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.