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Pharmacy Formulary Pharmacy Formulary Applicable to: Medi-Cal Alliance Care IHSS Health Plans This formulary and other plan-specific coverage documents are accessible online at: https://thealliance.health/for-providers/manage-care/ pharmacy-services/ Link to the Medi-Cal and Alliance Care IHSS members’ homepage: https://thealliance.health/for-members/ Notice: This formulary is subject to change and all previous versions of the formulary are no longer in effect. October 1, 2021 www.thealliance.health Notice of non-discrimination Discrimination is against the law. Central California Alliance for Health (the Alliance) complies with applicable federal and State civil rights laws and does not discriminate (exclude or treat people differently) on the basis of race, color, national origin, creed, ancestry, religion, language, age, marital status, sex, sexual orientation, gender identity, health status, physical or mental disability, or identification with any other persons or groups defined in Penal Code 422.56, and the Alliance will provide all Covered Services in a culturally and linguistically appropriate manner. The Alliance: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (braille, large print, audio, accessible electronic formats, and other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Member Services. If you believe that the Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, creed, ancestry, religion, language, age, marital status, sex, sexual orientation, gender identity, health status, physical or mental disability, or identification with any other persons or groups defined in Penal Code 422.56, you can file a grievance with: Central California Alliance for Health Attn: Grievance Department 1600 Green Hills Road, Scotts Valley, CA 95066 800-700-3874 x5816 / (TTY: 1-800-735-2929) Fax: 831-430-5579 Email: [email protected] You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Member Services or a Grievance Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at https://www.hhs.gov/ocr/filing-with-ocr. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-700-3874 (TTY: Llame al 1-800-855-3000). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 800-700-3874 (TTY: 1-800-735-2929). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 800-700-3874 (TTY: 1-800-735-2929). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 800-700-3874 (TTY: 1-800-735-2929) 번으로 전화해 주십시오. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-700-3874 (TTY: 1-800-735-2929）。 ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խո ս ո ւ մ եք հայ ե ր ե ն , ապա ձեզ ան վ ճ ար կար ո ղ են տր ամ ադ ր վ ե լ լե զ վ ակ ան աջ ակ ց ո ւ թ յ ան ծառ այ ո ւ թյ ո ւ ն ն ե ր : Զան գ ահ ար ե ք 800-700-3874 (TTY (հ ե ռ ատի պ)՝ 1-800-735-2929): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 800-700-3874 (телетайп: 1-800-735-2929). توجه: اگر به زبان فارسی گفتگو می کنید، تسهیﻻت زبانی بصورت رایگان برای شما فراهم می باشد. با (TTY: 1-800-735-2929) 3874-700-800 تماس بگیرید. 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。800-700- 3874 (TTY: 1-800-735-2929）まで、お電話にてご連絡ください。 LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau [1-800-700-3874] (TTY: [1-800-735-2929]). ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।ﹱ ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧ 800-700-3874 (TTY: 1-800-735-2929) 'ਤੇ ਕਾਲ ਕਰੋ। فإن خدمات المساعدة اللغویة تتوافرﻚﻟ بالمجان. اتصل ﻢﻗﺮﺑ 800-700-3874 )رقم هاتف الصم والبكم :2929-735-800-1). ملحوظة: إذا كنت تتحدث اذكر اللغة، उपलब्ध ℂ। 800-700- ﴂदी बोलते ℂ तो आपके ललए मुफ्त मᴂ भाषा स ायता सेवाएﴂ 鵍यान दᴂ: यदद आप द 3874 (TTY: 1-800-735-2929) पर कॉल करᴂ। เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 800-700-3874 (TTY: 1-800-735-2929). ប្រយ័㿒ន៖ បរ ើសិនᾶ诒នកនិ架យ 徶羶ខ្មែ , ប ស玶ជំនួយខ្មែនក徶羶 រោយមិនគិ㿒⏒ន ួល គឺ讶ច掶នសំ殶រ់រំរ ើ诒នក។ ចូ ទូ ស័寒ទ 800-700-3874 (TTY: 1-800-735-2929)។ ໂປດຊາບ:ຖ້ າວ່ າ ທ່ ານເ ວ້ າພາສາ ລາວ,ການໍບິລການຊ່ ວຍເຫ ອດ້ ານພາສາ, ໂດຍໍ່ບເສັ ຽຄ່ າ, ແມ່ ນີມ ພ້ ອມໃຫ້ ທ່ ານ. ໂທຣ 800-700-3874 (TTY: 1-800-735-2929 Table of Contents Informational Section .............................................................................................................................................. 2 Analgesic, Anti-Inflammatory Or Antipyretic - Drugs For Pain And Fever .......................................... 24 Anesthetics - Drugs For Pain And Fever ...................................................................................................... 32 Anorectal Preparations - Rectal Preparations ............................................................................................. 32 Antidotes And Other Reversal Agents - Drugs For Overdose Or Poisoning ...................................... 33 Anti-Infective Agents - Drugs For Infections ............................................................................................... 33 Antineoplastics - Drugs For Cancer ............................................................................................................... 41 Antiseptics And Disinfectants - Antiseptics And Disinfectants ............................................................. 51 Biologicals - Biological Agents ....................................................................................................................... 51 Cardiovascular Therapy Agents - Drugs For The Heart ........................................................................... 60 Central Nervous System Agents - Drugs For The Nervous System ..................................................... 68 Chemical Dependency, Agents To Treat - Drugs For Addiction ............................................................ 80 Chemicals-Pharmaceutical Adjuvants .......................................................................................................... 81 Cognitive Disorder Therapy - Drugs For The Nervous System .............................................................. 83 Contraceptives - Drugs For Women ............................................................................................................... 83 Dermatological - Drugs For The Skin ............................................................................................................ 93 Eating Disorder Therapy - Drugs For Eating Disorders.......................................................................... 106 Electrolyte Balance-Nutritional Products - Drugs For Nutrition ........................................................... 106 Endocrine - Hormones ..................................................................................................................................... 127 Gastrointestinal Therapy Agents - Drugs For The Stomach ................................................................. 136 Genitourinary Therapy - Drugs For The Urinary System ....................................................................... 152 Gout And Hyperuricemia Therapy - Drugs For Pain And Fever ........................................................... 155 Hematological Agents - Drugs For The Blood .......................................................................................... 155 Immunosuppressive Agents - Drugs For Organ Transplants ............................................................... 159 Locomotor System - Drugs For Muscles, Ligaments, Tendons, And Bones ................................... 159 Medical Supplies And Durable Medical Equipment (Dme) - Medical Supplies And Durable Medical Equipment ........................................................................................................................................... 160 Medical Supply, Fdb Superset ....................................................................................................................... 173 Metabolic Modifiers - Drugs That Alter Metabolism ................................................................................ 184 Mouth-Throat-Dental - Preparations - Drugs For The Mouth And Throat .......................................... 184 Ophthalmic Agents - Drugs For The Eye .................................................................................................... 186 Otic (Ear) - Drugs For The Ear ....................................................................................................................... 194 Respiratory Therapy Agents - Drugs For The Lungs .............................................................................. 195 Vaginal Products - Drugs For Women ......................................................................................................... 214 TOC-1 Informational Section
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