Medi-Cal Rx Contract Drugs List
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Medi-Cal Rx Contract Drugs List October 1, 2021 © 2021 California Department of Health Care Services. All rights reserved. Revision History Drug Name Description Effective Date Naloxegol Oxalate Labeler code (57841) restriction added. November 1, 2020 Albuterol Sulfate All labeler restrictions (00085, 59310, & January 1, 2021 00173) removed. Apraclonidine Labeler code restriction removed. January 1, 2021 Diazepam rectal gel Prior authorization requirement removed. January 1, 2021 Diagnosis, age, quantity, and labeler code (66490 & 00187) restrictions added. Dulaglutide Additional strengths added to injection (3 January 1, 2021 mg/0.5 ml, 4.5 mg/0.5 ml). Elbasvir/grazoprevir Note updated. January 1, 2021 Glecaprevir/pibrentasvir Prior authorization requirements removed. January 1, 2021 Diagnosis, quantity restrictions, and note updated. Insulin Aspart Date of service restriction removed. Labeler January 1, 2021 code (00169) restriction added. Insulin Aspart (niacinamide) Added to CDL. January 1, 2021 Insulin Aspart Protamine Labeler code (00169) restriction added. January 1, 2021 suspension/Insulin Aspart, Prefilled pens added to CDL. (rDNA origin) Insulin Degludec Added to CDL. January 1, 2021 Insulin Detemir (rDNA origin) Date of service restriction removed. Labeler January 1, 2021 code (00169) restriction added. Insulin Lispro, (rDNA origin) Labeler code (00024 & 66733) added to January 1, 2021 restriction. 3 ml injection added with labeler code (00024) restriction. Lasmiditan Succinate Added to CDL January 1, 2021 Ledipasvir/sofosbuvir Pellet packets added to CDL. Labeler January 1, 2021 restriction (61958) removed. Duration and note updated. Liraglutide Added to CDL. January 1, 2021 Methylphenidate HCl Extended release capsules added to CDL. January 1, 2021 Pancrelipase Extended release capsules and labeler January 1, 2021 restrictions (00032 & 00023) added. Semaglutide Added to CDL. January 1, 2021 Sofosbuvir Prior authorization requirements updated. January 1, 2021 Pellet packets added to CDL. Note updated. Sofosbuvir/velpatasvir Prior authorization requirements removed. January 1, 20201 Diagnosis, quantity restrictions, and note added. Tablets (200 mg/50 mg) added. Triazolam Date of service restriction (February 1, January 1, 2021 2021). Will be moved to outdated section after this date. Page 2 Medi-Cal Rx Contract Drugs List Introduction Drug Name Description Effective Date Ulipristal Acetate Labeler code (73302) restriction added. January 1, 2021 Colchicine Labeler code (13310 & 64764) exclusion February 1, 2021 removed for tablets. Eslicarbazepine Acetate Date of service restriction (February 28, February 1, 2021 2021). Will be moved to outdated section after this date. Fludarabine Phosphate Labeler code (50419) exclusion removed for February 1, 2021 powder for injection. Glucagon (R-DNA Origin) Labeler code (00002 & 00169) restrictions February 1, 2021 added. Goserelin Acetate Removed from CDL. February 1, 2021 Ombitasvir/Paritaprevir/ Removed from CDL. February 1, 2021 Ritonavir and Dasabuvir Triazolam Removed from CDL. February 1, 2021 Bumetanide Added to CDL. March 1, 2021 Ceritinib Added to CDL. March 1, 2021 Colesevelam HCl Trial and failure restriction (of HMG-CoA March 1, 2021 reductase inhibitor) removed. Diclofenac Sodium 1% gel added to CDL. March 1, 2021 Flecainide Acetate Added to CDL. March 1, 2021 Levalbuterol HCl Inhalation solution added to CDL. March 1, 2021 Levalbuterol Tartrate Oral inhaler without chlorofluorocarbons as March 1, 2021 the propellant added to CDL. Lidocaine Viscous solution 2%, jelly 2%, cream 3%, & March 1, 2021 ointment 5% added to CDL. Pramipexole Dihydrochloride Labeler restriction (00597) removed from March 1, 2021 extended-release tablets. Sildenafil Citrate Added to CDL. March 1, 2021 Tamoxifen Diagnosis restriction (for treatment of March 1, 2021 cancer only) removed. Tretinoin Cream & gel added to CDL. March 1, 2021 Asenapine FDA approved indication specific to April 1, 2021 beneficiaries residing in nursing home removed. Cabotegravir/Rilpivirine Added to CDL with a restriction. April 1, 2021 Exenatide Extended release injectable suspension vial April 1, 2021 obsolete. Removed from CDL. Leuprolide Acetate Injection and powder for injection removed April 1, 2021 from CDL. Labeler restriction updated to 00074 only. Lurasidone Hydrochloride FDA approved indication specific to April 1, 2021 beneficiaries residing in nursing home removed. Morphine Sulfate/Naltrexone Drug obsolete. Removed from CDL. April 1, 2021 Medi-Cal Rx Contract Drugs List Introduction Page 3 Drug Name Description Effective Date Nevirapine Labeler restriction (00597) added to liquid April 1, 2021 only. Propranolol Additional liquid strength (4.28 mg/ml) April 1, 2021 added to CDL with a restriction. Relugolix Added to CDL with a restriction. April 1, 2021 Sodium Zirconium Added to CDL with labeler code restriction. April 1, 2021 Cyclosilicate Enzalutamide Tablets added to CDL (coverage policy May 1, 2021 effective March 1, 2021). Saquinavir Mesylate Capsules removed from CDL. May 1, 2021 Travoprost Additional labeler code (00078) added to May 1, 2021 labeler restriction. Margetuximab-cmkb Added to CDL with restrictions (coverage June 1, 2021 policy effective April 1, 2021). Morphine Sulfate Labeler restriction (52544 & 00023) June 1, 2021 removed from extended-release pellet capsules. Long-acting tablets added to CDL with a restriction. Palonosetron HCL Date of service restriction (July 31, 2021). June 1, 2021 Will be moved to outdated section after this date. Potassium Bicarbonate/ Labeler exclusion (00245 & 66758) June 1, 2021 Citric Acid removed. Potassium Chloride Labeler exclusion (00074, 00245, & 66758) June 1, 2021 removed. Sacituzumab Govitecan-hziy Added to CDL with restrictions (coverage June 1, 2021 policy effective April 1, 2021). Apremilast Added to CDL with restrictions. July 1, 2021 Dostarlimab-gxly Added to CDL with restrictions. July 1, 2021 Elagolix Added to CDL with restrictions. July 1, 2021 Elagolix, Estradiol and Added to CDL with restrictions. July 1, 2021 Norethindrone Acetate Etanercept Added to CDL with restrictions. July 1, 2021 Evolocumab Added to CDL with prior authorization July 1, 2021 requirements. Fremanezumab-VFRM Added to CDL with restrictions. July 1, 2021 Lactic Acid, Citric Acid and Added to CDL with restrictions. July 1, 2021 Potassium Bitartrate Melphalan Flufenamide Added to CDL with restrictions. July 1, 2021 Perampanel Suspension & tablets added to CDL with July 1, 2021 restrictions. Pralsetinib Additional labeler code (50242) added to July 1, 2021 labeler restriction. Semaglutide Additional strength (1 mg/3 ml) added to July 1, 2021 prefilled pens. Page 4 Medi-Cal Rx Contract Drugs List Introduction Drug Name Description Effective Date Tepotinib Added to CDL with restrictions. July 1, 2021 Tivozanib Added to CDL with restrictions. July 1, 2021 Umbralisib Added to CDL with restrictions. July 1, 2021 Amivantamab-vmjw Added to CDL with restrictions. August 1, 2021 Avapritinib Additional strengths (25 mg and 50 mg) August 1, 2021 added to CDL. Hydroxyurea Additional strength (100 mg) added to CDL August 1, 2021 with restrictions. Diagnosis and labeler code (71770) restrictions added to tablets only. Sotorasib Added to CDL with restrictions. August 1, 2021 Triptorelin Pamoate Labeler code (74676) restriction added. August 1, 2021 Removed syringes from CDL. Aldesleukin Removed from the CDL. September 1, 2021 Amlodipine/Valsartan Labeler code (00078) restriction removed. September 1, 2021 Amlodipine/Valsartan/ Labeler code (00078) restriction removed. September 1, 2021 Hydrochlorothiazide Asparaginase Erwinia Added to CDL with diagnosis and prior September 1, 2021 Chrysanthemi (Recombinant- authorization requirements. Rywn) Colchicine Quantity limit added to the tablets. September 1, 2021 Aprepitant Labeler code restriction (00006) removed. October 1, 2021 Bismuth Subcitrate Added to CDL with a restriction. October 1, 2021 Potassium/Metronidazole/ Tetracycline HCL Clarithromycin Date of service restriction (November 1, October 1, 2021 2021) for the extended-release tablets. Will be moved to outdated section after this date. COVID-19 Vaccine Added to CDL with restrictions. October 1, 2021 Deutetrabenazine Added to CDL with restrictions. October 1, 2021 Didanosine Date of service restriction (November 1, October 1, 2021 2021) for the capsules, delayed release, E.C. Will be moved to outdated section after this date. Encorafenib Date of service restriction (November 1, October 1, 2021 2021) for the 50 mg capsules. Will be moved to outdated section after this date. Infigratinib Added to CDL with restrictions. October 1, 2021 Insulin Glargine (rDNA Origin) Additional labeler code (49502) added to October 1, 2021 labeler restriction. Leuprolide Acetate Added to CDL with restrictions. October 1, 2021 (Fensolvi®) Leuprolide Acetate (Eligard®) Added to CDL with restrictions. October 1, 2021 Levonorgestrel and Ethinyl Patches added to CDL with restrictions. October 1, 2021 Estradiol Medi-Cal Rx Contract Drugs List Introduction Page 5 Drug Name Description Effective Date Loncastuximab Tesirine-LPYL Added to CDL with restrictions. October 1, 2021 Olaratumab Date of service restriction (November 1, October 1, 2021 2021). Will be moved to outdated section after this date. Omeprazole/Amoxicillin/ Added to CDL with a restriction. October 1, 2021 Rifabutin Somatropin Added to CDL with restrictions. October 1, 2021 Sorafenib Labeler code restriction (50419) removed. October 1, 2021