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HPSJ State Medicaid Formulary List of Covered Drugs (Formulary) Line of Business: Managed Medi-Cal Updated: July 19, 2021 Notice: The formulary is subject to change and all previous versions of the formulary are no longer in effect. Link to the electronic formulary: https://www.hpsj.com/formulary/ Link to the Evidence of Coverage: https://www.hpsj.com/medi-cal-evidence-coverage-2/ HPSJ Medi - Cal Formulary Table of Contents Informational Section............................................................................................................................................................. 3 Alternative Therapy - Vitamins And Minerals.......................................................................................................................9 Analgesic, Anti-Inflammatory Or Antipyretic - Drugs For Pain And Fever........................................................................9 Anesthetics - Drugs For Pain And Fever............................................................................................................................ 17 Anorectal Preparations - Rectal Preparations....................................................................................................................18 Antidotes And Other Reversal Agents - Drugs For Overdose Or Poisoning.................................................................. 18 Anti-Infective Agents - Drugs For Infections......................................................................................................................19 Antineoplastics - Drugs For Cancer....................................................................................................................................25 Antiseptics And Disinfectants - Antiseptics And Disinfectants....................................................................................... 30 Biologicals - Biological Agents........................................................................................................................................... 30 Cardiovascular Therapy Agents - Drugs For The Heart.................................................................................................... 34 Central Nervous System Agents - Drugs For The Nervous System.................................................................................42 Chemical Dependency, Agents To Treat - Drugs For Addiction.......................................................................................51 Chemicals-Pharmaceutical Adjuvants................................................................................................................................ 52 Cognitive Disorder Therapy - Drugs For The Nervous System........................................................................................ 52 Contraceptives - Drugs For Women....................................................................................................................................53 Dermatological - Drugs For The Skin..................................................................................................................................58 Diagnostic Agents.................................................................................................................................................................68 Eating Disorder Therapy - Drugs For Eating Disorders.................................................................................................... 68 Electrolyte Balance-Nutritional Products - Drugs For Nutrition.......................................................................................69 Endocrine - Hormones..........................................................................................................................................................84 Fdb Class Obsolete-Not Used..............................................................................................................................................92 Gastrointestinal Therapy Agents - Drugs For The Stomach.............................................................................................92 Genitourinary Therapy - Drugs For The Urinary System.................................................................................................106 Gout And Hyperuricemia Therapy - Drugs For Pain And Fever..................................................................................... 108 Hematological Agents - Drugs For The Blood..................................................................................................................108 Immunosuppressive Agents - Drugs For Organ Transplants.........................................................................................113 Locomotor System - Drugs For Muscles, Ligaments, Tendons, And Bones................................................................ 114 Medical Supplies And Durable Medical Equipment (Dme) - Medical Supplies And Durable Medical Equipment..... 115 Medical Supply, Fdb Superset........................................................................................................................................... 129 Metabolic Disease Enzyme Replacement Agents - Drugs For Metabolic Disease....................................................... 143 Metabolic Modifiers - Drugs That Alter Metabolism.........................................................................................................143 Mouth-Throat-Dental - Preparations - Drugs For The Mouth And Throat......................................................................144 Multiple Sclerosis Agents - Drugs For The Nervous System..........................................................................................145 Ophthalmic Agents - Drugs For The Eye.......................................................................................................................... 146 Otic (Ear) - Drugs For The Ear........................................................................................................................................... 152 Respiratory Therapy Agents - Drugs For The Lungs.......................................................................................................152 Vaginal Products - Drugs For Women...............................................................................................................................171 TOC-2 Managed Medi-Cal List of Covered Drugs (Formulary) Introduction: Health Plan of San Joaquin’s (HPSJ) Managed Medi-Cal List of Covered Drugs tells you which outpatient prescription drugs and over-the-counter drugs and items are covered. This list also lets you know if there are any restrictions on any drugs covered by HPSJ. The list can be searched alphabetically using the Index found at the end of this list. If a generic equivalent for the brand name drug is not available or is not covered, the drug will not be separately listed by its generic name. The list of covered drugs may be updated on a monthly basis when changes need to be made. These changes include but are not limited to (1) change in drug or dosage form, (2) changes in tier placement, and (3) changes in formulary restrictions. At minimum the list is updated quarterly, 45 business days after the formulary changes alert is posted onto the HPSJ website following a Pharmacy & Therapeutics Committee meeting. Also, note that the presence of a prescription drug on the formulary does not guarantee that your provider will prescribe the drug for your particular medical condition. For medications that are covered under the medical benefit (e.g. drugs provided by/and administered by the provider), they are not included in this list and requests can be submitted by your provider using the “Medical Authorization Form” found on https://www.hpsj.com/forms-documents/. If you have questions about covered drugs or how to submit a prior authorization/exception request, please call the Health Plan of San Joaquin Customer Service Department, Monday through Friday, 8 a.m. to 6 p.m. at: (209) 942-6320, or 1-888- 936-PLAN (7526), toll free (209) 942-6306 (TDD). Definitions: (A) “Brand name drug” is a drug that is marketed under a proprietary, trademark protected name. The brand name drug shall be listed in all CAPITAL letters. (B) “Coinsurance” is a percentage of the cost of a covered health care benefit that an enrollee pays after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit. (C) “Copayment” is a fixed dollar amount that an enrollee pays for a covered health care benefit after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit. 3 (D) “Deductible” is the amount an enrollee pays for covered health care benefits before the enrollee's health plan begins payment for all or part of the cost of the health care benefit under the terms of the policy. (E) “Drug Tier” is a group of prescription drugs that corresponds to a specified cost sharing tier in the health plan's prescription drug coverage. The tier in which a prescription drug is placed determines the enrollee's portion of the cost for the drug. (F) “Enrollee” is a person enrolled in a health plan who is entitled to receive services from the plan. All references to enrollees in this formulary template shall also include subscribers as defined in this section below. (G) “Exception request” is a request for coverage of a prescription drug. If an enrollee, his or her designee, or prescribing health care provider submits an exception
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