Formulary Medi-Cal 2020 Medi-Cal DHCS Carve Out Medication List The medications listed below are excluded (not covered) by IEHP. However, you may still have access to these medications through your Medi-Cal fee-for-service (FFS) benefit. Please note that this list is updated often by Medi-Cal. Drugs may be added or deleted. For questions about a benefit or service listed here, please call Medi-Cal Support at 1-800-541-5555. Psychiatric Drugs Drug Name (Brand Name) Amantadine HCl Amantadine HCl ER Aripiprazole Aripiprazole lauroxil (Aristada Initio) Asenapine (Saphris) Benztropine Mesylate Brexpiprazole Cariprazine Chlorpromazine HCl Clozapine Fluphenazine Decanoate Fluphenazine HCl Haloperidol Haloperidol Decanoate Haloperidol Lactate Iloperidone (Fanapt) Isocarboxazid Lithium Carbonate Lithium Citrate Loxapine Succinate Loxapine Aerosol Powder Breath Activated (Adasuve) Lurasidone Hydrochloride Molindone HCl Olanzapine Olanzapine Fluoxetine HCl Olanzapine Pamoate Monohydrate (Zyprexa Relprevv) Paliperidone (Invega) Paliperidone Palmitate (Invega Sustenna) Paliperidone Palmitate (Invega Trinza) Perphenazine Phenelzine Sulfate Pimavanserin (Nuplazid) Pimozide Updated 01/07/2020 (v14) 1 Drug Name (Brand Name) Quetiapine Risperidone Risperidone ER injectable suspension (Perseris) Risperidone Microspheres Selegiline (transdermal only) Thioridazine HCl Thiothixene Thiothixene HCl Tranylcypromine Sulfate Trifluoperazine HCl Trihexyphenidyl Ziprasidone HCl Ziprasidone Mesylate AIDS Drugs Drug Name (Brand Name) Abacavir/Lamivudine Abacavir Sulfate Abacavir Sulfate/Dolutegravir/Lamivudine (Triumeq) Atazanavir Sulfate Atazanavir/Cobicistat (Evotaz) Bictegravir/Emtricitabine/Tenofovir Alafenamide (Biktarvy) Cobicistat (Tybost) Darunavir Ethanolate Darunavir/Cobicistat (Prezcobix) Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (Symtuza) Delavirdine Mesylate Dolutegravir (Tivicay) Dolutegravir/Lamivudine (Dovato) Dolutegravir/ Rilpivirine (Juluca) Doravine (Pifeltro) Doravirine/ Lamivudine/ Tenofovir disoproxil fumarate (Delstrigo) Efavirenz Efavirenz/Emtricitabine/Tenofovir Disoproxil Fumarate (Atripla) Efavirenz/Lamivudine/Tenofovir Disoproxil Fumarate (Symfi LO) Efavirenz/Lamivudine/Tenofovir Disoproxil Fumarate (Symfi) Elvitegravir (Vitekta) Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Disoproxil Fumarate (Stribild) Elvitegravir/Cobicistat/Emtricitabine/Tenofovir alafenamide (Genvoya) Emtricitabine/Rilpivirine/Tenofovir Alafenamide (Odefsey) Emtricitabine/Rilpivirine/ Tenofovir Disoproxil Fumarate (Complera) Emtricitabine/Tenofovir Alafenamide (Descovy) Emtricitabine Enfuvirtide Etravirine Fosamprenavir Calcium 2 Drug Name (Brand Name) Ibalizumab-uiyk (Trogarzo) Indinavir Sulfate Lamivudine Lamivudine/Tenofovir Disoproxil Fumarate (Cimduo) Lamivudine/ Tenofovir Disoproxil Fumarate (Temixys) Lopinavir/Ritonavir Maraviroc Nelfinavir Mesylate Nevirapine Raltegravir Potassium Rilpivirine Hydrochloride Ritonavir Saquinavir Saquinavir Mesylate Stavudine Tenofovir Alafenamide (Vemlidy) Tenofovir Disoproxil-Emtricitabine Tenofovir Disoproxil Fumarate Tipranavir Zidovudine/Lamivudine Zidovudine/Lamivudine/ Abacavir Sulfate Alcohol, Heroin Detoxification, and Dependency Treatment Drugs Drug Name (Brand Name) Acamprosate Calcium Buprenorphine HCl Buprenorphine Extended-Release Inj (Sublocade) Buprenorphine HCl (Belbuca) Buprenorphine Implant (Probuphine) Buprenorphine/Naloxone HCl Disulfiram (Antabuse) Lofexidine Hydrochloride (Lucemyra) Naloxone HCl Naltrexone (oral) Naltrexone Microsphere Injectable Suspension (Vivitrol) Blood Factor Products Drug Name (Brand Name) Antihemophilic factor VIII/von Willebrand factor complex (human) Anti-inhibitor Coagulation factor X (human) Factor VIIa (antihemophilic factor, recombinant) Factor VIII (antihemophilic factor, human) Factor VIII (antihemophilic factor, recombinant) 3 Drug Name (Brand Name) Factor VIII (antihemophilic factor, recombinant) (Novoeight) Factor IX (antihemophilic factor, purified, nonrecombinant) Factor IX (antihemophilic factor, recombinant) Factor IX (antihemophilic factor, recombinant) (Rixubis) Factor IX (antihemophilic factor, recombinant), glycopegylated, (Rebinyn), Per IU Factor IX complex Factor XIII (antihemophilic factor, human) Factor XIII A-Subunit (recombinant) Hemlibra Hemophilia clotting factor, not otherwise classified Injection, factor VIII (antihemophilic factor, recombinant) (Obizur) Injection, factor VIII, fc fusion (recombinant) Injection, factor VIII, fc fusion protein (recombinant) Injection, factor IX fusion protein (recombinant) Von Willebrand factor complex (human), Wilate Von Willebrand factor complex (Humate-P) 4 IEHP Medi-Cal 2020 Formulary Based on American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification Table of Contents ANTIHISTAMINE DRUGS - DRUGS FOR ALLERGY .................................................................................... 6 ANTI-INFECTIVE AGENTS - DRUGS FOR INFECTIONS ............................................................................ 8 ANTINEOPLASTIC AGENTS - DRUGS FOR CANCER ............................................................................... 14 ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM ........ 16 AUTONOMIC DRUGS - DRUGS FOR THE NERVOUS SYSTEM ............................................................... 22 BLOOD FORMATION, COAGULATION, THROMBOSIS - DRUGS FOR THE BLOOD ....................... 28 CARDIOVASCULAR DRUGS - DRUGS FOR THE HEART ......................................................................... 31 CENTRAL NERVOUS SYSTEM AGENTS - DRUGS FOR THE NERVOUS SYSTEM ............................. 46 CONTRACEPTIVES (E.G. FOAMS, DEVICES) - DRUGS FOR WOMEN .................................................. 58 DEVICES - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT ......................................... 59 DIAGNOSTIC AGENTS ....................................................................................................................................... 60 ELECTROLYTIC, CALORIC, AND WATER BALANCE ............................................................................. 60 EYE, EAR, NOSE AND THROAT (EENT) PREPS. ......................................................................................... 65 GASTROINTESTINAL DRUGS ......................................................................................................................... 70 GASTROINTESTINAL DRUGS - DRUGS FOR THE STOMACH ............................................................... 71 GOLD COMPOUNDS ........................................................................................................................................... 75 HEAVY METAL ANTAGONISTS - DRUGS TO REDUCE IRON ................................................................ 75 HORMONES AND SYNTHETIC SUBSTITUTES - HORMONES ................................................................ 75 MISCELLANEOUS THERAPEUTIC AGENTS ............................................................................................... 87 OXYTOCICS - DRUGS FOR WOMEN ............................................................................................................. 92 RESPIRATORY TRACT AGENTS - DRUGS FOR THE LUNGS ................................................................. 92 SKIN AND MUCOUS MEMBRANE AGENTS - DRUGS FOR THE SKIN .................................................. 99 SMOOTH MUSCLE RELAXANTS - DRUGS TO RELAX MUSCLES ....................................................... 108 VITAMINS ........................................................................................................................................................... 109 INDEX ................................................................................................................................................................... 115 5 IEHP Medi-Cal 2020 Formulary Based on American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification CURRENT AS OF 2/1/2020 Coverage Requirements Prescription Drug Name Drug Tier and Limits ANTIHISTAMINE DRUGS - DRUGS FOR ALLERGY ETHANOLAMINE DERIVATIVES - DRUGS FOR ALLERGY BENADRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML F QL (240 ML per 30 days) (diphenhydramine) CHILDREN'S WAL-DRYL ALLERGY ORAL PREFILLED F QL (240 ML per 30 days) SPOON 12.5 MG/5 ML (diphenhydramine) diphenhydramine hcl oral capsule 25 mg, 50 mg F QL (100 EA per 30 days) diphenhydramine hcl oral elixir 12.5 mg/5 ml F QL (240 ML per 30 days) diphenhydramine hcl oral syrup 12.5 mg/5 ml F QL (240 ML per 30 days) diphenhydramine hcl oral tablet 25 mg F QL (100 EA per 30 days) NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET 25 MG F QL (100 EA per 30 days) (diphenhydramine) FIRST GEN. ANTIHIST. DERIVATIVES, MISC. - DRUGS FOR ALLERGY cyproheptadine oral syrup 2 mg/5 ml F cyproheptadine oral tablet 4 mg F FIRST GENERATION ANTIHISTAMINES - DRUGS FOR ALLERGY BENADRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML F QL (240 ML per 30 days) (diphenhydramine) CHILDREN'S WAL-DRYL ALLERGY ORAL PREFILLED F QL (240 ML per 30 days) SPOON 12.5 MG/5 ML (diphenhydramine) chlorpheniramine maleate oral tablet 4 mg F chlorpheniramine maleate oral tablet extended release 12 mg F cyproheptadine oral syrup 2 mg/5 ml F cyproheptadine oral tablet 4 mg F diphenhydramine hcl oral capsule 25 mg, 50 mg F QL (100 EA per 30 days) diphenhydramine hcl oral elixir 12.5 mg/5 ml F QL (240 ML per 30 days) diphenhydramine hcl oral syrup 12.5 mg/5 ml F QL (240 ML per 30 days) diphenhydramine hcl oral tablet 25 mg F QL (100 EA per 30 days)