac tinal,non-aspirin pain relief,aphen 07/01/2021 d3-50,vitamin cholecalciferol (vitamin d3) CHANGE TIER Tier 1 d3,decara,optima l d3,weekly-d 07/01/2021 panoxyl- benzoyl peroxide,benzoyl CHANGE TIER Tier 1 4,benzoyl peroxide & skin cleanser peroxide,lavoclen combination no.5 -4,creamy acne face,panoxyl 07/01/2021 magnesium magnesium oxide CHANGE TIER Tier 1 oxide,magox 400,magox,diase nse magnesium,mgo

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 95 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 konsyl-d,natural psyllium seed (with CHANGE TIER Tier 1 fiber,natural dextrose),psyllium seed vegetable powder,fiber,natu ral fiber powder,natural psyllium fiber,metamucil,n atural vegetable laxative,reguloid, metafiber,fiber supplement,genfi ber,vegetable laxative

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 96 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 poly- multivitamin CHANGE TIER Tier 1 vitamin,children's chewable vitamin,children's multivitamins,mult ivitamins,animal shapes vitamins,children' s multivit w-extra c,child little animals vitamins,gummi bear multivitamin,flintst ones,flintstones with extra c,zoo chews,animal shapes,children's chewable,animal chews,kid's vitamins + extra c,kid's vitamins,kid's vitamins complete,kid's gummy bear vitamins,fruity chews,children's chewable complete,gummy swirls,child's vitamin with vitamin c,fruity vitamin,ultra choice,bugs bunny vit plus minerals,bugs bunny with extra c,child chew

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 97 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value vitamin,animal shapes plus c,child chew with extra c,children's multivit complete,child's multivitamins,hon ey bears,children's chewable with c 07/01/2021 ferrous ferrous sulfate CHANGE TIER Tier 1 sulfate,ferosul,iro n,iron supplement,feoso l,ferro- time,ferrousul,alb afort 07/01/2021 vitamin d3,delta cholecalciferol (vitamin CHANGE TIER Tier 1 d3,vitamin d3),ergocalciferol (vitamin d,vitamin d-400 d2) 07/01/2021 micatin,desenex, miconazole nitrate CHANGE TIER Tier 1 cruex,athlete's foot spray,lotrimin af,miconazole nitrate,neosporin af 07/01/2021 docusate docusate sodium CHANGE TIER Tier 1 sodium,diocto,do c-q-lace,stool softener,dioctyl,si lace,colace

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 98 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 I-VITE,OPTI- beta-carotene(a) w-c and CHANGE TIER Tier 1 VITAMIN,ANTIO e/lutein/minerals,beta- XIDANT carotene(a) w-c & VITAMINS,OCUV e/lutein/minerals ITE WITH LUTEIN,HEALTH Y EYES,EYE HEALTH PLUS LUTEIN,VISION VITAMINS,VISIO N FORMULA,VISIO N FORMULA WITH LUTEIN,EYE HEALTH AND LUTEIN 07/01/2021 infant's ibuprofen CHANGE TIER Tier 1 ibuprofen,infants' ibuprofen,infants ibuprofen,infants' motrin,infant's motrin,infants' advil,children's ibuprofen,infants ibu-drops,ibu- drops,infants profenib,infants medi- profen,ibuprofen, children's motrin 07/01/2021 ibuprofen,motrin, ibuprofen CHANGE TIER Tier 1 advil junior strength,ibuprofe n ib,ibuprofen jr,children's motrin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 99 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 children's ibuprofen CHANGE TIER Tier 1 motrin,motrin,chil dren's ibuprofen,ibuprof en,children's advil,child ibuprofen,childre n's profenib,children' s profen ib,children's medi-profen 07/01/2021 SARNA pramoxine hcl CHANGE TIER Tier 1 SENSITIVE,PRA X,SENSITIVE ANTI-ITCH,ANTI- ITCH,SARNA,CE RAVE ITCH RELIEF 07/01/2021 ibuprofen,motrin ibuprofen CHANGE TIER Tier 1 ib,wal- profen,advil,ibu- 200,ibuprofen ib,i-prin,medi- profen,nuprin,pro vil,profen ib,cap- profen,addaprin 07/01/2021 lamisil tolnaftate CHANGE TIER Tier 1 af,tinactin,anti- fungal,tolnaftate, podactin,aftate 07/01/2021 melatonin,melatin melatonin CHANGE TIER Tier 1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 100 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 vagistat- tioconazole CHANGE TIER Tier 1 1,tioconazole 1,tioconazole- 1,monistat 1,1- day 07/01/2021 child triaminic acetaminophen CHANGE TIER Tier 1 fever reducer,infant triaminic fever reducer,ed- apap,children's pain and fever,q- pap,mapap,aceta minophen,childre n's non- aspirin,pain relief,children's pain relief,children's q- pap,silapap,little remedies fever- pain,children's mapap,m- pap,children's acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 101 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 WAL- psyllium husk (with sugar) CHANGE TIER Tier 1 MUCIL,REGULOI D,NATURAL VEGETABLE FIBER,NATURAL FIBER,FIBER LAXATIVE,META MUCIL,NATURA L FIBER LAXATIVE,FIBE R,NATURAL DAILY FIBER,FIBER THERAPY,GERI- MUCIL,MULTIHE ALTH FIBER

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 102 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 WAL-ITIN D 12 loratadine/pseudoephedrine CHANGE TIER Tier 1 HOUR,ALLERGY sulfate -CONGESTION RELIEF 12HR,ALAVERT, LORATADINE- D,CLARITIN-D 12 HOUR,ALLERGY RELIEF- D,ALLERGY RELIEF D,ALLERGY RELIEF D12,ALLERGY- CONGESTION 12HR,ALLERCL EAR D- 12HR,ALLERGY- CONGESTION RELIEF- D,ALLERGY RELIEF- D12,ALLERGY RELIEF D-12

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 103 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 doxidan,bisacody bisacodyl CHANGE TIER Tier 1 l,gentle laxative,dulcolax, women's laxative,laxative,b isa-lax,woman's laxative,alophen pills,ducodyl,wom en's gentle laxative,reliable gentle laxative,bisac- evac,stimulant laxative,c-lax laxative 07/01/2021 naproxen naproxen sodium CHANGE TIER Tier 1 sodium,all day pain relief,wal- proxen,midol,alev e,flanax,all day relief,mediproxen 07/01/2021 gas-x,gas simethicone CHANGE TIER Tier 1 relief,simethicone ,mytab gas maximum strength,mylanta gas maximum strength,simethic one gas relief

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 104 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 children's saline sodium chloride CHANGE TIER Tier 1 nasal spray,saline nasal spray,ocean,ayr saline,saline mist,sea soft,deep sea,saline nose spray,ultra saline,nasal spray,nasal moisturizing,nasa l moist,sodium chloride,little remedies,altamist ,nasal moisturizer,little remedies stuffy nose 07/01/2021 KONSYL,WAL- psyllium husk (with CHANGE TIER Tier 1 MUCIL sugar),psyllium seed (with NATURAL FIBER sugar),psyllium LAX,REGULOID, seed/aspartame FIBER THERAPY,NATU RAL VEGETABLE POWDER,META MUCIL,NATURA L FIBER LAXATIVE,FIBE R,DAILY FIBER,NATURAL FIBER,GERI- MUCIL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 105 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 benzoyl benzoyl peroxide CHANGE TIER Tier 1 peroxide,benzac ac,benzac w wash,desquam- x,bp wash,bpo- 5,ethexderm,adv anced exfoliating cleanser 07/01/2021 allergy- loratadine/pseudoephedrine CHANGE TIER Tier 1 congestion sulfate relief,wal-itin d,loratadine- d,lorata-dine d,allergy relief- nasal decongest,claritin -d 24 hour,lorata- d,allergy relief d- 24hr,allergy relief d-24,loratadine- pseudoephed,alle rgy-congestion relief-d,allergy relief d,allerclear d-24hr 07/01/2021 clearlax,smoothla polyethylene glycol 3350 CHANGE TIER Tier 1 x,polyethylene glycol 3350,miralax,pow derlax,laxative peg 3350,gavilax,pure lax,healthylax

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 106 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 robitussin-dm guaifenesin/dextromethorph CHANGE TIER Tier 1 cough,robitussin- an hbr cough-chest- cong,tussin dm,tussin dm cough-chest congest,guaifene sin- dextromethorpha n,guiatuss dm,genatuss dm,adult wal- tussin dm,extra action cough,cough,guai fenesin dm,cough dm,q-tussin dm,robafen- dm,robafen dm cough-chest congest,robafen- dm clear,tussin dm clear,expectorant dm,cough formula dm,tussin dm cough,antitussive dm,wal-tussin dm,super tussin dm,super tussin,cough control dm,creo- terpin,vicks pediatric 44e,cough syrup dm,ultra tuss,medi-tussin dm,adult tussin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 107 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value dm,ri-tussin dm,siltussin dm,geri-tussin dm,altarussin dm 07/01/2021 cortaid,anti- hydrocortisone,hydrocortiso CHANGE TIER Tier 1 itch,hydrocortison ne acetate e,ala- cort,hydrocortiso ne plus 12,hydroskin,pre paration h,recort plus,neosporin,co rtizone- 10,cortizone-10 plus,hydrocream, hydrocortisone plus,cortisone,ec zema anti- itch,soothing care,proctocort,n oble formula hc,hydrocortisone acetate 07/01/2021 clearlax,smoothla polyethylene glycol 3350 CHANGE TIER Tier 1 x,polyethylene glycol 3350,miralax,laxa tive peg 3350,glycolax,ge ntlelax,gavilax,pu relax,laxaclear,du lcolax balance,polyethyl ene glycol,powderlax, natura-lax

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 108 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 prevacid lansoprazole CHANGE TIER Tier 1 24hr,lansoprazol e,heartburn relief 24 hour,prevacid,he artburn treatment 24 hour 07/01/2021 glutofac,vitabee b complex with vitamin c,b- CHANGE TIER Tier 1 w-c,total b with complex with vitamin c c,farbee w- c,superplex- t,vitamin b- complex with vit c,super b complex-vitamin c,b-complex with vitamin c,b- complex plus vitamin c,b complex-vitamin c,vitamin b&c,surbex w- c,super b- complex & c,thex forte,bec with zinc,surbex-t,high potency b,vitamin b complex-c,b- complex with c,vitamin b complex-vitamin c

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 109 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 fer-in-sol,fer- ferrous sulfate CHANGE TIER Tier 1 iron,ferrous sulfate,children's iron,children's ferrous sulfate,iron,pedia iron,pediatric iron,pediatric fe- vite

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 110 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 adult robitussin guaifenesin/dextromethorph CHANGE TIER Tier 1 peak cold an hbr dm,iophen dm- nr,robafen dm cough,tussin dm,broncotron,ult ra dm free & clear,tussin cough,cough control dm,cheracol d,tussin cough dm,tussin cough- chest congestion,biocot ron,medi-tussin dm diabetic,guaifene sin- dextromethorpha n,g-tron,adult tussin cough congest dm,safetussin dm,guaifenesin dm nr,siltussin dm das,diabetic siltussin- dm,tusnel diabetic,gani- tuss-dm nr,diabetic tussin dm,tussin dm clear,iophen dm,super tussin dm,tussin dm cough-chest congest,sorbuge n nr,tussin dm

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 111 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value max,guaiasorb dm,geri-tussin dm,robafen dm peak cold,giltuss diabetic,giltuss hbp,maxi-tuss g,giltuss cough- congestion,chest congestion relief dm 07/01/2021 calcium calcium carbonate CHANGE TIER Tier 1 antacid,tums,anta cid,cal- gest,calcium carbonate,tums freshers,gaviscon 07/01/2021 anti- selenium sulfide,pyrithione CHANGE TIER Tier 1 dandruff,dandruff zinc shampoo,selsun blue,dandrex,me dicated dandruff shampoo,selsun blue 2-in-1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 112 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 debrox,ear carbamide peroxide CHANGE TIER Tier 1 drops,earwax treatment,earwax treatment drops,carbamide peroxide,ear wax drops,ear wax removal,auraphe ne-b,ear system,carbamox ide,carbamide,h. e.a.r.,auro,murine ear wax removal system,murine ear drops 07/01/2021 konsyl,wal- psyllium husk CHANGE TIER Tier 1 mucil,reguloid,fib er laxative,psyllium fiber,fiber,fiber therapy,metamuc il,natural fiber,medi- mucil,daily fiber,genfiber 07/01/2021 calcium 600 + vit calcium CHANGE TIER Tier 1 d,calcarb 600 carbonate/cholecalciferol with vitamin (vitamin d3) d,calcium 600-vit d3,super calcium 600-vit d3,super calcium w-vitamin d

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 113 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 imodium a-d,anti- loperamide hcl CHANGE TIER Tier 1 diarrheal,loperam ide,ultra a-d,anti- diarrhea,antidiarr heal,diamode,lo- peramide,imperi m 07/01/2021 mineral mineral oil CHANGE TIER Tier 1 oil,mineral oil heavy,mineral oil extra heavy 07/01/2021 infants' pain acetaminophen CHANGE TIER Tier 1 reliever,triaminic fever reducer,infant's pain relief,infants tylenol,acetamino phen,pain & fever,mapap infant,infant's pain reliever,infant's non- aspirin,pediacare fever reducer,infants' non- aspirin,infants' pain relief,tylenol

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 114 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 benadryl diphenhydramine hcl CHANGE TIER Tier 1 allergy,allergy relief,genahist,wa l-dryl allergy,nighttime allergy relief,diphenhist,d iphenhydramine hcl,banophen,anti histamine,valu- dryl allergy medicine,allergy medicine,complet e allergy,allergy,all ergy medication,diphe dryl,vicks qlearquil nighttime,diphedr yl allergy,aler- tab,diphen,aller- g-time,simply allergy,geri- dryl,complete allergy relief,total allergy 07/01/2021 calcium 500-vit calcium CHANGE TIER Tier 1 d3,calcium 500 + carbonate/cholecalciferol vit d,oyster shell (vitamin d3) calcium-vitamin d,oystercal- d,oyster shell calcium,oyster shell calcium w- vit d

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 115 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 sodium sodium chloride CHANGE TIER Tier 1 chloride,muro- 128,sochlor,altac hlore,retaine nacl 07/01/2021 adult nasal pseudoephedrine hcl CHANGE TIER Tier 1 decongestant,sup hedrin,children's sudafed,children' s silfedrine,nasal decongestant,chil dren's suphedrine,tyleno l simply stuffy

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 116 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 maalox magnesium CHANGE TIER Tier 1 advanced,antacid hydroxide/aluminum plus anti- hydroxide/simethicone,magn gas,advanced esium hydroxide/aluminum antacid- hydroxide antigas,mag-al plus,antacid,comf ort gel,antacid m,almacone,rulox ,mi acid,mintox,antac id with simethicone,anta cid- antigas,mylanta,li quid antacid,flanax,alu m-mag hydroxide- simethicone,ri- gel,ri- mox,maglox,geri- lanta,geri- mox,milantex,ma alox,di- gel,masanti,maldr oxal,magnesium hydr-aluminum hydr,advanced antacid,mi- acid,antacid plus gas relief

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 117 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 vitamin ascorbic acid CHANGE TIER Tier 1 c,ascorbic acid,ascorbic acid with rh,vitamin c with rose hips,soothing pureway-c,c- 500,vitamin c with acerola,natural vitamin c-rose hips 07/01/2021 lidocare,aspercre lidocaine CHANGE TIER Tier 1 me lidocaine,lidocain e pain relief,lido king,salonpas,lid ocaine,pain relief,blue-emu lidocaine patch,asperflex 07/01/2021 zinc zinc sulfate CHANGE TIER Tier 1 sulfate,orazinc,zi ncate,zinc-220

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 118 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 children's acetaminophen CHANGE TIER Tier 1 tylenol,tylenol,inf ants' tylenol,children's pain relief,children's pain-fever,infants' pain- fever,children's non- aspirin,infants' acetaminophen,c hildren's acetaminophen,c hildren's q- pap,mapap,infant s' mapap,children's pain reliever,infants' pain reliever,acetamin ophen,child fever reducer-pain relvr,non- aspirin,fever reducer-pain reliever,infant fever-pain reliever,infants' fever-pain reliever,childrens suspension,pedia care fever reducer,infants' pain relief,infant's pain relief,infant pain-fever,child's accudial

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 119 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value acetaminophen,in fant pain relief,children's medi- tabs,betatemp,chi ldren's aurophen pain- fever,nortemp 07/01/2021 vitamin c,vitamin ascorbic acid CHANGE TIER Tier 1 c with rose hips,cemill- 1000,c-1000 with rose hips,c- 1000,buffered vitamin c

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 120 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 excedrin extra aspirin/acetaminophen/caffei CHANGE TIER Tier 1 strength,excedrin ne migraine,excedrin menstrual complete,migrain e formula,headach e formula,headach e relief,migraine relief,pain reliever plus,added strength headache,added strength pain reliever,pain reliever,bayer migraine,pain relief extra strength,headach e pain,migraine pain- reliever,pamprin max,goody's extra strength,goody's migraine relief,pain- off,super pain relief,genaced,su per strength reliever,aspirin- acetaminphen- caffeine,extraprin ,pain relief plus,extra pain relief

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 121 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 HYDRATING mineral CHANGE TIER Tier 1 HEALING,PETR oil/petrolatum,hydrophilic,pet OLATUM,AQUA rolatum,white PHOR,DERMAP HOR,AMERIPHO R,SEVERE DRY,AQUAPHO R WITH NATURAL HEALING 07/01/2021 vitamin ascorbic acid CHANGE TIER Tier 1 c,ascorbic acid,vitamin c with rose hips 07/01/2021 docusate docusate sodium CHANGE TIER Tier 1 sodium,diocto,do c-q- lace,silace,stool softener,docu liquid,colace 07/01/2021 ANTI-ITCH benzocaine/resorcinol CHANGE TIER Tier 1 CREAM,VAGISIL ,VAGICAINE,VA GICREAM,VAGI NAL ITCH CREAM,ANTI- ITCH VAGINAL 07/01/2021 lac- ammonium lactate CHANGE TIER Tier 1 hydrin,amlactin,la clotion,ammoniu m lactate,lac- hydrin twelve,skin treatment,al- 12,geri- hydrolac,moist skin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 122 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 dramamine less meclizine CHANGE TIER Tier 1 drowsy,antivert,m hcl,dimenhydrinate eclizine hcl,motion sickness,motion sickness relief,motion sickness relief ii,motion relief,medi- meclizine,motion sickness ii,verticalm,drama mine ii,travel motion sickness,ambizin e,travel-ease,wal- dram 2 07/01/2021 niacin,slo- niacin CHANGE TIER Tier 1 niacin,endur- acin,niavasc

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 123 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 benadryl diphenhydramine hcl CHANGE TIER Tier 1 allergy,children's allergy,diphenhyd ramine hcl,genahist,hydr amine,children's wal-dryl allergy,wal-dryl allergy,children's benadryl allergy,diphenhist ,q- dryl,banophen,all ergy relief,children's allergy relief,diphedryl allergy,diphedryl, allergy medication,pedia care allergy,allergy medicine,complet e allergy,allergy,me di- phedryl,siladryl,g eri-dryl,children's aurodryl allergy,m- dryl,children's diphenhydramine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 124 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 chlor- chlorpheniramine maleate CHANGE TIER Tier 1 trimeton,allergy,w al-finate,ed- chlortan,aller- chlor,chlorphenir amine maleate,allergy 4- hour,pharbechlor, chlorhist,chlortab s,allergy- time,allergy relief 07/01/2021 tavist loratadine CHANGE TIER Tier 1 nd,loratadine,alle rgy relief,claritin,wal- itin,allergy,alavert ,non-drowsy allergy,vicks qlearquil allergy,loradame d,allerclear 07/01/2021 REESE'S pyrantel pamoate CHANGE TIER Tier 1 PINWORM,PIN- X,PINWORM MEDICINE,PINW ORM TREATMENT,PI NAWAY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 125 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 micatin,miranel miconazole nitrate CHANGE TIER Tier 1 af,antifungal cream,miconazol e nitrate,micro- guard,baza antifungal,secura antifungal,inzo antifungal,anti- fungal cream,monistat- derm,micaderm,d ermafungal,nuzol e,neosporin af,anti- fungal,theracure 07/01/2021 organidin guaifenesin CHANGE TIER Tier 1 nr,organ-i nr,guaifenesin,ref enesen,expector ant,medifin expectorant,coug htab,mucus relief,gg 200 nr,mucus relief chest congestion

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 126 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 benzoyl benzoyl peroxide CHANGE TIER Tier 1 peroxide,benzac ac,persa- gel,bp,acne treatment,benzac w wash,acneclear,p anoxyl,acne 10,desquam- x,acne medication,acne pimple medication,daylo gic acne treatment 07/01/2021 simethicone,infan simethicone CHANGE TIER Tier 1 ts' gas relief,gas relief,infants' mylicon,infant gas relief,equalizer gas relief,simeped,ge nasyme,mylicon,f latulex,infantaire,l ittle remedies gas relief,infants' simethicone

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 127 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 guaifenesin- codeine CHANGE TIER Tier 1 codeine,myci- phosphate/guaifenesin,guaif gc,cheratussin enesin/codeine phosphate ac,iophen-c nr,robafen ac,guaifenesin ac,guiatuss ac,guaiatussin ac,gani-tuss nr,mytussin ac,virtussin ac,codeine- guaifenesin,ambit ussin ac,g tussin ac,maxi-tuss ac 07/01/2021 heartburn cimetidine CHANGE TIER Tier 1 relief,tagamet hb,cimetidine,aci d reducer,acid relief,heartburn 200 07/01/2021 vitamin c,vitamin ascorbic acid/ascorbate CHANGE TIER Tier 1 c with rose hips sodium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 128 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 robitussin,robitus guaifenesin CHANGE TIER Tier 1 sin mucus-chest congest,tussin mucus-chest congestion,childr en's mucus relief,tussin,guaif enesin,children's chest congestion,adult wal-tussin,scot- tussin,cough syrup,q- tussin,iophen nr,robafen,pediatr ic cough- cold,tussin honey,expectora nt,chest congestion relief,expectorant cough syrup,tussin chest congestion,wal- tussin,cough control,siltussin sa,medifin expectorant mucus rlf,mucus relief,guiatuss,me di-tussin,chest congestion,adult tussin chest congestion,ri- tussin,guaifenesi n nr,siltussin das,diabetic siltussin das-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 129 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value na,geri- tussin,ganidin nr,diabetic tussin ex,child mucinex chest congestion,childr en's mucinex,buckley' s chest congest mix,adult mucus relief,altarussin,or ganidin nr,super tussin,scot-tussin expectorant,muc us-chest congestion,tusnel -ex,mucinex fast- max chest- congest,diabetic tussin 07/01/2021 maxilube,lubricati chlorhexidine CHANGE TIER Tier 1 ng jelly,k-y gluconate/glycerin/hydroxyet lubricating hylcellulose,methylcellulose jelly,personal lubricant,lubricati ng gel,personal lubricating jelly,feminine moist & lubricating,k- y,lubrigel,k-y jelly 07/01/2021 chlor-trimeton chlorpheniramine maleate CHANGE TIER Tier 1 allergy,chlorpheni ramine maleate,allergy relief,chlorphen sr

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 130 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 meribin,biotin biotin CHANGE TIER Tier 1 07/01/2021 docusate docusate sodium CHANGE TIER Tier 1 sodium,dok,stool softener,col- rite,dss 07/01/2021 vitamin b-12,b-12 cyanocobalamin (vitamin b- CHANGE TIER Tier 1 12) 07/01/2021 aspirin,st joseph aspirin CHANGE TIER Tier 1 aspirin,children's aspirin,bayer chewable aspirin,baby aspirin,st. joseph aspirin 07/01/2021 glucose,trueplus dextrose CHANGE TIER Tier 1 glucose,dex4 glucose,ultilet 07/01/2021 gentle bisacodyl CHANGE TIER Tier 1 laxative,bisacodyl ,bisac- evac,biscolax,lax ative suppository,fast relief laxative,dulcolax, magic bullet 07/01/2021 vitamin cholecalciferol (vitamin d3) CHANGE TIER Tier 1 d3,dialyvite vitamin d 07/01/2021 vitamin b- thiamine hcl CHANGE TIER Tier 1 1,thiamine hcl 07/01/2021 vitamin d3,thera- cholecalciferol (vitamin d3) CHANGE TIER Tier 1 d,d3 dots,vitamin d

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 131 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 pepcid,acid famotidine CHANGE TIER Tier 1 reducer,famotidin e,acid controller,heartbu rn relief,pepcid ac,heartburn prevention,acid control,acid- pep,zantac-360 (famotidine) 07/01/2021 daily vite with multivitamin with CHANGE TIER Tier 1 iron,tab-a-vite iron,multivitamins with iron with iron,daily multivitamin with iron,multivitamins with iron,one daily plus iron,hair vitamin,one daily with iron,daily vitamin + iron,one-tab-daily with iron,uni-daily with iron,daily vitamin with iron 07/01/2021 lactaid,lac- lactase CHANGE TIER Tier 1 dose,lactase,dair y relief,dairy digest

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 132 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 plan b one- levonorgestrel CHANGE TIER Tier 1 step,my way,next choice one dose,levonorgest rel,take action,fallback solo,opcicon one- step,aftera,econtr a ez,react,option 2,my choice,econtra one-step,new day 07/01/2021 clotrimazole,gyne clotrimazole CHANGE TIER Tier 1 -lotrimin- 7,clotrimazole- 7,gyne-lotrimin 07/01/2021 SELSUN selenium sulfide/menthol CHANGE TIER Tier 1 BLUE,ANTI- DANDRUFF WITH MENTHOL,DAN DRUFF SHAMPOO- MENTHOL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 133 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 centrum multivitamin w- CHANGE TIER Tier 1 silver,cerovite minerals/lutein,multivitamin senior,central-vite with minerals/lutein,folic select,vision plus acid/multivitamin w- lutein,vitrum minerals/lutein,multivitamin senior,a thru z with iron and other minerals select,a thru z,century with lutein,milltrium senior,multi-vite 50 & over,certa plus senior,multivital platinum,century vitamin,multivitam in 50 plus,century mature,spectravit e senior,theratrum complete 50 plus,high potency multivitamin,cent ury senior,super aytinal,vitatrum,c erovite silver,central vite,multivitamins with minerals 07/01/2021 sodium sodium chloride CHANGE TIER Tier 1 chloride,muro- 128,sochlor,altac hlore,retaine nacl 07/01/2021 motion sickness meclizine hcl CHANGE TIER Tier 1 relief,meclizine hcl,travel sickness,bonine,v ertin-32,motion- time

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 134 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 senna s,stool sennosides/docusate CHANGE TIER Tier 1 softener- sodium,sennosides laxative,senna- s,docusate sodium- senna,senexon- s,doc-q- lax,sennalax- s,senna plus,dok plus,stool softener,stool softener- stimulant lax,lax stool softener with senna,senna laxative,p-col rite,sennosides- docusate sodium,senna- docusate sodium,stimulant laxative plus,medi-natural senna stool soft,senna-c plus,laxacin,seno kot-s,peri- colace,medi- laxx,easy-lax plus,senna,senna -time s,colace 2- in-1,docusate sodium- sennosides,senn a-s laxative,docuzen, vegetable lax- stool softener

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 135 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 pseudoephedrine pseudoephedrine hcl CHANGE TIER Tier 1 hcl,sudafed,nasal decongestant,ge naphed,wal- phed,sudogest,n asal & sinus decongestant,sup hedrine,suphedri n,suphedrine sinus congestion,decon gestant,medi- phedrine,tylenol simply stuffy 07/01/2021 magnesium magnesium citrate CHANGE TIER Tier 1 citrate,citroma,citr ate of magnesia 07/01/2021 gyne-lotrimin,3- clotrimazole CHANGE TIER Tier 1 day vaginal cream,clotrimazol e-3,clotrimazole 3 07/01/2021 kaopectate,docus docusate calcium CHANGE TIER Tier 1 ate calcium,kao- tin,calcium stool softener,stool softener,surfak,d c-240 07/01/2021 diphenhydramine diphenhydramine hcl CHANGE TIER Tier 1 hcl,banophen,co mplete allergy medicine,pharbe dryl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 136 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 allergy diphenhydramine hcl CHANGE TIER Tier 1 relief,genahist,dip henhydramine hcl,wal- dryl,diphenhist,q- dryl,banophen,an tihistamine,allerg y medication,compl ete allergy,benadryl,a llergy medicine,pharbe dryl,allergy,diphe dryl,aler- caps,diphen,medi -phedryl,geri-dryl 07/01/2021 hydrocortisone,a hydrocortisone CHANGE TIER Tier 1 nti-itch,cortizone- 10,cortisone,aqu aphor itch relief 07/01/2021 pseudoephedrine pseudoephedrine hcl CHANGE TIER Tier 1 hcl,sudogest,pse udogest 07/01/2021 ecotrin,aspirin aspirin CHANGE TIER Tier 1 ec,aspir- trin,ecpirin,genac ote 07/01/2021 d-vi-sol,vitamin cholecalciferol (vitamin d3) CHANGE TIER Tier 1 d3,d-vita,just d,pedia d- vite,pediatric vitamin d3,pediatric d-vite

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 137 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 oncovite,therems, multivitamin,therapeutic,mult CHANGE TIER Tier 1 thera- ivitamins,therapeutic tabs,thera,therap eutic,therapeutic multivitamin 07/01/2021 ARTIFICIAL mineral oil/petrolatum,white CHANGE TIER Tier 1 TEARS,LUBRIFR ESH PM,LUBRICANT EYE,ARTIFICIAL EYE LUBRICANT 07/01/2021 caltrate calcium carbonate CHANGE TIER Tier 1 600,calcarb 600,calcium,calci um carbonate,super calcium,high potency calcium 07/01/2021 bacitracin,bacitra bacitracin CHANGE TIER Tier 1 ycin plus,first aid bacitracin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 138 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 aspirin aspirin CHANGE TIER Tier 1 ec,ecotrin,low dose aspirin ec,aspir-low,lo- dose aspirin ec,adult low dose aspirin ec,miniprin,halfpri n,aspir 81,st. joseph aspirin ec,adult low strength aspirin,aspirin,st joseph aspirin,adult low strength,adult aspirin regimen,adult aspirin 07/01/2021 calcium calcium carbonate,calcium CHANGE TIER Tier 1 carbonate,oyst- cal-500,oysco- 500,oyster shell calcium,natural calcium,calcium,h i-cal,natural o-s cal 07/01/2021 famotidine,acid famotidine CHANGE TIER Tier 1 reducer,acid controller,heartbu rn relief,pepcid ac,heartburn prevention,zantac -360 (famotidine)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 139 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 balanced b- folic acid/vitamin b complex CHANGE TIER Tier 1 complex,b- and vitamin c,folic complex with acid/vitamin b comp w-c vitamin c,super b- complex,super b complex,vita-bee with c,super vitamin b,b- complex plus vitamin c,super vitamin b complex,super b complex-vitamin c,vitamin b complex-vitamin c 07/01/2021 lmx lidocaine CHANGE TIER Tier 1 5,recticare,anecr eam5,lc- 5,lidocaine,rectas moothe,hemorrho idal relief 07/01/2021 lmx lidocaine CHANGE TIER Tier 1 4,anecream,lidoc ream,lc- 4,lidocaine,blue tube

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 140 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 os-cal 500-vit calcium CHANGE TIER Tier 1 d3,oyst-cal-d carbonate/cholecalciferol 500,oyster shell (vitamin d3) calcium w-vit d,oysco 500-vit d3,os-cal 500+d,oyster shell calcium-vit d3,calcium 500- vit d3,hi- cal,calcium 500 + vit d,calcium 500 + d 07/01/2021 MUSCLE RUB methyl CHANGE TIER Tier 1 ULTRA salicylate/menthol/camphor STRENGTH,PAI N RELIEVING RUB,PAIN RELIEF,PAIN- RELIEF,MUSCL E RUB,ULTRA STRENGTH RUB,PAIN RELIEVING,NUP RIN,BENGAY ULTRA STRENGTH,ULT RA STRENGTH PAIN RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 141 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 enema,enema sodium CHANGE TIER Tier 1 disposable,phosp phosphate,monobasic/sodiu hate m phosphate,dibasic enema,saline enema,disposabl e enema,fleet enema,complete ready-to-use enema,curad enema,pure and gentle saline enema 07/01/2021 flonase allergy fluticasone propionate CHANGE TIER Tier 1 relief,fluticasone propionate,24 hour allergy relief,children's flonase allergy rlf,allergy relief,aller- flo,clarispray,chil dren 24 hr allergy relief,24 hour allergy 07/01/2021 ex-lax milk of magnesium hydroxide CHANGE TIER Tier 1 magnesia,milk of magnesia,phillips' milk of magnesia,dulcola x 07/01/2021 artificial polyvinyl alcohol CHANGE TIER Tier 1 tears,liquitears,lu bricant eye,tearfair,tears again,polyvinyl alcohol,teargen,li quid tears

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 142 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 PREPARATION witch hazel,glycerin/aloe CHANGE TIER Tier 1 H,PREPARATIO vera/witch hazel N H TOTABLES,MED I- PADS,MEDICAT ED PADS,MEDICAT ED WIPES,TUCKS,T UCKS TAKE- ALONGS,HYGIE NIC CLEANSING PADS,HEMORR HOIDAL HYGIENE,HEMO RRHOIDAL PADS,HEMORR HOIDAL MEDICATED WIPES 07/01/2021 lamisil af tolnaftate,clotrimazole CHANGE TIER Tier 1 defense,tinactin,t olnaftate,q- naftate,fungoid- d,antifungal cream,athlete's foot cream,fungi- guard,antifungal,t heracure,athlete's foot 07/01/2021 BENADRYL diphenhydramine hcl CHANGE TIER Tier 1 ITCH STOPPING,ANTI -ITCH,ITCH RELIEF

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 143 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 robitussin dm guaifenesin/dextromethorph CHANGE TIER Tier 1 max,adt an hbr robitussin peak cld dm max,robitussin cough-chest- cong dm,tussin dm max,guaifenesin dm,adult wal- tussin dm max,robafen dm max,adult cough formula dm max,cough control dm max,tussin dm cough & chest,diabetic siltussin-dm max str,naldecon dx,maxi-tuss gmx,diabetic tussin dm,diabetic tussin max- strength 07/01/2021 lac- ammonium lactate CHANGE TIER Tier 1 hydrin,amlactin,a mmonium lactate,geri- hydrolac,lactrex

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 144 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 fruity chews with multivitamins with CHANGE TIER Tier 1 iron,chewable- iron,multivitamin with vite with iron,child iron,multivits w- chew + iron,hematinic iron,children's vitamins with iron,children's multivitamin- iron,animal shapes plus iron,little animals with iron,animal shapes with iron,children's vitamin-iron,kid's vitamins + iron,chewable multivitamin w- iron,child's vitamin with iron,spectravite,vi talets,vitrum jr,bugs bunny+iron multivitamin,multi vitamins with iron 07/01/2021 phazyme,gas-x simethicone CHANGE TIER Tier 1 ultra strength,gas relief,simethicone ,anti-gas 07/01/2021 nicotine nicotine polacrilex CHANGE TIER Tier 1 gum,thrive nicotine,nicorette, nicorelief,stop smoking aid,quit 4

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 145 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 allegra,fexofenadi fexofenadine hcl CHANGE TIER Tier 1 ne hcl,wal-fex allergy,allergy relief,aller- ease,allegra allergy,aller- fex,mucinex allergy 07/01/2021 allegra,fexofenadi fexofenadine hcl CHANGE TIER Tier 1 ne hcl,aller- ease,wal-fex allergy,allergy relief,allegra allergy 07/01/2021 jock clotrimazole CHANGE TIER Tier 1 itch,desenex,crue x,lotrimin af,clotrimazole,an tifungal,jock itch relief,clotrimazole af,athlete's foot,athletic foot cream,ringworm,l otrimin,mycelex,it ch relief,antifungal ringworm

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 146 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 wal-act d cold & triprolidine CHANGE TIER Tier 1 allergy,ed a-hist hcl/pseudoephedrine pse,aprodine,cold hcl,pseudoephedrine , allergy & hcl/triprolidine hcl sinus,nasal decongestant- antihist,cold & allergy,nasal decongest- antihistamine,pse udo- trip,triprolidine- pseudoephedrine ,genac,allerfrim,d econgestant- antihistamine,tript ifed,trifedrine,anti histamine- decongestant,ap hedrid,nasal decongestant,trif ed,tri- sofed,sudafed sinus nighttime,histafed 07/01/2021 aspirin,bayer aspirin CHANGE TIER Tier 1 aspirin,lite coat aspirin,st. joseph aspirin,analgesic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 147 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 panoxyl,benzoyl benzoyl peroxide CHANGE TIER Tier 1 peroxide,benzac ac,benzac w wash,desquam- x,bp wash,acne foaming face wash,bpo- 10,ethexderm,ac ne foaming wash,bp foaming wash,foaming acne face wash,clean-clear continuous control,daylogic acne foaming wash,acne control cleanser 07/01/2021 wal- loratadine CHANGE TIER Tier 1 itin,alavert,loratad ine,allergy relief,claritin,wal- itin aller- melts,wal-vert 07/01/2021 thrive nicotine polacrilex CHANGE TIER Tier 1 nicotine,nicotine gum,nicorette,nic orelief,stop smoking aid,quit 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 148 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 natural senna sennosides CHANGE TIER Tier 1 laxative,senna,se nna- gen,sennagen,se nexon,senna lax,senna laxative,evac-u- gen,sen-o- tab,laxative,seno kot,vegetable laxative,natural laxative,medi- natural,sennoside s,senna-c,senna concentrate,geri- kot,sennacon,sen no,natural vegetable laxative,senokot to go 07/01/2021 aquanil hydrocortisone CHANGE TIER Tier 1 hc,hydrocortisone ,itch-x hc,hydro skin,beta hc,dermarest eczema,sarnol-hc 07/01/2021 multi- folic acid/multivit with CHANGE TIER Tier 1 vitamin,adult minerals/lutein multivitamin gummies 07/01/2021 xyzal,levocetirizin levocetirizine CHANGE TIER Tier 1 e dihydrochloride dihydrochloride,2 4hr allergy relief,allergy relief

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 149 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 natural fiber,fiber psyllium seed (with CHANGE TIER Tier 1 smooth,fiber sugar),psyllium supplement,fiber seed/aspartame laxative,natural fiber powder,metamuci l ot,metamucil,natu ral vegetable powder,metafiber ,fiber therapy,laxmar,n atural psyllium,genfiber, vegetable laxative 07/01/2021 hydrocortisone- hydrocortisone/aloe CHANGE TIER Tier 1 aloe,hydrocortiso vera,hydrocortisone ne plus,cortisone,hy drocortisone,hydr oskin,cortizone- 10,cortisone with aloe,anti-itch with aloe 07/01/2021 senexon,senna sennosides CHANGE TIER Tier 1 07/01/2021 oyst-cal-d,oysco calcium CHANGE TIER Tier 1 d,calcium 250-vit carbonate/cholecalciferol d3,oyster shell (vitamin d3) calcium w-vit d,oyster shell- d,oyster shell calcium-vit d3

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 150 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 dramamine,wal- dimenhydrinate CHANGE TIER Tier 1 dram,dimenhydri nate,driminate,tra vel sickness,motion sickness relief,motion sickness,trav- tabs,travel-ease 07/01/2021 pedia tri- vitamin a palmitate/ascorbic CHANGE TIER Tier 2 vite,pediatric tri- acid/cholecalciferol (vit d3) vitamin,pediatric tri-vite 07/01/2021 liquid corn-callus salicylic acid CHANGE TIER Tier 2 remover,wart remover,duofilm, salicylic acid,compound w,maximum strength wart remover,corn & callus remover,occlusal- hp,corn-callus remover 07/01/2021 BIOTENE,BIOTE saliva substitute combo no.9 CHANGE TIER Tier 2 NE PBF 07/01/2021 ketone test urine acetone test,strips CHANGE TIER Tier 2 strip,ketostix reagent,diascree n 1k reagent,ketone care test strip,chemstrip k,trueplus ketone test strip,ketocare

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 151 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 VCF nonoxynol 9 CHANGE TIER Tier 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 152 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 CENTRUM multivitamin w-minerals/folic CHANGE TIER Tier 2 SILVER,ADULTS acid/lycopene/lutein,multivita ' 50+ DAILY min with minerals/folic FORMULA,CERT acid/lycopene/lutein,multivita AVITE min w-minerals/lutein SENIOR,COMPL ETE SENIOR,COMPL ETE 50 PLUS,CENTRAL- VITE SENIOR,CENTR AL-VITE,A THRU Z SELECT,A THRU Z SELECT 50 PLUS,CENTURY MATURE FORMULA,SENT RY SENIOR,CENTU RY,SPECTRAVI TE ADVANCED FORM,SPECTRA VITE ADULT 50+,THERATRU M COMPLETE 50 PLUS,ABC PLUS,COMPLET E MV ADULT 50 PLUS,CENTURY MATURE,SENIO R TABS,ADULTS 50 PLUS MULTIVITAMIN, CENTRAVITES 50 PLUS,ADULTS 50 PLUS DAILY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 153 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value FORMULA,SPEC TRAVITE ADULT 50 PLUS 07/01/2021 peptic relief,pink bismuth subsalicylate CHANGE TIER Tier 2 bismuth,bismatrol ,pepto-bismol to- go,pepto- bismol,bismuth,st omach relief,diotame,me di- bismuth,soothe,bi s-mate,pep-t- med,digestive relief 07/01/2021 pedia poly- pediatric multivitamin no.171 CHANGE TIER Tier 2 vite,poly- vita,pediatric poly-vitamin 07/01/2021 calcium calcium carbonate CHANGE TIER Tier 2 antacid,tums x- str,tums,tums smoothies,tums calcium for life,x- strength antacid,antacid extra strength,smooth antacid,antacid,s mooth dissolving antacid,ban- acid,flavor chews antacid,titralac extra strength,calcium carbonate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 154 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 pedialyte,pedialyt electrolytes/dextrose,electrol CHANGE TIER Tier 2 e electrolyte yte,oral,electrolytes singles,enfalyte,e nfamil enfalyte,oralyte,p ediatric electrolyte,pediatr ic freezer pops,pedialyte advanced care,pedia- pop,electrolyte,ki nderlyte,hydralyte 07/01/2021 CULTURELLE lactobacillus rhamnosus gg CHANGE TIER Tier 2 HEALTH- WELLNESS,CUL TURELLE 07/01/2021 phos- sodium CHANGE TIER Tier 2 nak,phosphorous phosphate/potassium ,sodium phosphates, monobasic and phosphate- bibasic potassium pho,sodium- potassium- phosphorus,phos phorus-sodium- potassium 07/01/2021 double bacitracin zinc/polymyxin b CHANGE TIER Tier 2 antibiotic,polyspo sulfate rin,wal- sporin,poly bacitracin,bacitra cin-polymyxin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 155 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 alcohol prep alcohol antiseptic pads CHANGE TIER Tier 2 pads,alcohol swabs,webcol,cur ity alcohol preps,single use swab,alcohol prep swabs,alcohol wipes,glucopro,e asy touch alcohol prep pads,ultilet alcohol swab,alcohol swab,iv prep wipes,iv antiseptic wipes,sure-prep alcohol prep pads,sure comfort alcohol,alcohol pads,incontrol alcohol pads,pro comfort alcohol pads,caretouch alcohol prep pad,true comfort alcohol pads,alcohol prep pad,easy comfort alcohol pad,pure comfort alcohol pad,true comfort pro alcohol pads

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 156 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 cough dm dextromethorphan CHANGE TIER Tier 2 er,delsym,dextro polistirex,dextromethorphan methorphan hbr polistirex,children' s delsym cough,children's cough dm er,12- hour cough relief,children's robitussin er,robitussin er 07/01/2021 CHILDREN'S pediatric multivitamin no.101 CHANGE TIER Tier 1 MULTIVITAMIN, GUMMY 07/01/2021 SOOTHE,BISMA bismuth subsalicylate CHANGE TIER Tier 1 TROL,PEPTO- BISMOL,STOMA CH RELIEF,PINK BISMUTH,BISMU TH,DIGESTIVE RELIEF,KAOPE CTATE 07/01/2021 ANIMAL pediatric multivitamin CHANGE TIER Tier 1 SHAPES no.43/ferrous fumarate COMPLETE,FLI NTSTONES COMPLETE 07/01/2021 nasacort,children' triamcinolone acetonide CHANGE TIER Tier 2 s nasacort,nasal allergy,triamcinol one acetonide,24 hour nasal allergy,aller-cort

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 157 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 THEREMS- multivits with calcium and CHANGE TIER Tier 2 M,THERA- minerals/iron fumarate/folic M,THERA M acid PLUS,ONE-A- DAY TEEN ADVANTAGE,TH ERAPEUTIC- M,HIGH POTENCY MULTIVITAMIN 07/01/2021 BEDSIDE-CARE benzethonium chloride CHANGE TIER Tier 2 PERINEAL,PERI NEAL SKIN CLEANSER,ANT ISEPTIC WOUND-SKIN 07/01/2021 wal- loratadine CHANGE TIER Tier 2 itin,loratadine,clar itin,children's claritin,allergy relief,children's loratadine,childre n's allergy relief,loratadine hives relief,loratadine allergy,children's allergy 07/01/2021 triple neomycin sulfate/bacitracin CHANGE TIER Tier 2 antibiotic,neospor zinc/polymyxin b in,antibiotic,first aid antibiotic,alba- 3,trisporic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 158 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 stool docusate sodium CHANGE TIER Tier 2 softener,sof- lax,docusate sodium,dulcolax stool softener,doc-q- lace,docusoft s,dok,docu soft,col- rite,phillips' laxative,womens stool softener,colace,d ss,docusil,dulcoe ase,correctol extra gentle,genasoft,w oman's laxative- docusate sod,laxa basic 100 07/01/2021 allegra,children's fexofenadine hcl CHANGE TIER Tier 2 wal- fex,fexofenadine hcl,children's allegra allergy,children's allergy relief,aller- ease

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 159 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 daily- multivitamin with folic CHANGE TIER Tier 2 vite,multivitamins, acid,multivitamin,iron/vitami daily multiple n b complex/minerals vitamin,daily vitamin,central- vite hp,pharmacist favorite multi- vite,one daily,super multivitamin,multi ple vitamins,one- a-day essential,tab a vite,multi-day vitamins,essential one daily,daily diet support,daily vitamin formula,multi- vitamin daily,one daily essential,daily vite,one daily multivitamin,meg a multivitamin,multi vitamins hi- po,men's multi- vitamin,vitamins for hair,one-daily multi- vitamin,multiple vitamins daily,daily value,once daily,super nu- thera,one-tablet- daily,uni-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 160 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value daily,tab-a- vite,high potency multi-vitamin,daily multivitamin,natur al rda multivitamin,esse ntial balance,one daily vitamin,central vite,multivitamin 07/01/2021 os-cal 500-vit calcium CHANGE TIER Tier 2 d3,calcium 500- carbonate/cholecalciferol vit d3 (vitamin d3) 07/01/2021 eye itch ketotifen fumarate CHANGE TIER Tier 2 relief,zaditor,ketot ifen fumarate,wal- zyr,zyrtec itchy eye,itchy eye,children's alaway,alaway,all ergy eye,antihistamine eye drops,allergy eye drops,refresh

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 161 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 EXCEDRIN acetaminophen/caffeine CHANGE TIER Tier 2 TENSION HEADACHE,TEN SION HEADACHE,TEN SION HEADACHE PAIN RELIEVER,HEA DACHE RELIEF,TENSIO N HEADACHE RELIEF,PAIN- RELIEVER 07/01/2021 FUNGOID miconazole nitrate CHANGE TIER Tier 2 TINCTURE,AZOL EN TINCTURE,FUN GOID 07/01/2021 hydrocortisone,co hydrocortisone REMOVE FROM Non-Formulary rtizone- FORMULARY 10,cortisone,anti- itch 07/01/2021 hydrocortisone,co hydrocortisone CHANGE UM: COV Excluded rtizone- 10,cortisone,anti- itch 07/01/2021 lidocaine hcl lidocaine hcl CHANGE TIER Tier 1 viscous 07/01/2021 sodium sodium chloride for CHANGE TIER Tier 1 chloride,nebusal inhalation

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 162 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 deplin,l- levomefolate calcium CHANGE TIER Tier 1 methylfolate calcium,l- methylfolate,elfol ate 07/01/2021 triple-vitamin w- pediatric multivit with a,c,d3 CHANGE TIER Tier 1 fluoride,tri-vitamin no.21/sodium with fluoride,pediatric fluoride,vitamins multivitamins a,c,& d3 no.21 a,c,d and with sodium fluoride,vitamins fluoride,fluoride/vitamins a,d,c and a,c,and d fluoride,tri- vitamin- fluoride,tri-vite with fluoride 07/01/2021 dexamethasone, dexamethasone CHANGE TIER Tier 1 baycadron,decad ron 07/01/2021 fluoritab,sodium fluoride (sodium),sodium CHANGE TIER Tier 1 fluoride,epiflur,lud fluoride ent fluoride,fluoride,r enaf,luride,ethed ent 07/01/2021 sulfamethoxazole sulfamethoxazole/trimethopr CHANGE TIER Tier 1 - im trimethoprim,sulf atrim,septra 07/01/2021 phenadoz,promet promethazine hcl CHANGE TIER Tier 1 hegan,promethaz ine hcl,phenergan

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 163 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 compro,prochlorp prochlorperazine,prochlorpe CHANGE TIER Tier 1 erazine,compazin razine maleate e,prochlorperazin e maleate 07/01/2021 ACTHIB,HIBERI haemophilus b conjugate CHANGE TIER Tier 2 X vaccine(tetanus toxoid conjugate)/pf 07/01/2021 hypotears polyethylene glycol ADD TO FORMULARY Tier 1 400/polyvinyl alcohol,polyvinyl alcohol 07/01/2021 TEARS dextran 70/hypromellose/pf CHANGE TIER Tier 1 NATURALE FREE,BION TEARS,ARTIFICI AL TEARS,NATURA L TEARS,GENTEA L TEARS 07/01/2021 ARTIFICIAL dextran 70/hypromellose CHANGE TIER Tier 1 TEARS,AKWA TEARS RENEWED,TEA RS RENEWED,NAT URAL BALANCE TEARS,NATURE' S TEARS,GENTEA L TEARS,LUBRIC ATING TEARS 07/01/2021 erythrocin erythromycin stearate CHANGE TIER Tier 2 Tier 1 stearate,erythrom ycin stearate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 164 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 2 / 30 DAYS 36 / 30 days hfa 07/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 2 / 30 DAYS 17 / 30 days hfa 07/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 2 / 30 DAYS 17 / 30 days hfa 07/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 2 / 30 DAYS 17 / 30 days hfa 07/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 2 / 30 DAYS 13.4 / 30 days hfa 07/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 2 / 30 DAYS 13.4 / 30 days hfa 07/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 2 / 30 DAYS 13.4 / 30 days hfa 07/01/2021 albuterol sulfate albuterol sulfate CHANGE UM: QUANTITY 2 / 30 DAYS 13.4 / 30 days hfa

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 165 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 nutrimix,inpersol hyperalimentation CHANGE TIER Tier 1 peritoneal cath. equipment,dialysis 11fr,nordipen (peritoneal) kits,syringe 5,nordipen accessory,syr biopsy- 15,astra self- aspiration reusable,syringe aspirating with dental,insulin needle,disposable,insulin 1 syringe,ultra ml,syringe with comfort,easy- needle,insulin,0.5 touch insulin ml,syringe, disposable syringe,toomey irrigation, 70 ml,syringe syringe,davol disposable irrigation,syringe, irrigation disposable, 60 ml,syringe syringe,monoject, with needle,disposable, 3 monoject ml,syringe, disposable, 1 syringe,monoject ml,syringe, disposable, 140 tb ml,syringe with syringe,monoject needle,disposable, 1 luer lock tb ml,syringe, disposable, 20 syringe,monoject ml,syringe, disposable, 12 tb,monoject ml,syringe with pharmacy needle,disposable, 12 tray,dover bulb ml,syringe, disposable, 3 syringe,monoject ml,syringe, disposable, 35 safety syr tip ml,syringe w- cap,monoject needle,disposb,0.5ml,syring insulin e, disposable, 6 ml,syringe syringe,ulticare with needle,disposable, 6 syringe,ulticare,in ml,syringe disposable sumed,exel irrig,60 ml,syringe, needle, insulin safety 1.5 ml,self-contained syringe,tuberculin disposal unit,syringe with syringe- needle, insulin,1 ml and needle,exel tb sharps container,syringe with needle,exel with needle,insulin tuberculin disposable,0.3 ml/empty syringe,exel containr,syringe- allergy needle,insulin,0.5 syringe,allergy ml/container,empty,syringe

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 166 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,exel with needle,insulin,0.3 syringe,yale ml,syringe with glass tb needle,insulin syringe,yale disposable,0.3 ml,syringe, syringe,syringe,c disposable, 5 ml,syringe, ornwall syringes disposable, 10 ml,syringe, luer-lok disposable, 30 ml,syringe, tip,cornwall metal disposable, 50 ml,syringe pipeting reusable, 0.25 ml,syringe holder,allergist reusable, 1 ml,syringe syringe,allergist reusable, 2 ml,syringe syringe with reusable, 5 ml,syringe needle,allergist reusable, 10 ml,syringe tray,allergist reusable, 20 ml,syringe syringe reusable, 30 ml,syringe tray,tuberculin reusable, 50 ml,syringe syringe,asepto reusable, 3 ml,syringe bulb syringe reusable,syring w-needl 0.5 glass tip,bulk ml,kit-tray,syringe with syringe,syringe needle 1 ml, disposable kit- luer-lok non- tray,syringe with sterile,syringe needle,disposable, 0.5 slip tip non- ml,syringe, irrigation, sterile,syringe reusable,syringe with catheter tip non- cannula, disposable, 3 ster,luer-lok ml,syringe with cannula, syringe,luer-lok disposable, 5 ml,syringe tip with cannula, disposable, 10 syringe,cannula,i ml,syringe with needle and nterlink cannula, disposable, 10 syringe,lever lock ml,syringe, disposable, 2.5 cannula,twinpak ml,syringe,safety with dual needle,3 ml,syringe,safety cannula,interlink with needle,1 syringe w- ml,syringe,safety with cannula,cornwall needle,5 ml,syringe,safety syringe tip with needle,10 ml,syringe connector,glaspa with needle,disposable, 10 k,integra ml,syringe without

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 167 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,safety-lok needle,insulin disposible, 1 safety ml,syringe with syringes,safety- needle,disposable, 5 lok safety ml,syringe with syringe,medsaver needle,insulin 0.3 ml (half ,syringe unit mark),syringe with bulk,syringe needle,insulin storage disposable,0.5 ml,syringe bin,syringe- with needle, insulin, safety, needle,eclipse 1 ml,syringe with needle, syringe,eclipse insulin, safety, 0.5 ml,syring syringe- w-ndl,disp,insul,0.5 needle,eclipse ml/container,empty,syring w- luer-lok ndl,disp,insul,0.3 syringe,safety ml/container,empty,safety syringe- syringe with needle, needle,syringe tip disposable kit-tray, 1 cap,safetyglide ml,insulin pump syringe, 3 syringe,safetyglid ml,insulin pump syringe, 1.8 e insulin ml,syringe, safety 3 ml, self- syringe,safetyglid contained disposal e tb unit,syringe, safety 5 ml, syringe,safetyglid self-contained disposal e allergy unit,syringe w-needle 0.3 syringe,safetyglid ml,insulin,safety w-self- e allergy,syringe- cont.dis.unit,insulin syringe- luer tip cap,luer- needle,safety,disposal lok syringe- unit,0.5 ml,syringe with needle,precisiong needle 1 ml,insulin,safety w- lide,safety-lok self- syringes,syringe- con.disp.unit,syringe,needle, precisionglide safety 1 ml,self-contained needle,syringe disposal unit,syringe 3 ml catheter tip,tb with safety needle,self- syringe,syringe contained disposal luer-lok,syringe unit,syringe, safety needle 5 slip tip,syringe ml and self-contained luer-lok disposal unit,syringe, safety sterile,luerslip 10 ml, self-contained

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 168 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,veo disposal unit,syringe,safety insulin needle 10 ml and self- syringe,assure id contained disposal insulin unit,syringe, safety,ultilet disposable,syringe with insulin cannula, disposable, 1 syringe,ultracomf ml,syringe w-cannula,disp, 6 ort,orsini insulin ml,syrng w-ndl,dsp kit- syringe,careone, tray,0.5ml,syrng w-ndl,disp. prodigy count-a- kit-tray,1ml,syringe with dose,prodigy needle,insulin insulin disposable,syringe w- syringe,easy needle,disposab,3ml,syringe touch w- fluringe,easy needle,disposab,6ml,syringe touch,easy touch ,safety with needle,12 insulin ml,syringe with safety,easy touch cannula,disposable 12 syr allergy ml,syringe with cannula, tray,easy touch disposable, 6 ml,syringe fluringe flu with tray,easy touch needle,disposable,syringe insulin with needle, insulin, safety, syringe,thinset,fift 0.3 ml,alcohol swab y50 cap,syringe w/needle,insulin reservoir,safesna disposable 0.3 ml (half unit p mark),syringe filter,injector syringe,safesnap device,syringe, disposable, insulin 1ml,syringe w- syringe,safesnap needle,disposab,12ml,syring tuberculin e with syringe,safesnap needle,disposable,insulin,pe allergy n injector device,syringe, syringe,needle- insulin u-500 with needle, pro edge,syringe disposable, 0.5 ml,syringe, without safety 3 ml,syringe, enfit 1 needle,lifeshield ml, sterile,syringe, enfit 6 ml, blunt sterile,syringe, enfit 35 ml, cannula,allergist sterile,syringe, enfit 60 ml,

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 169 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value tray syr-perm sterile,syringe, enfit 3 ml, needle,monoject sterile,syringe, enfit 12 ml, allergy tray- sterile,syringe,enfit 3 needle,monoject ml,non-sterile,syringe, enfit tuberculin 12 ml, non-sterile,syringe, syringe,allergist enfit 1 ml, non- tray syr-detach sterile,syringe, enfit 6 ml, ndl,monoject non-sterile,syringe, enfit 35 insulin safety ml, non-sterile,syringe, enfit syrng,monoject 60 ml, non-sterile,syringe tuberculin safety cap, enfit,non-sterile,syringe syr,monoject with needle,insulin 0.5 ml control (half unit mark) syringe,monoject syringe pharmacy tray,monoject safety syringe,safety syringe with shield,monoject smartip cannula,monoject magellan,finger grip extender,magella n tuberculin syringe,magellan tb safety syringe,magellan insulin safety syrng,magellan insulin syringe,kendall disinfectant cap,terumo insulin syringe,terumo surguard2,thinpro insulin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 170 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,terumo surguard,terumo allergy syringe,terumo syringe,terumo hypodermic needle- syrin,vanishpoint, syringe with needle disp,exacta- mix,syringe filling fixture,exacta- med tip extender,supor,lu er lock tip cap,self-righting luer slip tip,self- righting luer tip cap,self-righting luer lock tip,trueplus insulin syringe,inject- ease,lite touch,litetouch insulin syringe,topcare ultra comfort,syringe filter, millex- gp,syringe filter, millex-gs,luer lock syringe,glucopro, norm-ject,filter, millex-or syringe,sure-ject insulin syringe,universal

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 171 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe tip adaptor,minimed reservoir,paradig m,irrigation syringe,sure comfort,ultra-thin ii,easy comfort insulin syringe,maxi- comfort,advocate syringes,comfort ez insulin syringe,freestyle precision,omnitro pe pen 5,anti- stick insulin,anti- stick tuberculin,precisi on,insulin cartridge,reservoi r,inpersol w-o auto shutoff valv,inpersol-auto shutoff valve,accusure,lu er slip tip cap,luer-lock syringe,luer slip tip syringe tray,slip-tip syringe,humatrop en,luer tip cap tray,easy touch uni-slip,easy touch fliplock syringes,easy touch fliplock syringe,easy touch sheathlock

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 172 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,easy touch luer lock syringe,easy touch luer lock insulin,easy touch fliplock insulin,easy touch sheathlock insulin,easy touch sheathlock syrg-ndl,easy touch fluringe fliplock,easy touch fluringe sheathlock,easy touch tuberculin sheathlk,easy touch tuberculin fliplock,ulticare insulin syringe,sure comfort insulin syringe,insulin syringe u- 500,vanishpoint syringe,ulticare safety syringe,carepoint luer slip syringe,easy glide luer lock syringe,easy glide luer slip tb syring,easy glide catheter tip syring,easy glide dental irrig syring,caretouch insulin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 173 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,ulticare tb safety syringe,monoject enfit syringe,monoject enfit syringe cap,piston enfit syringe,magellan safety syringe,norm-ject tuberkulin syringe,norm-ject syringe,techlite insulin syringe,pro comfort insulin syringe,droplet insulin syringe,true comfort insulin syringe,ultracare insulin syringe,easy glide insulin syringe,q-cliq pen (for natpara),healthwi se insulin syringe,maxicomf ort insulin syringe,ultra flo insulin syringe,vanishpoi nt insulin syringe,carepoint luer lock,ulticare low dead space syring,ultiguard safepack-insulin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 174 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value syr,carepoint luer slip syring-ndl 07/01/2021 condoms,durex condoms, latex, CHANGE TIER Tier 1 avanti lubricated,condoms, latex, bare,trustex non-lubricated,condoms, condom,trustex- female,condoms, non-latex, ria,trustex latex lubricated condom,trustex,f antasy,fc condom, female,kimono,ki mono maxx,kimono microthin,kimono microthin aqua lube,kimono textured,reality,ai msco,fc2 female condom,durex avanti bare real feel

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 175 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 huggies snug and diaper/brief,infant-toddler, CHANGE TIER Tier 2 dry,goodnites,ten disposable,diaper,brief,yout a h,disposable,incontinence serenity,serenity pad,liner,disp,underpads,dia ultra per,brief,adult, plus,durasorb,sim disposable,incontinence plicity pants, reusable,fecal liner,simplicity,ma collector with charcoal xicare,presence,s filter,diaper,brief,adult,dispo ure care sable,fecal collector w- protective charcoal underwear,handi filter/catheter/syringe, care,surecare,ver dispos,fecal collector with salon,sure care charcoal protective filter/catheter/syringe,incont undergmnt,surety device,muscle s,wings toner,elt,incontinence bed underpad,unigard sheets,covers,ostomy ,wings classic supply,incontinence alarms youth briefs,wings classic adult briefs,wings classic,wings choice plus youth briefs,wings choice plus adult briefs,wings choice adult brief,simplicity adult poly,wings,simpli city adult flat fold xl,simplicity pants,curity run arounds,curity runarounds,curity sleep pants,tendersorb,

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 176 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value diapers-disp- polyethylene back,curity ultra fits,maxicare underpads,wings supreme,sta- put,wings maxima,wings fluff and polymer,underpa d,bladder control pad,shield,under garment,brief,brie f, medium,ep brief,overnites,su re choice pantiliners,belted undergarment,dia pers,bladder control pads for women,briefs for men & women,panty shields,tugaboos diapers,panty liners,tugaboos overnights,under wear for men,kid pants,protective underwear,surec hoice,briefs x- large,over nites,underpads,li nen fresh,non- slip underpads,delux e underpads,under wear for

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 177 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value women,guards for men,underwear men- women,boxers for men,tugaboos training pants,disposable brief,bladder control,comfort- stretch,premium comfort- stretch,fitted briefs,fitted brief,certainty,sle ep pants,premium baby diaper,premium training pants,well beginnings sleep pants,depend,hu ggies,huggies pull-ups,depend silhouette,depend real fit,poise pads,depend guards for men,poise liners,depend overnite,depend protection,huggie s goodnites,goodnit es sleep shorts,huggies slip-on,depend shields for

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 178 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value men,huggies overnites,huggies ultratrim,luvs,pam pers premium,pamper s ultra dry thin,pampers baby- dry,pampers unisex,pampers cruisers,underja ms,pampers easy ups,pampers extra protection,pampe rs swaddlers sensitive,pamper s preemie,pampers swaddlers,pampe rs,newborn baby- dry,pampers premature,pampe rs ultra dry,pampers newborn,pamper s rash care,pampers premie,luvs overnight,pamper s non- elasticized,pamp ers ultra phases,ultra + pampers,pamper s thick phases,pads,slee p overs,cuties,cutie

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 179 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value pants,underwear, super underpad,regular pad,super pad,baby darlings diapers,extra absorbent undergarment,trai ning pants,little darlings,personal confidence pads,beltless undergarments,p ersonal confidence briefs,overnight brief,personal confidence underpad,slip-on undergarments,b aby basics,basics for kids,personal confidence liners,overnight protective,person al confidence underwear,flexi- seal fecal,protective pads,jumbo diapers,supreme diapers,diapers mega,kidpant,bla dder control pad ultra,guard male,diaper,sleep comforts,overnig ht briefs,x-abs underwear,wome

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 180 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value n's underwear,men's underwear,overni tes diaper,wonderpa nts,up & up baby diaper,flexi-seal fms,flexi-seal signal fms,harmonie,dry comfort extra,tena,dry comfort,tena pants,tena classic,tena stretch ultra,tena classic plus,tena protective underwear,tranqu ility premium underwear,atn brief,select underwear,select disposable briefs,select underpads,diaper booster pad,tranquility topliner pads,select kids briefs,supreme,o ptions liners,options pads,tena underwear,option s ultra thins,day & night brief,securely yours,ez-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 181 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value sorb,attends,atte nds undergarments,at tends insert,attends underwear,attend s guards,attends light insert,attends booster,attends disposable underpads,affirm underwear,affirm pads,snap pants,mesh pants,adult brief,prevail bladder control,pant liner large plus,pant liner large,prevail curve,prevail underwear,nu-fit brief,breezers,per -fit brief,value buy,prevail brief,prevail stretch fit,nufit underwear,prevai l simply stretch fit,prevail boxers,procare,pr evail full coverage undrwear,nufit brief,per-fit underwear,perfit brief,prevail per- fit,ben-e-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 182 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value fit,prevail breezers,prevail extra underwear,prevai l bariatric,prevail super plus,prevail protective underwear,prevai l adjustable,prevail classic fit underwear,prevai l smooth fit,prevail pm,prevail ultra plus,prevail ultra bladder,prevail panty liner,prevail extra plus bladder,prevail extra bladder,prevail guards for men,prevail pads,prevail male guard,curity underpads,lil swimmer small pant,lil swimmer medium pant,lil swimmer large pant,poise,depen d belted shields,huggies pure & natural,huggies overnite,huggies newborn,huggies convertibles,pelvi

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 183 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value c muscle trainer,incontinen t liner,dignity regular,dignity extra-duty,dignity regular duty,dignity natural extra,dignity diaper,dignity underpad,free & active super,dignity,dign ity plus,dignity plus liners,briefmates, prevent plus,dignity plus fitted brief,dignity plus regular brief,lady dignity plus brief,sir dignity plus brief,sheet protector,brief youth,promise pad,ultra-soft plus,ultra-soft classic,protection plus underpad,protecti on plus,protection plus classic,ultima tuckables,cairpad ,ultima incontinence,adh eres,tuffsorb,tuck ables,prevail fits

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 184 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value to a t,youth brief,adult frontal tape brief,pant liners,xtremefit brief,ultrathin,flexi -seal,molicare classic brief,ultra soft,dry time diaper,protection plus liner,economy underpad,extra absorbent shield,bed pad,wet- stop,depend elastic leg undergarmnt,dep end fitted brief,goodnite,hu ggies snuggems,huggie s convertible clip strip,huggies supreme,topcare belted shield,topcare underpad,topcare male guard,topcare pads,slip- on,entrust plus undergarment,be d underpads,contro l pads,super absorbent underwear,ultra- thin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 185 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value underwear,absor bent shield,premier adult brief,well beginnings diapers,prevail breezers 360,prevail,prevai l per-fit 360,nighttime underpants,well beginnings training pants,goodnites tru-fit,dry time training pants,capri bladder control pads,prevail purseready,depe nd fit-flex,huggies little snugglers,belted shields,purseread y underwear for women,huggies little movers,always discreet,assuranc e,poise microliners,comfo rts diapers size 6,comforts diapers size 3,comforts diapers size 4,comforts diapers size 5,pad for

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 186 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value women,tranquility bariatric brief,curity boys training pants,curity girls training pants,curity youth pants,curity baby diaper,girls training pants,slimline brief,overnight pad for women,comfort shield,adjustable underwear,stretc h fit brief,overnight underwear,premi um underpad,men's guard,bed mat,boys training pants,entrust plus,clever choice,total care underpads,clever choice comfort protect,comfort touch underpad

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 187 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2021 ultilet pen pen needle, diabetic,pen CHANGE TIER Tier 1 needle,unifine needle, diabetic, pentips safety,needleless plus,novofine dispensing pin,needles, 32,novofine,novof blood collection,needles, ine disposable,needles, insulin autocover,novotw disposable,needles, safety ist,hurricaine huber, disposable,needles, luer- huber disposable,needles, lock,monoject reusable,needles, huber blood reuse,needles, spinal- collection,hypode anesthetic,needles, rmic biopsy,bone,aspirate,blunt needle,unifine needle, disposable,needles, pentips,pen filter,needles, needle,incontrol safety,needles, insulin pen needle,pen disposable, safety,pen needles,healthy needle, diabetic disposable, accents unifine safety,needles, pharmacy pentip,ulticare compound,transfer device, pen closed system,needleless needle,insupen,in accessory device, sulin pen insulin,needles, needle,exel subcutaneous set,transfer hypodermic needle,pen needle, diabetic, needle,exel mti remover and disposal unit drawing needle,exel huber,exel huber needle,yale needle regular bevel,yale needle,yale needle short bevel,special needle,intraveno us,arterial & blood,yale needle huber

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 188 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value bevel,pudendal & parasympathetic, whitacre spinal needle,rosenthal, osgood,security bead needle, local,klatskin,yale spinal needle,quince spinal needle,precisiong lide,needle,speci alty use needles,regular bevel needles,needles, yale needles,short bevel needles,blunt needle,thin wall needles,filter needle,nokor needle,nokor admix needle,integra needle,eclipse needle,safetyglid e needle,ultra- fine short pen needle,ultra-fine mini pen needle,ultra-fine nano pen needle,ultra-fine original pen needle,autoshield pen needle,autoshield

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 189 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value duo pen needle,clickfine,r elion pen needles,ultracomf ort,prodigy pen needle,easy touch pen needle,1st tier unifine pentips,1st tier unifine pentips plus,lifeshield blunt cannula,transfer needle,bone marrow aspir needle,filter aspirator needle,terumo surguard2,cytosa fe dipensing pin,sterile two-fer needle,lite touch,phaseal protector,topcare clickfine,aimsco ultra thin ii,aimsco mini ultra-thin ii,needle free syringe kit a,needle free syringe kit b,needle free syringe kit c,medi-jector needle-free syr a,medi-jector needle-free syr b,medi-jector

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 190 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value needle-free syr c,sure-fine pen needles,chemo transfer pin,flow- eze,mini transfer pin,transfer pin,polyfin,sure comfort,poly hub needle,easy comfort pen needles,ultra-thin ii,mini ultra-thin ii,easy comfort pen needle,advocate pen needles,comfort ez pen needle,iv transfer needles,chemopl us dispensing pin,gripper plus,carefine pen needle,novofine plus,pentips,dropl et pen needle,easy touch fliplock needle,easy touch fliplock needles,easy touch hypodermic needle,techlite pen needle,monoject filter needle,trueplus pen needle,pro comfort pen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 191 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value needle,integra precisionglide needle,caretouch pen needle,advocate pen needle,ultra- fine micro pen needle,easy glide pen needle,assure id pen needle,dropsafe pen needle,ultracare pen needle,ultra flo pen needle,microdot insulin pen needle,true comfort pen needle,safety pen needle,maxicomf ort safety pen needle,nano 2nd gen pen needle,verifine pen needle,prevent dropsafe pen needle,healthwis e pen needle,magellan safety needle,maxicomf ort ii pen needle,easypoint needle,ultra thin,unifine pentips

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 192 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value maxflow,unifine pentips plus maxflow,ultiguard safepack-pen needle,pure comfort pen needle,easy touch safety pen needle,abouttime pen needle,unifine safecontrol,dropl et micron pen needle,assure id duo- shield,securesafe pen needle,comfort touch pen needle,ulticare safety pen needle,pip pen needle,sure comfort safety pen needle,unifine pen needle 07/01/2021 HETLIOZ LQ tasimelteon REMOVE UM: COV Excluded 07/08/2021 acetaminophen acetaminophen ADD TO FORMULARY Tier 1 07/08/2021 JANSSEN covid-19 vac, ad26.cov2.s ADD UM: NTWK CARVE OUT: COVID-19 (janssen)/pf FFS MEDI-CAL VACCINE (EUA) 07/08/2021 POLY-VI-SOL pediatric multivitamin CHANGE UM: AGE At least 13 yrs Up to 12 yrs old WITH IRON no.189/ferrous sulfate old

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 193 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 NUTRI- lactose-reduced ADD TO FORMULARY Tier 3 DRINK,NUTRITI food,lactose-free food ONAL LIQUID 07/16/2021 NUTRI- lactose-reduced ADD UM: PANAME PA Applies DRINK,NUTRITI food,lactose-free food ONAL LIQUID 07/16/2021 SCOOBY-DOO multivitamin with iron and ADD TO FORMULARY Tier 1 other minerals 07/16/2021 B-12 DOTS cyanocobalamin (vitamin b- ADD TO FORMULARY Tier 1 12) 07/16/2021 THERAPEUTIC mineral oil/petrolatum,white ADD TO FORMULARY Tier 1 MOISTURIZING 07/16/2021 SELSUN BLUE selenium sulfide/aloe vera ADD TO FORMULARY Tier 1 MOISTURIZING 07/16/2021 CURITY sodium chloride irrigating ADD TO FORMULARY Tier 1 solution 07/16/2021 VANICREAM HC hydrocortisone acetate ADD TO FORMULARY Tier 1 07/16/2021 VANICREAM HC hydrocortisone acetate ADD UM: QUANTITY 240 / 30 days 07/16/2021 DHS SAL salicylic acid ADD TO FORMULARY Tier 1 07/16/2021 EYE ALLERGY olopatadine hcl ADD TO FORMULARY Tier 3 ITCH-REDNESS RLF 07/16/2021 LICE piperonyl ADD TO FORMULARY Tier 1 TREATMENT butoxide/pyrethrins 07/16/2021 lice treatment piperonyl ADD TO FORMULARY Tier 1 butoxide/pyrethrins 07/16/2021 LICE PYRINYL piperonyl ADD TO FORMULARY Tier 1 SHAMPOO butoxide/pyrethrins 07/16/2021 RID piperonyl ADD TO FORMULARY Tier 1 butoxide/pyrethrins

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 194 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 docosanol docosanol ADD TO FORMULARY Tier 2 07/16/2021 docosanol docosanol ADD UM: QUANTITY 2 / 30 days 07/16/2021 docosanol docosanol ADD TO FORMULARY Tier 2 07/16/2021 docosanol docosanol ADD UM: QUANTITY 2 / 30 days 07/16/2021 docosanol docosanol ADD TO FORMULARY Tier 2 07/16/2021 docosanol docosanol ADD UM: QUANTITY 2 / 30 days 07/16/2021 RENAL VITAMIN folic acid/vitamin b complex ADD TO FORMULARY Tier 1 and vitamin c 07/16/2021 RENAL-VITE folic acid/vitamin b complex ADD TO FORMULARY Tier 1 and vitamin c 07/16/2021 ANTI-ITCH benzocaine/resorcinol/aloe ADD TO FORMULARY Tier 1 VAGINAL MAX vera/vit e acet/vitamins a STRENGTH and d 07/16/2021 ZOSTRIX HP capsaicin ADD TO FORMULARY Tier 1 FOOT 07/16/2021 ZOSTRIX HP capsaicin ADD UM: QUANTITY 42.5 / 30 days FOOT 07/16/2021 V-C FORTE multivitamin with minerals ADD TO FORMULARY Tier 1 no.7/folic acid 07/16/2021 SPECTRAVITE multivitamin/ferrous ADD TO FORMULARY Tier 1 ADVANCED fumarate/folic acid FORMULA 07/16/2021 SENTRY multivitamin/ferrous ADD TO FORMULARY Tier 1 fumarate/folic acid 07/16/2021 CENTURY multivitamin/ferrous ADD TO FORMULARY Tier 1 ULTIMATE fumarate/folic acid WOMEN'S 07/16/2021 ESSENTIA multivitamin/ferrous ADD TO FORMULARY Tier 1 fumarate/folic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 195 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 HIGH POTENCY multivitamin/ferrous ADD TO FORMULARY Tier 1 MULTIVITAMIN fumarate/folic acid 07/16/2021 CENTRUM multivitamin/ferrous ADD TO FORMULARY Tier 1 ADULTS fumarate/folic acid 07/16/2021 DAILY VITAMIN multivitamin/ferrous ADD TO FORMULARY Tier 1 FORMULA-IRON fumarate/folic acid 07/16/2021 CEROVITE multivitamin/ferrous ADD TO FORMULARY Tier 1 ADVANCED fumarate/folic acid FORMULA 07/16/2021 MULTI-DAY multivitamin/ferrous ADD TO FORMULARY Tier 1 PLUS IRON fumarate/folic acid 07/16/2021 COMPLETE multivitamin/ferrous ADD TO FORMULARY Tier 1 WOMEN fumarate/folic acid 07/16/2021 ONE-A-DAY multivitamin/ferrous ADD TO FORMULARY Tier 1 TEEN fumarate/folic acid ADVANTAGE 07/16/2021 CENTURY multivitamin/ferrous ADD TO FORMULARY Tier 1 fumarate/folic acid 07/16/2021 A THRU Z multivitamin/ferrous ADD TO FORMULARY Tier 1 ADVANCED fumarate/folic acid FORMULA 07/16/2021 DAILY multivitamin/ferrous ADD TO FORMULARY Tier 1 MULTIVITAMIN- fumarate/folic acid IRON,MULTIVIT AMIN WITH IRON 07/16/2021 MULTI multivitamin/ferrous ADD TO FORMULARY Tier 1 COMPLETE- fumarate/folic acid IRON 07/16/2021 ONE DAILY multivitamin/ferrous ADD TO FORMULARY Tier 1 MULTIVITAMIN- fumarate/folic acid IRON

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 196 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 multivitamins with pediatric multivitamins no.17 CHANGE TIER Tier 1 fluoride,multivita with sodium min with fluoride,pediatric fluoride,multi- multivitamins combination vitamin with no.12/sodium fluoride fluoride,pediatric multivitamin no.16/sodium fluoride,multivitamins with fluoride 07/16/2021 HEALTHY EYES vit c/vit e acetate/zinc ADD TO FORMULARY Tier 1 LUTEIN- oxid/cupric ZEAXANTHIN oxide/lutein/zeaxanthin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 197 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 NUTRIHEAL,CO lactose-free food,lactose- CHANGE TIER Tier 3 MPLEAT reduced food MODIFIED FORMULA,ISOS OURCE,BOOST PLUS,BOOST HIGH PROTEIN,NUTRI TIONAL SUPPLEMENT,N UTRITIONAL SUPPLEMENT PLUS,NUTRI- DRINK,BALANC ED NUTRITIONAL,N UTRITIONAL DRINK,NUTRITI ONAL DRINK PLUS,NUTRITIO NAL SHAKE,NUTRAF IT PLUS,NUTRAFIT ,COMPLETE NUTRITION,CO MPLETE NUTRITION PLUS,TRAUMAC AL,BOOST,LIQUI D NUTRITION PLUS,NUTRITIO N PLUS,LIQUID NUTRITION,ENS URE LIQUID,ENSURE ACTIVE HIGH PROTEIN,ENSU RE HIGH

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 198 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value PROTEIN,ENSU RE ACTIVE MUSCLE HEALTH,ENSUR E CLEAR,ENSURE MUSCLE HEALTH,ENSUR E ACTIVE CLEAR,NUTRITI ONAL SHAKE PLUS,HIGH- PROTEIN NUTRITIONAL SHAKE,ISOCAL, NUTRITIONAL LIQUID,NUTRITI ONAL PLUS LIQUID,OSMOLI TE,ENSURE ENLIVE,PREFER RED PLUS,KINDERC AL TF,KINDERCAL, BRIGHT BEGINNINGS,A- SOY,ENSURE ACTIVE HEART HEALTH,ENSUR E ACTIVE PROTEIN- MUSCLE,ENSUR E ACTIVE LIGHT,BOOST COMPACT,ENS URE ORIGINAL,BOO ST CALORIE

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 199 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value SMART,ENSURE COMPACT,PRO TEIN NUTRITIONAL SHAKE,ENSURE MAX PROTEIN 07/16/2021 NEPHROCAPS,T vitamin b complex and CHANGE TIER Tier 1 RIPHROCAPS,R vitamin c no.20/folic ENALPREN,MYN acid,vitamin b complex & EPHROCAPS,R vitamin c no.20/folic ENAL acid,folic acid/vitamin b CAPS,RENO comp w-c CAPS,RENAL SOFTGEL,VIRT- CAPS,MYNEPH RON 07/16/2021 lice killing,rid,lice piperonyl CHANGE TIER Tier 1 pyrinyl butoxide/pyrethrins shampoo,lice treatment,licide,a -200 lice killing 07/16/2021 sodium citrate- citric acid/sodium citrate CHANGE TIER Tier 1 citric acid,cytra- 2,bicitra,liqui- dualcitra,virtrate- 2 07/16/2021 sodium citrate- citric acid/sodium citrate CHANGE UM: QUANTITY 120 / day citric acid,cytra- 2,bicitra,liqui- dualcitra,virtrate- 2

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 200 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 NEPHRO- folic acid/vitamin b complex CHANGE TIER Tier 1 VITE,DIALYVITE and vitamin c,folic 800,FOLIC ACID acid/vitamin b comp w-c XTRA,FULL SPECTRUM B,RENA- VITE,RENAVIT,R ENAL VITAMIN,RENAL -VITE,WEST- VITE WITH FOLIC ACID

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 201 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 CENTRUM multivitamin/ferrous ADD TO FORMULARY Tier 2 COMPLETE,CEN fumarate/folic acid TRUM ULTRA WOMEN'S,ADUL TS' DAILY FORMULA,CER OVITE ADVANCED FORMULA,CERT AVITE- ANTIOXIDANT,T AB A VITE WEIGHT SLIM,COMPLET E MULTI-VIT- MINERAL,CENT RAL- VITE,VITATRUM COMPLETE,A THRU Z ADVANCED FORMULA,ESSE NTIA,ONE-A- DAY TEEN ADVANTAGE,DA ILY MULTIPLE VITAMINS- IRON,DAILY MULTI,MULTI COMPLETE- IRON,MULTI- VITE,DAILY MULTIVITAMIN- IRON,SENTRY PERFORM,SENT RY,DAILY MULTIPLE,CENT URY,ONE DAILY PLUS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 202 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value IRON,CENTURY ULTIMATE WOMEN'S,SPEC TRAVITE ADVANCED FORMULA,SPEC TRAVITE ULTRA WOMEN,DAILY TEEN MULTI- VITAMIN,ONE DAILY WITH IRON,YELETS,M ULTI-DAY PLUS IRON,COMPLET E MULTIVITAMIN, ONE DAILY MULTIVITAMIN- IRON,DAILY VITAMIN FORMULA- IRON,COMPLET E WOMEN,CENTR UM WOMEN,CENTR UM ADULTS,MULTIV ITAMIN WITH IRON,TAB-A- VITE MULTIVIT WITH IRON,SPECTRA VITE WOMEN,HIGH POTENCY MULTIVITAMIN, SPECTRAVITE ADULT

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 203 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 NUTRITIONAL pediatric nutrition with iron, CHANGE TIER Tier 3 DRINK,PEDIATR lactose free IC DRINK,PEDIATR IC BALANCED NUTRITION,BOO ST KID ESSENTIALS,PE DIASURE ENTERAL,PEDIA SURE,PEDIASU RE GROW- GAIN,PEDIASUR E GROW-GAIN ORGANIC 07/16/2021 NUTRITIONAL lactose-reduced CHANGE TIER Tier 3 SHAKE food,lactose-free food PLUS,NUTRITIO NAL SUPPLEMENT PLUS,ENSURE PLUS,ENSURE CLINICAL STRENGTH,ENS URE COMPLETE,NUT RISURE PLUS,NUTRITIO N SHAKE PLUS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 204 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 NUTRITIONAL lactose-reduced food CHANGE TIER Tier 3 SHAKE,NUTRITI ONAL SUPPLEMENT,C OMPLETE NUTRITION,BOO ST BREEZE,ENSUR E ORIGINAL,ENSU RE IMMUNE HEALTH,COMPL ETE NUTRITIONAL 07/16/2021 DHS SAL,T- salicylic acid CHANGE TIER Tier 2 SAL,SELSUN BLUE NATURALS,THE RAPEUTIC T+PLUS,PSORIA SIS MEDICATED,TH ERAPEUTIC,BE TASAL,DERMAR EST PSORIASIS,THE RA-SAL,SELSUN BLUE,THERAPE UTIC DANDRUFF SHAMPOO 07/16/2021 SPECTRAVITE multivitamin/ferrous ADD TO FORMULARY Tier 2 WOMEN fumarate/folic acid 07/16/2021 SELSUN BLUE salicylic acid CHANGE TIER Tier 1 Tier 2 07/16/2021 SELSUN BLUE salicylic acid CHANGE TIER Tier 1 Tier 2 NATURALS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 205 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 DHS SAL salicylic acid CHANGE TIER Tier 1 Tier 2 07/16/2021 NEPHRO-VITE folic acid/vitamin b complex REMOVE FROM Tier 2 Non-Formulary and vitamin c,folic FORMULARY acid/vitamin b comp w-c 07/16/2021 FULL folic acid/vitamin b complex CHANGE TIER Tier 2 Tier 1 SPECTRUM B and vitamin c 07/16/2021 WEST-VITE folic acid/vitamin b complex ADD TO FORMULARY Tier 2 WITH FOLIC and vitamin c ACID 07/16/2021 VANICREAM HC hydrocortisone acetate CHANGE TIER Tier 1 Tier 2 07/16/2021 NUTRITIONAL pediatric nutrition with iron, CHANGE UM: PANAME PA Applies DRINK,PEDIATR lactose free IC DRINK,PEDIATR IC BALANCED NUTRITION,BOO ST KID ESSENTIALS,PE DIASURE ENTERAL,PEDIA SURE,PEDIASU RE GROW- GAIN,PEDIASUR E GROW-GAIN ORGANIC

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 206 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 NUTRITIONAL lactose-reduced CHANGE UM: PANAME PA Applies SHAKE food,lactose-free food PLUS,NUTRITIO NAL SUPPLEMENT PLUS,ENSURE PLUS,ENSURE CLINICAL STRENGTH,ENS URE COMPLETE,NUT RISURE PLUS,NUTRITIO N SHAKE PLUS 07/16/2021 NUTRITIONAL lactose-reduced food CHANGE UM: PANAME PA Applies SHAKE,NUTRITI ONAL SUPPLEMENT,C OMPLETE NUTRITION,BOO ST BREEZE,ENSUR E ORIGINAL,ENSU RE IMMUNE HEALTH,COMPL ETE NUTRITIONAL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 207 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/16/2021 NUTRIHEAL,KIN lactose-free food,lactose- CHANGE UM: PANAME PA Applies DERCAL reduced food TF,KINDERCAL, COMPLEAT MODIFIED FORMULA,ISOS OURCE,BOOST PLUS,BOOST HIGH PROTEIN,NUTRI TIONAL SUPPLEMENT,N UTRITIONAL SUPPLEMENT PLUS,NUTRI- DRINK,NUTRITI ONAL LIQUID,NUTRITI ONAL PLUS LIQUID,BALANC ED NUTRITIONAL,N UTRITIONAL DRINK,NUTRITI ONAL DRINK PLUS,NUTRITIO NAL SHAKE,HIGH- PROTEIN NUTRITIONAL SHAKE,LIQUID NUTRITION,LIQ UID NUTRITION PLUS,COMPLET E NUTRITION,CO MPLETE NUTRITION PLUS,NUTRAFIT

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 208 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value PLUS,NUTRAFIT ,TRAUMACAL,B OOST,ISOCAL,B OOST COMPACT,BOO ST CALORIE SMART,NUTRITI ON PLUS,PROTEIN NUTRITIONAL SHAKE,ENSURE LIQUID,ENSURE ACTIVE HIGH PROTEIN,ENSU RE HIGH PROTEIN,ENSU RE ACTIVE MUSCLE HEALTH,ENSUR E CLEAR,ENSURE MUSCLE HEALTH,ENSUR E ACTIVE CLEAR,OSMOLI TE,ENSURE ENLIVE,ENSUR E ACTIVE HEART HEALTH,ENSUR E ACTIVE PROTEIN- MUSCLE,ENSUR E ACTIVE LIGHT,ENSURE ORIGINAL,ENSU RE COMPACT,ENS URE MAX

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 209 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value PROTEIN,PREF ERRED PLUS,NUTRITIO NAL SHAKE PLUS,BRIGHT BEGINNINGS,A- SOY 07/28/2021 NEXTSTELLIS drospirenone/estetrol ADD TO FORMULARY Tier 2 07/28/2021 NEONATAL-DHA prenatal vit no.175/iron ADD TO FORMULARY Tier 2 fum/folic acid/dha/schiz. algal oil 07/28/2021 INGREZZA valbenazine tosylate ADD UM: SPECIALTY Specialty Drug 07/28/2021 COSENTYX secukinumab ADD UM: SPECIALTY Specialty Drug SYRINGE 07/28/2021 INGREZZA valbenazine tosylate ADD TO FORMULARY Tier 4 07/28/2021 INGREZZA valbenazine tosylate ADD UM: PANAME PA Applies 07/28/2021 FLUZONE HIGH- influenza virus vaccine ADD TO FORMULARY Tier 2 DOSE QUAD quadrival split 2021-22(65 yr 2021-22 up)/pf 07/28/2021 FLUZONE QUAD influenza virus vaccine ADD TO FORMULARY Tier 2 2021-2022 quadrival 2021-2022(6 mos and up)/pf 07/28/2021 FLUZONE QUAD influenza virus vaccine ADD TO FORMULARY Tier 2 2021-2022 quadrivalent 2021-22 (6 mos and up) 07/28/2021 FLUAD QUAD influenza vaccine ADD TO FORMULARY Tier 2 2021-2022 quadrivalent 2021-22 (65 yr up)/mf59c.1/pf 07/28/2021 FLULAVAL influenza virus vaccine ADD TO FORMULARY Tier 2 QUAD 2021- quadrival 2021-2022(6 mos 2022 and up)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 210 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/28/2021 FLUCELVAX flu vaccine quadriv 2021- ADD TO FORMULARY Tier 2 QUAD 2021- 2022(2 years and older)cell 2022 derived 07/28/2021 FLUARIX QUAD influenza virus vaccine ADD TO FORMULARY Tier 2 2021-2022 quadrival 2021-2022(6 mos and up)/pf 07/28/2021 FLUBLOK QUAD influenza virus vaccine qv ADD TO FORMULARY Tier 2 2021-2022 2021-22(18 yrs and older)rcmb/pf 07/28/2021 FLUCELVAX flu vaccine quad 2021- ADD TO FORMULARY Tier 2 QUAD 2021- 2022(2 years and older)cell 2022 derived/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine ADD TO FORMULARY Tier 2 2021-22 (3YR quadrivalent 2021-22 (36 UP) mos up)/pf 07/28/2021 FLUZONE QUAD influenza virus vaccine ADD TO FORMULARY Tier 2 2021-2022 quadrival 2021-2022(6 mos and up)/pf 07/28/2021 PREVNAR 20 pneumococcal 20-valent ADD TO FORMULARY Tier 2 conjugate vaccine (diphtheria crm)/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine ADD TO FORMULARY Tier 2 2021-2022 quadrivalent 2021-22 (6 mos and up) 07/28/2021 AFLURIA QUAD influenza virus vaccine ADD TO FORMULARY Tier 2 2021-22 (6- quadrival 2021-22 (6 mos- 35MO) 35 mos)/pf 07/28/2021 FLUZONE HIGH- influenza virus vaccine ADD UM: QUANTITY 1 / 270 days DOSE QUAD quadrival split 2021-22(65 yr 2021-22 up)/pf 07/28/2021 FLUZONE HIGH- influenza virus vaccine ADD UM: AGE At least 19 yrs DOSE QUAD quadrival split 2021-22(65 yr old 2021-22 up)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 211 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/28/2021 FLUZONE QUAD influenza virus vaccine ADD UM: QUANTITY 1 / 270 days 2021-2022 quadrival 2021-2022(6 mos and up)/pf 07/28/2021 FLUZONE QUAD influenza virus vaccine ADD UM: AGE At least 19 yrs 2021-2022 quadrival 2021-2022(6 mos old and up)/pf 07/28/2021 FLUZONE QUAD influenza virus vaccine ADD UM: QUANTITY 1 / 270 days 2021-2022 quadrivalent 2021-22 (6 mos and up) 07/28/2021 FLUZONE QUAD influenza virus vaccine ADD UM: AGE At least 19 yrs 2021-2022 quadrivalent 2021-22 (6 mos old and up) 07/28/2021 FLUAD QUAD influenza vaccine ADD UM: QUANTITY 1 / 270 days 2021-2022 quadrivalent 2021-22 (65 yr up)/mf59c.1/pf 07/28/2021 FLUAD QUAD influenza vaccine ADD UM: AGE At least 19 yrs 2021-2022 quadrivalent 2021-22 (65 yr old up)/mf59c.1/pf 07/28/2021 FLULAVAL influenza virus vaccine ADD UM: QUANTITY 1 / 270 days QUAD 2021- quadrival 2021-2022(6 mos 2022 and up)/pf 07/28/2021 FLULAVAL influenza virus vaccine ADD UM: AGE At least 19 yrs QUAD 2021- quadrival 2021-2022(6 mos old 2022 and up)/pf 07/28/2021 FLUCELVAX flu vaccine quadriv 2021- ADD UM: QUANTITY 1 / 270 days QUAD 2021- 2022(2 years and older)cell 2022 derived 07/28/2021 FLUCELVAX flu vaccine quadriv 2021- ADD UM: AGE At least 19 yrs QUAD 2021- 2022(2 years and older)cell old 2022 derived 07/28/2021 FLUARIX QUAD influenza virus vaccine ADD UM: QUANTITY 1 / 270 days 2021-2022 quadrival 2021-2022(6 mos and up)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 212 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/28/2021 FLUARIX QUAD influenza virus vaccine ADD UM: AGE At least 19 yrs 2021-2022 quadrival 2021-2022(6 mos old and up)/pf 07/28/2021 FLUBLOK QUAD influenza virus vaccine qv ADD UM: QUANTITY 1 / 270 days 2021-2022 2021-22(18 yrs and older)rcmb/pf 07/28/2021 FLUBLOK QUAD influenza virus vaccine qv ADD UM: AGE At least 19 yrs 2021-2022 2021-22(18 yrs and old older)rcmb/pf 07/28/2021 FLUCELVAX flu vaccine quad 2021- ADD UM: QUANTITY 1 / 270 days QUAD 2021- 2022(2 years and older)cell 2022 derived/pf 07/28/2021 FLUCELVAX flu vaccine quad 2021- ADD UM: AGE At least 19 yrs QUAD 2021- 2022(2 years and older)cell old 2022 derived/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine ADD UM: QUANTITY 1 / 270 days 2021-22 (3YR quadrivalent 2021-22 (36 UP) mos up)/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine ADD UM: AGE At least 19 yrs 2021-22 (3YR quadrivalent 2021-22 (36 old UP) mos up)/pf 07/28/2021 FLUZONE QUAD influenza virus vaccine ADD UM: QUANTITY 1 / 270 days 2021-2022 quadrival 2021-2022(6 mos and up)/pf 07/28/2021 FLUZONE QUAD influenza virus vaccine ADD UM: AGE At least 19 yrs 2021-2022 quadrival 2021-2022(6 mos old and up)/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine ADD UM: QUANTITY 1 / 270 days 2021-2022 quadrivalent 2021-22 (6 mos and up) 07/28/2021 AFLURIA QUAD influenza virus vaccine ADD UM: AGE At least 19 yrs 2021-2022 quadrivalent 2021-22 (6 mos old and up)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 213 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/28/2021 AFLURIA QUAD influenza virus vaccine ADD UM: QUANTITY 1 / 270 days 2021-22 (6- quadrival 2021-22 (6 mos- 35MO) 35 mos)/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine ADD UM: AGE At least 19 yrs 2021-22 (6- quadrival 2021-22 (6 mos- old 35MO) 35 mos)/pf 07/28/2021 FLUCELVAX flu vaccine quad 2020- REMOVE FROM Tier 2 Non-Formulary QUAD 2020- 2021(4 years and older)cell FORMULARY 2021 derived/pf 07/28/2021 FLUCELVAX flu vaccine quad 2020- REMOVE UM: AGE At least 19 yrs QUAD 2020- 2021(4 years and older)cell old 2021 derived/pf 07/28/2021 FLUCELVAX flu vaccine quad 2020- REMOVE UM: QUANTITY 1 / 270 DAYS QUAD 2020- 2021(4 years and older)cell 2021 derived/pf 07/28/2021 FLUCELVAX flu vaccine quadriv 2020- REMOVE FROM Tier 2 Non-Formulary QUAD 2020- 2021(4 years and older)cell FORMULARY 2021 derived 07/28/2021 FLUCELVAX flu vaccine quadriv 2020- REMOVE UM: AGE At least 19 yrs QUAD 2020- 2021(4 years and older)cell old 2021 derived 07/28/2021 FLUCELVAX flu vaccine quadriv 2020- REMOVE UM: QUANTITY 1 / 270 DAYS QUAD 2020- 2021(4 years and older)cell 2021 derived 07/28/2021 FLUAD QUAD influenza vaccine REMOVE FROM Tier 2 Non-Formulary 2020-2021 quadrivalent 2020-21 (65 yr FORMULARY up)/mf59c.1/pf 07/28/2021 FLUAD QUAD influenza vaccine REMOVE UM: QUANTITY 1 / 270 DAYS 2020-2021 quadrivalent 2020-21 (65 yr up)/mf59c.1/pf 07/28/2021 FLUMIST QUAD influenza vaccine REMOVE FROM Tier 2 Non-Formulary 2020-2021 quadrivalent live 2020-2021 FORMULARY (2 yrs-49 yrs)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 214 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/28/2021 FLUMIST QUAD influenza vaccine REMOVE UM: AGE At least 19 yrs 2020-2021 quadrivalent live 2020-2021 old (2 yrs-49 yrs) 07/28/2021 FLUMIST QUAD influenza vaccine REMOVE UM: QUANTITY 1 / 270 DAYS 2020-2021 quadrivalent live 2020-2021 (2 yrs-49 yrs) 07/28/2021 FLULAVAL influenza virus vaccine REMOVE FROM Tier 2 Non-Formulary QUAD 2020- quadrival 2020-2021(6 mos FORMULARY 2021,FLUZONE and up)/pf QUAD 2020- 2021,FLUARIX QUAD 2020- 2021 07/28/2021 FLULAVAL influenza virus vaccine REMOVE UM: AGE At least 19 yrs QUAD 2020- quadrival 2020-2021(6 mos old 2021,FLUZONE and up)/pf QUAD 2020- 2021,FLUARIX QUAD 2020- 2021 07/28/2021 FLULAVAL influenza virus vaccine REMOVE UM: QUANTITY 1 / 270 DAYS QUAD 2020- quadrival 2020-2021(6 mos 2021,FLUZONE and up)/pf QUAD 2020- 2021,FLUARIX QUAD 2020- 2021 07/28/2021 AFLURIA QUAD influenza virus vaccine REMOVE FROM Tier 2 Non-Formulary 2020-21 (6- quadrival 2020-21 (6 mos- FORMULARY 35MO) 35 mos)/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine REMOVE UM: AGE At least 19 yrs 2020-21 (6- quadrival 2020-21 (6 mos- old 35MO) 35 mos)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 215 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/28/2021 AFLURIA QUAD influenza virus vaccine REMOVE UM: QUANTITY 1 / 270 DAYS 2020-21 (6- quadrival 2020-21 (6 mos- 35MO) 35 mos)/pf 07/28/2021 FLUZONE HIGH- influenza virus vaccine REMOVE FROM Tier 2 Non-Formulary DOSE QUAD quadrival split 2020-21(65 yr FORMULARY 2020-21 up)/pf 07/28/2021 FLUZONE HIGH- influenza virus vaccine REMOVE UM: QUANTITY 1 / 270 DAYS DOSE QUAD quadrival split 2020-21(65 yr 2020-21 up)/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine REMOVE FROM Tier 2 Non-Formulary 2020-21 (3YR quadrivalent 2020-21 (36 FORMULARY UP) mos up)/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine REMOVE UM: AGE At least 19 yrs 2020-21 (3YR quadrivalent 2020-21 (36 old UP) mos up)/pf 07/28/2021 AFLURIA QUAD influenza virus vaccine REMOVE UM: QUANTITY 1 / 270 DAYS 2020-21 (3YR quadrivalent 2020-21 (36 UP) mos up)/pf 07/28/2021 FLUZONE QUAD influenza virus vaccine REMOVE FROM Tier 2 Non-Formulary 2020- quadrivalent 2020-21 (6 mos FORMULARY 2021,AFLURIA and up) QUAD 2020- 2021 07/28/2021 FLUZONE QUAD influenza virus vaccine REMOVE UM: AGE At least 19 yrs 2020- quadrivalent 2020-21 (6 mos old 2021,AFLURIA and up) QUAD 2020- 2021 07/28/2021 FLUZONE QUAD influenza virus vaccine REMOVE UM: QUANTITY 1 / 270 DAYS 2020- quadrivalent 2020-21 (6 mos 2021,AFLURIA and up) QUAD 2020- 2021

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 216 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/28/2021 FLUBLOK QUAD influenza virus vaccine qv REMOVE FROM Tier 2 Non-Formulary 2020-2021 2020-21(18 yrs and FORMULARY older)rcmb/pf 07/28/2021 FLUBLOK QUAD influenza virus vaccine qv REMOVE UM: AGE At least 19 yrs 2020-2021 2020-21(18 yrs and old older)rcmb/pf 07/28/2021 FLUBLOK QUAD influenza virus vaccine qv REMOVE UM: QUANTITY 1 / 270 DAYS 2020-2021 2020-21(18 yrs and older)rcmb/pf 07/28/2021 DUPIXENT PEN dupilumab ADD TO FORMULARY Tier 4 07/28/2021 AYVAKIT avapritinib ADD TO FORMULARY Tier 4 07/28/2021 AYVAKIT avapritinib ADD TO FORMULARY Tier 4 07/28/2021 DUPIXENT PEN dupilumab ADD UM: SPECIALTY Specialty Drug 07/28/2021 AYVAKIT avapritinib ADD UM: SPECIALTY Specialty Drug 07/28/2021 AYVAKIT avapritinib ADD UM: SPECIALTY Specialty Drug 07/28/2021 DUPIXENT PEN dupilumab ADD UM: PANAME PA Applies 07/28/2021 AYVAKIT avapritinib ADD UM: PANAME PA Applies 07/28/2021 AYVAKIT avapritinib ADD UM: PANAME PA Applies 07/28/2021 TRIKAFTA elexacaftor/tezacaftor/ivacaft ADD TO FORMULARY Tier 4 or 07/28/2021 TRIKAFTA elexacaftor/tezacaftor/ivacaft ADD UM: PANAME PA Applies or 07/28/2021 TRIKAFTA elexacaftor/tezacaftor/ivacaft ADD UM: SPECIALTY Specialty Drug or 07/28/2021 PREVIDENT fluoride (sodium) REMOVE FROM Tier 2 Non-Formulary FORMULARY 07/28/2021 PREVIDENT fluoride (sodium) REMOVE FROM Tier 2 Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 217 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/30/2021 PROPECIA finasteride REMOVE FROM Non-Formulary FORMULARY 07/30/2021 PROPECIA finasteride REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 218 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

August, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/06/2021 potassium potassium chloride ADD TO FORMULARY Tier 1 chloride 08/06/2021 potassium potassium chloride ADD TO FORMULARY Tier 1 chloride 08/09/2021 ALLEGRA fexofenadine hcl REMOVE FROM Tier 1 Non-Formulary ALLERGY FORMULARY 08/13/2021 DERMACINRX cholecalciferol (vit d3)/folic REMOVE FROM Non-Formulary PUREFOLTIN acid FORMULARY 08/13/2021 DERMACINRX multivitamin with minerals REMOVE FROM Non-Formulary RIBOTIN-E no.89/ferrous fumarate/folic FORMULARY acid 08/13/2021 DERMACINRX multivitamin with minerals REMOVE FROM Non-Formulary ZINTREXYL-C no.89/ferrous fumarate/folic FORMULARY acid 08/13/2021 DERMACINRX prenatal vitamins ADD TO FORMULARY Tier 2 PRETRATE no.170/ferrous fumarate/folic acid 08/13/2021 TAYSOFY norethindrone acetate- ADD TO FORMULARY Tier 1 ethinyl estradiol/ferrous fumarate 08/13/2021 TAYSOFY norethindrone acetate- ADD TO FORMULARY Tier 1 ethinyl estradiol/ferrous fumarate 08/13/2021 telmisartan- telmisartan/hydrochlorothiazi REMOVE FROM Non-Formulary hydrochlorothiazi de FORMULARY d 08/13/2021 telmisartan- telmisartan/hydrochlorothiazi REMOVE FROM Non-Formulary hydrochlorothiazi de FORMULARY d

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 219 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/13/2021 telmisartan- telmisartan/hydrochlorothiazi REMOVE FROM Non-Formulary hydrochlorothiazi de FORMULARY d 08/13/2021 telmisartan- telmisartan/hydrochlorothiazi REMOVE FROM Non-Formulary hydrochlorothiazi de FORMULARY d 08/13/2021 telmisartan- telmisartan/hydrochlorothiazi REMOVE FROM Non-Formulary hydrochlorothiazi de FORMULARY d 08/13/2021 telmisartan- telmisartan/hydrochlorothiazi REMOVE FROM Non-Formulary hydrochlorothiazi de FORMULARY d 08/13/2021 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 08/13/2021 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 08/13/2021 vardenafil hcl vardenafil hcl ADD UM: COV Excluded 08/13/2021 vardenafil hcl vardenafil hcl ADD UM: COV Excluded 08/13/2021 VYTORIN ezetimibe/simvastatin REMOVE FROM Non-Formulary FORMULARY 08/13/2021 VYTORIN ezetimibe/simvastatin REMOVE FROM Non-Formulary FORMULARY 08/13/2021 VYTORIN ezetimibe/simvastatin REMOVE FROM Non-Formulary FORMULARY 08/13/2021 isoproterenol hcl isoproterenol hcl REMOVE FROM Non-Formulary FORMULARY 08/13/2021 isoproterenol hcl isoproterenol hcl REMOVE FROM Non-Formulary FORMULARY 08/13/2021 isoproterenol hcl isoproterenol hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 220 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/13/2021 isoproterenol hcl isoproterenol hcl REMOVE FROM Non-Formulary FORMULARY 08/17/2021 KLOXXADO naloxone hcl REMOVE FROM Non-Formulary FORMULARY 08/17/2021 KLOXXADO naloxone hcl ADD UM: NTWK CARVE OUT: FFS MEDI-CAL 08/18/2021 AMITIZA lubiprostone REMOVE FROM Tier 3 Non-Formulary FORMULARY 08/18/2021 AMITIZA lubiprostone REMOVE FROM Tier 3 Non-Formulary FORMULARY 08/18/2021 COSENTYX secukinumab ADD TO FORMULARY Tier 4 SYRINGE 08/18/2021 COSENTYX secukinumab ADD UM: PANAME PA Applies SYRINGE 08/18/2021 isotretinoin isotretinoin ADD TO FORMULARY Tier 3 08/18/2021 isotretinoin isotretinoin ADD UM: PANAME PA Applies 08/18/2021 isotretinoin isotretinoin ADD TO FORMULARY Tier 3 08/18/2021 isotretinoin isotretinoin ADD UM: PANAME PA Applies 08/18/2021 PATADAY ONCE olopatadine hcl ADD TO FORMULARY Tier 3 DAILY RELIEF 08/18/2021 PATADAY ONCE olopatadine hcl ADD UM: STEP ST applies DAILY RELIEF 08/19/2021 DIASTAT diazepam CHANGE UM: QUANTITY 3 / 365 DAYS 0.07 / day 08/19/2021 DIASTAT diazepam CHANGE UM: QUANTITY 3 / 365 DAYS 0.07 / day ACUDIAL 08/19/2021 DIASTAT diazepam CHANGE UM: QUANTITY 3 / 365 DAYS 0.07 / day ACUDIAL 08/19/2021 ciclopirox ciclopirox CHANGE UM: QUANTITY 6.6 / 30 DAYS 0.22 / day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 221 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/19/2021 ciclopirox ciclopirox REMOVE UM: Limit 12 fills per QUANTITYCUSTOM lifetime 08/20/2021 midazolam hcl midazolam hcl REMOVE FROM Tier 1 Non-Formulary FORMULARY 08/20/2021 docusate docusate sodium REMOVE FROM Tier 1 Non-Formulary sodium,diocto,do FORMULARY c-q-lace,stool softener,dioctyl,si lace,colace 08/20/2021 bacitracin bacitracin zinc REMOVE FROM Tier 1 Non-Formulary zinc,antibiotic FORMULARY 08/20/2021 PATADAY ONCE olopatadine hcl ADD TO FORMULARY Tier 3 DAILY RELIEF 08/20/2021 PATADAY ONCE olopatadine hcl ADD UM: STEP ST applies DAILY RELIEF 08/20/2021 desvenlafaxine desvenlafaxine succinate ADD TO FORMULARY Tier 1 succinate er 08/20/2021 desvenlafaxine desvenlafaxine succinate ADD TO FORMULARY Tier 1 succinate er 08/20/2021 desvenlafaxine desvenlafaxine succinate ADD TO FORMULARY Tier 1 succinate er 08/20/2021 fluoxetine hcl fluoxetine hcl ADD TO FORMULARY Tier 1 08/20/2021 fluoxetine hcl fluoxetine hcl ADD TO FORMULARY Tier 1 08/20/2021 fluoxetine hcl fluoxetine hcl ADD TO FORMULARY Tier 1 08/20/2021 FIRVANQ vancomycin hcl REMOVE UM: QUANTITY 400 / 10 DAYS 08/20/2021 TIROSINT-SOL levothyroxine sodium REMOVE FROM Non-Formulary FORMULARY 08/20/2021 TIROSINT-SOL levothyroxine sodium ADD UM: COV Excluded 08/20/2021 TIROSINT-SOL levothyroxine sodium REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 222 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2021 TIROSINT-SOL levothyroxine sodium ADD UM: COV Excluded 08/20/2021 TIROSINT-SOL levothyroxine sodium ADD UM: NTI Narrow Therapeutic Indicator 08/20/2021 TIROSINT-SOL levothyroxine sodium ADD UM: NTI Narrow Therapeutic Indicator 08/20/2021 TIROSINT-SOL levothyroxine sodium REMOVE FROM Non-Formulary FORMULARY 08/20/2021 TIROSINT-SOL levothyroxine sodium ADD UM: COV Excluded 08/20/2021 TIROSINT-SOL levothyroxine sodium ADD UM: NTI Narrow Therapeutic Indicator 08/20/2021 XOFLUZA baloxavir marboxil ADD TO FORMULARY Tier 2 08/20/2021 XOFLUZA baloxavir marboxil ADD UM: QUANTITY 2 / 180 days 08/20/2021 droxidopa droxidopa ADD TO FORMULARY Tier 1 08/20/2021 droxidopa droxidopa ADD TO FORMULARY Tier 1 08/20/2021 droxidopa droxidopa ADD TO FORMULARY Tier 1 08/20/2021 TOBRADEX tobramycin/dexamethasone ADD UM: STEP ST applies 08/20/2021 TOBRADEX tobramycin/dexamethasone CHANGE TIER Tier 2 Tier 3 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 223 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/20/2021 buprenorphine buprenorphine hcl ADD UM: NTWK CARVE OUT: hcl FFS MEDI-CAL 08/20/2021 buprenorphine buprenorphine hcl ADD UM: NTWK CARVE OUT: hcl FFS MEDI-CAL 08/20/2021 buprenorphine buprenorphine hcl ADD UM: NTWK CARVE OUT: hcl FFS MEDI-CAL 08/20/2021 buprenorphine buprenorphine hcl ADD UM: NTWK CARVE OUT: hcl FFS MEDI-CAL 08/20/2021 buprenorphine buprenorphine hcl ADD UM: NTWK CARVE OUT: hcl FFS MEDI-CAL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 224 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2021 buprenorphine buprenorphine hcl ADD UM: NTWK CARVE OUT: hcl FFS MEDI-CAL 08/20/2021 buprenorphine buprenorphine hcl ADD UM: NTWK CARVE OUT: hcl FFS MEDI-CAL 08/20/2021 dextroamphetami dextroamphetamine sulfate REMOVE FROM Non-Formulary ne sulfate FORMULARY 08/20/2021 dextroamphetami dextroamphetamine sulfate REMOVE FROM Non-Formulary ne sulfate FORMULARY 08/20/2021 dextroamphetami dextroamphetamine sulfate REMOVE FROM Non-Formulary ne sulfate FORMULARY 08/20/2021 sunitinib malate sunitinib malate ADD TO FORMULARY Tier 4 08/20/2021 sunitinib malate sunitinib malate ADD TO FORMULARY Tier 4 08/20/2021 sunitinib malate sunitinib malate ADD TO FORMULARY Tier 4 08/20/2021 sunitinib malate sunitinib malate ADD TO FORMULARY Tier 4 08/20/2021 sunitinib malate sunitinib malate ADD UM: NTWK US BIOSERVICES SPECIALTY PHARMACY 08/20/2021 sunitinib malate sunitinib malate ADD UM: NTWK US BIOSERVICES SPECIALTY PHARMACY 08/20/2021 sunitinib malate sunitinib malate ADD UM: SPECIALTY Specialty Drug 08/20/2021 sunitinib malate sunitinib malate ADD UM: SPECIALTY Specialty Drug 08/20/2021 sunitinib malate sunitinib malate ADD UM: NTWK US BIOSERVICES SPECIALTY PHARMACY 08/20/2021 sunitinib malate sunitinib malate ADD UM: SPECIALTY Specialty Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 225 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2021 sunitinib malate sunitinib malate ADD UM: NTWK US BIOSERVICES SPECIALTY PHARMACY 08/20/2021 sunitinib malate sunitinib malate ADD UM: SPECIALTY Specialty Drug 08/20/2021 enalapril maleate enalapril maleate REMOVE FROM Non-Formulary FORMULARY 08/20/2021 ZOCOR simvastatin REMOVE FROM Non-Formulary FORMULARY 08/20/2021 REMERON mirtazapine REMOVE FROM Non-Formulary FORMULARY 08/20/2021 ZOCOR simvastatin REMOVE FROM Non-Formulary FORMULARY 08/20/2021 REMERON mirtazapine REMOVE FROM Non-Formulary FORMULARY 08/20/2021 REMERON mirtazapine REMOVE FROM Non-Formulary FORMULARY 08/20/2021 esomeprazole esomeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY 08/20/2021 esomeprazole esomeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY 08/20/2021 REMERON mirtazapine REMOVE FROM Non-Formulary FORMULARY 08/20/2021 REMERON mirtazapine REMOVE FROM Non-Formulary FORMULARY 08/20/2021 ZOCOR simvastatin REMOVE FROM Non-Formulary FORMULARY 08/20/2021 CLARINEX desloratadine REMOVE FROM Non-Formulary FORMULARY 08/20/2021 SINGULAIR montelukast sodium REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 226 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/20/2021 CLARINEX-D 12 desloratadine/pseudoephedr REMOVE FROM Non-Formulary HOUR ine sulfate FORMULARY 08/20/2021 PLENITY carboxymethylcellulose/citric REMOVE FROM Non-Formulary acid FORMULARY 08/20/2021 PLENITY carboxymethylcellulose/citric REMOVE FROM Non-Formulary acid FORMULARY 08/20/2021 CLINDAVIX clindamycin REMOVE FROM Non-Formulary phosphate/dimethicone/zinc FORMULARY oxide 08/25/2021 APIDRA insulin glulisine REMOVE FROM Tier 2 Non-Formulary FORMULARY 08/25/2021 APIDRA insulin glulisine REMOVE FROM Tier 2 Non-Formulary SOLOSTAR FORMULARY 08/25/2021 ZICLOPRO diclofenac sodium/capsicum REMOVE FROM Non-Formulary oleoresin FORMULARY 08/25/2021 CORTI-SAV hydrocortisone/iodoquinol REMOVE FROM Non-Formulary FORMULARY 08/25/2021 ibuprofen- ibuprofen/famotidine REMOVE FROM Non-Formulary famotidine FORMULARY 08/25/2021 doxycycline doxycycline hyclate REMOVE FROM Non-Formulary hyclate FORMULARY 08/25/2021 VYTORIN ezetimibe/simvastatin REMOVE FROM Non-Formulary FORMULARY 08/25/2021 levetiracetam levetiracetam REMOVE FROM Non-Formulary FORMULARY 08/25/2021 sirolimus sirolimus REMOVE FROM Non-Formulary FORMULARY 08/25/2021 MYRBETRIQ mirabegron REMOVE FROM Non-Formulary FORMULARY 08/25/2021 chlorpromazine chlorpromazine hcl REMOVE FROM Non-Formulary hcl FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 227 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/25/2021 chlorpromazine chlorpromazine hcl ADD UM: NTWK CARVE OUT: hcl FFS MEDI-CAL 08/25/2021 chlorpromazine chlorpromazine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/25/2021 chlorpromazine chlorpromazine hcl ADD UM: NTWK CARVE OUT: hcl FFS MEDI-CAL 08/25/2021 hydrocortisone- hydrocortisone REMOVE FROM Non-Formulary pramoxine acetate/pramoxine hcl FORMULARY 08/25/2021 KERENDIA finerenone REMOVE FROM Non-Formulary FORMULARY 08/25/2021 KERENDIA finerenone ADD UM: COV FDA Moratorium 08/25/2021 KERENDIA finerenone REMOVE FROM Non-Formulary FORMULARY 08/25/2021 KERENDIA finerenone ADD UM: COV FDA Moratorium 08/26/2021 tramadol hcl tramadol hcl CHANGE UM: QUANTITY 240 / 30 DAYS 8 / day 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 360 / 30 DAYS 12 / day 08/26/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 360 / 30 DAYS 12 / day 08/26/2021 acetaminophen- acetaminophen with codeine CHANGE UM: QUANTITY 360 / 30 days 12 / day codeine phosphate 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 360 / 30 DAYS 12 / day 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 360 / 30 DAYS 12 / day 08/26/2021 oxycodone oxycodone hcl CHANGE UM: QUANTITY 360 / 30 DAYS 12 / day hcl,oxycodone concentrate 08/26/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day 08/26/2021 ENDOCET oxycodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day hcl/acetaminophen 08/26/2021 codeine sulfate codeine sulfate CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 228 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/26/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day 08/26/2021 oxycodone- oxycodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day acetaminophen hcl/acetaminophen 08/26/2021 acetaminophen- acetaminophen with codeine CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day codeine phosphate 08/26/2021 hydrocodone- hydrocodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day acetaminophen bitartrate/acetaminophen,hy drocodone bit/acetaminophen 08/26/2021 ENDOCET oxycodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day hcl/acetaminophen 08/26/2021 hydrocodone- hydrocodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day acetaminophen bitartrate/acetaminophen,hy drocodone bit/acetaminophen 08/26/2021 ENDOCET oxycodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day hcl/acetaminophen 08/26/2021 acetaminophen- acetaminophen with codeine CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day codeine phosphate 08/26/2021 hydrocodone- hydrocodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day acetaminophen bitartrate/acetaminophen 08/26/2021 oxycodone- oxycodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day acetaminophen hcl/acetaminophen 08/26/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day 08/26/2021 tramadol hcl- tramadol hcl/acetaminophen CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day acetaminophen 08/26/2021 acetaminophen- acetaminophen with codeine CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day codeine phosphate 08/26/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day 08/26/2021 oxycodone- oxycodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day acetaminophen hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 229 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/26/2021 oxycodone hcl oxycodone hcl CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day 08/26/2021 hydromorphone hydromorphone hcl CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day hcl 08/26/2021 codeine sulfate codeine sulfate CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day 08/26/2021 hydromorphone hydromorphone hcl CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day hcl 08/26/2021 hydrocodone- hydrocodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day acetaminophen bitartrate/acetaminophen,hy drocodone bit/acetaminophen 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day 08/26/2021 hydromorphone hydromorphone hcl CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day hcl 08/26/2021 oxycodone- oxycodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day acetaminophen,o hcl/acetaminophen xycodone hcl- acetaminophen 08/26/2021 codeine sulfate codeine sulfate CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day 08/26/2021 ENDOCET oxycodone CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day hcl/acetaminophen 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 120 / 30 DAYS 4 / day 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 90 / 30 DAYS 3 / day er,morphine sulfate,morphine sulfate cr 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 90 / 30 DAYS 3 / day er,morphine sulfate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 230 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 90 / 30 DAYS 3 / day er,morphine sulfate,morphine sulfate cr 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 90 / 30 DAYS 3 / day er,morphine sulfate,morphine sulfate cr 08/26/2021 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 90 / 30 DAYS 3 / day er,morphine sulfate,morphine sulfate cr

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 231 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

September, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/14/2021 FLUMIST QUAD influenza vaccine ADD TO FORMULARY Tier 2 2021-2022 quadrivalent live 2021-2022 (2 yrs-49 yrs) 09/14/2021 FLUMIST QUAD influenza vaccine ADD UM: QUANTITY 1 / 270 days 2021-2022 quadrivalent live 2021-2022 (2 yrs-49 yrs) 09/14/2021 FLUMIST QUAD influenza vaccine ADD UM: AGE At least 19 yrs 2021-2022 quadrivalent live 2021-2022 old (2 yrs-49 yrs) 09/15/2021 FERRIPROX,FE deferiprone REMOVE FROM Non-Formulary RRIPROX (3 FORMULARY TIMES A DAY) 09/15/2021 APLENZIN bupropion hbr REMOVE FROM Non-Formulary FORMULARY 09/15/2021 APLENZIN bupropion hbr REMOVE FROM Non-Formulary FORMULARY 09/15/2021 APLENZIN bupropion hbr REMOVE FROM Non-Formulary FORMULARY 09/15/2021 carisoprodol carisoprodol REMOVE FROM Non-Formulary FORMULARY 09/15/2021 carisoprodol carisoprodol REMOVE FROM Non-Formulary FORMULARY 09/15/2021 FERRIPROX deferiprone REMOVE FROM Non-Formulary FORMULARY 09/15/2021 hydrocortisone hydrocortisone acetate REMOVE FROM Non-Formulary acetate FORMULARY 09/15/2021 sodium iodide i- sodium iodide-123 REMOVE FROM Non-Formulary 123 FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 232 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/15/2021 WELLBUTRIN bupropion hcl REMOVE FROM Non-Formulary XL FORMULARY 09/15/2021 WELLBUTRIN bupropion hcl REMOVE FROM Non-Formulary XL FORMULARY 09/15/2021 DERMACINRX lidocaine hcl REMOVE FROM Non-Formulary LIDOGEL FORMULARY 09/15/2021 EB-A7 DR s- REMOVE FROM Non-Formulary adenosylmeth/collagen/hyal FORMULARY uronic/boswellia/turmeric/pe pper 09/15/2021 WELIREG belzutifan ADD TO FORMULARY Tier 4 09/15/2021 WELIREG belzutifan ADD UM: SPECIALTY Specialty Drug 09/15/2021 HAPRODERM emollient combination REMOVE FROM Non-Formulary no.56/hyaluronic acid FORMULARY 09/15/2021 desmopressin desmopressin acetate REMOVE FROM Non-Formulary acetate FORMULARY 09/15/2021 DERMACINRX multivitamin with minerals REMOVE FROM Non-Formulary VENTRIXYL FE no.86/ferrous fumarate/folic FORMULARY acid 09/15/2021 nebivolol hcl nebivolol hcl REMOVE FROM Non-Formulary FORMULARY 09/15/2021 nebivolol hcl nebivolol hcl REMOVE FROM Non-Formulary FORMULARY 09/15/2021 nebivolol hcl nebivolol hcl REMOVE FROM Non-Formulary FORMULARY 09/15/2021 nebivolol hcl nebivolol hcl REMOVE FROM Non-Formulary FORMULARY 09/15/2021 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 09/15/2021 gentamicin gentamicin sulfate REMOVE FROM Non-Formulary sulfate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 233 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/15/2021 metaxalone metaxalone REMOVE FROM Non-Formulary FORMULARY 09/15/2021 paroxetine paroxetine hcl REMOVE FROM Non-Formulary er,paroxetine FORMULARY cr,paroxetine hcl 09/15/2021 paroxetine paroxetine hcl REMOVE FROM Non-Formulary er,paroxetine FORMULARY hcl,paroxetine cr 09/15/2021 paroxetine paroxetine hcl REMOVE FROM Non-Formulary er,paroxetine FORMULARY hcl,paroxetine cr 09/15/2021 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 09/15/2021 triamcinolone triamcinolone acetonide ADD TO FORMULARY Tier 1 acetonide 09/15/2021 LOREEV XR lorazepam REMOVE FROM Non-Formulary FORMULARY 09/15/2021 LOREEV XR lorazepam REMOVE FROM Non-Formulary FORMULARY 09/15/2021 LOREEV XR lorazepam REMOVE FROM Non-Formulary FORMULARY 09/16/2021 PROLIA denosumab ADD UM: MED Medical Drug 09/17/2021 WELIREG belzutifan ADD UM: PANAME PA Applies 09/17/2021 blood pressure blood pressure test kit-large ADD TO FORMULARY Tier 1 monitor 09/17/2021 TRIHEAL-80 triamcinolone REMOVE FROM Non-Formulary acetonide/dimethicone/silico FORMULARY ne, adhesive 09/17/2021 new image urostomy pouch REMOVE FROM Non-Formulary urostomy FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 234 UPDATED 10/2021 SAN FRANCISCO HEALTH PLAN MEDI-CAL FORMULARY Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/17/2021 clomipramine hcl clomipramine hcl REMOVE FROM Non-Formulary FORMULARY 09/17/2021 clomipramine hcl clomipramine hcl REMOVE FROM Non-Formulary FORMULARY 09/17/2021 clomipramine hcl clomipramine hcl REMOVE FROM Non-Formulary FORMULARY 09/17/2021 fosfomycin fosfomycin tromethamine REMOVE FROM Non-Formulary tromethamine FORMULARY 09/17/2021 fosfomycin fosfomycin tromethamine REMOVE FROM Non-Formulary tromethamine FORMULARY 09/17/2021 ivermectin ivermectin REMOVE FROM Non-Formulary FORMULARY 09/17/2021 potass cit-sod cit- sodium/potassium/potassiu REMOVE FROM Non-Formulary citric acid m citrate/sodium citrate/cit FORMULARY ac 09/17/2021 potassium citrate- potassium citrate/citric acid REMOVE FROM Non-Formulary citric acid FORMULARY 09/17/2021 urea urea REMOVE FROM Non-Formulary FORMULARY 09/17/2021 TRUDHESA dihydroergotamine mesylate REMOVE FROM Non-Formulary FORMULARY 09/17/2021 TRUDHESA dihydroergotamine mesylate REMOVE FROM Non-Formulary FORMULARY 09/17/2021 hydroxychloroqui hydroxychloroquine sulfate ADD TO FORMULARY Tier 1 ne sulfate 09/17/2021 hydroxychloroqui hydroxychloroquine sulfate ADD TO FORMULARY Tier 1 ne sulfate 09/17/2021 hydroxychloroqui hydroxychloroquine sulfate ADD TO FORMULARY Tier 1 ne sulfate 09/24/2021 mupirocin mupirocin calcium REMOVE UM: COV Excluded

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 235 UPDATED 10/2021